Student Nursing Case
Introduction The student nurse chose this case study to discover more about the disease process and how to impart more therapeutic interventions that would lend a hand to the patient to recover better as soon as possible. Cast an eye over more facts about the disease and how significant each signs and symptoms the patient is manifesting and its effect to the body of the patient. This case abets the student nurse to obtain appropriate knowledge as well as gain understanding that will be used further in inculcating the therapeutic regimen and exhibit a positive attitude in rendering holistic nursing care to the client with the disease condition. Through this case study, the student nurse expects to acquire more about the disease process,
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how the patient obtains such disease. The student nurse would also like to discern more interventions that would ease the patient’s condition, the student nurse would also want to relate the manifestations and do research through books, journals and even in internet. Conveying knowledge to the patient as well as the significant others and expounding and instructing possible interventions. Hyperthyroidism may due to over functioning of the entire gland or, less commonly to single or multiple functioning adenomas of thyroid cancer. Over treatment of myxedema with thyroid hormones may also result in hyperthyroidism. The most common form of hyperthyroidism is Grave’s disease (toxic, diffuse goiter), which has three principal hallmarks: hyperthyroidism, thyroid enlargement (goiter), and exophthalmos (abnormal protrusion of eyes. Grave’s disease is an autoimmune disorder mediated by immunoglobulin G (IgG) antibody that binds to and activates thyroid stimulating hormone receptors on the surface of the thyroid cells. Other causes of hyperthyroidism include toxic nodular goiter, toxic adenoma (benign), and thyroid carcinoma, subacute and chronic thyroiditis, ingestion of thyroid hormones, and ingestion of amiodarone hydrochloride for atrial fibrillation. Health maintenance and restoration activities include monitoring thyroid levels if thyroid replacement is given, removal of thyroid tumors and administration of antithyroid medications. Thyroidectomy involves the surgical removal of all or part of the thyroid gland. Surgeons often perform a Thyroidectomy when a patient has thyroid cancer or some other condition of the thyroid gland (such as hyperthyroidism). Other indications for surgery include cosmetic (much enlarged thyroid), or symptomatic obstruction (causing difficulties in swallowing or breathing). One of the complications of "Thyroidectomy" is voice change and patients are strongly advised to only be operated on by surgeons who protect the voice by using electronic nerve monitoring
Objective
Student Nurse Centered Objectives
General Objectives: After 1 day of student nurse-patient interaction, the student nurse will be able to acquire knowledge, skills and attitude in the care of patient with Right Thyroid Goiter who underwent Subtotal Thryroidectomy.
Specific Objectives: After 45 minutes of student nurse-patient interaction, the student nurse will be able to: 1. establish rapport to the patient. 2. discuss the anatomy and physiology of the thyroid gland. 3. impart knowledge about hyperthyroidism, hypothyroidism and thyroidectomy. 4. relate the condition of the patient in accordance with the pathophysiology of the disease process. 5. name the signs and symptoms of hyperthyroidism and hypothyroidism. 6. inform knowledge about the possible complications of the disease condition. 7. plan a comprehensive health teaching plan for patient who undergone thyroidectomy. 8. create a health teaching plan for a patient with right thyroid goiter who undergone Subtotal Thryroidectomy. 9. equip adequate nursing care and therapeutic interventions to the patient. 10. promote positive attitude towards caring the patient.
Patient Centered Objectives
General Objectives: After 1 day of holistic nursing care, the patient and significant others will be able to gain knowledge, skills and attitude about the management of the condition.
Specific Objectives: After 45 minutes of student nurse-patient interaction, the patient and significant others will be able to:
1. establish rapport with the student nurse. 2. define thyroidectomy, hyperthyroidism and hypothyroidism at the level of her understanding. 3. elaborate the possible factors that contributes to the occurrence of right thyroid goiter. 4. enumerate the clinical manifestations of right thyroid goiter. 5. determine the possible treatment for right thyroid goiter like eating food rich in iodine such as seafoods. 6. enumerate the complications that may occur during early stage of the disease process. 7. establish positive outlook towards optimum level of functioning.
Nursing Assessment
Personal History Patient’s Profile Name: Mrs. Rebecca S. Villanueva Age: 60 years old Sex: Female Civil Status: Married Religion: Roman Catholic Date of Admission: January 31, 2011 at 7pm Room No.: Surgical Mission 35 Complaints: Anterior Neck Mass Diagnosis: Right Thyroid Goiter Physician: Dr. Penserga
Family and Individual Information
Mrs. Rebecca S. Villanueva married to Rodolfo Villanueva with 4 offsprings, 3 male and 1 female. Her family currently living at Bilwang, Isabel Leyte. She was admitted to OSPA last January 31, 2011 at 7pm under surgical mission of Society of Philippine Surgeons American Association (SPSA) headed by Congresswoman Lucy Torres-Gomez. She is only a housewife. Twenty-five years prior to admission, patient noted a growing mass on her anterior neck portion but can be tolerated. She has a medication maintained to maintain for her goiter, which is Tyrax 600mg per day. But she has known hypertension with BP controlled by taking Metoprolol 100g 1 tab BID. This was her first time to be admitted in the said hospital. According to her, they have a familial disease of goiter, and she has no allergies to foods.
Level of Growth and Development at a Particular Stage
Normal Growth and Development Some adults are financially dependent on their families for many years. Adulthood may also be indicated by moving away from home and establishing one’s own living arrangements. Yet this independence also varies greatly. In recent years, however more young adults have been choosing to remain at home. In addition, many adults under 30 have returned to their parent’s homes to live. Maturity is the state of maximal function and integration or the state of being fully developed. Mature individuals are guided by an underlying philosophy of life. Mature persons are open to new experiences and continued growth; they can tolerate ambiguity are flexible, and can adapt to change. In addition, mature people have the quality of self-acceptance; they are able to be reflective and insightful about life and to see themselves as others see them. Young adults are typically busy people who face many challenges. They are expected to assume some new roles at work in the home and in the community, and to develop interest, values and attitudes related to these roles.
Physical Development People in their own early 20’s are in their prime physical years. The musculoskeletal system is well developed and coordinated. This is the period of when athletic endeavors reach their peak. All other systems of the body (e.g., cardiovascular, visual, auditory, and reproductive) are also functioning at peak efficiency. Although physical changes are minimal during this stage, weight and muscle mass may change as a result of diet and exercise. In addition, extensive physical and psychosocial changes occur in pregnant and lactating women.
Psychosocial Development According to Erikson, adulthood is in the intimate relationship versus isolation wherein intimate relationship with another person and commitment to work and relationships. The other side of isolation wherein there is an impersonal relationships; avoidance of relationship, career or lifestyle commitments.
Cognitive Development Piaget believes that cognitive structures are complete during the formal operations period, from roughly 11 to 15 years. From that time, formal operations (for example, generating hypotheses) characterize thinking throughout adulthood and are applied to more areas. Egocentrism continues to decline; however according to Piaget these changes do not involve a change in the structure of thought, only a change in its content and stability. Recently, researches in the field of psychology have suggested that Piaget’s formal operational stage is not the last stage of human development. Some have proposed a concept of post formal thought. Post formal thought, sometimes called the problem finding stage, is (some have proposed a concept of post formal) characterized by “creative thought in the form of discovered problems, relativistic thinking, the formation of generic problems, the raising of general questions from ill-defined problems, the use of intuition, insight and hunches, and the development of significant scientific thought.” In addition to the adolescent ability to think in abstract terms, post formal thinkers process an understanding of the temporary or relative nature of knowledge. They are able to comprehend and balance arguments created by both logic and emotion.
Moral Development Young adults who have mastered the previous stages of Kohlberg’s theory of moral development now enter the post conventional level. At this time, the person is able to separate self from the expectations and rules of others and to define morality in terms of personal principles. When individuals perceive a conflict with society’s rules or laws, they judge according to their own principles. Gilligan argues that as individuals approach young adulthood, men and women tend to define moral problems somewhat differently. Men often use an “ethic of justice” and define in terms of obligation to care and to avoid hurt.
Spiritual Development According to Fowler, the individual enters the individuating-reflective period sometime after 18 years of age. During this period, the individual focuses on reality. 27 years-old adult may ask philosophic questions regarding spirituality and may be self-conscious about spiritual matters. The religious teaching that the young adult has a child may now be accepted or redefined.
The Ill Person at This Stage of the Patient
Adulthood is generally a healthy time of life. Health problems that do not occur and are common in this age group include accidents, suicide, substance abuse, hypertension, sexually transmitted disease, abuse women, and certain malignancies. Some of the accidents such as accidents, substance abuse, and sexually transmitted disease are related to behaviors that could possibly be prevented through appropriate education and other primary prevention strategies. Thoroughly assessment and patient-specific management are necessary in order for those factors that contribute to the severity of the patient will be prevented. During the patient hospitalization, she is always lying on bed. She doesn’t want to so some stretching exercises because she feels fatigue and dizziness. Her diet is soft diet, due to post-operative condition. She was always complaining about odynophagia (pain swallowing) and fatigue. Sometimes she is anxious because she always thinks about her condition.
Functional Health Pattern (Pre-Operative)
Health Perception/Health Management Mrs. Rebecca S. Villanueva understands the cause why she had acquired that certain disease and effect behind it. The student nurse asked what she thinks about her disease and she said that she is looking forward for the success of her operation. She also stated that she usually eat 3 times per day.
Nutritional-Metabolic Pattern Before admission, she used to eat 3 times a day with 1 cup of rice with fish and vegetables. She only eats meat sometimes due to insufficient income. She drinks 8-10 glasses of water. She has no allergies to foods and medications.
Activity/ Exercise Pattern Before admission she does household chore everyday. While during her hospitalization she always lying on bed and felt pain and fatigue.
Cognitive/Perceptual Pattern Patient has no sensory deficit, she was oriented to time and place so as the person. She responds to verbal and physical stimuli.
Rest/Sleep Pattern Before hospitalization, she sleeps 6-7 hours per day. She sleeps at 11pm and wakes up at 6am, but during her admission she can’t sleep well due to environmental factor. She tries to sleep at 11pm then suddenly she wakes up at 3am.
Self-Perception Pattern Even though that she has a goiter, still it’s not the end of the world for her. There are always solutions in every problem. Mrs. Villanueva is hoping for a better recovery from the said condition. She perceives herself as an important one because she loves her family and they need her, she want to love, care and serve her family until the last breath of her life.
Roles/ Relationship Pattern Mrs. Rebecca S. Villanueva lives with her husband, Rodolfo Villanueva and with her 4 offspring. She expresses a good relationship with her family members, she only does household chores and sometimes she cook if someone ordered. Mrs. Villanueva’s role in the family is she’s the one who took care of the house and her family members which include her loving and supportive husband and a loving offspring.
Sexuality-Reproductive Pattern Mrs. Villanueva is now 60 years old, she is in genital stage according to Sigmund Freud’s stage of development, where energy is directed towards full sexual maturity and function and development of skills needed to cope with the environment. According to Mrs. Villanueva, her sexual relationship with her husband is good. They understand each other and they plan those actions regarding their family’s status.
Coping-Stress Tolerance Pattern According to Mrs. Villanueva, her way of coping from such problems is through prayers, expression and verbalization of her thoughts and feelings to her husband and sometimes in family members. Prior to surgery, her coping management was stronger faith in God with prayers for her surgery and looking forward for better result and recovery.
Values-Belief System Mrs. Villanueva was a Roman Catholic. They are all God-fearing and always attend mass. And her faith in God goes stronger and concrete every minutes of her time. She also believe on superstitious belief, but she quoted that even if she believes in superstitious still her faith and love in God doesn’t change, she is always loyal and God-fearing to whom he believe in.
Functional Health Pattern (Post-Operative)
Health Perception/Health Management Mrs. Villanueva understands and she is well aware of her current condition that she would lessen the causes and factors that would trigger the reoccurrence of her condition, such as stress, lack of iodine intake and too much toxic nodular goiter. Eating nutritious foods, fruits and adequate rest and sleep would help her recover and the reoccurrence of goiter would be prevented.
Nutritional-Metabolic Pattern Post-operatively, the patient was instantaneously to NPO for the first 15 hours and then DAT was ordered by the attending physician. After which, if the patient was allowed to eat anything if she can tolerate to eat and swallow semi-solid or solid food.
Elimination Pattern 1 day after the surgery, the patient was not able to defecate. Though, the bowel sound had returned within 24 hours after the procedure. With the concern to her bladder elimination, she can urinate 4-6 times per shift with an average of 800ml of urine per shift.
Activity/ Exercise Pattern Post-operatively, patient’s activity was limited and encourages bed rest for faster recovery. 1 Day after the surgery, the patient was encourage to begin ambulation like sluggish walk from bed to comfort room.
Cognitive/Perceptual Pattern Mrs. Villanueva was a high school level. She has no sensory deficit, but she has a difficulty in maintaining a long conversation due to pain on her anterior neck post operatively and odynophagia.
Rest/Sleep Pattern Post-operatively, the patient can only sleep more or less than 4 hours due to environmental factors that interferes her sleep pattern.
Self-Perception Pattern Even though the patient accepts her condition at present and is willing to undergo surgery, still she express worries and concerns, if she can conquer her problem. For her, she needs to be cured and recover fast in order for her to go back to her normal and regular work and to take care for her family so that her family won’t be worried about her.
Sexuality-Reproductive Pattern Although Mrs. Villanueva underwent to surgery which is thyroidectomy, according to her, her relationship to her husband regarding sexuality doesn’t change. They understand one another and they really plan those actions for their family’s status. Even though she is still in recovery stage after the procedure, her husband still anticipates for enough rest and sleep to get along with the condition.
Coping-Stress Tolerance Pattern Post-operatively, Mrs. Villanueva’s way of coping from the problems is through sharing to her husband of what she feels after the surgery and through prayers. She already accepts her condition and the needs for enough rest and sleep periods.
Values-Belief System Post-operatively, Mrs. Villanueva continues to believe in God. She believes that this condition she felt right now is a test given by God. She remains loyal and trust God every consequences she encountered. She also believe that every problem has always a great solutions.
Patient’s Name: Mrs. Rebecca S. Villanueva
Impression/Diagnosis: Right Thyroid Goiter
Attending physician: Dr. Penserga
Pre-Operative Diagnostic Test
|Diagnostic Test |Normal Values |Patient’s Result |Significance |
|Hematology | | | |
|January 31, 2011 | | | |
|Hemoglobin |12.3-15.3 |13.1mg/dL |Normal |
|Hematocrit |35.9-44.6 |40 % |Normal |
|Red Blood Cells |4.5-5.9 |4.67 10^2/L |Normal |
| | | | |
| | | | |
|White Blood Cells |4,000-11,000 |12,240 10^3/L |Increased; indicate infection |
| | | |such abscess, meningitis, |
| | | |appendicitis or tonsillitis |
| | | |Normal |
| | | |Normal |
|MCV |80-96 |86 fL |Normal |
|MCH |27-32 |28.1 |Normal |
|Platelet Count |150,000-450,000 |355,000 |Normal |
|Neutrophils |40-70 |60.3 % |Normal |
|Basophils |0-1 |0.3 % |Normal |
|Eosinophils |1-5 |3.9 % |Normal …show more content…
|
|Lymphocytes |20-40 |29.7 % | |
|Monocytes |0-8 |5.8 % | |
Pathophysiology and Rationale
Anatomy and Physiology of Thyroid Gland
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The thyroid is one of the largest endocrine glands in the body. This gland is found in the neck inferior to (below) the thyroid cartilage (also known as the Adam's apple in men) and at approximately the same level as the cricoid cartilage. The thyroid controls how quickly the body burns energy, makes proteins, and how sensitive the body should be to other hormones. The thyroid participates in these processes by producing thyroid hormones, principally thyroxine (T4) and triiodothyronine (T3). These hormones regulate the rate of metabolism and affect the growth and rate of function of many other systems in the body. Iodine is an essential component of both T3 and T4. The thyroid also produces the hormone calcitonin, which plays a role in calcium homeostasis. The thyroid is controlled by the hypothalamus and pituitary. The gland gets its name from the Greek word for "shield", after the shape of the related thyroid cartilage. Hyperthyroidism (overactive thyroid) and hypothyroidism (underactive thyroid) are the most common problems of the thyroid gland.
Anatomy
The thyroid gland is butterfly-shaped organ and is composed of two cone-like lobes or wings: lobus dexter (right lobe) and lobus sinister (left lobe), connected with the isthmus. The organ is situated on the anterior side of the neck, lying against and around the larynx and trachea, reaching posteriorly the oesophagus and carotid sheath. It starts cranially at the oblique line on the thyroid cartilage (just below the laryngeal prominence or Adam's apple) and extends inferiorly to the fourth to sixth tracheal ring. It is difficult to demarcate the gland's upper and lower border with vertebral levels as it moves position in relation to these during swallowing. The thyroid isthmus is variable in presence and size, and can encompass a cranially extending pyramid lobe (lobus pyramidalis or processus pyramidalis), remnant of the thyroglossal duct. The thyroid is one of the larger endocrine glands, weighing 2-3 grams in neonates and 18-60 grams in adults, and is increased in pregnancy. The thyroid is supplied with arterial blood from the superior thyroid artery, a branch of the external carotid artery, and the inferior thyroid artery, a branch of the thyrocervical trunk, and sometimes by the thyroid ima artery, branching directly from the aortic arch. The venous blood is drained via superior thyroid veins, draining in the internal jugular vein, and via inferior thyroid veins, draining via the plexus thyroideus impar in the left brachiocephalic vein. Lymphatic drainage passes frequently the lateral deep cervical lymph nodes and the pre- and parathracheal lymph nodes. The gland is supplied by sympathetic nerve input from the superior cervical ganglion and the cervicothoracic ganglion of the sympathetic trunk, and by parasympathetic nerve input from the superior laryngeal nerve and the recurrent laryngeal nerve.
Physiology
The primary function of the thyroid is production of the hormones thyroxine (T4), triiodothyronine (T3), and calcitonin. Up to 80% of the T4 is converted to T3 by peripheral organs such as the liver, kidney and spleen. T3 is about ten times more active than T4.
T3 and T4 production and action
Thyroxine (T4) is synthesized by the follicular cells from free tyrosine and on the tyrosine residues of the protein called thyroglobulin (TG). Iodine is captured with the "iodine trap" by the hydrogen peroxide generated by the enzyme thyroid peroxidase (TPO)[6] and linked to the 3' and 5' sites of the benzene ring of the tyrosine residues on TG, and on free tyrosine. Upon stimulation by the thyroid-stimulating hormone (TSH), the follicular cells reabsorb TG and proteolytically cleave the iodinated tyrosines from TG, forming T4 and T3 (in T3, one iodine is absent compared to T4), and releasing them into the blood. Deiodinase enzymes convert T4 to T3. Thyroid hormone that is secreted from the gland is about 90% T4 and about 10% T3. Cells of the brain are a major target for the thyroid hormones T3 and T4. Thyroid hormones play a particularly crucial role in brain maturation during fetal development.[8] A transport protein (OATP1C1) has been identified that seems to be important for T4 transport across the barrier. A second transport protein (MCT8) is important for T3 transport across brain cell membranes. In the blood, T4 and T3 are partially bound to thyroxine-binding globulin, transthyretin and albumin. Only a very small fraction of the circulating hormone is free (unbound) - T4 0.03% and T3 0.3%. Only the free fraction has hormonal activity. As with the steroid hormones and retinoic acid, thyroid hormones cross the cell membrane and bind to intracellular receptors (α1, α2, β1 and β2), which act alone, in pairs or together with the retinoid X-receptor as transcription factors to modulate DNA transcription.
T3 and T4 regulation
The production of thyroxine and triiodothyronine is regulated by thyroid-stimulating hormone (TSH), released by the anterior pituitary (that is in turn released as a result of TRH release by the hypothalamus).
The thyroid and thyrotropes form a negative feedback loop: TSH production is suppressed when the T4 levels are high, and vice versa. The TSH production itself is modulated by thyrotropin-releasing hormone (TRH), which is produced by the hypothalamus and secreted at an increased rate in situations such as cold (in which an accelerated metabolism would generate more heat). TSH production is blunted by somatostatin (SRIH), rising levels of glucocorticoids and sex hormones (estrogen and testosterone), and excessively high blood iodide
concentration.
Calcitonin
An additional hormone produced by the thyroid contributes to the regulation of blood calcium levels. Parafollicular cells produce calcitonin in response to hypercalcemia. Calcitonin stimulates movement of calcium into bone, in opposition to the effects of parathyroid hormone (PTH). However, calcitonin seems far less essential than PTH, as calcium metabolism remains clinically normal after removal of the thyroid, but not the parathyroids.
Significance of iodine
In areas of the world where iodine (essential for the production of thyroxine, which contains four iodine atoms) is lacking in the diet, the thyroid gland can be considerably enlarged, resulting in the swollen necks of endemic goiter. Thyroxine is critical to the regulation of metabolism and growth throughout the animal kingdom. Among amphibians, for example, administering a thyroid-blocking agent such as propylthiouracil (PTU) can prevent tadpoles from metamorphosing into frogs; conversely, administering thyroxine will trigger metamorphosis. In humans, children born with thyroid hormone deficiency will have physical growth and development problems, and brain development can also be severely impaired, in the condition referred to as cretinism. Newborn children in many developed countries are now routinely tested for thyroid hormone deficiency as part of newborn screening by analysis of a drop of blood. Children with thyroid hormone deficiency are treated by supplementation with synthetic thyroxine, which enables them to grow and develop normally. Because of the thyroid's selective uptake and concentration of what is a fairly rare element, it is sensitive to the effects of various radioactive isotopes of iodine produced by nuclear fission. In the event of large accidental releases of such material into the environment, the uptake of radioactive iodine isotopes by the thyroid can, in theory, be blocked by saturating the uptake mechanism with a large surplus of non-radioactive iodine, taken in the form of potassium iodide tablets. While biological researchers making compounds labeled with iodine isotopes do this, in the wider world such preventive measures are usually not stockpiled before an accident, nor are they distributed adequately afterward. One consequence of the Chernobyl disaster was an increase in thyroid cancers in children in the years following the accident. The use of iodized salt is an efficient way to add iodine to the diet. It has eliminated endemic cretinism in most developed countries, and some governments have made the iodination of flour or salt mandatory. Potassium iodide and Sodium iodide are the most active forms of supplemental iodine. Contradictory, recent studies on some populations are showing that excess of iodine could be related to the raise of autoimmune disease driving to permanent Hypothyroidism. Some governments are reviewing the quantity of iodine added to salt using local salt consumption data.
Pathophysiology of Hyperthyroidism
Predisposing Factors Precipitating Factors - heredity - excessive intake of iodine - endocrine abnormalities - stress (Diabetes mellitus, thyroiditis) - surgery - production of autoantibodies - infection - toxemia of pregnancy - diabetic ketoacidosis
↑ Thyroid hormones
• ↑metabolic rate; oxygen consumption • ↑ Calorigenesis • Altered protein, fat, carbohydrate metabolism • Stimulation of bone and bone marrow functions (bone resorption of calcium) • ↑ Sympathetic activity and CNS function • Altered reproductive function
Changes in body
Hyperthyroidism/ Thyrotoxicosis
Signs and Symptoms:
Thyroid Disturbances Ophthalmopathy
- Restlessness, nervousness, irritability, agitation - exophthalmos
- Fine tremors - accumulation of fluids at the
- Tachycardia fat pads behind the eyeballs,
- Hypertension pushing the eyeballs forward
- ↑ Appetite to eat
- Weight loss
- Diaphoresis
- Diarrhea
- Heat intolerance
- Fine silky hair
- Pliable nails
Treatment/Management
Nursing Management Medical Management Surgical Management
- Record V/Sand weight - Adrenergic blocking agents - Thyroidectomy
- Carefully serum electrolytes - Sodium iodide
- Avoid excessive palpation of - Glucocorticoids the thyroid - Dexamethasone
- Closely monitor BP - Propylthiouracil
- Check intake and output
- High-calorie, high protein diet
Disease Process and its Effects on the Organ/Systems Hyperthyroidism is the term for overactive tissue within the thyroid gland, resulting in overproduction and thus an excess of circulating free thyroid hormones: thyroxine (T4), triiodothyronine (T3), or both. Thyroid hormone is important at a cellular level, affecting nearly every type of tissue in the body. Thyroid hormone functions as a stimulus to metabolism, and is critical to normal function of the cell. In excess, it both overstimulates metabolism and exacerbates the effect of the sympathetic nervous system, causing "speeding up" of various body systems, and symptoms resembling an overdose of epinephrine (adrenalin). These include fast heart beat and symptoms of palpitations; nervous system tremor and anxiety symptoms; digestive system hypermotility (diarrhea), and weight loss. Lack of functioning thyroid tissue results in a symptomatic lack of thyroid hormone, termed hypothyroidism.
Causes
Functional thyroid tissue producing an excess of thyroid hormone occurs in a number of clinical conditions. The major causes in humans are: • Graves' disease (the most common etiology with 70-80%) • Toxic thyroid adenoma • Toxic multinodular goitre High blood levels of thyroid hormones (most accurately termed hyperthyroxinemia) can occur for a number of other reasons: • Inflammation of the thyroid is called thyroiditis. There are a number of different kinds of thyroiditis including Hashimoto's (immune mediated), and subacute (DeQuervain's). These may be initially associated with secretion of excess thyroid hormone, but usually progress to gland dysfunction and thus, to hormone deficiency and hypothyroidism. • Oral consumption of excess thyroid hormone tablets is possible, as is the rare event of consumption of ground beef contaminated with thyroid tissue, and thus thyroid hormone (termed "hamburger hyperthyroidism"). • Amiodarone, an anti-arrhythmic drug is structurally similar to thyroxine and may cause both under- or overactivity of the thyroid. • Postpartum thyroiditis (PPT) occurs in about 7% of women during the year after they give birth. PPT typically has several phases, the first of which is hyperthyroidism. This form of hyperthyroidism usually corrects itself within weeks or months without the need for treatment.
Signs and symptoms
Major clinical signs include weight loss (often accompanied by an increased appetite), anxiety, intolerance to heat, fatigue, hair loss, weakness, hyperactivity, irritability, apathy, depression, polyuria, polydipsia, delirium, and sweating. Additionally, patients may present with a variety of symptoms such as palpitations and arrhythmias (notably atrial fibrillation), shortness of breath (dyspnea), loss of libido, nausea, vomiting, and diarrhea. Long term untreated hyperthyroidism can lead to osteoporosis. In the elderly, these classical symptoms may not be present. Neurological manifestations can include tremors, chorea, myopathy, and in some susceptible individuals (particularly of asian descent) periodic paralysis. An association between thyroid disease and myasthenia gravis has been recognized. The thyroid disease, in this condition, is autoimmune in nature and approximately 5% of patients with myasthenia gravis also have hyperthyroidism. Myasthenia gravis rarely improves after thyroid treatment and the relationship between the two entities is not well understood. Some very rare neurological manifestations that are dubiously associated with thyrotoxicosis are pseudotumor cerebri, amyotrophic lateral sclerosis and a Guillain-Barré-like syndrome. Minor ocular (eye) signs, which may be present in any type of hyperthyroidism, are eyelid retraction ("stare") and lid-lag. In hyperthyroid stare (Dalrymple sign) the eyelids are retracted upward more than normal (the normal position is at the superior corneoscleral limbus, where the "white" of the eye begins at the upper border of the iris). In lid-lag (von Graefe's sign), when the patient tracks an object downward with their eyes, the eyelid fails to follow the downward moving iris, and the same type of upper globe exposure which is seen with lid retraction occurs, temporarily. These signs disappear with treatment of the hyperthyroidism. Neither of these ocular signs should be confused with exophthalmos (protrusion of the eyeball) which occurs specifically and uniquely in Graves' disease. This forward protrusion of the eyes is due to immune mediated inflammation in the retro-orbital (eye socket) fat. Exophthalmos, when present, may exacerbate hyperthyroid lid-lag and stare.[1] Thyrotoxic crisis is a rare but severe complication of hyperthyroidism, which may occur when a thyrotoxic patient becomes very sick or physically stressed. Its symptoms can include: an increase in body temperature to over 40 degrees Celsius (104 degrees Fahrenheit), tachycardia, arrhythmia, vomiting, diarrhea, dehydration, coma and death.
Treatment
The major and generally accepted modalities for treatment of hyperthyroidism in humans involve initial temporary use of suppressive thyrostatics medication, and possibly later use of permanent surgical or radioisotope therapy. All approaches may cause under active thyroid function (hypothyroidism) which is easily managed with levothyroxine supplementation.
1. Temporary medical therapy:
Thyrostatics
Thyrostatics are drugs that inhibit the production of thyroid hormones, such as carbimazole (used in UK) and methimazole (used in US), and propylthiouracil. Thyrostatics are believed to work by inhibiting the iodination of thyroglobulin by thyroperoxidase, and thus, the formation of tetra-iodothyronine (T4). Propylthiouracil also works outside the thyroid gland, preventing conversion of (mostly inactive) T4 to the active form T3. Because thyroid tissue usually contains a substantial reserve of thyroid hormone, thyrostatics can take weeks to become effective, and the dose often needs to be carefully titrated over a period of months. A very high dose is often needed early in treatment, but if too high a dose is used persistently, patients can develop symptoms of hypothyroidism.
Beta-blockers
Many of the common symptoms of hyperthyroidism such as palpitations, trembling, and anxiety are mediated by increases in beta adrenergic receptors on cell surfaces. Beta blockers are a class of drug which offset this effect, reducing rapid pulse associated with the sensation of palpitations, and decreasing tremor and anxiety. This doesn't help the underlying problem of excess thyroid hormone, but makes the symptoms much more manageable, particularly as definitive treatment with thryostatic drugs can take a number of months to work. Propranolol in the UK, and Metoprolol in the US, are most frequently used to augment treatment for hyperthyroid patients.
2. Permanent treatments
Surgery as an option predates the use of the less invasive radioisotope therapy, but is still required in cases where the thyroid gland is enlarged and causing compression to the neck structures, or the underlying cause of the hyperthyroidism may be cancerous in origin.
Surgery
Surgery (to remove the whole thyroid or a part of it) is not extensively used because most common forms of hyperthyroidism are quite effectively treated by the radioactive iodine method. However, some Graves' disease patients who cannot tolerate medicines for one reason or another, patients who are allergic to iodine, or patients who refuse radioiodine opt for surgical intervention. Also, some surgeons believe that radioiodine treatment is unsafe in patients with unusually large gland, or those whose eyes have begun to bulge from their sockets, claiming that the massive dose of iodine needed will only exacerbate the patient's symptoms. The procedure is quite safe - some surgeons even perform partial thyroidectomies on an out-patient basis.
Radioiodine
In iodine-131 (Radioiodine) radioisotope therapy, radioactive iodine-131 is given orally (either by pill or liquid) on a one-time basis to destroy the function of a hyperactive gland. Patients who do not respond to the first dose are sometimes given an additional radioactive iodine treatment in a larger dose. The iodine given for ablative treatment is different from the iodine used in a scan. Radioactive iodine is given after a routine iodine scan, and uptake of the iodine is determined to confirm hyperthyroidism. The radioactive iodine is picked up by the active cells in the thyroid and destroys them. Since iodine is only picked up by thyroid cells (and picked up more readily by over-active thyroid cells), the destruction is local, and there are no widespread side effects with this therapy. Radioactive iodine ablation has been safely used for over 50 years, and the only major reasons for not using it are pregnancy and breast-feeding.
Comparative Chart of the Clinical and Classical Signs and Symptoms
Pre-Operative
|Classical Symptoms |Clinical Symptoms |Rationale |
| increased blood pressure |Not manifested |Thyroid hormones directly stimulate the |
| | |heart. It results to increased heart rate |
| | |causing increased cardiac and blood flow. |
| | |Source: Medical Surgical Nursing 5th ed. |
| | |Vol. 2 pg. 1481 by Ignatavicius |
| | |Reflects hyper metabolic states in which |
| | |nutrients needed for cellular energy and |
| | |growth are lacking. |
|fatigue |Manifested |Source: Signs and Symptoms, Lippincott |
| |The patient complaints fatigue. |Williams and Wilkins pg. 172 |
| | |Produces a continuous feeling of being |
| | |overheated and at times, profuse |
| | |diaphoresis due to hyper metabolism. |
| | |Source: Signs and Symptoms, Lippincott |
| | |Williams and Wilkins pg. 471 |
| |Not manifested |The weight loss is due to the unexplained |
|heat Intolerance | |loss of lean body tissue like muscle, not |
| | |due to loss of fat. |
| | |Source: Understanding of pathophysiology |
| | |3rd ed. Pg. 482 by Huether |
| | | |
| | | |
| | | |
| | |Visual changes may be the earliest problem |
| |Manifested |client may manifest. Visual changes such as|
|weight loss |The patient has an increased appetite in |blurring of vision occur maybe because of |
| |food. Food intake does not meet energy |eye muscle fatigability due to increased |
| |demands and she losses weight. |release of thyroid hormones leading to |
| |Before hospitalization, her weight is 53 |difficulty falling asleep and then sleeping|
| |kgs. |for only a brief of time. |
| |During hospitalization. Her weight is 50 |Source: Signs and Symptoms, Lippincott |
| |kgs. |Williams and Wilkins pg. 372 |
| |Manifested |Increased in transcription in cellular |
| |The patient verbalized that she cannot |proteins causing an increase in the basal |
| |sleep. There is presence of dark circles |metabolic rate. |
|insomnia |under her eyes. She can only sleep “20-30 |Source: Understanding of pathophysiology |
| |minutes” then she will wake up again |3rd ed. Pg. 483 by Huether |
| |because of what she feels, nervousness. |Thyroid hormones directly stimulate the |
| | |heart. It results to increased heart rate |
| | |causing increased cardiac and blood flow. |
| | |Source: Medical Surgical Nursing 5th ed. |
| | |Vol. 2 pg. 1481 by Ignatavicius |
| | |Increased work in breathing would be the |
| | |result of decreased lung compliance. |
| |Not manifested |Source: Medical Surgical Nursing 5th ed. |
| | |Vol. 2 pg. 636 by Ignatavicius |
| | | |
| | | |
| | | |
| | | |
| | | |
|warm, moist hands | | |
| |Manifested | |
| |The patient has a heart of 102 bpm. | |
| | | |
| | | |
| | | |
| | | |
| | | |
|irregular pulse rate |Not manifested | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
|breathlessness | | |
Post-Operative
|Classical Symptoms |Clinical Symptoms |Rationale |
| | | |
|Respiratory obstruction |Not manifested |Respiratory obstruction caused by edema of |
| | |the glottis, bilateral laryngeal nerve |
| | |damage, or tracheal compression from |
| | |hemorrhage. |
| | |Source: Medical Surgical Nursing 7th ed. |
| | |Vol. 1 pg. 1205 by Black |
| | | |
| | |Weakness and hoarseness of voice from |
| | |trauma or damage to one laryngeal nerve. |
| | |Source: Medical Surgical Nursing 7th ed. |
|Weakness and hoarseness of voice |Not manifested |Vol. 1 pg. 1205 by Black |
| | | |
| | |Hypocalcemia and tetany from accidental |
| | |removal of one or more parathyroid glands. |
| | |Source: Medical Surgical Nursing 7th ed. |
| | |Vol. 1 pg. 1205 by Black |
| | | |
|Hypocalcemia and tetany | |Hemorrhage is most likely to occur during |
| |Not manifested |the first 24 hours after surgery. It may |
| | |also be seen as bleeding at the incision |
| | |site or as respiratory distress caused by |
| | |tracheal compression |
| | |Source: Medical Surgical Nursing 5th ed. |
| | |Vol. 2 pg. 1487 by Ignatavicius |
|Hemorrhage | | |
| | |Muscle cramps and spasm from accidental |
| |Not manifested |removal of one or more parathyroid glands. |
| | |Source: Medical Surgical Nursing 7th ed. |
| | |Vol. 1 pg. 1205 by Black |
| | | |
| | |Decreased vocal range from trauma or damage|
| | |to one laryngeal nerve. |
| | |Source: Medical Surgical Nursing 7th ed. |
| | |Vol. 1 pg. 1205 by Black |
| | | |
| | | |
| | | |
|muscles cramps and spasm | | |
| | | |
| |Not manifested | |
| | | |
| | | |
| | | |
| | | |
|decreased vocal range | | |
| | | |
| | | |
| |Not manifested | |
| | | |
how the patient obtains such disease. The student nurse would also like to discern more interventions that would ease the patient’s condition, the student nurse would also want to relate the manifestations and do research through books, journals and even in internet. Conveying knowledge to the patient as well as the significant others and expounding and instructing possible interventions. Hyperthyroidism may due to over functioning of the entire gland or, less commonly to single or multiple functioning adenomas of thyroid cancer. Over treatment of myxedema with thyroid hormones may also result in hyperthyroidism. The most common form of hyperthyroidism is Grave’s disease (toxic, diffuse goiter), which has three principal hallmarks: hyperthyroidism, thyroid enlargement (goiter), and exophthalmos (abnormal protrusion of eyes. Grave’s disease is an autoimmune disorder mediated by immunoglobulin G (IgG) antibody that binds to and activates thyroid stimulating hormone receptors on the surface of the thyroid cells. Other causes of hyperthyroidism include toxic nodular goiter, toxic adenoma (benign), and thyroid carcinoma, subacute and chronic thyroiditis, ingestion of thyroid hormones, and ingestion of amiodarone hydrochloride for atrial fibrillation. Health maintenance and restoration activities include monitoring thyroid levels if thyroid replacement is given, removal of thyroid tumors and administration of antithyroid medications. Thyroidectomy involves the surgical removal of all or part of the thyroid gland. Surgeons often perform a Thyroidectomy when a patient has thyroid cancer or some other condition of the thyroid gland (such as hyperthyroidism). Other indications for surgery include cosmetic (much enlarged thyroid), or symptomatic obstruction (causing difficulties in swallowing or breathing). One of the complications of "Thyroidectomy" is voice change and patients are strongly advised to only be operated on by surgeons who protect the voice by using electronic nerve monitoring
Objective
Student Nurse Centered Objectives
General Objectives: After 1 day of student nurse-patient interaction, the student nurse will be able to acquire knowledge, skills and attitude in the care of patient with Right Thyroid Goiter who underwent Subtotal Thryroidectomy.
Specific Objectives: After 45 minutes of student nurse-patient interaction, the student nurse will be able to: 1. establish rapport to the patient. 2. discuss the anatomy and physiology of the thyroid gland. 3. impart knowledge about hyperthyroidism, hypothyroidism and thyroidectomy. 4. relate the condition of the patient in accordance with the pathophysiology of the disease process. 5. name the signs and symptoms of hyperthyroidism and hypothyroidism. 6. inform knowledge about the possible complications of the disease condition. 7. plan a comprehensive health teaching plan for patient who undergone thyroidectomy. 8. create a health teaching plan for a patient with right thyroid goiter who undergone Subtotal Thryroidectomy. 9. equip adequate nursing care and therapeutic interventions to the patient. 10. promote positive attitude towards caring the patient.
Patient Centered Objectives
General Objectives: After 1 day of holistic nursing care, the patient and significant others will be able to gain knowledge, skills and attitude about the management of the condition.
Specific Objectives: After 45 minutes of student nurse-patient interaction, the patient and significant others will be able to:
1. establish rapport with the student nurse. 2. define thyroidectomy, hyperthyroidism and hypothyroidism at the level of her understanding. 3. elaborate the possible factors that contributes to the occurrence of right thyroid goiter. 4. enumerate the clinical manifestations of right thyroid goiter. 5. determine the possible treatment for right thyroid goiter like eating food rich in iodine such as seafoods. 6. enumerate the complications that may occur during early stage of the disease process. 7. establish positive outlook towards optimum level of functioning.
Nursing Assessment
Personal History Patient’s Profile Name: Mrs. Rebecca S. Villanueva Age: 60 years old Sex: Female Civil Status: Married Religion: Roman Catholic Date of Admission: January 31, 2011 at 7pm Room No.: Surgical Mission 35 Complaints: Anterior Neck Mass Diagnosis: Right Thyroid Goiter Physician: Dr. Penserga
Family and Individual Information
Mrs. Rebecca S. Villanueva married to Rodolfo Villanueva with 4 offsprings, 3 male and 1 female. Her family currently living at Bilwang, Isabel Leyte. She was admitted to OSPA last January 31, 2011 at 7pm under surgical mission of Society of Philippine Surgeons American Association (SPSA) headed by Congresswoman Lucy Torres-Gomez. She is only a housewife. Twenty-five years prior to admission, patient noted a growing mass on her anterior neck portion but can be tolerated. She has a medication maintained to maintain for her goiter, which is Tyrax 600mg per day. But she has known hypertension with BP controlled by taking Metoprolol 100g 1 tab BID. This was her first time to be admitted in the said hospital. According to her, they have a familial disease of goiter, and she has no allergies to foods.
Level of Growth and Development at a Particular Stage
Normal Growth and Development Some adults are financially dependent on their families for many years. Adulthood may also be indicated by moving away from home and establishing one’s own living arrangements. Yet this independence also varies greatly. In recent years, however more young adults have been choosing to remain at home. In addition, many adults under 30 have returned to their parent’s homes to live. Maturity is the state of maximal function and integration or the state of being fully developed. Mature individuals are guided by an underlying philosophy of life. Mature persons are open to new experiences and continued growth; they can tolerate ambiguity are flexible, and can adapt to change. In addition, mature people have the quality of self-acceptance; they are able to be reflective and insightful about life and to see themselves as others see them. Young adults are typically busy people who face many challenges. They are expected to assume some new roles at work in the home and in the community, and to develop interest, values and attitudes related to these roles.
Physical Development People in their own early 20’s are in their prime physical years. The musculoskeletal system is well developed and coordinated. This is the period of when athletic endeavors reach their peak. All other systems of the body (e.g., cardiovascular, visual, auditory, and reproductive) are also functioning at peak efficiency. Although physical changes are minimal during this stage, weight and muscle mass may change as a result of diet and exercise. In addition, extensive physical and psychosocial changes occur in pregnant and lactating women.
Psychosocial Development According to Erikson, adulthood is in the intimate relationship versus isolation wherein intimate relationship with another person and commitment to work and relationships. The other side of isolation wherein there is an impersonal relationships; avoidance of relationship, career or lifestyle commitments.
Cognitive Development Piaget believes that cognitive structures are complete during the formal operations period, from roughly 11 to 15 years. From that time, formal operations (for example, generating hypotheses) characterize thinking throughout adulthood and are applied to more areas. Egocentrism continues to decline; however according to Piaget these changes do not involve a change in the structure of thought, only a change in its content and stability. Recently, researches in the field of psychology have suggested that Piaget’s formal operational stage is not the last stage of human development. Some have proposed a concept of post formal thought. Post formal thought, sometimes called the problem finding stage, is (some have proposed a concept of post formal) characterized by “creative thought in the form of discovered problems, relativistic thinking, the formation of generic problems, the raising of general questions from ill-defined problems, the use of intuition, insight and hunches, and the development of significant scientific thought.” In addition to the adolescent ability to think in abstract terms, post formal thinkers process an understanding of the temporary or relative nature of knowledge. They are able to comprehend and balance arguments created by both logic and emotion.
Moral Development Young adults who have mastered the previous stages of Kohlberg’s theory of moral development now enter the post conventional level. At this time, the person is able to separate self from the expectations and rules of others and to define morality in terms of personal principles. When individuals perceive a conflict with society’s rules or laws, they judge according to their own principles. Gilligan argues that as individuals approach young adulthood, men and women tend to define moral problems somewhat differently. Men often use an “ethic of justice” and define in terms of obligation to care and to avoid hurt.
Spiritual Development According to Fowler, the individual enters the individuating-reflective period sometime after 18 years of age. During this period, the individual focuses on reality. 27 years-old adult may ask philosophic questions regarding spirituality and may be self-conscious about spiritual matters. The religious teaching that the young adult has a child may now be accepted or redefined.
The Ill Person at This Stage of the Patient
Adulthood is generally a healthy time of life. Health problems that do not occur and are common in this age group include accidents, suicide, substance abuse, hypertension, sexually transmitted disease, abuse women, and certain malignancies. Some of the accidents such as accidents, substance abuse, and sexually transmitted disease are related to behaviors that could possibly be prevented through appropriate education and other primary prevention strategies. Thoroughly assessment and patient-specific management are necessary in order for those factors that contribute to the severity of the patient will be prevented. During the patient hospitalization, she is always lying on bed. She doesn’t want to so some stretching exercises because she feels fatigue and dizziness. Her diet is soft diet, due to post-operative condition. She was always complaining about odynophagia (pain swallowing) and fatigue. Sometimes she is anxious because she always thinks about her condition.
Functional Health Pattern (Pre-Operative)
Health Perception/Health Management Mrs. Rebecca S. Villanueva understands the cause why she had acquired that certain disease and effect behind it. The student nurse asked what she thinks about her disease and she said that she is looking forward for the success of her operation. She also stated that she usually eat 3 times per day.
Nutritional-Metabolic Pattern Before admission, she used to eat 3 times a day with 1 cup of rice with fish and vegetables. She only eats meat sometimes due to insufficient income. She drinks 8-10 glasses of water. She has no allergies to foods and medications.
Activity/ Exercise Pattern Before admission she does household chore everyday. While during her hospitalization she always lying on bed and felt pain and fatigue.
Cognitive/Perceptual Pattern Patient has no sensory deficit, she was oriented to time and place so as the person. She responds to verbal and physical stimuli.
Rest/Sleep Pattern Before hospitalization, she sleeps 6-7 hours per day. She sleeps at 11pm and wakes up at 6am, but during her admission she can’t sleep well due to environmental factor. She tries to sleep at 11pm then suddenly she wakes up at 3am.
Self-Perception Pattern Even though that she has a goiter, still it’s not the end of the world for her. There are always solutions in every problem. Mrs. Villanueva is hoping for a better recovery from the said condition. She perceives herself as an important one because she loves her family and they need her, she want to love, care and serve her family until the last breath of her life.
Roles/ Relationship Pattern Mrs. Rebecca S. Villanueva lives with her husband, Rodolfo Villanueva and with her 4 offspring. She expresses a good relationship with her family members, she only does household chores and sometimes she cook if someone ordered. Mrs. Villanueva’s role in the family is she’s the one who took care of the house and her family members which include her loving and supportive husband and a loving offspring.
Sexuality-Reproductive Pattern Mrs. Villanueva is now 60 years old, she is in genital stage according to Sigmund Freud’s stage of development, where energy is directed towards full sexual maturity and function and development of skills needed to cope with the environment. According to Mrs. Villanueva, her sexual relationship with her husband is good. They understand each other and they plan those actions regarding their family’s status.
Coping-Stress Tolerance Pattern According to Mrs. Villanueva, her way of coping from such problems is through prayers, expression and verbalization of her thoughts and feelings to her husband and sometimes in family members. Prior to surgery, her coping management was stronger faith in God with prayers for her surgery and looking forward for better result and recovery.
Values-Belief System Mrs. Villanueva was a Roman Catholic. They are all God-fearing and always attend mass. And her faith in God goes stronger and concrete every minutes of her time. She also believe on superstitious belief, but she quoted that even if she believes in superstitious still her faith and love in God doesn’t change, she is always loyal and God-fearing to whom he believe in.
Functional Health Pattern (Post-Operative)
Health Perception/Health Management Mrs. Villanueva understands and she is well aware of her current condition that she would lessen the causes and factors that would trigger the reoccurrence of her condition, such as stress, lack of iodine intake and too much toxic nodular goiter. Eating nutritious foods, fruits and adequate rest and sleep would help her recover and the reoccurrence of goiter would be prevented.
Nutritional-Metabolic Pattern Post-operatively, the patient was instantaneously to NPO for the first 15 hours and then DAT was ordered by the attending physician. After which, if the patient was allowed to eat anything if she can tolerate to eat and swallow semi-solid or solid food.
Elimination Pattern 1 day after the surgery, the patient was not able to defecate. Though, the bowel sound had returned within 24 hours after the procedure. With the concern to her bladder elimination, she can urinate 4-6 times per shift with an average of 800ml of urine per shift.
Activity/ Exercise Pattern Post-operatively, patient’s activity was limited and encourages bed rest for faster recovery. 1 Day after the surgery, the patient was encourage to begin ambulation like sluggish walk from bed to comfort room.
Cognitive/Perceptual Pattern Mrs. Villanueva was a high school level. She has no sensory deficit, but she has a difficulty in maintaining a long conversation due to pain on her anterior neck post operatively and odynophagia.
Rest/Sleep Pattern Post-operatively, the patient can only sleep more or less than 4 hours due to environmental factors that interferes her sleep pattern.
Self-Perception Pattern Even though the patient accepts her condition at present and is willing to undergo surgery, still she express worries and concerns, if she can conquer her problem. For her, she needs to be cured and recover fast in order for her to go back to her normal and regular work and to take care for her family so that her family won’t be worried about her.
Sexuality-Reproductive Pattern Although Mrs. Villanueva underwent to surgery which is thyroidectomy, according to her, her relationship to her husband regarding sexuality doesn’t change. They understand one another and they really plan those actions for their family’s status. Even though she is still in recovery stage after the procedure, her husband still anticipates for enough rest and sleep to get along with the condition.
Coping-Stress Tolerance Pattern Post-operatively, Mrs. Villanueva’s way of coping from the problems is through sharing to her husband of what she feels after the surgery and through prayers. She already accepts her condition and the needs for enough rest and sleep periods.
Values-Belief System Post-operatively, Mrs. Villanueva continues to believe in God. She believes that this condition she felt right now is a test given by God. She remains loyal and trust God every consequences she encountered. She also believe that every problem has always a great solutions.
Patient’s Name: Mrs. Rebecca S. Villanueva
Impression/Diagnosis: Right Thyroid Goiter
Attending physician: Dr. Penserga
Pre-Operative Diagnostic Test
|Diagnostic Test |Normal Values |Patient’s Result |Significance |
|Hematology | | | |
|January 31, 2011 | | | |
|Hemoglobin |12.3-15.3 |13.1mg/dL |Normal |
|Hematocrit |35.9-44.6 |40 % |Normal |
|Red Blood Cells |4.5-5.9 |4.67 10^2/L |Normal |
| | | | |
| | | | |
|White Blood Cells |4,000-11,000 |12,240 10^3/L |Increased; indicate infection |
| | | |such abscess, meningitis, |
| | | |appendicitis or tonsillitis |
| | | |Normal |
| | | |Normal |
|MCV |80-96 |86 fL |Normal |
|MCH |27-32 |28.1 |Normal |
|Platelet Count |150,000-450,000 |355,000 |Normal |
|Neutrophils |40-70 |60.3 % |Normal |
|Basophils |0-1 |0.3 % |Normal |
|Eosinophils |1-5 |3.9 % |Normal …show more content…
|
|Lymphocytes |20-40 |29.7 % | |
|Monocytes |0-8 |5.8 % | |
Pathophysiology and Rationale
Anatomy and Physiology of Thyroid Gland
[pic]
The thyroid is one of the largest endocrine glands in the body. This gland is found in the neck inferior to (below) the thyroid cartilage (also known as the Adam's apple in men) and at approximately the same level as the cricoid cartilage. The thyroid controls how quickly the body burns energy, makes proteins, and how sensitive the body should be to other hormones. The thyroid participates in these processes by producing thyroid hormones, principally thyroxine (T4) and triiodothyronine (T3). These hormones regulate the rate of metabolism and affect the growth and rate of function of many other systems in the body. Iodine is an essential component of both T3 and T4. The thyroid also produces the hormone calcitonin, which plays a role in calcium homeostasis. The thyroid is controlled by the hypothalamus and pituitary. The gland gets its name from the Greek word for "shield", after the shape of the related thyroid cartilage. Hyperthyroidism (overactive thyroid) and hypothyroidism (underactive thyroid) are the most common problems of the thyroid gland.
Anatomy
The thyroid gland is butterfly-shaped organ and is composed of two cone-like lobes or wings: lobus dexter (right lobe) and lobus sinister (left lobe), connected with the isthmus. The organ is situated on the anterior side of the neck, lying against and around the larynx and trachea, reaching posteriorly the oesophagus and carotid sheath. It starts cranially at the oblique line on the thyroid cartilage (just below the laryngeal prominence or Adam's apple) and extends inferiorly to the fourth to sixth tracheal ring. It is difficult to demarcate the gland's upper and lower border with vertebral levels as it moves position in relation to these during swallowing. The thyroid isthmus is variable in presence and size, and can encompass a cranially extending pyramid lobe (lobus pyramidalis or processus pyramidalis), remnant of the thyroglossal duct. The thyroid is one of the larger endocrine glands, weighing 2-3 grams in neonates and 18-60 grams in adults, and is increased in pregnancy. The thyroid is supplied with arterial blood from the superior thyroid artery, a branch of the external carotid artery, and the inferior thyroid artery, a branch of the thyrocervical trunk, and sometimes by the thyroid ima artery, branching directly from the aortic arch. The venous blood is drained via superior thyroid veins, draining in the internal jugular vein, and via inferior thyroid veins, draining via the plexus thyroideus impar in the left brachiocephalic vein. Lymphatic drainage passes frequently the lateral deep cervical lymph nodes and the pre- and parathracheal lymph nodes. The gland is supplied by sympathetic nerve input from the superior cervical ganglion and the cervicothoracic ganglion of the sympathetic trunk, and by parasympathetic nerve input from the superior laryngeal nerve and the recurrent laryngeal nerve.
Physiology
The primary function of the thyroid is production of the hormones thyroxine (T4), triiodothyronine (T3), and calcitonin. Up to 80% of the T4 is converted to T3 by peripheral organs such as the liver, kidney and spleen. T3 is about ten times more active than T4.
T3 and T4 production and action
Thyroxine (T4) is synthesized by the follicular cells from free tyrosine and on the tyrosine residues of the protein called thyroglobulin (TG). Iodine is captured with the "iodine trap" by the hydrogen peroxide generated by the enzyme thyroid peroxidase (TPO)[6] and linked to the 3' and 5' sites of the benzene ring of the tyrosine residues on TG, and on free tyrosine. Upon stimulation by the thyroid-stimulating hormone (TSH), the follicular cells reabsorb TG and proteolytically cleave the iodinated tyrosines from TG, forming T4 and T3 (in T3, one iodine is absent compared to T4), and releasing them into the blood. Deiodinase enzymes convert T4 to T3. Thyroid hormone that is secreted from the gland is about 90% T4 and about 10% T3. Cells of the brain are a major target for the thyroid hormones T3 and T4. Thyroid hormones play a particularly crucial role in brain maturation during fetal development.[8] A transport protein (OATP1C1) has been identified that seems to be important for T4 transport across the barrier. A second transport protein (MCT8) is important for T3 transport across brain cell membranes. In the blood, T4 and T3 are partially bound to thyroxine-binding globulin, transthyretin and albumin. Only a very small fraction of the circulating hormone is free (unbound) - T4 0.03% and T3 0.3%. Only the free fraction has hormonal activity. As with the steroid hormones and retinoic acid, thyroid hormones cross the cell membrane and bind to intracellular receptors (α1, α2, β1 and β2), which act alone, in pairs or together with the retinoid X-receptor as transcription factors to modulate DNA transcription.
T3 and T4 regulation
The production of thyroxine and triiodothyronine is regulated by thyroid-stimulating hormone (TSH), released by the anterior pituitary (that is in turn released as a result of TRH release by the hypothalamus).
The thyroid and thyrotropes form a negative feedback loop: TSH production is suppressed when the T4 levels are high, and vice versa. The TSH production itself is modulated by thyrotropin-releasing hormone (TRH), which is produced by the hypothalamus and secreted at an increased rate in situations such as cold (in which an accelerated metabolism would generate more heat). TSH production is blunted by somatostatin (SRIH), rising levels of glucocorticoids and sex hormones (estrogen and testosterone), and excessively high blood iodide
concentration.
Calcitonin
An additional hormone produced by the thyroid contributes to the regulation of blood calcium levels. Parafollicular cells produce calcitonin in response to hypercalcemia. Calcitonin stimulates movement of calcium into bone, in opposition to the effects of parathyroid hormone (PTH). However, calcitonin seems far less essential than PTH, as calcium metabolism remains clinically normal after removal of the thyroid, but not the parathyroids.
Significance of iodine
In areas of the world where iodine (essential for the production of thyroxine, which contains four iodine atoms) is lacking in the diet, the thyroid gland can be considerably enlarged, resulting in the swollen necks of endemic goiter. Thyroxine is critical to the regulation of metabolism and growth throughout the animal kingdom. Among amphibians, for example, administering a thyroid-blocking agent such as propylthiouracil (PTU) can prevent tadpoles from metamorphosing into frogs; conversely, administering thyroxine will trigger metamorphosis. In humans, children born with thyroid hormone deficiency will have physical growth and development problems, and brain development can also be severely impaired, in the condition referred to as cretinism. Newborn children in many developed countries are now routinely tested for thyroid hormone deficiency as part of newborn screening by analysis of a drop of blood. Children with thyroid hormone deficiency are treated by supplementation with synthetic thyroxine, which enables them to grow and develop normally. Because of the thyroid's selective uptake and concentration of what is a fairly rare element, it is sensitive to the effects of various radioactive isotopes of iodine produced by nuclear fission. In the event of large accidental releases of such material into the environment, the uptake of radioactive iodine isotopes by the thyroid can, in theory, be blocked by saturating the uptake mechanism with a large surplus of non-radioactive iodine, taken in the form of potassium iodide tablets. While biological researchers making compounds labeled with iodine isotopes do this, in the wider world such preventive measures are usually not stockpiled before an accident, nor are they distributed adequately afterward. One consequence of the Chernobyl disaster was an increase in thyroid cancers in children in the years following the accident. The use of iodized salt is an efficient way to add iodine to the diet. It has eliminated endemic cretinism in most developed countries, and some governments have made the iodination of flour or salt mandatory. Potassium iodide and Sodium iodide are the most active forms of supplemental iodine. Contradictory, recent studies on some populations are showing that excess of iodine could be related to the raise of autoimmune disease driving to permanent Hypothyroidism. Some governments are reviewing the quantity of iodine added to salt using local salt consumption data.
Pathophysiology of Hyperthyroidism
Predisposing Factors Precipitating Factors - heredity - excessive intake of iodine - endocrine abnormalities - stress (Diabetes mellitus, thyroiditis) - surgery - production of autoantibodies - infection - toxemia of pregnancy - diabetic ketoacidosis
↑ Thyroid hormones
• ↑metabolic rate; oxygen consumption • ↑ Calorigenesis • Altered protein, fat, carbohydrate metabolism • Stimulation of bone and bone marrow functions (bone resorption of calcium) • ↑ Sympathetic activity and CNS function • Altered reproductive function
Changes in body
Hyperthyroidism/ Thyrotoxicosis
Signs and Symptoms:
Thyroid Disturbances Ophthalmopathy
- Restlessness, nervousness, irritability, agitation - exophthalmos
- Fine tremors - accumulation of fluids at the
- Tachycardia fat pads behind the eyeballs,
- Hypertension pushing the eyeballs forward
- ↑ Appetite to eat
- Weight loss
- Diaphoresis
- Diarrhea
- Heat intolerance
- Fine silky hair
- Pliable nails
Treatment/Management
Nursing Management Medical Management Surgical Management
- Record V/Sand weight - Adrenergic blocking agents - Thyroidectomy
- Carefully serum electrolytes - Sodium iodide
- Avoid excessive palpation of - Glucocorticoids the thyroid - Dexamethasone
- Closely monitor BP - Propylthiouracil
- Check intake and output
- High-calorie, high protein diet
Disease Process and its Effects on the Organ/Systems Hyperthyroidism is the term for overactive tissue within the thyroid gland, resulting in overproduction and thus an excess of circulating free thyroid hormones: thyroxine (T4), triiodothyronine (T3), or both. Thyroid hormone is important at a cellular level, affecting nearly every type of tissue in the body. Thyroid hormone functions as a stimulus to metabolism, and is critical to normal function of the cell. In excess, it both overstimulates metabolism and exacerbates the effect of the sympathetic nervous system, causing "speeding up" of various body systems, and symptoms resembling an overdose of epinephrine (adrenalin). These include fast heart beat and symptoms of palpitations; nervous system tremor and anxiety symptoms; digestive system hypermotility (diarrhea), and weight loss. Lack of functioning thyroid tissue results in a symptomatic lack of thyroid hormone, termed hypothyroidism.
Causes
Functional thyroid tissue producing an excess of thyroid hormone occurs in a number of clinical conditions. The major causes in humans are: • Graves' disease (the most common etiology with 70-80%) • Toxic thyroid adenoma • Toxic multinodular goitre High blood levels of thyroid hormones (most accurately termed hyperthyroxinemia) can occur for a number of other reasons: • Inflammation of the thyroid is called thyroiditis. There are a number of different kinds of thyroiditis including Hashimoto's (immune mediated), and subacute (DeQuervain's). These may be initially associated with secretion of excess thyroid hormone, but usually progress to gland dysfunction and thus, to hormone deficiency and hypothyroidism. • Oral consumption of excess thyroid hormone tablets is possible, as is the rare event of consumption of ground beef contaminated with thyroid tissue, and thus thyroid hormone (termed "hamburger hyperthyroidism"). • Amiodarone, an anti-arrhythmic drug is structurally similar to thyroxine and may cause both under- or overactivity of the thyroid. • Postpartum thyroiditis (PPT) occurs in about 7% of women during the year after they give birth. PPT typically has several phases, the first of which is hyperthyroidism. This form of hyperthyroidism usually corrects itself within weeks or months without the need for treatment.
Signs and symptoms
Major clinical signs include weight loss (often accompanied by an increased appetite), anxiety, intolerance to heat, fatigue, hair loss, weakness, hyperactivity, irritability, apathy, depression, polyuria, polydipsia, delirium, and sweating. Additionally, patients may present with a variety of symptoms such as palpitations and arrhythmias (notably atrial fibrillation), shortness of breath (dyspnea), loss of libido, nausea, vomiting, and diarrhea. Long term untreated hyperthyroidism can lead to osteoporosis. In the elderly, these classical symptoms may not be present. Neurological manifestations can include tremors, chorea, myopathy, and in some susceptible individuals (particularly of asian descent) periodic paralysis. An association between thyroid disease and myasthenia gravis has been recognized. The thyroid disease, in this condition, is autoimmune in nature and approximately 5% of patients with myasthenia gravis also have hyperthyroidism. Myasthenia gravis rarely improves after thyroid treatment and the relationship between the two entities is not well understood. Some very rare neurological manifestations that are dubiously associated with thyrotoxicosis are pseudotumor cerebri, amyotrophic lateral sclerosis and a Guillain-Barré-like syndrome. Minor ocular (eye) signs, which may be present in any type of hyperthyroidism, are eyelid retraction ("stare") and lid-lag. In hyperthyroid stare (Dalrymple sign) the eyelids are retracted upward more than normal (the normal position is at the superior corneoscleral limbus, where the "white" of the eye begins at the upper border of the iris). In lid-lag (von Graefe's sign), when the patient tracks an object downward with their eyes, the eyelid fails to follow the downward moving iris, and the same type of upper globe exposure which is seen with lid retraction occurs, temporarily. These signs disappear with treatment of the hyperthyroidism. Neither of these ocular signs should be confused with exophthalmos (protrusion of the eyeball) which occurs specifically and uniquely in Graves' disease. This forward protrusion of the eyes is due to immune mediated inflammation in the retro-orbital (eye socket) fat. Exophthalmos, when present, may exacerbate hyperthyroid lid-lag and stare.[1] Thyrotoxic crisis is a rare but severe complication of hyperthyroidism, which may occur when a thyrotoxic patient becomes very sick or physically stressed. Its symptoms can include: an increase in body temperature to over 40 degrees Celsius (104 degrees Fahrenheit), tachycardia, arrhythmia, vomiting, diarrhea, dehydration, coma and death.
Treatment
The major and generally accepted modalities for treatment of hyperthyroidism in humans involve initial temporary use of suppressive thyrostatics medication, and possibly later use of permanent surgical or radioisotope therapy. All approaches may cause under active thyroid function (hypothyroidism) which is easily managed with levothyroxine supplementation.
1. Temporary medical therapy:
Thyrostatics
Thyrostatics are drugs that inhibit the production of thyroid hormones, such as carbimazole (used in UK) and methimazole (used in US), and propylthiouracil. Thyrostatics are believed to work by inhibiting the iodination of thyroglobulin by thyroperoxidase, and thus, the formation of tetra-iodothyronine (T4). Propylthiouracil also works outside the thyroid gland, preventing conversion of (mostly inactive) T4 to the active form T3. Because thyroid tissue usually contains a substantial reserve of thyroid hormone, thyrostatics can take weeks to become effective, and the dose often needs to be carefully titrated over a period of months. A very high dose is often needed early in treatment, but if too high a dose is used persistently, patients can develop symptoms of hypothyroidism.
Beta-blockers
Many of the common symptoms of hyperthyroidism such as palpitations, trembling, and anxiety are mediated by increases in beta adrenergic receptors on cell surfaces. Beta blockers are a class of drug which offset this effect, reducing rapid pulse associated with the sensation of palpitations, and decreasing tremor and anxiety. This doesn't help the underlying problem of excess thyroid hormone, but makes the symptoms much more manageable, particularly as definitive treatment with thryostatic drugs can take a number of months to work. Propranolol in the UK, and Metoprolol in the US, are most frequently used to augment treatment for hyperthyroid patients.
2. Permanent treatments
Surgery as an option predates the use of the less invasive radioisotope therapy, but is still required in cases where the thyroid gland is enlarged and causing compression to the neck structures, or the underlying cause of the hyperthyroidism may be cancerous in origin.
Surgery
Surgery (to remove the whole thyroid or a part of it) is not extensively used because most common forms of hyperthyroidism are quite effectively treated by the radioactive iodine method. However, some Graves' disease patients who cannot tolerate medicines for one reason or another, patients who are allergic to iodine, or patients who refuse radioiodine opt for surgical intervention. Also, some surgeons believe that radioiodine treatment is unsafe in patients with unusually large gland, or those whose eyes have begun to bulge from their sockets, claiming that the massive dose of iodine needed will only exacerbate the patient's symptoms. The procedure is quite safe - some surgeons even perform partial thyroidectomies on an out-patient basis.
Radioiodine
In iodine-131 (Radioiodine) radioisotope therapy, radioactive iodine-131 is given orally (either by pill or liquid) on a one-time basis to destroy the function of a hyperactive gland. Patients who do not respond to the first dose are sometimes given an additional radioactive iodine treatment in a larger dose. The iodine given for ablative treatment is different from the iodine used in a scan. Radioactive iodine is given after a routine iodine scan, and uptake of the iodine is determined to confirm hyperthyroidism. The radioactive iodine is picked up by the active cells in the thyroid and destroys them. Since iodine is only picked up by thyroid cells (and picked up more readily by over-active thyroid cells), the destruction is local, and there are no widespread side effects with this therapy. Radioactive iodine ablation has been safely used for over 50 years, and the only major reasons for not using it are pregnancy and breast-feeding.
Comparative Chart of the Clinical and Classical Signs and Symptoms
Pre-Operative
|Classical Symptoms |Clinical Symptoms |Rationale |
| increased blood pressure |Not manifested |Thyroid hormones directly stimulate the |
| | |heart. It results to increased heart rate |
| | |causing increased cardiac and blood flow. |
| | |Source: Medical Surgical Nursing 5th ed. |
| | |Vol. 2 pg. 1481 by Ignatavicius |
| | |Reflects hyper metabolic states in which |
| | |nutrients needed for cellular energy and |
| | |growth are lacking. |
|fatigue |Manifested |Source: Signs and Symptoms, Lippincott |
| |The patient complaints fatigue. |Williams and Wilkins pg. 172 |
| | |Produces a continuous feeling of being |
| | |overheated and at times, profuse |
| | |diaphoresis due to hyper metabolism. |
| | |Source: Signs and Symptoms, Lippincott |
| | |Williams and Wilkins pg. 471 |
| |Not manifested |The weight loss is due to the unexplained |
|heat Intolerance | |loss of lean body tissue like muscle, not |
| | |due to loss of fat. |
| | |Source: Understanding of pathophysiology |
| | |3rd ed. Pg. 482 by Huether |
| | | |
| | | |
| | | |
| | |Visual changes may be the earliest problem |
| |Manifested |client may manifest. Visual changes such as|
|weight loss |The patient has an increased appetite in |blurring of vision occur maybe because of |
| |food. Food intake does not meet energy |eye muscle fatigability due to increased |
| |demands and she losses weight. |release of thyroid hormones leading to |
| |Before hospitalization, her weight is 53 |difficulty falling asleep and then sleeping|
| |kgs. |for only a brief of time. |
| |During hospitalization. Her weight is 50 |Source: Signs and Symptoms, Lippincott |
| |kgs. |Williams and Wilkins pg. 372 |
| |Manifested |Increased in transcription in cellular |
| |The patient verbalized that she cannot |proteins causing an increase in the basal |
| |sleep. There is presence of dark circles |metabolic rate. |
|insomnia |under her eyes. She can only sleep “20-30 |Source: Understanding of pathophysiology |
| |minutes” then she will wake up again |3rd ed. Pg. 483 by Huether |
| |because of what she feels, nervousness. |Thyroid hormones directly stimulate the |
| | |heart. It results to increased heart rate |
| | |causing increased cardiac and blood flow. |
| | |Source: Medical Surgical Nursing 5th ed. |
| | |Vol. 2 pg. 1481 by Ignatavicius |
| | |Increased work in breathing would be the |
| | |result of decreased lung compliance. |
| |Not manifested |Source: Medical Surgical Nursing 5th ed. |
| | |Vol. 2 pg. 636 by Ignatavicius |
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| | | |
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|warm, moist hands | | |
| |Manifested | |
| |The patient has a heart of 102 bpm. | |
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|irregular pulse rate |Not manifested | |
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|breathlessness | | |
Post-Operative
|Classical Symptoms |Clinical Symptoms |Rationale |
| | | |
|Respiratory obstruction |Not manifested |Respiratory obstruction caused by edema of |
| | |the glottis, bilateral laryngeal nerve |
| | |damage, or tracheal compression from |
| | |hemorrhage. |
| | |Source: Medical Surgical Nursing 7th ed. |
| | |Vol. 1 pg. 1205 by Black |
| | | |
| | |Weakness and hoarseness of voice from |
| | |trauma or damage to one laryngeal nerve. |
| | |Source: Medical Surgical Nursing 7th ed. |
|Weakness and hoarseness of voice |Not manifested |Vol. 1 pg. 1205 by Black |
| | | |
| | |Hypocalcemia and tetany from accidental |
| | |removal of one or more parathyroid glands. |
| | |Source: Medical Surgical Nursing 7th ed. |
| | |Vol. 1 pg. 1205 by Black |
| | | |
|Hypocalcemia and tetany | |Hemorrhage is most likely to occur during |
| |Not manifested |the first 24 hours after surgery. It may |
| | |also be seen as bleeding at the incision |
| | |site or as respiratory distress caused by |
| | |tracheal compression |
| | |Source: Medical Surgical Nursing 5th ed. |
| | |Vol. 2 pg. 1487 by Ignatavicius |
|Hemorrhage | | |
| | |Muscle cramps and spasm from accidental |
| |Not manifested |removal of one or more parathyroid glands. |
| | |Source: Medical Surgical Nursing 7th ed. |
| | |Vol. 1 pg. 1205 by Black |
| | | |
| | |Decreased vocal range from trauma or damage|
| | |to one laryngeal nerve. |
| | |Source: Medical Surgical Nursing 7th ed. |
| | |Vol. 1 pg. 1205 by Black |
| | | |
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|muscles cramps and spasm | | |
| | | |
| |Not manifested | |
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|decreased vocal range | | |
| | | |
| | | |
| |Not manifested | |
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