This document discusses the surgical management of hyperthyroidism through thyroidectomy. Key points include: Thyroidectomy is performed to treat hyperthyroidism and large goiters. It may be partial or total removal of the thyroid gland. Postoperative care focuses on monitoring for bleeding, breathing issues, hypocalcemia, and thyroid storm. Nursing care involves assessing these risks and providing education to the patient.

1. HYPERTHYROIDSIM
SURGICAL MANAGEMENT
S Makonde

2. DEF
• Thyroidectomy is the surgical removal of the
thyroid gland performed for benign or
malignant tumour, hyperthyroidism,
thyrotoxicosis, or thyroiditis in patients with
very large goitres, or for patients unable to be
treated with radioiodine or thioamides.

3. Thyroidectomy
• Partial or complete thyroidectomy may be
carried out as primary treatment of thyroid
carcinoma, hyperthyroidism, or
hyperparathyroidism.
• The type and extent of the surgery depend on the
diagnosis, goal of surgery, and prognosis.
• Thyroidectomy may be the treatment of choice
for patients with symptomatic
hyperparathyroidism large goitres, adenoma
(thyroid cancer), and some nodules..

4. • The patient undergoing surgery for treatment of
hyperthyroidism is given appropriate medications
to return the thyroid hormone levels and
metabolic rate to normal and to reduce the risk
for thyroid storm and haemorrhage during the
postoperative period.
• Medications that may prolong clotting (eg,
aspirin) are stopped several weeks before surgery
to minimize the risk for postoperative bleeding.

5. • Efforts are made to spare parathyroid tissue to reduce
the risk for postoperative hypocalcemia and tetany.
• After surgery, ablation procedures are carried out with
radioactive iodine to eradicate residual thyroid tissue if
the tumour is radiosensitive.
• Radioactive iodine also maximizes the chance of
discovering thyroid metastasis at a later date if total-
body scans are carried out.
• After surgery, thyroid hormone is administered in
suppressive doses to lower the levels of TSH to a
euthyroid state.

6. Nursing Management
• Important preoperative goals are to gain the
patient’s confidence and reduce anxiety.

7. PREOPERATIVE CARE
• Risk for Injury related to invasive procedure of
the neck
• Nutrition
• Risk for Injury related to possible removal of
parathyroid glands

8. • Imbalanced Nutrition: Less Than Body
Requirements related to hypermetabolic state
and fluid loss through diaphoresis
– The nurse instructs the patient about the importance
of eating a diet high in carbohydrates and proteins.
– A high daily caloric intake is necessary because of the
increased metabolic activity and rapid depletion of
glycogen reserves.
– Supplementary vitamins, particularly thiamine and
ascorbic acid, may be prescribed.
– The patient is reminded to avoid tea, coffee, cola, and
other stimulants

9. • Provide a quiet, calm environment at meals.
• Restrict stimulants (tea, coffee, alcohol); explain
rationale of requirements and restrictions to
patient.
• Encourage and permit the patient to eat alone if
embarrassed or if otherwise disturbed by
voracious appetite
• Monitor fluid and nutritional status by weighing
the patient daily and by keeping accurate intake
and output records

10. Injury
• The nurse also informs the patient about the
purpose of preoperative tests, if they are to be
performed, and explains what preoperative
preparations to expect.
• The information should help to reduce the
patient’s anxiety about the surgery.
• Ensure a good night’s rest before surgery,
although many patients are admitted to the
hospital on the day of surgery.

11. • Preoperative teaching includes demonstrating
to the patient how to support the neck with
the hands after surgery to prevent stress on
the incision.
• This involves raising the elbows and placing
the hands behind the neck to provide support
and reduce strain and tension on the neck
muscles and the surgical incision.

12. • The patient must be euthyroid at time of surgery,
so thioamides are administered to control
hyperthyroidism.Carbimazole 20-30mg
• Iodide is given to increase firmness of thyroid
gland and to reduce its vascularity after blood
loss.Aq Iodine solution 1-3mls dilute with milk tds
• An attempt is made to counteract the effects of
hypermetabolism by maintaining a restful and
therapeutic environment and by providing a
nutritious diet.

13. • The patient is prepared for surgery physically
and emotionally in the following ways:
• Make a special effort to ensure that patient
has a good night’s rest preceding surgery.
• Explain to patient that speaking is to be
minimized immediately postoperatively and
that oxygen may be administered to facilitate
breathing.

14. • Explain that postoperatively, fluids may be
given via IV line to maintain fluid, electrolyte,
and nutritional needs;
• IV glucose may also be given in the hours
before the administration of anaesthetic
agents.

15. • Thyroid function tests
• Blood pressure control
• Glucocorticoids decrease the peripheral
conversion of T4 to T3, a more potent thyroid
hormone
• Hyperthermia cooling blanket, acetaminophen
(Tylenol).
• Dehydration administration of I.V. fluids and
electrolytes.
• Treatment of precipitating event

16. Maintaining Skin Integrity:-
• Assess skin frequently to detect diaphoresis.
• Bathe frequently with cool water; change linens
when damp.
• Avoid soap to prevent drying and use lubricant
skin lotions to pressure points.
• Protect and relieve pressure from bony
prominences while immobilized or while
hypothermia blanket is used.

17. Promoting Normal Thought
Processes:-
• Explain procedures to patient in an
unhurried, calm manner.
• Limit visitors; avoid stimulating
conversations or television programs.
• Reduce stressors in the environment;
reduce noise and lights.

18. • Promote sleep and relaxation through use of
prescribed medications, massage, and
relaxation exercises.
• Minimize disruption of the patient's sleep or
rest by clustering nursing activities.
• Use safety measures to reduce risk of trauma or
falls (padded side rails, bed in low position).

19. Relieving Anxiety
• Encourage the patient to verbalize concerns and
fears about illness and treatment.
• Support the patient who is undergoing various
diagnostic tests.
– Explain the purpose and requirements of each
prescribed test.
– Explain results of tests if unclear to the patient or if
questions arise.
• Clear up misconceptions about treatment
options.

20. Postoperative Management
• The patient is monitored for bleeding and respiratory
distress that indicates laryngeal oedema, secondary to
swelling in the area of surgery.
• Signs of hypocalcaemia are watched for—irritability,
twitching, spasms of hands and feet.
• Calcium levels are monitored. If in 48 hours level falls
below 7 mg/100 mL (3 mEq), IV calcium (gluconate,
lactate) replacement is given.
• IV calcium is used cautiously in patients who have renal
disease or who are taking digoxin.
• Thyroid function is monitored after surgery.

21. Nursing Interventions
• Risk for Ineffective Breathing Pattern related to
laryngeal oedema, haematoma,dimisished ability to
clear secretions
• Risk for Injury: Hypocalcaemia related to removal of
parathyroid glands
• Risk for Injury: Thyroid Storm, Hyperthyroidism related
to increased of thyroid hormone
• Deficient Knowledge related to lack of familiarity with
surgical treatment and medications
• Pain
• infection

22. Ineffective Breathing Pattern
• Assess pt`s resp rate and depth as an increase
in resp rate is an early indication of post
operative oedema or haematoma formation in
the upper airways.
• Elevate head of bed to 45 degrees to minimise
oedema and haematoma formation at the
operated site hence promoting a clear airway.
• Ice collar is used appropriately as cold
compress decreases oedema formation.

23. • Encourage the pt to do deep breathing to keep alveoli
open hence promoting effective breathing
• Use of an incentive spirometer hourly is done to keep
the alveoli open and promoting effective breathing.
• Instruct the pt to cough when needed as excessive
coughing may irritate the incisional site thereby
triggering oedema
• Suctioning of secretions is done to clear secretions if
the patient is un able to.
• Administer humidified O2 to promote easier breathing.

24. Hypocalcaemia
• Monitor serum ionized calcium levels and
notify physician if levels drop below 2,1
mEq/Lt.
• Assess for presence of circumoral and
peripheral paraesthesia such as tetany, facial
grimacing as neuromuscular irritability is an
early indicator of hypocalcaemia.

25. • Observe for tremors in the extremities and any seizure
activity as these are clear signs of neuromuscular
irritability from hypocalcaemia.
• Check for the presence of the Chvostek`s sign , a
positive result will indicate hypocalcaemia(Tap the
cheek over the facial nerve , a positive sign results in a
twitch of the lip or facial muscles)
• Check for Trousseau`s sign, a positive result is
indicative of hypocalcaemia( inflate the BP cuff
20mmHg above the pt`s systolic BP for 3 minutes and if
carpal spasms are seen the result is positive)

26. • Monitor serum potassium and magnesium
levels as hyperkalaemia and
hypomagnesaemia potentiate cardiac and
neuromuscular irritability in the presence of
hypocalcaemia.
• Administer calcium gluconate ivi as prescribed
t correct hypocalcaemia.

27. • Institute seizure precautions as appropriate to
prevent injury
• A calcium rich diet if offered to boost calcium
levels in the body.
• If the patient is able to tolerate oral
medications , oral calcium is administered as
prescribed

28. Thyroid Storm
• Assess for the pt`s HR,Temp and Bp as any increase maybe
due to increased thyroid hormone release from
manipulation of the thyroid gland.
• Maintain the pt on iv infusion for hydration and electrolyte
balance.
• Lower the temp by using hypothermia
blanket,antipyretics,bath
• Administer antithyroid medication as prescribed
• Administer beta adrenergic blocking agents to decrease the
cardiovascular and neuromascular effects of thyroid
hormone.
• Administer adrenal corticosteroids as indicated to block
thyroid hormone secretion.

29. Knowledge deficit
• Instruct the pt to report any of the following
– Circumoral or peripheral paraesthesia
– Signs of infection
– Signs of haematoma
– SnS of thyroid storm

30. • Instruct the pt to avoid abrupt head and neck movements
until suture line heals as this may cause dehiscence
• Instruct the pt in dosage, schedule , desired effects and side
effects of the medications to help the pt develop basic
understanding of long term need for thyroid replacement
therapy and consequences of failing to take the medication.
• Instruct the pt on range of motion exercises for the neck as
these will strengthen the neck and aid in healing process
• Instruct the pt to avoid temp extremes as exposure to hot or
cold temps promote thyroid hyperplasia and thereby
increasing thyroid hormone levels.

31. Pain
• Assess the characteristics of pain such as type, quality
and severity of pain or discomfort this helps to plan
management strategies for the relief of pain.
• Anticipate the need for pain relief for early
intervention
• Respond immediately to reports of pain by the pt as
fear and anxiety associated with delayed pain relief can
exacerbate the pain experience.
• Provide rest periods to facilitate comfort, sleep and
relaxation
• Administer narcotic analgesics as prescribed

32. Infection
• Monitor temp( first 48 to 72, the routine post op
observation and after 72hrs routine ward observation
maybe done . Pyrexia is indication of infection.
• Monitor wbc count as an elevated wbc is indicative of
infection
• Assess the wound for redness, drainage, swelling and
increased pain if found these indicate wound infection
• Wash hands before coming into contact with the post
op pt as this is the most effective way to prevent
infection

33. • Use aseptic technique during wound dressing
change to prevent introduction of pathogens
• Encourage adequate nutritional intake as
proteins, vitamins and minerals are essential to
promote immune system function and wound
healing.
• Administered antibiotics as prescribed to combat
the infection
• Nurse the patient away from patients with
respiratory tract infection and other infectious
diseases.

34. Complications
• Haemorrhage, oedema of the glottis,
• Thyroid storm
• Damage to laryngeal nerve.
• Hypothyroidism following subtotal thyroidectomy
occurs in 5% of patients in first postoperative
year; increases at rate of 2% to 3% per year.
• Hypoparathyroidism occurs in about 4% of
patients and is usually mild and transient;
requires calcium supplements via IV
administration and orally when more severe.