CASE STUDY PRESENTATIONMENTORING PROGRAM 3/2013

Title : Care and Management of Total Thyroidectomy

Presenter : Sn. Laiwinnei binti Binjil

0BJECTIVE1) Understand the anatomy and physiology of the th yroid gland

related to surgery.

2) Enable to understand and how ideal to handle the instrument, scope and principle of aseptic technique.

3) Prepare the OT before arrival of the patient.

4) Prepare the right equipment for the surgery.

5) Assist the surgeon more efficiently.

6) To learn and understand the nursing care preoperatively, intra operatively and post operatively

TOTAL THYROIDECTOMY

DEFINITIONA thyroidectomy is an operation that involves the surgical removal of all or part of the thyroid gland.

Total thyroidectomy - Entire gland is removed. Done in case of follicular carcinoma of thyroid, medullary carcinoma of thyroid.

Total thyroidectomy: The gland is removed completely. Usually done in the case of malignancy. Thyroid replacement therapy is necessary for life.

SKIN INCISION FOR THYROIDECTOMY The initial incision is made

over the marked line as described in the preparation section.

SIGN AND SYMPTOMS Some factors that may increase the risk of complications include:

Severe hyperthyroidism Large goiter Obesity Smoker Alcoholism Poor nutrition Long-term illness such as diabetes

INVESTIGATIONS Physical exam Laboratory and imaging tests to assess thyroid function and

anatomy, such as: Ultrasound MRI scan Thyroid hormone testing Anti-thyroid medicine to suppress thyroid activity in patients

with hyperthyroidism Thyroid scan CT scan will assess retrosternal extension or tracheal

compression. Nuclear medicine scan only serves to confirm the presence

of multinodular change and has little value.

TREATMENTS͏ Surgical treatment of a multinodular goitre include the presence of

obstructive symptoms, thyrotoxicosis, suspicious or malignant changes on FNAC, a strong family history of thyroid cancer, the presence of retrosternal extension, or a past history of head and neck irradiation.

͏ Patient with a large multinodular goitre who is otherwise asymptomatic, thyroidectomy may also be considered for cosmetic reasons. The only effective treatment is surgical excision. If surgery is undertaken, total thyroidectomy is the preferred option, because it removes all tissue likely to cause symptoms and avoids the possibility of later recurrence, which is of the order of 30%.

͏ Lifelong thyroxine replacement is required after total thyroidectomy.

͏ You may be asked to stop taking some medications up to one week before the procedure, like:• Anti-inflammatory medications, such as ibuprofen• Blood thinners• Antiplatelet medications

͏ Do not eat or drink anything after midnight the night before the procedure. At least 6hours nil by mouth.

PATIENT’S PARTICULAR

Name : Madam X

Sex : Female

Age : 46

Address : Jalan Bunga Raya Utama, Taman Bumiko, 98000 Miri.

RN no : 2014/000840

Status : Married with one child

Family history : no history of malignancy

Medical and surgical history : No medical illness

Social history : Ex smoker 10years ago, occasional alcohol drinker

NURSING ASSESMENT

Preoperative

1. Activity / exerciseInsomnia, increased sensitivity, muscle weakness, impaired coordination, severe fatigue, muscle atrophy, increased respiratory frequency, tachypnea, dyspnea

2. EliminationUrine in large amounts, diarrhea.

3. Coping / self defenseExperiencing severe anxiety and stress, both emotional and physical, emotional instability, depression.

CONT. 4. Nutrition and metabolic

Nausea and vomiting, the temperature rises above 37.4 º C. Enlargement of the thyroid, non-pitting edema, especially in the pretibial, diarrhea or constipation.

5. Cognitive and sensoryTalk fast and raucous, confusion, restlessness, coma, tremors of the hands, hyperactive deep tendon reflexes, orbital pain, photophobia, palpitations, chest pain (angina).

6. Reproductive / sexualDecreased libido, hypomenorrhea, menorea and impotent.

Postoperative

1. Basic assessment data The pattern of activity / rest: insomnia, severe weakness, impaired

coordination Neuro-sensory patterns: impaired mental status and behavior, such

as confusion, disorientation, anxiety, sensitive to stimuli, hyperactive deep tendon reflexes.

2. Priority of Nursing Returns the status of hyperthyroidism with preoperative Preventing complications Eliminating pain Provide information on procedures

CONT.

3. Purpose of repatriation Complications can be prevented or reduced Pain disappeared Surgical procedure / prognosis and treatment can be understood May need assistance in treatment techniques partially or completely, Daily activities, maintaining the house chores.

PRE OPERATIVE CARE

At airlock Ask the patient name and confirm with the case note and check the

wrist band.

Make sure all the documents such as, consent for operation, medication chart, chest x-ray, ultrasound and blood investigations are available.

Make sure all consents was signed by patient and checked according to standard checklist.

Patient wheel into the operation theatre.

RECEPTION BAY

Induction Room Operation Room

IN THE THEATRE

Make sure the humidity (50% – 60%) and temperature of the theatre is suitable (18- 22°C ) to prevent the growth of microorganism.

IN THE THEATRE Double check all the consents,

site of operation, procedure and patient identity with identity tag to make sure that

everything is correct.

IN THE THEATRE Confirm with anesthetist team

if patient has any allergy, airway risk, risk of blood loss and adequate intravenous access.

HARMONIC MACHINE Make sure the harmonic

machine can be functioning

during an operation.

IN THE THEATRE Check for the functioning of

the diathermy, GA machine, pulse oxymeter, and suction machine to ensure that the operation will run smoothly.

Prepare and check the set required for the procedure and make sure it is complete.

Basic Set

INSTRUMENT

Used poviden iodine 10% -remove as many bacteria as possible from the operative site and surrounding area before operating to prevent growth of the microorganism.

POSITION PATIENT FOR THYROIDECTOMY

patient should be placed in supine position with the apex of the patient head at the top of the operating bed.

A shoulder roll or gel pad should be placed at the level of the acromion process of the scapula to help extend the neck.

INTRA OPERATIVE CARE

INTRA OPERATIVE Used povioden iodine 10% -remove as many bacteria as possible

from the operative site and surrounding area before operating to prevent growth of the microorganism.

Only sterile items are use to prevent infection. Swab and instrument count are done before, during and after the

procedure to ensure that it tally. Be alert to ensure smooth running during the procedure. Redivac drain size 10 is ready in case surgeon need it to monitor

bleeding and bile secretion. Make sure specimen is correct

SCRUBING GOWNING

GLOVING

Diathermy plate applied at the correct site ( muscle area, no hairy area, avoid body prominence and implant insitu.) to prevent diathermy burn

Swab and instrument count are done before, during and after the procedure to ensure that it tally.

Be alert to ensure smooth running during

the procedure.

Swab and instrument count form

SPECIMEN THROID GLAND FOR HPE

POST OP CARE

AT RECOVERY BAY

After surgery patients are required to remain in a recovery area until the immediate effects of anesthesia subside and vital signs is stable.

Face mask oxygen 5L/minutes to maintains oxygen concentration and to prevent hypoxia because patient was under general anaesthesia

CONT. Monitored : Vital signs to ensure that there are no reactions to anesthesia or

internal injuries present. There may be some nausea and vomiting. Check intravenous access and make sure it is patent.

Check dressing drain site for bleeding.

Keep patient warm

CONT. Before discharge to the ward anesthetist have to sign the discharge

form to ensure patient is fit for discharge.

Make sure patient’s document is available such as post operative note order, x-ray film, case note, medication chart.

Specimen enter in the specimen book

Hand-over to ward staff regarding patient condition and post operative order. 

Nursing care plan

Pre operative care

Intra operative care

Post operative care

NURSING CARE PRE OP

Nursing diagnosis

Objective Nursing interventions

Evaluation

1. Anxiety / fear related to operation procedures

Patient will verbalise reduced anxiety

1. Provide emotional support by talking to patient2. Inform patient regarding the outcomes of the operation procedure3. Explain to patient the pre operative preparation and post operative care

Patient verbalise that she is ready for operation

NURSING CARE INTRA OP

Nursing diagnosis

Objective Nursing interventions

Evaluation

2. Potential swabs and instruments irregularities.

Swabs and instruments counts maintain correct.

1. Do initial,second and finalswabs andInstrumentscount.2.Take note on allnewly addedsharps, swabs,instruments andloose items.3. Keep track and tag on any swabs or instrument inserted into patient’s cavity intra operatively

Swab and instrument count done by circulating nurse and scrub nurse. Count tally. Surgeon informed .form signed by scrub and circulating nurse.

Nursing diagnosis

Objective Nursing interventions Evaluation

3. High risk for electrical burns related to the use of the electrosurgical unit

Patient will not sustain electrical burns

1. Check diathermy machine for proper functioning order before use2. Assess size and patient’s skin condition before applying diathermy plate.3. Select appropriate size of adhesive electro surgical pad.4.Do not place pad in

areasof scarred tissue, bonyprominence or hairy

areas.5. Protect patient from contact with metal surfaces

No redness over pt`s.skin at diathermy plate area

NURSING CARE POST OP

Nursing diagnosis

Objective Nursing interventions Evaluation

1. Pain related to surgery-operation site

Patient verbalise experiencing less pain

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

2. Place in semi-Fowler’s position and support head/neck with sandbags or small pillows.

3.  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.

 Useful in evaluating pain, choice of interventions, effectiveness of therapy. Prevents hyperextension of the neck and protects integrity of the suture line. Prevents stress on the suture line and reduces muscle tension

Nursing diagnosis

Objective Nursing interventions Evaluation

4.  Give cool liquids or soft foods, such as ice cream or popsicles.

5. Encourage patient to use relaxation techniques, e.g., guided imagery, soft music, progressive relaxation.

6.  Administer analgesics and/or analgesic throat sprays/lozenges as necessary. Provide ice collar if indicated.

Although both may be soothing to sore throat, soft foods may be tolerated better than liquids if patient experiences difficulty swallowing. Helps refocus attention and assists patient to manage pain/discomfort more effectively. Reduces pain and discomfort; enhances rest.

Nursing diagnosis

Objective Nursing interventions Evaluation

2. Communication, impaired verbalMay be related to•Vocal cord injury/laryngeal nerve damage•Tissue edema; pain/discomfort

Establish method of communication in which needs can be understood.

1. Assess speech periodically; encourage voice rest.2.  Keep communication simple; ask yes/no questions.3. Provide alternative methods of communication as appropriate, e.g., slate board, letter/picture board. Place IV line to minimize interference with written communication.

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. Reduces demand for response; promotes voice rest. Facilitates expression of needs.

Nursing diagnosis

Objective Nursing interventions Evaluation

4. Anticipate needs as possible. Visit patient frequently.

5.  Post notice of patient’s voice limitations at central station and answer call bell promptly.

6.  Maintain quiet environment.

Reduces anxiety and patient’s need to communicate. Prevents patient from straining voice to make needs known/summon assistance. Enhances ability to hear whispered communication and reduces necessity for patient to raise/strain voice to be heard.

HEALTH EDUCATION Post op day 2. advice patient and give health education about the

medication and folloe up with doctor. Take your medication as directed as doctor instruction.

Use a pillbox labeled with the days of the week. This will help you remember whether you’ve taken your medication each day.

Take your medication with a liquid. But avoid taking it with soy milk. Soy milk can affect how well your body absorbs the medication. The pill needs to reach your stomach and not dissolve in your throat.

Try to take your medication with the same types and amounts of food and liquid each day. This helps control the amount of thyroid hormone in your system.

After taking your medication: Wait 4 hours before eating or drinking anything that contains soy. Wait 4 hours before taking certain medications. These include:

• Iron supplements• Calcium supplements• Antacids that contain either calcium or aluminum hydroxide• Medications that lower your cholesterol

Do not stop taking your medication even if you become pregnant.

Never stop taking medications on your own.

Keeping Your Doctor’s Appointments

See your doctor for regular visits. These are needed to monitor your health.

Have routine blood tests done. These check the level of thyroid hormone in your body. This helps your doctor know whether to adjust the dosage of your medication if needed.

Tell your doctor about any signs of further thyroid problems.

Signs that you may have too much thyroid hormone in your body include: Restlessness Rapid weight loss Sweating

Signs that you may have too little thyroid hormone in your body include: Fatigue or sluggishness Puffy hands, face, or feet Hoarseness Muscle pain Slow pulse (less than 60 beats per minute)

To see doctor when : Call your doctor right away if you have any of the following: Fever above 37.2c Swelling or bleeding at the incision site Choking Short of breathing A sore throat that last longer than 7 days Tingling or cramps in your hands, feet, or lips