throidectomy nursing care plan (8)

Patients who have been diagnosed with hyperthyroidism and other disorders of the thyroid that leads to excessively high thyroid hormones in the bloodstream often become candidates to undergo thyroidectomy. Conditions like thyroid cancers, the presence of non-malignant nodules on the thyroid, and goiter are only some of the most common reasons for prescribing a thyroidectomy. Previously a highly risky procedure, thyroidectomy is the surgical removal of the thyroid gland of the patient. 

This removal may be total or partial, depending on the diagnosis. Most cases of patients who have undergone the procedure require thyroid hormone supplementation, especially those who have undergone total removal of the gland.

A nurse caring for a patient who has undergone thyroidectomy must remember that the surgical site (neck) places the patient at a higher risk for airway problems. This is due to the potential for the patient to develop laryngeal edema secondary to the injury to the surrounding tissues. Apart from this, there are also other complications that may arise from the procedure that the nurse must be aware of so that the patient can be safely transitioned from the operating and recovery units to the ward and eventually discharged.

           One of the primary responsibilities of the nurse in caring for patients who have undergone thyroidectomy is to carefully assess the patient’s vital signs and determine what signs or symptoms need to be reported to the physician immediately. Positioning the patient appropriately is another priority of nursing care, ensuring that the patient is not just able to breathe effectively but that the risk for aspiration is also prevented. Monitoring for bleeding is also a priority of care, as well as assessment for potential problems in speaking. This is due to laryngeal nerve damage that may happen to the patient when there is an accidental injury to the nerve during surgery. 

           While other problems may also be seen on the patient may range from actual to potential problems, the nurse must also remember that there is a need to prioritize the health needs of the patient well. Attending to needs with the highest priority allows the nurse to prevent other more serious complications while also ensuring that other health problems are prevented. Moreover, since patients who have undergone thyroidectomy may need lifetime supplementation of thyroid hormones in some cases, the need to emphasize rehabilitative care and lifetime management should be included in the care plan. Some of the most common problems that nurses can encounter in these patients include:

  • Bleeding- the resulting bleeding occurring among patients who have undergone thyroid surgery results from the incision to the operative site as well as the relative number of blood vessels in the surrounding area. Bleeding is a potentially life-threatening complication and needs to be addressed immediately.
  • Parathyroid Gland damage- accidental damage or removal of the parathyroid gland can result in a decrease in the circulating blood calcium levels and a marked increase in the calcium in the bones. This places the patient at risk for hypocalcemia.
  • Hypocalcemia, a resulting condition due to the accidental removal of the parathyroid gland, causes the patient to present with symptoms such as muscle twitching, upset stomach (usually in the form of diarrhea), and positive Chvostek’s and Trousseau’s signs.
    • Chvostek Sign- is an abnormal response of the facial nerve to stimulation. This can be obtained by tapping on the cheek of the patient and observing for facial twitching.
    • Trousseau’s Sign- indicates the presence of hypocalcemia on the patient when while applying pressure on the arm causes an abnormal reaction of the hand. The sign is assessed through inflating a blood pressure cuff (normally 20mmHg above the known diastolic rate of the patient) and observing for spasms on the hands and fingers of the patient.

Listing of all nursing diagnoses would also help the nurse to focus care and ensure that the patient has a good prognosis after surgery. Below are some of the 8 most common nursing diagnoses which can be made after assessing patients post-thyroidectomy.

  1. Pain
  2. Ineffective Airway Clearance/Risk for Ineffective Airway Clearance
  3. Impaired Verbal Communication
  4. Risk for Aspiration
  5. Risk for Injury
  6. Self-care Deficit
  7. Impaired Nutrition: Less than body requirements
  8. Deficient Knowledge

Below are examples of the most common nursing care plans that can be used for caring for patients who have undergone thyroidectomy. Note that while there are numerous assessment findings included in these care plans, nurses may still add other findings which may be elicited during the assessment of the patient.

Acute Pain

Acute pain related to mechanical trauma to the tissues secondary to surgery (other related factors may also be used such as presence of postoperative edema, manipulation of the tissues, etc.) as evidenced by:

  • Patient reports of pain
  • Restlessness and irritability
  • Guarding behavior towards the operative site
  • Narrowed focus
  • Increased vital signs (HR, PR, RR)

Desired Outcomes

After nursing interventions, the patient is expected to:

  • Report relief or decreased intensity of pain
  • Manifest ability to use diversionary measures to help decrease pain perception
Nursing Action Rationale
Monitor the patient’s vital signs, especially noting for parameters of respiratory function such as depth, rhythm, and rate.

 

This creates baseline information for patient condition and helps plan for effective care.
Assess patient’s perception of pain, noting how he determines it according to scale (with 0 indicating no pain and 10 to denote excruciating pain). Also, assess for the PQRST of pain.

P- perception

Q- quality

R-radiation

S- severity

T- time

 

Determining the exact perception of the patient on pain sensation helps the nurse plan for effective care for the patient.
Position the patient in a Semi-Fowler’s position, ensuring the head and neck are supported with sandbags. Placing the head and neck in Semi-Fowler’s position prevents hyperexenstion of the neck and relieves pressure on the suture line. The sandbags at each side of the neck help keep the head and neck in the midline position.
Teach the patient how to support the head and the neck during movements, placing the hands behind the neck and slowly moving when needed. This action prevents additional strain on the suture line, decreasing pain perception while allowing the patient mobility on the head and neck.
Provide the patient with cool liquids such as juices or popsicles. Ice cream and sorbet may also be given.

 

If the patient is allowed to have oral feeding, he may also be provided with softened or mashed foods.

Cooled liquids may be soothing to the throat and neck while also allowing the patient to swallow easier. Mashed or softened foods also help decrease the risk of aspiration for patients who were just cleared to take oral feedings.
Encourage the patient to explore non-pharmacologic measures to divert attention away from pain perception.

 

Techniques such as guided imagery, soft music and use of progressive relaxation may be used to this aim.

These activities help shift away from the focus of the patient from the pain and into something else. When used prior to the peak of pain perception, these measures also can decrease the overall pain scale rating.
Prepare to administer/provide the patient an ice collar if necessary. For patients with pain related to an edematous incision site, the ice collar helps reduce swelling and provides pain relief.

 

NOTE: For patients with ice collar, ensure that proper assessment of the site is done during the application of the collar to prevent skin breakdown.

If needed, administer prescribed analgesic and other medications for pain and/or swelling. These medications may act to help relieve pain, reduce swelling and provide overall comfort to the patient.

Ineffective Airway Clearance

Ineffective airway clearance related to presence of (choose one of the following possible factors: laryngeal spasms, tracheal obstruction, mechanical trauma to the trachea, swelling, bleeding operative site) as evidenced by:

  • Abnormal breath sounds upon auscultation
  • Changes in respiratory rate, rhythm and depth
  • Patient complaints of dyspnea
  • Unproductive coughing, increased effort during coughing
  • Use of accessory muscles of respiration

Desired Outcomes

After nursing interventions, the patient is expected to:

  • Keep and maintain a patent airway
  • Exhibit easy, effortless respirations
Nursing Action Rationale
Monitor the patient’s vital signs, especially noting for parameters of respiratory function such as depth, rhythm and rate.

 

This creates a baseline information for patient condition and help plan for effective care.
Auscultate breath sounds, noting for the presence of adventitious sounds such as crackles, wheezes, rhonchi and others. Document these findings.

 

Presence of adventitious breath sounds may indicate airway blockage and its severity. Any finding should be documented and used as a baseline.
Assess the patient for complaints of dyspnea, stridor, presence of circumoral cyanosis or crowing (more pronounced during inspiration). These are indicative of laryngeal spasms and may need an emergency referral. A laryngeal spasm is a life-threatening condition.
Teach the patient how to support the head and the neck during movements, placing the hands behind the neck and slowly moving when needed. This action prevents additional strain on the suture line, decreasing pain perception while allowing the patient mobility on the head and neck.

 

This move also helps ensure that the client has a patent airway, improved ventilation, and gas exchange.

Teach patient deep breathing and coughing and positioning, taking special consideration to ensure that the suture line would be free from unnecessary strain. Deep breathing and occasional coughing may help clear the airway from secretions. While it is not routinely done for patients post thyroidectomy, occasional breathing exercises are encouraged to clear secretions.
If needed, suction the patient’s mouth and trachea. Ensure that proper facility protocols are followed and the characteristics of the sputum is documented. Suctioning helps to clear the airway of tenacious secretions and facilitates easier air exchanges.
Encourage steam inhalation therapy. If needed, transfer the patient to the room where humidified air is available. Steam inhalation provides relief from soreness of the trachea and tissue edema. It also helps to liquefy secretions, making it easier to expectorate them.
Prepare to administer oxygen and other pharmacologic therapies if needed. Medications and oxygen may help relieve airway obstruction and gas exchange.
Anticipate a need for tracheostomy for patients with severe airway problems which cannot be addressed by other conservative measures. Tracheostomy is done to create an airway and help the patient to breathe easier when other measures are not effective.

Impaired Verbal Communication

Impaired verbal communication related to (choose one of the following possible factors: injury or damage to the vocal cords; laryngeal nerve damage; mechanical trauma to the tissues) secondary to thyroid removal surgery as evidenced by (other assessment findings may be added to this, however, these are the most common):

  • Inability of the patient to speak
  • Use of hand gestures when communicating
  • Patient use of other means of communication: writing pads, pictures, etc.

Desired Outcomes

After nursing interventions, the patient is expected to:

  • Be able to communicate more effectively
  • Use methods of communication that would be effective in helping him to be understood by others
Nursing Action Rationale
Assess the patient’s ability to speak and communicate prior and after surgery.

 

Comparing the verbal communication skills of the patient prior and after surgery helps to determine the presence of a problem in communication. Symptoms such as hoarseness of voice and sore throat need to be assessed and documented appropriately.
Keep communication with the patient short and simple. Use questions answerable with a yes or no.

 

This helps reduce the demand for the patient to speak and helps him rest his voice.
Provide the patient alternative means to communicate such as writing pads, slate boards and letter/picture boards. Using these measures helps the patient communicate his needs more effectively, reduces stress related to having to use his voice to speak and allows further rest.
Involve the patient’s family in his plan of care, especially when it comes to communication. This helps the family adjust to the changes in communication patterns (temporary or permanent, depending on prognosis) and allows for continuity of care.
Anticipate the needs of the patient by visiting him often and being aware of non-verbal cues. This reduces the anxiety and stress of the patient because of the need to express himself verbally. Anticipating his needs also promotes relaxation because there is a reduced need to use his voice to ask for assistance.

Thyroidectomy Nursing Care Plan Sample

Nursing Diagnosis: Knowledge deficit (learning need) regarding disease process, condition, prognosis, treatment, self-care, and discharge needs.

AssessmentDiagnosisPlanningInterventions / RationaleEvaluation
Subjective:
> 2 years PTA, the client
noticed an enlargement on
the right anterior portion of
her neck about 2cm in dm.
and did not go for
consultation nor take any
medication as reported.
> Expressed the need for
further information.
> Admits that her illness
was unexpected and
sudden.
> She believes it was
brought by lack of seafood's
in her diet.
> Describes herself as
healthy woman despite her
illness, with no major
changes in her physical
capacity/strength.
> Sedentary lifestyle as
reported.

Objectives:
> 37 year old, F/M
> high school graduate
> Lack of questions
> Obese
> increase BMI –30.0
> wt. - 90 kg, ht. - 1.50 m.
> waistline – 45 inches
> s/p thyroidectomy, day 7
> speaks softly
> with pressure dressing on anterior neck
> neck rigidity not noted
> with limited ROM of
neck
> NVE at 30 angle right
and left
Knowledge
deficit (learning
need) regarding
disease process,
condition,
prognosis,
treatment, self-care and
discharge needs.
Short Term Goal:
1. Patient and caregiver
verbalized
understanding of postoperative treatment and
care for post thyroidectomy.
2. Participate in
treatment regimen.
3. Participate in
learning process.
4. Exhibit increased
interest and assume
responsibility for own
learning by beginning
to look for information
and ask questions.
5. Verbalize
understanding of
condition and disease
process and treatment.
6. Identify relationship
of signs and symptoms
with causative factors.
Long Term Goal:
1. Self-esteem
enhancement.
2. Initiate necessary
lifestyle changes.
3. Identify
interferences to learning
and specific actions to
deal with them.
4. Perform necessary procedures correctly and explain reasons for
the actions.
Universal Self-care Requisites:
1. Activity and exercise therapy on strength
training, balance and muscle control with the promotion of body mechanics. Post-operative exercises to be instituted
after incision heals like flexion, extension,
rotation and lateral movement of head and neck.
Regular ROM exercises strengthen neck
muscles, enhance circulation and the healing
process. Encourage progressive general exercise
program. Exercise can stimulate the thyroid gland and the production of hormones, facilitating
recovery of general well-being.
2. Instruct in incisional care like cleansing and
dressing application which enables patient to provide competent self-care.

Developmental Self-care Requisites:
1. Discuss the 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.
2. Instruct the patient to avoid temperature
extremes. Exposure to hot and cold temperatures
promotes thyroid hyperplasia and increases the
thyroid levels, Avoid high environmental
temperatures.

Health-deviation Self-care Requisites:
1. Behavioral modification technique wherein
the patient will be guided to have a positive
outlook by undergoing the process of self-discovery.
2. Weight management program and Dietary
modification.
Nutritional counseling and management.
Discuss the need for well -balanced, nutritious diet because it promotes healing and helps patients to regain/maintain an appropriate weight. The use of iodized salt is often sufficient to meet iodine needs unless salt is restricted. Identify foods high in calcium and vitamin D which maximizes supply and absorption of calcium if the parathyroid function is impaired.
Maintain a low-calorie diet. During the hypothyroid period, the patient should reduce caloric intake to prevent weight gain.
Recommend avoidance of goitrogenic foods (thyroid
-inhibiting substances) which are contraindicated because these foods inhibit thyroid activity.
> Discuss understanding about the disease, condition, treatment, self-care and needs.
> Participate in the activities and nursing
interventions.
> Verbalize interest and adherence to
regimen.
> Follow instructions and interventions for a particular condition or s/sx.
> Positive outlook on immediate recovery.
> Life-style and behavioral changes.

References

  1. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis.
  2. Carpenito, L. (2016). Handbook of Nursing Diagnosis (15th ed.).
  3. Herdman, T., & Kamitsuru, S. (2018). NANDA International, Inc. nursing diagnoses (11th ed.).
  4. Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. (2017). Medical-
  5. Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). St. Louis: Elsevier.
  6. McCance, K.L. & Huether, S.E. (2017). Understanding Pathophysiology: The Biologic Basis for Disease in Adults and Children (6th ed.). St. Louis: Elsevier/Mosby.
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