Melanie Carlson
3/29/04
PERSON
Name: Melanie Carlson’s patient (rm 314)
Current Medical/Surgical Diagnosis: Goiter/Thyroidectomy
Admitted Date: 3/23/2004 Discharge Date: 3/25/2004
Age: 50
Code Status: Full LEO
Date of Care: 3/25/2004
P NEED:
This patient is a 50-year-old, 179-pound, 5’3”, married, white female who was admitted on March 23rd,
2004, complaining of an enlarging goiter, difficulty swallowing, and pressure on her windpipe while in the
supine position. She is pleasant, oriented times three, and accompanied by her husband, who is supportive.
She works for Teachers Ret. Systems (?) and is insured.
She states that the goiter has been enlarging for months, despite being on suppression therapy for at least
four months. She has educated herself about thyroidectomy, and requests that her thyroid be taken out. She
understands the risks of losing her voice and/or calcium metabolism problems, and the possibility that she
will have to remain on some thyroid hormones for life.
Past medical/surgical history is noncontributory (two previous cesarean sections and a tubal ligation).
She does not use tobacco or alcohol.
E NEED:
Patient does not report the increased urination or stool changes that are commonly seen with
hyperthyroidism. No complaints or abnormalities.
Meds: Phenergan 25 mg q.4-6h. IM p.r.n. nausea (given w/ Demerol)
R NEED:
Prior to surgery, the patient’s thyroid function tests were normal, and ultrasound consistent with goiter.
Immediately post-op on 3/23/04, the patient states her pain is sharp and constant in her neck at an 8/10.
However, she quickly improves and her last dose of pain medication was on 3/24/04 at 1135. She denies
pain on 3/25/04, and is ready to go home.
Labs: Post-operatively, calcium levels are ordered 2x day (doctor asked nurse to contact him if calcium was
<8.2). All values were WNL, ranging from 8.8 to 9.1 during her hospital visit [normal range is 8.5-10.1
mg/dL].
Meds: Demerol 50 mg q.4h. IM p.r.n. pain (given w/ Phenergan); Restoril (temazepam) 15 mg po p.r.n.
sleep; Vicodin (hydrocodone) 5/500 mg 1-2 tabs po p.r.n. pain; morphine sulfate 1-4 mg IV q.1-2h. p.r.n.
pain.
S NEED:
ALLERGIES: NKDA
CODE STATUS: Full LEO
The patient has visual impairment and wears glasses. Physical examination does not show signs of
exopthalmos. Patient has an IV in her right hand (wrist) that was started on 3/23/04. It is CDI, and infusing
dextrose 5% - 0.25 NS to KVO.
Postoperatively, the patient initially had a towel around her neck with a CDI surgical dressing beneath.
These were removed at 1315 on 3/24/04, and a smaller dressing replaced it. No excessive bleeding or
drainage noted.
Labs: CBC with differential was completed pre-operatively on 3/22/04. Everything was WNL, except
monocyte %, which was slightly elevated at 9.5.
O NEED:
The patient’s vital signs were stable during her entire hospital stay, with no signs of acute respiratory
distress or fever. Postoperatively, to assist with breathing, the head of the bed was placed at 30 degrees. O2
1
was administered at 3 lpm via nasal cannula for the first 24 hours after surgery, but discontinued on 3/24/04.
She was ambulatory on post-op day #1, and able to go to the bathroom without assistance.
Labs: O2 saturation remained stable even when O2 supply via nasal cannula was removed.
N NEED:
No recent weight loss. Appetite is normal. Pre-op physical exam does show marked enlargement of
both lobes of the thyroid, indicating a goiter. Preoperatively, the patient complains of compression
symptoms associated with this goiter, especially difficulty swallowing. She prefers to drink liquids instead
of eating solid foods.
Immediately postoperative, the patient continues to complain of some difficulty and pain with
swallowing. She chooses to remain on a liquid diet, although she is free to advance to regular diet when she
feels comfortable enough to do so. Intake & output are stable and as expected. Before discharge on
3/25/04, the patient is tolerating a soft diet without difficulty.
--------------------------------------------------------------------------------------------------------------------------------------
LIST OF APPLICABLE NURSING DIAGNOSES
1. Airway clearance, risk for ineffective related to tracheal obstruction secondary to swelling, bleeding or
laryngeal spasms
2. Knowledge, deficient related to prognosis, treatment, self-care and discharge needs
3. Communication, impaired verbal related to tissue edema and pain/discomfort
4. Injury, Risk for (tetany) related to chemical imbalance
5. Pain, acute related to surgical interruption/manipulation of tissues/muscles
6. Disturbed sensory perception related to visual impairment without glasses
MEDICATIONS
Name: Vicodin (hydrocodone bitartrate)
Dosage: 5/500 mg 1-2 tabs
Classification: CNS agent, Narcotic (opiate) agonist analgesic, antitussive
Action: CNS depressant with moderate to severe relief of pain; morphine derivative similar to codeine.
Indication: Patient is post-op thyroidectomy with mild to moderate pain at the surgical site.
Side Effects: Respiratory depression, constipation, nausea, drowsiness
Nursing Considerations: It is important to assess a patient for respiratory difficulties when administering
Vicodin after a thyroidectomy. Complications after thyroidectomy can include edema of the glottis; this
complication added to the possible respiratory depression from Vicodin could be potentially harmful.
Name: Restoril (temazepam)
Dose: 7.5 mg po p.r.n. sleep
Classification: CNS agent, anxiolytic, sedative-hypnotic, benzodiazepine
Action: Relieves insomnia associated with frequent nocturnal awakenings or early morning awakenings.
Benzodiazepine derivative with principal effect of significant improvement in sleep parameters.
Indication: Patients may have anxiety and/or insomnia associated with a surgery and the resulting pain.
Side Effects: drowsiness, dizziness, lethargy
Nursing Considerations: Assess patient for paradoxical reactions (excitement, hyperactivity or disorientation)
or dreams/nightmares that interfere with rest. Teach patient that medication will not improve sleep time until
after 2-3 doses of drug, and that difficulty getting to sleep may continue because medication just helps increase
amount of rest once asleep.
2
THYROIDECTOMY (secondary to goiter)
Lemone p. 449, 459
Doenges p. 414-419
Ulrich p. 771-776
Thyroidectomy, although rare, may be performed for patients with thyroid cancer, hyperthyroidism, and drug
reactions to antithyroid agents; pregnant women who cannot be managed with drugs; patients who do not want
radiation therapy; or patients with large goiters who do not respond to antithyroid drugs. Patients with enlarged
thyroid glands may have pressure on their esophagus or trachea that causes swallowing and/or breathing
problems. Total thyroidectomy is when the gland is removed completely; usually done in the case of
malignancy; and thyroid replacement is necessary for life. Subtotal thyroidectomy is up to 90% of the gland
removed when antithyroid drugs do not correct hyperthyroidism or RAI therapy is contraindicated. It is the
preferred procedure because the remaining gland tissue usually hypertrophies and eventually supplies adequate
amounts of thyroid hormone. Prior to surgery, the patient is usually given antithyroid agents for 6-8 weeks to
achieve a euthyroid state and minimize the risk of a thyrotoxic crisis.
Risk Factors for thyroidectomy are either colloid goiter, tumors or hyperthyroidism that does not respond to
iodine therapy and antithyroid drugs.
Clinical Manifestations:
Hoarseness for at least a few days; difficulty moving neck in any way; pain or difficulty swallowing;
surgical incision pain; and increased secretions from irritation of the respiratory tract are all normal
postoperative manifestations. If calcium metabolism is interrupted and hypocalcemia occurs, paresthesias in the
lips, hands & toes and muscle twitching & spasms (tetany) can be very serious.
Potential complications of thyroidectomy are (1) hemorrhage due to surgery in a highly vascular area; (2)
respiratory distress due to airway obstruction (tracheal compression or closure of glottis from laryngeal nerve
damage); (3) hypocalcemia due to damage of parathyroid glands during surgery; (4) thyroid storm (thyrotoxic
crisis) due to excessive amounts of thyroid hormone in blood; and (5) laryngeal nerve damage due to trauma
during surgery or pressure from swelling after surgery.
Diagnostic Studies:
Most of these are done preoperatively to help determine the cause of hyperthyroidism and to differentiate
between Graves’ disease and Plummer’s disease.
 Thyroid function tests
 Serum calcium (post-op), glucose and catecholamines
 Ultrasound or thyroid scan
 Needle or open biopsy
 Protein-bound iodine: Increased.
 Urine creatitine: Increased.
 Liver function tests: Abnormal.
 Electrolytes (hyponatremia and hypokalemia often occur with hyperthyroidism)
3
Nursing Dx &
Support Data
Airway clearance, risk
for ineffective related
to tracheal obstruction
secondary to swelling,
bleeding or laryngeal
spasms
Support Data
 Compression
symptoms before
surgery (diff. breathing
in supine position)
 Thyroidectomy
performed on 3/23/04
 Potential
complications of
thyroidectomy can all
quickly lead to airway
obstruction (see list in
Medical Diagnosis)
Goal/Outcome &
Outcome Attainment
1) Maintain patent
airway, with aspiration
prevented.
Nursing Interventions
Scientific Rationale
1a) Monitor respiratory
rate, depth and work or
breathing.
1a) Respirations may remain somewhat
rapid, but development of resp. distress
is indicative of tracheal compression
from edema or hemorrhage.
1b) Rhonchi may indicate airway
obstruction or accumulation of copious
thick secretions.
1c) May indicate edema/sequestered
bleeding in tissues surrounding
operative site.
Outcome Attainment
Patient was on oxygen
for 24 hours post-op.
She had no difficulties
during or after O2
therapy was
discontinued, and no
signs of distress were
ever noted in chart.
1b) Auscultate breath
sounds, noting presence
of rhonchi.
1c) Investigate reports of
difficulty swallowing,
drooling of oral
secretions.
1d) Assist w/
repositioning, deep
breathing exercises,
and/or coughing if
needed.
1e) Check dressing
frequently, esp. posterior
position.
1d) Maintains clear airway &
ventilation. “Routine” coughing is not
encouraged & is painful, it may be
needed to clear secretions.
1e) If bleeding occurs, anterior dressing
may appear dry because blood pools
dependently.
4
Evaluation
1a) Patient’s VS were monitored q.4h. Patient was
given strict instructions to call nurse using call light if
any problems breathing, and patient was monitored
frequently for resp. distress. No signs of difficulty
were ever noted in chart.
1b) On 2nd post-op day, normal breath sounds noted.
No abnormal breath sounds charted on previous days.
1c) Patient did complain of difficulty swallowing, but
stated difficulty was due mainly to pain & discomfort,
not swelling or compression.
1d) Head of patient’s bed was in Semi-Fowler position
during her entire hospital stay (pre- and post-op). She
did not have excessive secretions, but was taught to
deep breath and how to support her head when moving
in bed or when getting up to the bathroom.
1e) When I arrived at the hospital on Wed., the
dressing had just been changed 2 hours before by the
doctor, with no abnormalities or concerns noted or
related to the nurse at that time.
Nursing Dx &
Support Data
Knowledge,
deficient related to
prognosis, treatment,
self-care and
discharge needs
Support Data
 patient is
informed about
surgery itself, but
needs information
about care for
incision, prognosis,
and prescribed home
meds
 patient does not
know
signs/symptoms of
increased/decreased
thyroid hormone,
and when to report
to doctor
 need to teach
patient signs of
infection and other
complications
Goal/Outcome &
Outcome Attainment
1) Patient will verbalize
understanding of surgical
procedure & prognosis &
potential complications.
Outcome Attainment
Patient was very educated
about her condition, the
surgical procedure, and
easily understood the
signs/symptoms of the
various complications.
2) Patient will verbalize
understanding of
therapeutic needs and
participate in treatment
regimen.
Outcome Attainment
Patient was planning to
fill her prescriptions on
her way home from the
hospital with her husband.
She agreed to followup
with her doctor in one
week. She expected no
problems with incisional
care.
Nursing Interventions
Scientific Rationale
1a) Review surgical proc. & future
expectations.
1a) Provides knowledge base from
which patient can make informed
decisions before surgery.
1b) Discuss possibility of change in
voice.
1b) Alteration in vocal cord function
may cause changes in pitch and
quality of voice, which may be
temporary or permanent.
1c) Identify signs/symptoms requiring
medical evaluation, including fever,
chills, purulent or excessive wound
drainage, erythema, sudden weight
loss, heat or cold intolerance, N/V,
diarrhea, insomnia, weight gain,
fatigue, constipation or drowsiness.
2a) Review drug therapy and necessity
of continuing even when feeling well.
1c) Early recognition of developing
complications such as infection,
hyper- or hypothyroidism may
prevent progression to lifethreatening situation.
2b) Instruct in incisional care,
including cleansing and dressing
application.
2a) Patient needs to understand
rationale for replacement therapy and
consequences of failure to routinely
take medications.
2b) Enables patient to provide
competent self-care.
2c) Instruct patient to follow up with
doctor.
2c) Provides opportunity for
evaluating effectiveness of therapy
and prevention of complications
2d) Review post-op exercises to be
instituted after incision heals, e.g.
flexion, extension, rotation, and lateral
movement of head & neck.
2d) Regular ROM exercises
strengthen neck muscles, enhance
circulation and healing process.
5
Evaluation
1a) Patient had full understanding of the
surgical procedure and the risks involved.
She signed the forms, permitting the
surgeon to proceed.
1b) Patient was told to contact the doctor
with worsening hoarseness or if no
improvement in 3-5 days. Patient
understood the risks of voice alteration
before proceeding with surgery.
1c) Patient verbalizes signs/symptoms of
infection. She also verbalizes
understanding of the signs/symptoms of low
or high thyroid hormone. She was sent
home with papers describing all of these
symptoms.
2a) Patient verbalized understanding of
prescribed meds (Synthroid & Vicodin),
and understands the importance of taking
the Synthroid as prescribed.
2b) Patient was instructed not to soak the
incision and to use soap and warm water to
clean. Patient verbalized understanding of
keeping the area clean & dry.
2c) Patient understands the necessity of
following up with her doctor in one week
and agrees to make the appointment. The
Synthroid dosage will be reevaluated at that
time if necessary.
2d) Patient was provided verbal and written
instructions on ROM exercises, and
verbalized understanding of such.