1. The Thyroid Gland surgery
Logman Mohammed Alshaikh
BSc N- Gezira university
MSc in MSN- Alneelain university
2. 2
Introduction
The thyroid gland is a butterfly-shaped
organ located in the lower neck, anterior
to the trachea . It consists of two lateral
lobes connected by an isthmus.
3. 3
The gland is about 5 cm long and 3 cm wide and
weighs about 30 g.
The blood flow to the thyroid is very high (about 5
mL/min per gram of thyroid tissue). This reflects
the high metabolic activity of the thyroid gland.
4. 4
The thyroid gland produces three
hormones:
thyroxine (T4), triiodothyronine (T3),
and calcitonin. T4 and T3 known as
thyroid hormone.
5. 5
function of Thyroid hormones: (T3 ,T4)
They affect the metabolic rate of all
tissues including:
– the speed of chemical reactions
– the volume of oxygen consumed
– the amount of heat produced.
– Increase release of catecholamines (
adrenaline , noradrenaline )
– necessary for fetal and infant growth and
development .
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DISORDERS OF THE THYROID GLAND
HYPOTHYROIDISM
Is the conditions that arises from
inadequate amounts of thyroid
hormone in the bloodstream.
Causes : primary and secondary
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Primary hypothyroidism
Autoimmune disease (Hashimoto's thyroiditis).
Use of radioactive iodine.
Destruction, suppression, or removal of all or
some of the thyroid tissue by thyroidectomy.
Dietary iodide deficiency.
Subacute thyroiditis.
Lithium therapy.(antipsychotic )
Overtreatment with antithyroid drugs
8. 8
Secondary hypothyroidism
is caused by inadequate
secretion of TSH caused by
disease of the pituitary gland
(ie, tumor, necrosis).
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Pathophysiology :
Inadequate secretion of thyroid hormone leads to a
general slowing of all physical and mental
processes.
General depression of most cellular enzyme
systems and oxidative processes occurs.
The metabolic activity of all cells of the body
decreases, reducing oxygen consumption,
decreasing oxidation of nutrients for energy, and
producing less body heat.
10. 10
Clinical Manifestations :
Fatigue and lethargy.
Weight gain.
Complaints of cold hands and feet.
Temperature and pulse become subnormal; patient
cannot tolerate cold and desires increased room
temperature.
Reduced attention span; impaired short-term
memory.
Severe constipation; decreased peristalsis.
Generalized appearance of thick, puffy skin;
subcutaneous swelling in hands, feet, and eyelids.
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Hair thins; loss of the lateral one-third of eyebrow.
Menorrhagia or amenorrhea;
spontaneous abortion; decreased libido.
polyneuropathy, cerebellar ataxia, muscle aches
or weakness,
Hyperlipoproteinemia and hypercholesterolemia.
Enlarged heart on chest X-ray.
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Diagnostic Evaluation
Low T3 and T4 levels.
Elevated TSH levels in primary hypothyroidism.
Elevation of serum cholesterol.
Electrocardiogram (ECG) sinus bradycardia, low
voltage of QRS complexes, and flat or inverted T
waves.
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Management
Depends on severity of symptoms; may need
replacement therapy (thyroxine )in mild cases or
lifesaving support and treatment in severe
hypothyroidism and myxedema coma.
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Complications
Myxedema coma
hypotension, unresponsiveness,
brady-cardia,
hypoventilation,
hyponatremia, (possibly) convulsions,
hypothermia, cerebral hypoxia.
High mortality in myxedema coma.
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Etiology
More common in women than in men; occurs in
about 2% of the female population.
Graves' disease (most prevalent) diffuse
hyperfunction of the thyroid gland with
autoimmune etiology and associated with
ophthalmopathy; most common in younger
women; may subside spontaneously.
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Toxic nodular goiter (single or multiple) more
common in older women with preexisting goiter;
will continue to be overactive unless eradicated
or kept under suppressive therapy.
ingestion of excessive amounts of thyroid
hormone medication
18. 18
Pathophysiology
Hyperthyroidism is characterized by hypertrophy and
hyperplasia(over growth ) of the thyroid gland, which is
accompanied by increased vascularity and blood flow and
enlargement of the gland.
Hyperthyroidism ranges from a mild to the severe
hyperactivity known as thyrotoxicosis, thyroid storm, or
thyroid crisis
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Clinical Manifestations :
Most of the clinical manifestations result from increased :
metabolic rate,
excessive heat production,
increased neuromuscular and cardiovascular activity,
hyperactivity of the sympathetic nervous system.
As following:
Nervousness, emotional irritability
Difficulty in sitting quietly.
Rapid pulse
palpitations.
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Clinical manifestation continue
Heat intolerance; profuse perspiration; flushed skin
(eg, hands may be warm, soft, moist).
Fine tremor of hands;
change in bowel habits constipation or diarrhea
Increased appetite and progressive weight loss;
frequent stools.
Muscle fatigability and weakness; amenorrhea.
Atrial fibrillation
Bulging eyes (exophthalmos) seen only in Graves'
disease.
Thyroid gland may be palpable and a bruit may be
auscultated over gland.
It may progress to extreme nervousness, delirium,
disorientation, thyroid storm or crisis, and death
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Thyroid storm or crisis,
an extreme form of hyperthyroidism, is characterized
by hyperpyrexia, diarrhea, dehydration, tachycardia,
arrhythmias, extreme irritation, delirium, coma,
shock, and death if not adequately treated.Thyroid
storm may be precipitated by stress (surgery,
infection) or inadequate preparation for surgery in a
patient with known hyperthyroidism.
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Management
Goal of therapy is to bring the metabolic rate to normal as
soon as possible and to maintain it at this level.
Treatment depends on causes, age of patient, severity of
disease, and complications.
Remission of hyperthyroidism (Graves' disease) occurs
spontaneously within 1 to 2 years; however, relapse can
be expected in half the patients. Antithyroid drugs,
radiation, or surgery may be used for treatment.
Nodular toxic goiter by surgery or use of radioiodine is
preferred.
Thyroid carcinoma by surgery or radiation is used.
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Pharmacotherapy:
Drugs that inhibit hormone formation:
Thioamides , methimazole (Tapazole).
Act by depressing the synthesis of thyroid hormone by
inhibiting peroxidase.
Drugs to control peripheral manifestations of
hyperthyroidism:
Propranolol (Inderal) -Acts as a beta-adrenergic blocking
agent.
Glucocorticoids : decrease the peripheral conversion of
T4 to T3, a more potent thyroid hormone.
25. 25
Radioactive Iodine
Action : limits secretion of thyroid hormone by
destroying thyroid tissue.
If there is Hyperthermia by cooling blanket and
Dehydration by I.V. fluids and electrolytes.
Surgery : in complications
Complications
Thioamide toxicity : agranulocytosis
Hypothyroidism due to overtreated with
antithyroid medication or if radiation treatment
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Radiation thyroiditis .
Infiltrative ophthalmopathy (in 50% of ptwith
Graves' disease S/S : exophthalmos, weakness
of extraocular muscles, lid edema, lid lag.
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THYROIDECTOMY
Thyroidectomy involves the partial or complete
removal of the thyroid gland to treat thyroid tumors,
hyperthyroidism, or hyperparathyroidism.
1. Types of Procedures:
2. Total thyroidectomy (removal of the entire thyroid
gland)
3. subtotal thyroidectomy (95% of gland removed) to
prevent damage to the parathyroid glands;
4. partial (one lobe or isthmus removed) to treat nodular
disease.
Note : The parathyroid glands are usually
spared(secure ) to prevent hypocalcemia.
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Indications for thyroidectomy include :
1. Graves' disease (autoimmune thyroiditis) a
form of hyperthyroidism
2. large goiters (Iodine-Deficient)
3. adenoma (thyroid cancer)
4. Presence of numerous separate nodules
5. Pressure symptoms (Enlarged thyroid makes
breathing and swallowing difficult
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Preoperative Management
• General measures :
• Anti thyroid hormons before 2-3 month before
surgery
• Iodide is given to reduce size of gland and decrease
bleeding
• Adequate nutritious diet.
• Adequate rest
• The patient is prepared for surgery physically and
emotionally .
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Postoperative Management
Vital signs every 15 minutes until stable then
every 30 minute for next 20hours
Semi sitting position and head , neck are
supported with sand bag .
Pethadine (analgesic ) as order
Coughing & deep breathing
Suction if needed
The patient is monitored for bleeding
Tracheotomy set & oxygen therapy near the
patient.
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Temperature every 4 hors
Drainage observe for color and amount
Observe Signs of hypocalcaemia (irritability,
spasms of hands and feet. And give I.V. calcium
(gluconate, lactate) as prescribed. But take
cautiously in patient with renal disease or on
digoxin.
Observe and report immediately signs respiratory
distress and laryngeal oedema
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Complications of Thyroidectomy
Hemorrhage
hematoma formation,
edema of the glottis,
damage to laryngeal nerve.
Hypothyroidism occurs
Hypoparathyroidism (may requires calcium
supplements I.V. and orally in severe case .
Injury of parathyroid glands lead to
hypocalcaemia and tetany,
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Preventing Tetany
Watch for the development of tetany caused by
removal or disturbance of parathyroid glands
through a progression of signs:
Tingling of toes and fingers and around the
mouth; anxiety.
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Positive Chvostek's sign : tapping on the cheek
over the facial nerve causes a twitch of the lip or
facial muscles .
Positive Trousseau's sign : carpopedal spasm
induced by occluding circulation in the arm with
a BP cuff .
F(A) Chvostek's sign.
(B) Trousseau's sign.
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Be prepared to treat hypocalcemic tetany.
Position the patient for optimal ventilation; pillow
removed to prevent head from bending forward
and compressing trachea.
Keep side rails elevated and position the patient
to prevent injury if a seizure occurs; do not use
restraints because may result in muscle strain or
fractures.
Have equipment available to treat respiratory
difficulties that includes airway suction
equipment, tracheostomy, and cardiac arrest
equipment.
Administer I.V. calcium as directed.
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Nursing Diagnoses
Most proplem post thyroidectomy are :
1. Bleeding
2. Air obstrcution due to laryngeal oedema
3. Tetani duee to hypocalcemia
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Risk for injury R/T possible trauma to parathyroid
gland during surgery , laryngeal nerve damage , air
way obstruction , hemorrhage , thyroid storm
P.E.O.C: prevent complication
Nursing intervention :
– Check serum calcium and monitor for Chvostek's
sign &Trousseau's sign.
– Keep suction equipments and tracheotomy set , oxygen
at bed side
– Monitor vital signs frequently
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– watching S/S hemorrhage ( tachycardia and
hypotension ) (most likely between 12 and 24 hours
postoperatively).
– Observe for bleeding at sides and back of the neck,
and anteriorly
– Place the patient in semi-Fowler's position with
supported by pillows; avoid flexion of neck
Assess for dyspnea, stridor, change of voice may
indicate damage to laryngeal nerve
deep breathing exercises, and coughing, as
indicated.
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Check dressing frequently, posterior ,anterior
dressing for bleeding
Give humidified oxygen as prescribed
Watch early signs of hemorrhage and tracheal
compression suchas difficulty swallowing , irregular
breathing, swelling of the neck, and choking
Make dressing if indicated
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NURSING DIAGNOSIS: acute Pain related to
Surgical incision and Postoperative edema
E. O .C : Pain Control.
Nursing INTERVENTIONS
– Assess pain status
– Place in semi-Fowler’s position and support head
and neck with pillows as required
– Instruct client to use hands to support neck during
movement and to avoid hyperextension of neck.
– Give cool liquids or soft foods, such as ice cream .
– Administer analgesics as necessary.
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Knowledge deficit R/T postoperative
P.E.O.C: improve health teaching
Nursing intervention :
Teach pt how to support to prevent pressure on suture
line
Put both hand behind the neck when moving or cough
Teach patient S/S of hypothyriodism , hypocalcaemia
Improve adequate rest and nutrition
Important of voice rest in early postoperative period .
Teach about hormonal therapy in the case of total
thyriodectomy .
