CASE REPORT:

COLLOID NODULAR
GOITER
(THYROIDECTOMY)

I.

Introduction
Colloid nodular goiter is the enlargement of an otherwise normal thyroid

gland. Colloid nodular goiters are also known as endemic goiters. They are
usually caused by not getting enough iodine in the diet. Colloid nodular
goiters tend to occur in certain areas with iodine-poor soil. These areas are
usually away from the sea coast. An area is defined as endemic for goiter if
more than 10% of children ages 6 - 12 have goiters. Certain things in the
environment may also cause thyroid enlargement. Small- to moderate-sized
goiters are relatively common in the United States. The Great Lakes,
Midwest, and Intermountain regions were once known as the "goiter belt."
The routine use of iodized table salt now helps prevent this deficiency.
(http://health.nytimes.com/health/guides/disease/colloid-nodular-goiter)
Thyroid nodules are very common, with an estimated prevalence of
approximately 4% by palpation (5% in women and 1% in men living in iodinesufficient regions). A thyroid nodule larger than 1 cm in diameter is usually
palpable. However, the detection of a nodule by palpation also depends on its
location within the thyroid, on the structure of the patients neck and on the
experience of the examiner. In the Framingham Study, clinically apparent
thyroid nodules were present in 6.4% of the women and 1.6% of the men who
participated, with an estimated annual incidence, by palpation, of 0.001. The
lifetime risk of developing a thyroid nodule is reported to be 15%.
Nevertheless, only 5% of the clinically apparent thyroid nodules are
malignant. Thyroid carcinoma annual incidence is 1-2 per 100,000 population,
which accounts for 90% of the malignancies of the entire endocrine system,
1% of total human malignancies and 0.5% of total deaths from malignancies.
Although thyroid malignant tumors are not usually aggressive, thyroid
malignancies are responsible for more deaths than all other malignancies of
1

the

endocrine

system.

(http://emedicine.medscape.com/article/127491-

overview)
The overall prevalence in the Philippines of iodine deficiency among
patients with thyroid nodules is high at 63.4%. Despite of government efforts
to eliminate iodine deficiency in our country, this remains as a significant
health problem among adult Filipinos with thyroid nodules. It may be a risk
factor for nodular thyroid disease and these results show that it may also play
a crucial role in promoting the development of thyroid carcinoma, although
more patients are needed to accurately evaluate the association between
iodine exposure and risk of thyroid carcinoma. (R. Dejesus, et al., 2008)
There are new trends regarding the treatment, Thyroidectomy. Thyroid
surgery, which has traditionally been an overnight hospital procedure, can be
done safely in an outpatient setting, and in fact is preferable because it is less
expensive, according to a new study published in the April issue
of Otolaryngology-Head and Neck Surgery. The study's authors found not
only were complications low, but conducting the procedure in an outpatient
environment significantly lowered the cost by several thousand dollars.
(http://www.medicalnewstoday.com/articles/67471.php) Another is that the
scar less thyroid surgery was discovered as a new form of endoscopic
surgery. The technique uses the latest Da Vinci three dimensional, highdefinition robotic equipment to make a two-inch incision below the armpit that
allows doctors to maneuver a small camera and specially designed
instruments between muscles to access the thyroid. The diseased tissue is
then

removed

endoscopically

through

the

armpit

incision. This

technique safely removes the thyroid without leaving so much as a scratch on

the neck. The benefits of this new technique go beyond aesthetics. Unlike
other forms of endoscopic thyroid surgery, it doesn't require blowing gas into
the neck to create space to perform the operation. Those techniques can risk
complications if the gas is retained in the neck or chest after surgery, causing
significant discomfort and postoperative complications. There is a reduced
2

likelihood of laryngeal nerve damage and less risk of trauma to the

parathyroid glands, which are near the thyroid. There is also significant faster
recovery

time

and

less

discomfort

on

the part

of the

patients.

(http://www.sciencedaily.com /releases/2009/11/091124174735.htm)
It is important for the student nurses to study about such disease and
surgery since they will be future nurses. They can use their knowledge when
they will encounter the disease condition or surgery as they go along with
their career. This case report will help them understand and improve their
skills, and they can give the best care possible to their patients having
colloidal nodular goiter or some related diseases. New trends and
technologies about the surgery can be discovered and be shared to other
healthcare team especially to the surgeons and whole operating team.

II.

Anatomy and Physiology

Thyroid Gland

The thyroid gland is an endocrine gland located inferior to the larynx. It is

butterfly shaped and brownish-red in color, which lies on the trachea, in the
anterior neck. It establishes a structural form consisting of two lobes connected in
the middle by an isthmus, one on each side of the trachea, just inferior to the
larynx.
3

Internally, the thyroid gland consists of numerous follicles, which are small
spheres filled with a sticky, gelatinous material called cuboidal epithelial cells.
Each thyroid follicle is filled with proteins, called thyroglobulin, which are
synthesized and secreted by the cells of the thyroid follicles. As part of the
thyroglobulin molecules, large amounts of thyroid hormones are stored in the
thyroid follicles. In between the delicate network of loose connective tissue
between the follicles contains scattered parafollicular cells.
Thyroid Hormones
The

thyroid

hormones

are

triiodothyronine

known

as

T3

and

tetraiodothyronine known as T4. Another name for the T4 is thyroxin. T3

constitutes 90% of thyroid gland secretions and T4 10%. Although calcitonin is
secreted by the Para follicular cells of the thyroid gland, T3 and T4 are
considered to be thyroid hormones because they are more clinically important
and because they are secreted from the thyroid follicles.
T3 and T4 Synthesis
Thyroid stimulating hormone (TSH) from the anterior pituitary stimulates
thyroid hormone synthesis and secretions. TSH causes increase in the synthesis
if T3 and T4, which are then stored inside the thyroid follicles as part of the
thyroglobulin. TSH also causes T3 and T4 to be released from the thyroglobulin
and enter the circulatory system. An adequate amount of iodine is the diet is
required for thyroid hormone synthesis because iodine is a component of T3 and
T4.
Transport in the Blood
Thyroid hormones are transported in combination with plasma proteins in
the circulatory system. Approximately 70%-75% of circulating thyroid hormones
are bound to thyroxin-binding globulin (TBG), which is synthesized by the liver,
and 20%-30% are bound to other plasma proteins, including albumen. Thyroid
4

hormones, bound to these plasma proteins, form a large reservoir of circulating

thyroid hormones. Thyroid hormones are converted to other compounds and
excreted in the urine.
Effects of Thyroid Hormones
Thyroid hormones interact with their target tissues in a fashion similar to
that of the steroid hormones. They readily diffuse through plasma membranes
into the cytoplasm of cells. Within cells, they bind to receptor molecules in the
nuclei. Thyroid hormones combined with their receptor molecules interact with
DNA in the nuclei to influence genes and initiate new protein synthesis. The
newly synthesized proteins within the targets cells mediate the cells response to
thyroid hormones. It takes up to a week after the administration of thyroid
hormones for a maximal response to develop, and new protein synthesis
occupies much of that time.
Thyroid hormones affect nearly every tissue in the body, but not all tissues
respond identically. Metabolism is primarily affected in some tissues, and growth
and maturation are influenced in others. The normal rate of metabolism depends
on an adequate supply of thyroid hormone, which increases the rate at which
glucose, fat, and protein are metabolized. The metabolic rate can increase 60%100% when blood thyroid hormones are elevated. Maintaining normal body
temperature depends on an adequate amount of thyroid hormones.
Normal growth and maturation of organs also depend on thyroid
hormones. Specifically, bone, hair, teeth, connective tissue, and nervous tissue
require thyroid hormones for normal growth and development. Both normal
growth and maturation of brain require thyroid hormones.
Regulation of Thyroid Hormone Secretion
Thyroid hormone secretion is regulated by hormones produced in the
hypothalamus and anterior pituitary. Thyrotropin-releasing hormone (TRH) is
5

produced in the hypothalamus. Chronic exposure to cold increases TRH

secretion, whereas stress, starvation, injury, and infections, decreases TRH
secretion. TRH stimulates TSH secretion from the anterior pituitary. Small
fluctuations in blood levels of TSH occur on daily basis, with a small nocturnal
increase. TSH stimulates the secretion of thyroid hormones from the thyroid
gland. TSH also increases the synthesis of thyroid hormones, as well as causing
an increase in thyroid gland cell size and number. Decreased blood levels of TSH
lead to decreased secretion of thyroid hormones and thyroid gland atrophy.
Thyroid hormones have a negative feedback effect on the hypothalamus and
anterior pituitary gland. As thyroid hormone levels increase in the circulatory
system, they inhibit TRH and TSH secretion. Also, if the thyroid gland is removed
or if the secretion of thyroid hormones declines, TSH levels in the blood increase
dramatically.

III.

The Patient and His Illness

Non- Modifiable Factors:

Age (40 years old)

Modifiable Factors:
Lack of Iodine in diet

Gender (Female)

Living in an area where there is

endemic iodine deficiency

Family History of Goiter

Pregnancy

Decreased Iodine intake

Decreased Iodine in glandular cells

Inadequate secretion of Thyroid hormones (T3 andT4)

Lab results: T3: <75 ng/dL; T4: <10 mcg/dL
Pituitary gland will release< TSH as a compensatory
mechanism
Increased TSH production
Increased cellularity and hyperplasia of the Thyroid
gland

Increased size of Thyroid land

(Colloid Nodular Goiter)

PATHOPHYSIOLOGY (BOOK-CENTERED)

Compression of
trachea

Narrowed Airway
Difficulty in breathing

Compression of
the esophagus

Difficulty in swallowing

Severe enlargement

Compression of
vasculature

Narrowed thoracic inlet

when hands are raised

Obstruction of
venous return

Compression of blood
vessels to the head

Dysphagia

Venous engorgement
Decreased blood flow
Distended neck veins

Synthesis of the Disease

Dizziness
Pembertons sign

Enlargement of the thyroid, or goiter, is the most common manifestation of

thyroid

disease. Colloid

nodular

goiter impaired

synthesis

of

thyroid

hormone, most often caused by dietary iodine deficiency. Impairment of thyroid

hormone synthesis leads to a compensatory rise in the serum TSH, which in turn
causes hypertrophy and hyperplasia of thyroid follicular cells and, ultimately,
gross enlargement of the thyroid gland. The compensatory increase in functional
mass of the gland is enough to overcome the hormone deficiency, ensuring
a euthyroid metabolic state in the vast majority of affected persons. If the
8

underlying disorder is sufficiently severe (e.g., a congenital biosynthetic defect),

the compensatory responses may be inadequate to overcome the impairment in
hormone synthesis, resulting in goitrous hypothyroidism. The degree of thyroid
enlargement is proportional to the level and duration of thyroid hormone
deficiency.

(https://www.inkling.com/read/robbins-basic-pathology-

kumar-abbas-aster-9th/chapter-19/diffuse-and-multinodular-goiter)
Thyroid hormones are extremely important and have diverse actions. They act on
virtually every cell in the body to alter gene transcription: under- or overproduction of these hormones has potent effects. Disorders associated with
altered thyroid hormone secretion are common and affect about 5% women and
0.5% men. Like the catecholamines epinephrine and norepinephrine, thyroid
hormones are synthesized from the amino acid tyrosine. The synthesis of thyroid
hormones requires the iodination of tyrosine molecules and the combination of
two iodinated tyrosine residues. Whilst tyrosine is relatively easily iodinated,
iodine is rare, ranking 61st in the list of most common elements and forming just
0.000006% of the Earth's mantle. The thyroid gland has evolved not only to trap
this element avidly from dietary sources but also to maintain a large store of the
iodinated tyrosines to maintain the secretion of thyroid hormones during periods
of relative iodine deficiency. (http://www.ncbi.nlm.nih.gov/books/NBK28/)

1. Definition of the Disease

Colloid

nodular

normal thyroid gland.

goiter
Colloid

is

the

nodular

enlargement
goiters

are

of

an

also

otherwise
known

as

endemic goiters. They are usually caused by not getting enough iodine in the
diet. Colloid nodular goiters tend to occur in certain areas with iodine-poor
soil. These areas are usually away from the sea coast. An area is defined as
endemic for goiter if more than 10% of children ages 6 - 12 have goiters.
Certain things in the environment may also cause thyroid enlargement. Smallto moderate-sized goiters are relatively common in the United States. The
9

Great Lakes, Midwest, and Intermountain regions were once known as the
"goiter belt." The routine use of iodized table salt now helps prevent this
deficiency. (http://www.drugs.com/enc/colloid-nodular-goiter.html)
A risk factor for colloid nodular goiters include being over age 40, due to
the lack of nutritional iodine in early adult life. Another risk factor is having a
female gender since single and multiple thyroid nodules were found in 0.8%
of men and 5.3% of women, with an increased frequency in women over 45
years of age.(http://www.thyroidmanager.org/chapter/ multinodular-goiter/)
Family history of goiter is not really a major risk factor but it increases the risk
of having the disease. Living in an area where there is endemic iodine
deficiency and not getting enough iodine in your diet are also considered as
one of the risk factors for colloid nodular goiter since Iodine is vital to thyroid
hormone formation. (http://www.geocities. com/medipedia/001178.htm)
There are signs and symptoms of colloid nodular goiter which are
breathing difficulties, Dizziness when the arms are raised above the head
because of large goiter, enlarged neck veins, swallowing difficulties, thyroid
swelling

because

of

the

nodules,

and

pembertons

sign.

(http://www.drugs.com/enc/ colloid-nodular-goiter.html)

2. Non Modifiable/Modifiable Factors

Non Modifiable Factors:

40 years old- due to lack of nutritional iodine in early adult life

Female- Single and multiple thyroid nodules were found in 0.8% of men
and 5.3% of women, with an increased frequency in women over 45 years

of age.
Family History of Goiter- it increases the risk for acquiring the disease

Modifiable Factors:
10

Lacks of Iodine in diet- Endemic goiters occur within groups of people

living in geographical areas with iodine-depleted soil, usually regions away
from the sea coast. People in these communities might not get enough
iodine in their diet. The modern use of iodized table salt in the U.S.
prevents this deficiency. However, inadequate iodine is still common in

central Asia and central Africa.

Living in an area where there is endemic iodine deficiency- Iodine is vital

to the formation of thyroid hormone

Pregnancy- may increase the need for iodine and require thyroid
hypertrophy to increase iodine uptake that might otherwise satisfy minimal
needs. An elevated renal clearance

of iodine

occurs during normal

pregnancy. It has been suggested that in some patients with endemic

goiter there are similar increases in renal iodine losses.
3. Signs and Symptoms

Difficulty of breathing- due to the narrowed airway caused by enlargement

of thyroid gland which compresses the trachea

Dysphagia- Due to compression of esophagus made by the enlargement

of thyroid glands which causes difficulty of swallowing

Dizziness- decreased blood flow

Enlarged neck veins- due to compression of vasculature that leads to

venous engorgement
Pembertons sign- manifestations of latent increased pressure in the
thoracic inlet by altering arm position to further narrow the aperture.

IV.

Clinical Intervention

1.1 Description of prescribed surgical treatment performed.

11

The prescribed surgical treatment performed is known as Thyroidectomy.

Thyroidectomy is the removal of the thyroid gland; which can be total or partial. In
contrast, total thyroidectomy is performed to remove the entire gland. As for
subtotal or partial thyroidectomy it removes only part of the thyroid gland.
A thyroidectomy begins with general anesthesia administered by an
anesthesiologist. General anesthesia is a type of medically induced coma and
loss of protective reflexes resulting from the administration of one or more
general anesthetic agents. A variety of medications may be administered, to
ensure sleep, amnesia, analgesia, relaxation of skeletal muscles, and loss of
control of reflexes of the autonomic nervous system. However, some surgeons
are now using local anesthesia, plus a sedative, which associates with a shorter
hospital stay, shorter actual surgery time, and less vomiting and nausea during
post-operative.

The
anesthesiologist

is

who is in charge

with

administration of

the drugs into

the

veins

patient's

the

one
the
and

then places an

airway tube in

the windpipe to

ventilate

the
12

patient during the operation. After the patient has been anesthetized, the surgeon
makes an incision 3-inch to 4-inch cut in the middle of the neck, right on top of
the thyroid gland. Then the surgeon will remove all or part of the gland.

The initial incision is made over the marked line as described in the
preparation section. A number 15 blade is used to incise through the epidermis
and dermis. Using a Shaw scalpel or monopolar cautery, dissection is carried
through the subcutaneous fat to the platysma. Once the level of the platysma has
been identified along the length of the incision, the platysma is incised. Using the
double-pronged skin hooks and the Shaw scalpel or monopolar cautery,
subplatysmal flaps are elevated superiorly and inferiorly. After elevating the
subplatysmal flaps, the Mahorner or alternative self-retaining retractor may be
inserted. Precaution should be taken to not lacerate or damage the skin edges
with the retractor.
The strap muscles (sternohyoid and sternothyroid) should then be
identified. In the midline between the strap muscles, the cervical linea Alba can
be identified. Once identified, bluntly dissect through this fascia. The Harmonic
scalpel or monopolar cautery can then be used to dissect through this fascia
superiorly and inferiorly along the length of the sternohyoid muscle. In cases of
large goiter or neoplasm, the strap muscles may be divided to aid exposure.
13

Division of the strap muscles should be performed high (cephalad), as the

innervation of the strap muscles occurs more inferiorly. Just deep to this
dissection places the thyroid gland, and overlying fascia should be easily
identified.
If cancer has been identified, the surgeon removes all or part of the gland.
However, if other diseases or nodules are present, the surgeon may remove only
part of the gland. The total amount of glandular tissue removed depends on the
condition being treated. The surgeon may place a drain, which is a soft plastic
tube that allows tissue fluids to flow out of an area, before closing the incision.
The incision is closed with either sutures (stitches) or metal clips. Then a
dressing is placed over it. Once the thyroid gland is identified, attention should be
turned to a single lobe. Specifically, with the use of Richardson retractors and
blunt dissection, capsular dissection should be carried to the lateral aspect of the
thyroid lobe, where it meets the carotid sheath fascia. Once the lateral border of
the dissection has been performed, the carotid artery identified, blunt dissection
may be carried out superiorly.
After identifying and stimulating the recurrent laryngeal nerve, the thyroid
gland can be removed. Berrys ligament defines the posterolateral attachment of
the thyroid gland. Blunt dissection can be used to further expose this fascial
attachment. Then a harmonic scalpel can be used to transect the ligament.
Often, a minimal amount of thyroid tissue is left adjacent to the entrance of the
recurrent laryngeal nerve into the larynx, to reduce the risk of injuring the nerve.
If the patient is undergoing a total thyroidectomy, attention should first be
turned to the opposite thyroid lobe and recurrent laryngeal nerve. Once the entire
specimen has been dissected and is only attached posteriorly to the pretracheal
fascia, it can be removed. Then removed specimen should be inspected.
PATIENT POSITIONING

The patient should be placed in a supine position with the apex of the
14

patients head at the top of the operating bed.

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

Care should be taken to avoid hyperextension of the neck, and the head
should be supported to provide maximal exposure of the surgical field
without hyperextension.

Patients arms should be gently tucked by either side.

After intubation, the bed can either be rotated 180 from the
anesthesiologists or sufficiently moved away from their machines to
provide a maximal work area.

PROCEDURE

General

anesthesia is used.
Performed

under

general anesthesia with endotracheal intubation.

The following key anatomic locations should be found by superficial
palpation and marked with a marking pen: Thyroid cartilage, Cricoid
Cartilage, Superior edge of clavicles and Sternal notch.

15

Traditionally, a collar incision is used. The incision should be created in a

curvilinear fashion within a skin crease approximately 2 cm or 2 finger-breadths
above the superior edge of the clavicle and sternal notch. Although smaller
incisions lengths have been described, in the authors' experience, an incision
length of between 6 cm and 8 cm is used to allow for adequate exposure without
causing stretch injury to the surrounding skin.
1.2 Indication of prescribed general treatment.
Indications

Thyroid cancer

If medications were not effective during drug therapy

If there is pressure made in the larynx

16

If there are complications of dyspnea or difficulty of breathing

If goiter constricts airways

If multiple nodules are present and large

If there is difficulty swallowing

Graves Disease

Hyperthyroidism

Thyroid Toxic Nodule

Risk
Thyroidectomy is generally safe. But as of any surgery, thyroidectomy carries a
risk of complications.
Potential complications include:

Bleeding

Airway obstruction caused by bleeding

Permanent or weak voice due to nerve damage

Surgical scar

Anesthetic complications

Infections

Permanent hypothyroidism and hypocalcemia

Difficulty projecting the voice

Benefits

Scars heal quickly and nearly invisible

1 week recovery

1.3 Required instruments, devices, supplies, equipment, and facilities.

Basic surgical instruments required:
1. #3 knife handle- used to hold a variety of different surgical blades while
17

giving the user more maneuverability and comfort.

2. #15 blade- has a small curved cutting edge and is the most popular blade
shape ideal for making short and precise incisions.

3. Adson tissue forceps with and without teeth- standard thumboperated, wishbone type forceps for grasping tissue, with a rat-tooth tip
with a single point on one side fitting in between two teeth on the other.

4. DeBakey forceps- Forceps widely used in general abdominal and

vascular surgery. Designed to grasp delicate tissues without trauma.

18

5. Halsted mosquito forceps - is used to clamp blood vessels or tag sutures.

6. Reinhoff swan neck clamp (or Burlisher clamp) - is used to clamp deep
blood vessels.

Burlishers have two closed finger rings. Burlishers with an

open finger ring are called tonsil hemostats. Other names: Schmidt tonsil
forcep, Adson forcep.

19

7.Allis tissue forceps- forceps with inward-curving toothed blades and a

ratcheted handle. Designed for grasping fascia and tendons.

8.Richardson retractor (Small)- is a surgical instrument by which a surgeon

can either actively separate the edges of a surgical incision or wound, or can
hold back underlying organs and tissues, so that body parts under the incision
may be accessed.

9.

Peanut/Kittner sponges - help to not only apply pressure to stop bleeding, but
to prevent tissue trauma from suction tips and other instruments.

11.

Double-

pronged skin hooks20

is used to grasp, hold, and position delicate soft tissues during the suturing
phase of a surgical procedure.

12. Mahorner retractor To retract, secure and apply traction to soft tissue and
bone. To provide visualization and maintain wound exposure.

13. Bipolar electro cautery forceps- an electro cautery in which both active
and return electrodes are incorporated into a single handheld instrument,
so that the current passes between the tips of the two electrodes and
affects only a small amount of tissue.

14. Nerve Stimulator- is the use of electric current produced by a device to

21

stimulate the nerves for therapeutic purposes.

15. Electro cautery instrument - The medical practice or technique

of cauterization is the burning of part of a body to remove or close off a part
of it in a process called cautery, which destroys some tissue, in an attempt
to mitigate damage, remove an undesired growth, or minimize other
potential medical harmful possibilities such as infections, when antibiotics
are not available. The practice was once widespread for treatment of
wounds. Its utility before the advent of antibiotics was effective on several
levels:

useful in stopping severe blood-loss and preventing exsanguination

to close amputations
22

Equipments
a. Anesthesia Machine to render and deliver anesthesia accurately.
b. Operating table use in the operation where the patient lies.
Facilities
a) Operating room a place where operations are held.
1.4 Perioperative tasks and responsibilities of the nurse
Scrub Nurse
Pre-Operative

Ensures that all equipment are checked with the circulating nurse

Prepares the instruments needed for the operation

Applies sterile technique in scrubbing

Counts the surgical equipment with the circulating nurse

Performs sterile gowning o the surgeon and the assistant surgeon

Maintains sterility throughout the surgery

Intra-Operative

Maintain patients safety throughout the surgery

Maintains sterility throughout the surgery

Provides the equipment that the surgeon or assistant needs

Notifies the circulating nurse if there are more needed equipment

Remove excess equipment in the sterile field

Post-Operative

Counting the sponges in the operating room with the circulating nurse

Assist the surgeon or assistant surgeon when closing the wound

Helps apply the surgical dressing to the patient

De-gowning
23

Washing the equipment

Prepares patient for the recovery room

Completes the documentation

Circulating Nurse
Pre-Operative

The circulating nurse is responsible for checking the lighting and the
equipment that the surgical team will use

Ensures that all equipment are functioning correctly

Counts the equipment along with the scrub nurse to ensure its
complete

Reports the case and procedure to everyone in the operating room

Starts the opening prayer before the surgery

Intra-Operative

The circulating nurse monitors the operating room throughout the

whole operation

Counts the equipment that were used including those that were
dropped

Provides the equipment necessary in the operating room

Stays in the unsterile field until the end of the operation

Post-Operative

The circulating nurse counts all the equipment along with the scrub
nurse that was used throughout the operation

Reports that all equipment are complete

1.5 Expected outcomes of surgical treatment performed

Before a thyroidectomy is performed, the nurse should explain the
possible risk and complications that the patient will manifest. Inform the patient
24

that there is a risk that his/her voice will change after the surgery as well as
possible signs of infection. Since the surgery takes place in around the neck
area, it is expected that they will have difficulty swallowing.
After the surgical management, like every person after surgery they will
manifest drowsiness from the effects of anesthesia and lightly sedated. Its
important to monitor the vital signs especially the respiratory rate because of
respiratory depression from anesthesia. Soon as the effects of anesthesia wears
of, the patient will feel pain as a sign that its wearing off. As the patient manifests
pain, pain medication is given. The required dose should last for 24 hours. There
will be a possible risk for the patient to acquire infection because of the incision.
The wound dressing should be changed every 2 days.
Before feeding, assess signs of bowel movement including flatulence.
When bowel movement is present, ask the patient that if his/her throat hurts
before providing fluids. Due to the incision site made near the throat, provide
small amounts of fluid. Soon as pain from the site is gone, soft diet should be
provided. The patient can resume their normal diet soon as no pain is felt from
the incision site.
During the recovery period, the patient may feel very self conscious and
worried since the surgery may affect his/her voice. Explain to the patient that the
change in voice in normal. It is expected that the voice will normalize within 2-3
days.

25

1.6 Medical Management of Physiologuc Outcomes

Drugs taken for initial treatment of Hypothyroidism
Drugs used for treatment
General Information of Drug

Route of Admin. Dosage &

Frequency of Admin.

Indication or Purpose

Generic Name: Cytomel Oral

Route of Admission: Oral

Brand Name: Liothyronine Sodium

Dosage: 125mcg

It replaces a hormone that is normally produced by the thyroid gland.

Low thyroid levels can occur naturally or when the thyroid gland is
injured by radiation/medications or removed by surgery. It is important
to have adequate levels of thyroid hormone in your bloodstream to
maintain normal mental and physical activity.

Classification: Synthetic Hormone

Nursing Responsibilities
Before Treatment
1. Inform the patient that this should not be used alone or together with diet pills to treat obesity/cause weight loss in patients with
normal thyroid production
2. If used in combination with diet pills (appetite suppressant drugs), serious, even life-threatening effects could occur.
3. Assess for decreased renal and kidney function
During the Treatment
1. Ensure the patient takes the medication with a full glass of water.
2. For patients who have dyspahgia, crush the tablet and give medication dilated.
3. Stay at bedside with the patient when taking the medication.
After the Treatment
1. Assess for signs of allergies
2. Inform the patient not to use this medication for weight loss or dietary purposes.
3. Tell patient that over dosage of this medication will lead to life threatening effects.
26

General Information of Drug

Route of Admin. Dosage &

Frequency of Admin.

Generic Name: Levothyroxine

Route of Admission: Oral

Brand Name: Levothoid, Levoxyl

Dosage: 12.5 - 50 mcg once a day

Classification: Synthetic Hormone

Indication or Purpose
Levothyroxine is used to treat an underactive thyroid
(hypothyroidism). It replaces or provides more thyroid hormone,
which is normally produced by the thyroid gland. Low thyroid
hormone levels can occur naturally or when the thyroid gland is
injured by radiation/medications or removed by surgery.

Nursing Responsibilities
Before Treatment
1. Take with full glass of water to prevent chocking, gagging, dysphagia or getting tablets stuck to throat.
2. Infants with congenital or acquired hypothyroidism, institute therapy with full doses as soon as the diagnosis is made.
3. Infants and children who cannot swallow tablets, the correct dosage maybe crushed and suspended in a small formula or water
and given by a dropper or spoon. The tablet may also be sprinkled over cooked cereal and apple sauce.
During the Treatment
1. Do not change brands of T4 products, due to possible bioequivalence problems.
2. Do not add IV doses to other IV fluids
3. Arrange for regular, periodic blood tests of thyroid function
After Treatment
1. This drug replaces an important hormone and will need to be taken for life. Do not discontinue without consulting the physician.
Serious problems can occur.
2. Report headache, chest pain, palpitations, fever, weight loss, sleeplessness, nervousness, irritability, unusual sweating,
intolerance to heat, diarrhea.
3. Wear a medical ID tag to alert emergency medical personnel that you are using this drug.

Drugs used during Thyroidectomy

27

Drugs given
General Information of Drug

Route of Admin. Dosage &

Frequency of Admin.

Indication or Purpose

Generic Name: Halothane

Classification: Inhalation Anesthetic

Route of Admission:
Inhalation
Dosage: variable

Volatilized Halothane, USP acts as an inhalation anesthetic.

Induction and recovery are rapid and depth of anesthesia can be
rapidly altered. Halothane anesthesia progressively depresses
respiration. There may be tachypnea with reduced tidal volume and
alveolar ventilation. Halothane vapor is not an irritant to the
respiratory tract, and no increase in salivary or bronchial secretions
ordinarily occurs. Pharyngeal and laryngeal reflexes are rapidly
obtunded. It causes bronchodilation. Hypoxia, acidosis, or apnea
may develop during deep anesthesia.

Nursing Responsibilities
Before Treatment
1. Only the anesthesiologist can provide this medication to the patient.
2. Explain the procedure to the patient if there are signs of anxiety present.
3. Advise the patient not to eat anything for 8 hours before the operation.
4. Keep food away from the site of the patient.

During the Procedure

1. Provide safety measures to prevent further injury.
2. Monitor respiratory rate.
3. Provide safety to the patient while sedated.
After the Surgical Procedure
1. Alert anesthesiologist if there is absence of patients breathing.
2. Monitor patients respiratory rate after surgery.
Medications given after surgery
28

General Information of Drug

Generic Name: Morphine Sulfate
Brand Name: Duramorph,
Epimorph
Classification: Narcotic Agonist

Route of Admin. Dosage

& Frequency of Admin.
Route of Admission: IV
Dosage: 1030 mg

Indication or Purpose
Morphine Sulfate is an opioid agonist indicated for the relief of moderate to
severe acute and chronic pain where use of an opioid analgesic is
appropriate

Nursing Responsibilities
Before Treatment:
1. Morphine and other opiates/opiods are common antigens in an allergic reaction. Check chart and ideally with patient for allergies
before administration.
2. Morphine is a CNS and Respiratory depressant. Extreme caution needs to be exercised in administration to compromised
patients.
3. Morphine should not be taken with other narcotics agents.
During Treatment:
1. Provide the dose needed for 24 hours. This may cause drug dependence.
2. Ensure it is given to the right patient when giving the medication
After Treatment:
1. Provide other techniques in relief pain.
2. Report physician if there is an occurrence of severe nausea, vomiting, constipation, shortness of breath or difficulty breathing,
rash.
1.7 Nursing management of physiologic and psychosocial outcomes.
29

Problem # 1: (Pre-Operative) Impaired Breathing Pattern related to Narrowing of airway

Assssment
S
O - The patient may
manifest:
>Dyspnea
>Change in
respiratory rate
>Difficulty vocalizing
>Orthopnea
>Cyanosis

Nursing
Diagnosis
Impaired
breathing
pattern
related to
narrowed
airway.

Scientific
Explanation
Impaired breathing
pattern is
characterized by
enlargement of the
thyroid gland which
compresses the
trachea that leads to
narrowed airway
which causes
difficulty of
breathing.

Objectives

Short Term: After

4-5 hours of, the
nursing
interventions
patient will be able
to demonstrate
behaviors to
improve breathing
pattern.
Long Term:
After 1-3 days of
nursing
interventions, the
patient will be able
to demonstrate
improved oxygen
exchange.

Nursing Interventions

Rationale

Expected
Outcome

1. Therapeutic
communication.
2. Monitor vital signs
frequently.
3. Monitor respirations
and breath sounds,
noting rate and
sounds.
4. Evaluate patients
cough/gag reflex and
swallowing ability.
5. Position head
appropriate for age
and condition.
6. Elevate head of bed
and change position
every 2 hours and
prn.
7. Assist with the use of
respiratory devices
and treatments.
8. Position the patient
appropriately.
9. Encourage deep
breathing and
coughing exercise.

1. To gain trust and

cooperation of the pt.
2. VS could indicate
possible bleeding.
3. To indicate respiratory
distress.
4. To determine ability to
protect own airway.
5. To open or maintain
open airway in at-rest or
compromised individual.
6. To decrease pressure on
the diaphragm and
enhance drainage of
ventilation to different
lung segments.
7. To maintain airways,
improve respiratory
function and gas
exchange.
8. To prevent vomiting with
aspiration into lungs.
9. To maximize effort.

Short Term:
After 4-5 hours of
nursing
interventions, the
patient shall have
demonstrated
behaviors to
improved breathing
pattern.
Long Term:
After 1-3 days of
nursing
interventions, the
patient shall have
demonstrated
improved oxygen
exchange.

Problem #2: (Post-Operative) Acute Pain related to Surgical Incision

30

Assessment
S-
Patient may
verbalize with a
pain scale of 8/10
O - patient may
manifest:
>Facial Grimaces
>Restlessness
>Irritability
>Sleep
Disturbances
>Moaning, crying
Change in blood
pressure, heart rate
and respiratory rate

Nursing Diagnosis
Acute Pain related
to surgical incision

Scientific
Explanation

Objectives

Nursing Interventions

Rationale

Expected
Outcome

Unpleasant sensory
arising from actual
or potential tissue
damage that
stimulate the of
peripheral nervous
system which
causes the
activation of central
nervous system at
the spinal cord level
transmits the signal
to the brain to
cause pain.

Short Term:
After 4-5 hours of,
the nursing
interventions, the
patient will
demonstrate use of
relaxation skills and
diversional
activities, as
indicated, for
individual situation.

1. Therapeutic
communication.
2. Monitor vital signs.
3. Assess verbal/nonverbal reports of
pain, noting location,
intensity (0-10
scale), and duration.
4. Accept the
description of pain.
Experienced and
convey acceptance
of clients response
to pain.
5. Determine clients
acceptable level of
pain and pain
control goals.
6. Provide comfort
measures (heat or
cold packs, quiet
environment and
calm activities).
7. Monitor skin color
and temperature
and vital signs.

1. To gain trust of
the patient.
2. For baseline
data.
3. Useful in
evaluating pain,
choice of
interventions,
effectiveness of
therapy.
4. Pain is a
subjective
experience and
cannot be felt by
others.
5. Varies with
individual and
situation.
6. To promote nonpharmacological
pain
management.
7. They are usually
altered in acute
pain.

Short Term:
After4-5 hours of
nursing
interventions, the
patient shall have
demonstrated use
of relaxation skills
and diversional
activities, as
indicated, for
individual situation.

Long Term:
After 3-4 days of
nursing
interventions, the
patient will report
relieve and
controlled pain.

Long Term:
After 3-4 days of
nursing
interventions, the
patient shall have
reported relieve and
controlled pain.

Problem # 3: (Pre-operative) Imbalanced Nutrition: Less Than Body Requirements related to hypermetabolic state and
impaired utilization and storage of nutrients.
31

Assessment

Nursing
Diagnosis

S-
O - the patient may
manifest:
> Loss of weight
>Restlessness
>Weakness of
muscles required
for mastication

Imbalanced
Nutrition: Less
Than Body
Requirements
related to
impaired or
lack of
consumption of
the nutrients
needed by the
body

Scientific
Explanation
The body needs
adequate nutrients
to
support
the
normal
bodily
function.
The risk factors of
colloid nodular
goiter will lead to
decreased iodine in
the glandular cells
which Imbalances
the nutrition. With
decreased Iodine in
the body, there will
be decrease
secretion of thyroid
hormones which
affects the growth
and metabolism.

Objectives

Nursing Interventions

Rationale

Short term:

1. Weigh daily

1. To monitor weight gain

After 6hrs of NI, the

pt will manifest a
increase in appetite
by
demonstrating
proper eating habits

2. Monitor nutritional

or loss
2. To determine intake of

intake
3. Provide oral hygiene
before meals
4. Assess for difficulty
swallowing
5. Administer

Long term:
After 2 days of NI,
the pt will maintain
weight and body
mass or begin to
gain weight by
consuming
adequate nutrients.

antiemetics as
ordered
6. Give fluids by mouth
as tolerated as
ordered
7. Provide small,
frequent meals.
8. Monitor electrolytes,
hemoglobin and
hematocrit.

Expected
Outcome
Short term:

swallowing.
5. To relieve nausea and

Patient shall have

manifested
an
increase
in
appetite
by
demonstrating
proper
eating
habits

vomiting
6. To promote adequate

Long term:

nutrients.
3. To Improve taste of food.
4. To determine difficulty of

hydration
7. To prevent feeling of
fullness and ensures
adequate nutritional
intake.
8. To Inadvertent removal

Patient shall have

maintained weight
and body mass or
begin to gain
weight by
consuming
adequate nutrients.

or devascularization of
the parathyroid glands
can cause postoperative
hypoparathyroidism.

Problem # 4: (Post-Operative) Risk for Impaired Verbal Communication related to Surgical Wound
Assessment
S:
O: Patient may
Manifest:

Nursing
Diagnosis

Scientific Explanation

Objectives

Risk for
Impaired
Verbal
Communicati
on related to

Unpleasant sensory
arising from actual or
potential tissue damage
that stimulate the of
peripheral nervous

Short Term:
After 4 hours of nursing
interventions, the patient
will be able to establish
methods of

Nursing Interventions
1.

2.

Assess speech
periodically;
encourage voice
rest.
Keep

Rationale
1. Hoarseness and sore
throat may occur
secondary to tissue
edema or surgical
damage to recurrent

Expected
Outcome
Short Term:
After 4 hours of
nursing
interventions,
the patient shall

32

>Speak or
verbalized with
difficulty.
>Difficulty of
forming words
or sentences.
>Hoarseness.
>Slurring.

surgical
wound

system which causes

the activation of central
nervous system at the
spinal cord level
transmits the signal to
the brain to cause pain.
If there is pain, the
patient may experience
difficulty when
speaking, which can
prevent the patient from
communicating orally.

>Stuttering.

communication in which
necessities can be
expressed.
3.
Long Term:
After 2-3 days of nursing
interventions, patient will
be able to participate in
therapeutic
communication and
demonstrate congruent
verbal or non-verbal
communication.
4.

i.
5.

6.

communication
simple; ask
yes/no questions.
Provide
alternative
methods of
communication as
appropriate, e.g.,
slate board,
letter/picture
board. Place IV
line to minimize
interference with
written
communication.
Anticipate needs
as possible. Visit
patient frequently.
Post notice of
patients voice
limitations at
central station and
answer call bell
promptly.
Maintain quiet
environment.

2.
3.
4.
5.

6.

laryngeal nerve and

may last several days.
Permanent nerve
damage can occur
(rare) that causes
paralysis of vocal cords
and/or compression of
the trachea.
To reduce demand for
response; promotes
voice rest.
To facilitate expression
of needs.
To reduce anxiety and
patients need to
communicate.
To prevent patient from
straining voice to make
needs known/summon
assistance.
To enhance ability to
hear whispered
communication and
reduces necessity for
patient to raise/strain
voice to be heard.

have
established
methods of
communication
in which
necessities can
be expressed.
Long Term:
After 2-3 days
of nursing
interventions,
he patient shall
have
participated in
therapeutic
communication
and
demonstrated
congruent
verbal and nonverbal
communication.

Problem # 5: (Post-Operative) Risk for Infection related to surgical wound

Assessment

Nursing
Diagnosis

Scientific
Explanation

Objectives

Nursing Interventions

Rationale

Expected
Outcome

33

S
O - The patient may
manifest:
>Pallor
>Weakness
>With dry and intact
dressing on the
excised area
>Swelling over the
incision area

Risk for Infection

related to
surgical wound

Contamination of
a wound surface
with
microorganism
thus these
colonization has a
complete new
cells for oxygen
and nutrition and
because their byproducts can
interfere with a
healthy surface
condition that
leads to infection

Short Term:
After 3-4 hours of, the
nursing interventions,
the patient will
verbalize
understanding of
individual causative
factors might
contribute infection.
Long Term:
After 4 days of
nursing interventions,
the patient will
achieve timely wound
healing.

1. Therapeutic
communication.
2. Monitor and record
vital signs.
3. Stress proper hand
washing technique.
4. Instruct on proper
wound care.
5. Encourage to eat
vitamin C rich foods.
6. Emphasized
necessity of taking
antibiotics as
directed.
7. Closely observe and
instruct to report
signs and symptoms
of infection such as
fever, sore throat,
swelling, pain and
drainage.
8. Inspect the wound
for swelling, unusual
drainage, odor
redness, or
separation of the
suture lines.

1. To gain trust and

cooperation of the
patient.
2. To obtain baseline
data.
3. Poor nutritional
status may cause
inability to muster a
cellular immune
response to
pathogens and are
therefore more
susceptible to
infection.
4. To maintain optimal
nutritional status.
5. To promote wound
healing.
6. To boost the
immune system.
7. To prevent and
detect as early as
possible the
presence of any
progressing
infection.
8. Wound infection is
accompanied by
signs of
inflammation and a
delay in healing.

Short Term:
After 3-4 hours of
nursing
interventions, the
patient shall have
verbalized
understanding of
individual causative
factors might
contribute infection.
Long Term:
After 4 days of
nursing
interventions, the
patient shall have
achieved timely
wound healing.

34

IV.

Conclusion
One type of goiter is Colloid nodular goiter. It is the enlargement of an

otherwise normal thyroid gland. They are also known as endemic goiters.
The risk factors for this disease are age of 40 years old, female gender,
family history of goiter due to their natural causes to an at-risk patient.
Since iodine is vital in the formation of thyroid hormones, lack of it can
also be considered as a risk factor. Some symptoms may also be
experienced.
The recommended surgery for colloid nodular goiter is Thyroidectomy
where in the thyroid gland is removed ablatively because if the disease is
left untreated, the disease may develop to more serious complications
such as thyroid cancer. Each of the operating team has their
responsibilities before, during and after the surgery. Certain anesthesia
and other drugs are administered even hours before the procedure.
This study is recommended for student nurses to use as a reference if
ever they will encounter this on their duty. This can also be used to widen
their knowledge or to hone their skills. This can help the future student
nurses if ever they will become interested as to what or how the case of
Colloid Nodular Goiter really works. We also recommend this study to the
other health care team to also hone their skills or use as a reference if
ever they will encounter the same case as the researchers. For the
community, I recommend this especially to people who are at risk and also
for those who already had this disease. This can help those who are at
risk to avoid, prevent, and not acquire at all. And for those who already
had the disease, this can help them to maintain their health or be aware of
what will happen if their problem aggravated.

The case report has given us the opportunity to learn about the
colloid nodular goiter. Doing this study enhanced our knowledge and
35

helped us know the complications of the disease that leads to severe

diseases. The knowledge we gained would be useful especially in our
duty, because we would be able to provide the best care possible to our
patient. As we continue with our career, we would more likely encounter
patients having this disease condition or surgery. Even us ourselves can
protect our health from the disease and we may also know the benefits
and disadvantages of having such surgery like thyroidectomy. Our
willingness to learn molds us towards being competent nurses. We
learned how to appreciate the importance of cooperation which enabled
us to finish our case report. We are thankful for the trust and guidance that
our clinical instructor gave us all throughout the process of this study.

36

V.

References/ Bibliography

BOOKS:

Seeleys Principles of Anatomy and Physiology 2009

J. Black, J. Hawks.2009.Medical-Surgical Nursing 8th edition: clinical
management for positive outcomes. Coronary Heart Disease. Pp.1410-1415
L. Williams, Wilkins. 2009. Professional Guide to Diseases 9th Edition. Coronary
Artery Disease. Pp. 42-46
M. Doenges, et.al. 2008. Nurses Pocket Guide: Diagnoses, Prioritized
Interventions, and Rationales.
L. Williams, Wilkins. 2013. Nursing 2013 Drug Handbook.

WEBSITES:

http://www.ohlonecenter.org/research-papers/the-thyroid-gland-anatomy-

physiology/
http://emedicine.medscape.com/article/1891109-overview#a15

http://www.rnpedia.com/home/notes/pharmacology-drug-studynotes/morphine-sulfate

http://www.drugs.com/levothyroxine.html

http://health.nytimes.com/health/guides/disease/colloid-nodular-goiter
http://www.surgeryencyclopedia.com/St-Wr/Thyroidecto my.html
http://emedicine.medscape.com/article/127491-overview

http://www.medicalnewstoday.com/articles/67471.php

http://www.sciencedaily.com /releases/2009/11/091124174735.htm
http://www.drugs.com/enc/colloid-nodular-goiter.html
http://www.geocities. com/medipedia/001178.htm
https://www.inkling.com/read/robbins-basic-pathology-kumar-abbas-aster9th/chapter-19/diffuse-and-multinodular-goiter
http://www.ncbi.nlm.nih.gov/books/NBK28/

37