SHARE

Thyroidectomy, although rare, may be performed to patients with thyroid cancer, hyperthyroidism, and drug reactions to antithyroid agents; pregnant women who cannot be managed with drugs; patients who do not want radiation therapy; and patients with large goiters who do not respond to antithyroid drugs.

thyroidectomy-nursing-care-plan

Thyroidectomy may entail different surgical interventions, depending on the type as well as the position of the nodules in the thyroid gland. The surgeon would always try to preserve a portion of the thyroid gland whenever it’s possible to facilitate continuous production of the thyroid hormones, and in the hope that it could avert predicaments with hypothyroidism postoperatively. During operation, it is very important to protect the parathyroid glands from damage or removal during the surgical procedure, and to also prevent damage to the recurrent laryngeal nerves. The common surgical procedures for thyroidectomy are as follows:

Thyroid Lobectomy: Only one of the lobe of the thyroid gland is removed which also includes the isthmus.

Near- total Lobectomy: Total lobectomy leaves less 1 gram of thyroid tissue behind, in order to protect the recurrent laryngeal nerve.

Near- total Thyroidectomy: This is the complete removal of one thyroid lobe and a near-total lobectomy on the contralateral side. The advantage of this surgical procedure is that the thyroid gland of the patient is still left intact which allows production of thyroid hormone. In addition, this also reduce the need for replacement thyroid hormones postoperatively.

Total Thyroidectomy: This is the removal of both lobes including the isthmus of the thyroid.

PRE-OPERATIVE CARE

It is important to achieve a Eurothyroid State through Lugol’s Solution and Anti-Thyroid Gland. The intake of medications and the solution would brought about a decrease in the vascularity of the thyroid gland in 2 to 3 weeks and would also prevent post-operative hemorrhage.

Complications

Hemorrhage- a tension hematoma could be due to the slipping of a ligature on the superior thyroid artery. Thus, an occasional hemorrhage from a thyroid remnant or thyroid vein could be possible.

Respiratory Obstruction – this is rarely due to the collapse or kicking of the trachea. Most cases of this complication is brought by laryngeal edema.   

Recurrent Laryngeal Nerve Paralysis – this complication may transpire unilaterally or bilaterally, transient or permanent.

Thyroid Insufficiency – occurs within 2 years after the time of operation, but may sometimes be delayed to 5 or more years.

Parathyroid insufficiency – this complication could be due to the removal of parathyroid glands or infarction through damage to the parathyroid end-artery. It is also often that both of these factors occur together.

Thyrotoxic Crisis – this is an acute exacerbation hyperthyroidism. This happens when the thyrotoxic patient has been inadequately prepared for thyroidectomy. Patients presenting thyrotoxic crisis are often managed with supportive and symptomatic treatments such as IV fluids, administration of oxygen, ice packs to cool patients, diuretic for cardiac failure, and digoxin for uncontrolled atrial fibrillation.

Wound Infection – there may be a possibility for a subcutaneous or deep cervical abscess, and this should be drained.

Hypertrophic or Keloid Scar – this is likely to form to a patient, especially if the incision overlies the sternum.

Stitch Granuloma – this complication may happen with or without sinus formation and is seen after the use of a non-absorbable suture material.             

POST-OPERATIVE CARE

  • The patient should be placed in Semi- Fowler’s position in order to reduce edema
  • Limit the patient movement by providing sandbag at side or side pillows.
  • Avert tension on the suture line.
  • Monitor patient for the following:
    • Hypocalcemia – this may transpire due to removal of the parathyroid
      • Check Chvostek’s sign (taping the face and noting for facial spasm).
      • Trousseau’s sign (taking blood pressure while noting for spasm of the wrist).
      • Give calcium gluconate (usually always available at bedside).
    • Respiratory Distress – results from laryngeal edema
      • Check respiratory rate, pattern, and efforts
      • Keep tracheostomy set, suction equipment at bedside
    • Thyroid Storm – acute episodes of thyroid hyperactivity brought by the release of thyroid hormone during surgery.
      • Observe for increase in temperature, delirium, extreme tachycardia, and marked respiratory distress
      • Hyperthermia is the earliest sign of thyroid storm. When checking for the vital signs, temperature should be taken rectally for post op patients.
      • Thyroid storm is considered an emergency case for it can cause heart failure and lead to death.
      • Administer Lugol’s solution, anti-thyroid drugs such as Methimazole or Propythiouracil, and cardiac drugs such as propranolol.
      • Use hypothermia mattress or blanket, ice packs, or expose in a cooler environment for elevated temperature. Patient may take medications such as acetaminophen or paracetamol, but they are not allowed to take in salicylates such as aspirin for it displace thyroid hormone from binding to proteins and worsens hyper metabolism.
    • The patient must be monitored for potential hemorrhage due to surgery. Always check the dressing and slide hands at the back of the head because this is where blood usually accumulates.
    • Check patient for possible laryngeal damage. This could be assess through hoarseness of voice or loss of voice. Hoarseness indicates unilateral damage while loss of voice indicates bilateral damage.

Nursing Priorities

  1. Reverse/manage hyperthyroid state preoperatively.
  2. Prevent complications.
  3. Relieve pain.
  4. Provide information about surgical procedure, prognosis, and treatment needs.

Thyroidectomy Nursing Care Plan (Based on NANDA)

Nursing Diagnosis: Airway Clearance, risk for ineffective

Risk factors may include

Tracheal obstruction; swelling, bleeding, laryngeal spasms

Possibly evidenced by

[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired outcomes/evaluation criteria—patient will:

Respiratory Status: Airway Patency

Maintain patent airway, with aspiration prevented.

Nursing InterventionsRationales
Independent

Monitor respiratory rate, depth, and work of breathing.

Respirations may remain somewhat rapid, but development of respiratory distress is indicative of tracheal compression from edema or hemorrhage.
Auscultate breath sounds, noting presence of rhonchi.Rhonchi may indicate airway obstruction/accumulation of copious thick secretions.
Assess for dyspnea, stridor, “crowing,” and cyanosis. Note quality of voice.Indicators of tracheal obstruction/laryngeal spasm, requiring prompt evaluation and intervention.
Caution patient to avoid bending neck; support head with pillows.Reduces likelihood of tension on surgical wound.
Assist with repositioning, deep breathing exercises, and/or coughing as indicated.Maintains clear airway and ventilation. Although “routine” coughing is not encouraged and may be painful, it may be needed to clear secretions.
Suction mouth and trachea as indicated, noting color and characteristics of sputum.Edema/pain may impair patient’s ability to clear own airway.
Check dressing frequently, especially posterior portion.If bleeding occurs, anterior dressing may appear dry because blood pools dependently.
Investigate reports of difficulty swallowing, drooling of oral secretions.May indicate edema/sequestered bleeding in tissues surrounding operative site.
Keep tracheostomy tray at bedside.Compromised airway may create a life-threatening situation requiring emergency procedure.
Collaborative

Provide steam inhalation; humidify room air.

Reduces discomfort of sore throat and tissue edema and promotes expectoration of secretions.
Assist with/prepare for procedures:

Tracheostomy

 May be necessary to maintain airway if obstructed by edema of glottis or hemorrhage.
Return to surgery.May require ligation of bleeding vessels.

Nursing Diagnosis: Communication, impaired verbal

May be related to

  • Vocal cord injury/laryngeal nerve damage
  • Tissue edema; pain/discomfort

Possibly evidenced by

  • Impaired articulation, does not/cannot speak; use of nonverbal cues such as gestures

Desired outcomes/evaluation criteria—patient will:

Communication Ability 

Establish method of communication in which needs can be understood.

Nursing InterventionsRationales
Communication Enhancement: Speech Deficit

Independent
Assess speech periodically; encourage voice rest.

 

Hoarseness and sore throat may occur secondary to tissue edema or surgical damage to recurrent laryngeal nerve and may last several days. Permanent nerve damage can occur (rare) that causes paralysis of vocal cords and/or compression of the trachea.
Keep communication simple; ask yes/no questions.Reduces demand for response; promotes voice rest.
Provide alternative methods of communication as appropriate, e.g., slate board, letter/picture board. Place IV line to minimize interference with written communication.Facilitates expression of needs.
Anticipate needs as possible. Visit patient frequently.Reduces anxiety and patient’s need to communicate.
Post notice of patient’s voice limitations at central station and answer call bell promptly.Prevents patient from straining voice to make needs known/summon assistance.
Maintain quiet environment.Enhances ability to hear whispered communication and reduces necessity for patient to raise/strain voice to be heard.

Nursing Diagnosis: Injury, risk for [tetany]

Risk factors may include

Chemical imbalance: excessive CNS stimulation

Possibly evidenced by

[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired outcomes/evaluation criteria—patient will:

Safety Status: Physical Injury 

Demonstrate absence of injury with complications minimized/controlled.

Nursing InterventionsRationales
Independent

Monitor vital signs noting elevating temperature, tachycardia (140–200 beats/min), dysrhythmias, respiratory distress, cyanosis (developing pulmonary edema/HF).

Manipulation of gland during subtotal thyroidectomy may result in increased hormone release, causing thyroid storm.
Evaluate reflexes periodically. Observe for neuromuscular irritability, e.g., twitching, numbness, paresthesias, positive Chvostek’s and Trousseau’s signs, seizure activity.Hypocalcemia with tetany (usually transient) may occur 1–7 days postoperatively and indicates hypoparathyroidism, which can occur as a result of inadvertent trauma to/partial-to-total removal of parathyroid gland(s) during surgery.
Keep side rails raised/padded, bed in low position, and airway at bedside. Avoid use of restraints.Reduces potential for injury if seizures occur.
Collaborative

Monitor serum calcium levels.

Patients with levels less than 7.5 mg/100 mL generally require replacement therapy.
Administer medications as indicated:

Calcium (gluconate, lactate);

Corrects deficiency, which is usually temporary but may be permanent. Note: Use with caution in patients taking digitalis because calcium increases cardiac sensitivity to digitalis, potentiating risk of toxicity.
Phosphate-binding agentsHelpful in lowering elevated phosphorus levels associated with hypocalcemia.
SedativesPromotes rest, reducing exogenous stimulation.
Anticonvulsants.Controls seizure activity until corrective therapy is successful.

Nursing Diagnosis: Pain, acute

May be related to

  • Surgical interruption/manipulation of tissues/muscles
  • Postoperative edema

Possibly evidenced by

  • Reports of pain
  • Narrowed focus; guarding behavior; restlessness
  • Autonomic responses

Desired outcomes/evaluation criteria—patient will:

Pain Control

Report pain is relieved/controlled.

Demonstrate use of relaxation skills and diversional activities appropriate to situation.

Nursing InterventionsRationales
Pain Management

Independent

Assess verbal/nonverbal reports of pain, noting location, intensity (0–10 scale), and duration.

Useful in evaluating pain, choice of interventions, effectiveness of therapy.
Place in semi-Fowler’s position and support head/neck with sandbags or small pillowsPrevents hyperextension of the neck and protects integrity of the suture line.
Maintain head/neck in neutral position and support during position changes. Instruct patient to use hands to support neck during movement and to avoid hyperextension of neck.Prevents stress on the suture line and reduces muscle tension.
Keep call bell and frequently needed items within easy reach.Limits stretching, muscle strain in operative area.
Give cool liquids or soft foods, such as ice cream or popsicles.Although both may be soothing to sore throat, soft foods may be tolerated better than liquids if patient experiences difficulty swallowing.
Encourage patient to use relaxation techniques, e.g., guided imagery, soft music, progressive relaxation.Helps refocus attention and assists patient to manage pain/discomfort more effectively.
Collaborative

Administer analgesics and/or analgesic throat sprays/lozenges as necessary.

Reduces pain and discomfort; enhances rest.
Provide ice collar if indicated.Reduces tissue edema and decreases perception of pain.

Nursing Diagnosis: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs

May be related to

  • Lack of exposure/recall, misinterpretation
  • Unfamiliarity with information resources

Possibly evidenced by

  • Questions; request for information; statement of misconception
  • Inaccurate follow-through of instructions/development of preventable complications

Desired outcomes/evaluation criteria—patient will:

Knowledge: Disease Process 

  • Verbalize understanding of surgical procedure and prognosis and potential complications.

Knowledge: Treatment Regimen 

  • Verbalize understanding of therapeutic needs.
  • Participate in treatment regimen.
  • Initiate necessary lifestyle changes
Nursing InterventionsRationales
Teaching; Disease Process 

Independent

Review surgical procedure and future expectations.

Provides knowledge base from which patient can make informed decisions.
Discuss need for well-balanced, nutritious diet and, when appropriate, inclusion of iodized salt.Promotes healing and helps patient regain/maintain appropriate weight. Use of iodized salt is often sufficient to meet iodine needs unless salt is restricted for other healthcare problems
Recommend avoidance of goitrogenic foods, e.g., excessive ingestion of seafood, soybeans, turnips.Contraindicated after partial thyroidectomy because these foods inhibit thyroid activity.
Identify foods high in calcium (e.g., dairy products) and vitamin D (e.g., fortified dairy products, egg yolks, liver).Maximizes supply and absorption of calcium if parathyroid function is impaired.
Encourage progressive general exercise program.In patients with subtotal thyroidectomy, exercise can stimulate the thyroid gland and production of hormones, facilitating recovery of general well-being.
Review postoperative exercises to be instituted after incision heals, e.g., flexion, extension, rotation, and lateral movement of head and neck.Regular ROM exercises strengthen neck muscles, enhance circulation and healing process.
Review importance of rest and relaxation, avoiding stressful situations and emotional outbursts.Effects of hyperthyroidism usually subside completely, but it takes some time for the body to recover.
Instruct in incisional care, e.g., cleansing, dressing application.Enables patient to provide competent self-care.
Recommend the use of loose-fitting scarves to cover scar, avoiding the use of jewelry.Covers the incision without aggravating healing or precipitating infections of suture line.
Apply cold cream after sutures have been removed.Softens tissues and may help minimize scarring.
Discuss possibility of change in voice.Alteration in vocal cord function may cause changes in pitch and quality of voice, which may be temporary or permanent.
Review drug therapy and the necessity of continuing even when feeling well.If thyroid hormone replacement is needed because of surgical removal of gland, patient needs to understand rationale for replacement therapy and consequences of failure to routinely take medication.
Identify signs/symptoms requiring medical evaluation, e.g., fever, chills, continued/purulent wound drainage, erythema, gaps in wound edges, sudden weight loss, intolerance to heat, nausea/vomiting, diarrhea, insomnia, weight gain, fatigue, intolerance to cold, constipation, drowsiness.Early recognition of developing complications such as infection, hyperthyroidism, or hypothyroidism may prevent progression to life-threatening situation. Note: As many as 43% of patients with subtotal thyroidectomy will develop hypothyroidism in time.
Stress necessity of continued medical follow-up.Provides opportunity for evaluating effectiveness of therapy and prevention of complications.

References

  • Balita, C. (2008). Ultimate learning guide to nursing review. Manila, Philippines: Tri-Mega Printing.
  • Pudner, R. (2010). Nursing the surgical patient. Philadelphia, PA: Elsevier Health Sciences.
  • Venkatesh, G. V. (2007). Medical surgical nursing. New Delhi, India: Jaypee Brothers Medical Publishers. 
SHARE
This is a community of professional nurses gifted with literary skills who share theoretical and clinical knowledge, nursing tidbits, facts, statistics, healthcare information, news, disease data, care plans, drugs and anything under the umbrella of nursing. All information expressed here are courtesies of the respective authors. Views on topics do not generally reflect that of the entire community. Articles submitted here are original but are checked for minor typographical errors, and are formatted for site compatibility.This is a site that continuously improves and broadcasts healthcare information relevant to today's ever-changing world.