Thyroidectomy Nursing Care Plan & Management

Definition

• Removal of all or a portion of the thyroid gland.
• The procedure is usually performed to treat various disease of the thyroid gland that may not be treated effectively by chemotherapy or medication.
• A total thyroidectomy is indicated for certain carcinomas and to relieve tracheal or esophageal compression.

Position

• Supine with rolled towel or sandbag between the scapulae, hyperextending the neck. If table is placed in reverse Trendelenberg position, a padded foot board should be used to prevent the patient from slipping down toward the end of the table.

Pack/ Drapes

• Laparotomy pack with small fenestrated sheet
• Rolled sheet/ towels

image credit to: michaelbickford.com.au

Instrumentation

• Major Lap tray
• Thyroid tray
• Lahey clamps
• Spring retractor

Supplies/ Equipment

• Basin set
• Suction
• Blades
• Needle counter
• Dissector sponge
• Small drain
• Solutions
• Sutures

Procedure Overview

1. The incision is made above the sternal notch.
2. The platysma muscle is incised and retracted.
3. The strap muscles are separated or divided, and blunt and sharp dissections are employed until the thyroid is exposed.
4. The gland is then mobilized, and all or part is removed depending on the involved pathology.
5. Hemostasis is obtained, and the wound is irrigated with warm saline.
6. A drain may be inserted, and the incision is closed in layers by an interrupted method.

Perioperative Nursing Consideration

1. The surgeon may request a fine silk suture to use to mark the incision line.
2. The dressing is usually secured by a thyroid collar using a towel folded in thirds lengthwise. The towel is placed around the neck and crisscrossed in front, then fastened with tape.
3. The scrub person should maintain the sterility of the back table/ Mayo until the patient is extubated and breathing is stabilized.
4. An emergency tracheostomy tray will accompany the patient to the postanesthesia care unit and later to the patient’s room until breathing is unlabored and the chance of airway obstruction secondary to edema has passed.

Nursing Priorities

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

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 Interventions

Independent

• Monitor respiratory rate, depth, and work of breathing.
  • Rationale: 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.
  • Rationale: Rhonchi may indicate airway obstruction/accumulation of copious thick secretions.
• Assess for dyspnea, stridor, “crowing,” and cyanosis. Note quality of voice.
  • Rationale: Indicators of tracheal obstruction/laryngeal spasm, requiring prompt evaluation and intervention.
• Caution patient to avoid bending neck; support head with pillows.
  • Rationale: Reduces likelihood of tension on surgical wound.
• Assist with repositioning, deep breathing exercises, and/or coughing as indicated.
  • Rationale: 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.
  • Rationale: Edema/pain may impair patient’s ability to clear own airway.
• Check dressing frequently, especially posterior portion.
  • Rationale: If bleeding occurs, anterior dressing may appear dry because blood pools dependently.
• Investigate reports of difficulty swallowing, drooling of oral secretions.
  • Rationale: May indicate edema/sequestered bleeding in tissues surrounding operative site.
• Keep tracheostomy tray at bedside.
  • Rationale: Compromised airway may create a life-threatening situation requiring emergency procedure.

Collaborative

• Provide steam inhalation; humidify room air.
  • Rationale: Reduces discomfort of sore throat and tissue edema and promotes expectoration of secretions.
• Assist with/prepare for procedures: Tracheostomy
  • Rationale: May be necessary to maintain airway if obstructed by edema of glottis or hemorrhage.
• Return to surgery.
  • Rationale: 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 Interventions

Communication Enhancement: Speech Deficit

Independent

• Assess speech periodically; encourage voice rest.
  • Rationale: 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.
  • Rationale: 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.
  • Rationale: Facilitates expression of needs.
• Anticipate needs as possible. Visit patient frequently.
  • Rationale: Reduces anxiety and patient’s need to communicate.
• Post notice of patient’s voice limitations at central station and answer call bell promptly.
  • Rationale: Prevents patient from straining voice to make needs known/summon assistance.
• Maintain quiet environment.
  • Rationale: 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 Interventions

Independent

• Monitor vital signs noting elevating temperature, tachycardia (140–200 beats/min), dysrhythmias, respiratory distress, cyanosis (developing pulmonary edema/HF).
  • Rationale: 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.
  • Rationale: 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.
  • Rationale: Reduces potential for injury if seizures occur.

Collaborative

• Monitor serum calcium levels.
  • Rationale: Patients with levels less than 7.5 mg/100 mL generally require replacement therapy.

Administer medications as indicated:

• Calcium (gluconate, lactate);
  • Rationale: 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 agents
  • Rationale: Helpful in lowering elevated phosphorus levels associated with hypocalcemia.
• Sedatives
  • Rationale: Promotes rest, reducing exogenous stimulation.
• Anticonvulsants.
  • Rationale: 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 Interventions

Pain Management

Independent

• Assess verbal/nonverbal reports of pain, noting location, intensity (0–10 scale), and duration.
  • Rationale: Useful in evaluating pain, choice of interventions, effectiveness of therapy.
• Place in semi-Fowler’s position and support head/neck with sandbags or small pillows
  • Rationale: Prevents 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.
  • Rationale: Prevents stress on the suture line and reduces muscle tension.
• Keep call bell and frequently needed items within easy reach.
  • Rationale: Limits stretching, muscle strain in operative area.
• Give cool liquids or soft foods, such as ice cream or popsicles.
  • Rationale: 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.
  • Rationale: Helps refocus attention and assists patient to manage pain/discomfort more effectively.

Collaborative

• Administer analgesics and/or analgesic throat sprays/lozenges as necessary.
  • Rationale: Reduces pain and discomfort; enhances rest.
• Provide ice collar if indicated.
  • Rationale: 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 Interventions

Teaching; Disease Process

Independent

• Review surgical procedure and future expectations.
  • Rationale: Provides knowledge base from which patient can make informed decisions.
• Discuss need for well-balanced, nutritious diet and, when appropriate, inclusion of iodized salt.
  • Rationale: 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.
  • Rationale: 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).
  • Rationale: Maximizes supply and absorption of calcium if parathyroid function is impaired.
• Encourage progressive general exercise program.
  • Rationale: 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.
  • Rationale: Regular ROM exercises strengthen neck muscles, enhance circulation and healing process.
• Review importance of rest and relaxation, avoiding stressful situations and emotional outbursts.
  • Rationale: 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.
  • Rationale: Enables patient to provide competent self-care.
• Recommend the use of loose-fitting scarves to cover scar, avoiding the use of jewelry.
  • Rationale: Covers the incision without aggravating healing or precipitating infections of suture line.
• Apply cold cream after sutures have been removed.
  • Rationale: Softens tissues and may help minimize scarring.
• Discuss possibility of change in voice.
  • Rationale: 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.
  • Rationale: 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.
  • Rationale: 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.
  • Rationale: Provides opportunity for evaluating effectiveness of therapy and prevention of complications.