PAPILLARY THYROID CA

GROUP. 1 B
GRAND CASE

SEPTEMBER 24, 2019

ADVISER : MRS. LUCY DE LEON, RN, MAN, PHD

 GRAND CASE PRSENTATION

Date: September 24, 2019

Time: 08:00 AM
Venue: NAL 101
Case: Papillary Thyroid CA / GROUP 1B
Adviser: Mrs. Lucy De Leon, RN, MAN, PhD

TOPIC REPORTER TIME ALLOTMENT

INTRODUCTION Edna S. Selda 10 minutes
GEN. OBJS / SPECIFIC OBJS.
OVER VIEW THYROID CA Hedaya M. Hadji Ali 10 minutes

ANATOMY AND Fate Anne Fontanilla 15 minutes

PHYSIOLOGY
PATHOPHYSIOLOGY Adora M. Dela Cruz 15 minutes
P.A / REVIEW OF SYSTEM
LABORATORY TEST Dianne G. Farinas 15 minutes

DRUG STUDY Kathrine R. Legaspi 15 minutes

PROBLEM LIST Norjannah M. Aloyoda 10minutes

CARE PLAN Sara E. Abdulhamid 20 minutes

 Introduction

Epidemiology

Cystic neck masses appearing in the anterior or posterior triangles of the neck are usually benign.
Papillary thyroid carcinoma is the most common thyroid malignancy, accounting for 80% of all thyroid
cancers. The most common presentation of thyroid cancer is an asymptomatic thyroid mass or a node
although rare (<2% of all nodules), is highly unlikely to be malignant. This process may also occur in the
metastatic lymph nodes, in which a subcortical liquefaction necrosis results in a cystic mass; this is more
common in younger patients. This cystic change can cause diagnostic problems.

Cancer of the thyroid is a disease in which malignant (cancerous) cells are found in the tissues of the
thyroid gland. The thyroid gland is located at the base of the throat and produces hormones that help the
body function normally. Most patients are between 25 and 65 years old, thyroid cancer is more common
in women than in men. It is the most common malignancy of the endocrine (hormone) system. There are
four main types of thyroid cancer (depending on the type of cell that the cancer developed in); papillary
carcinoma, follicular carcinoma, medullary carcinoma and anaplastic carcinoma. Occasionally other types
of cancer (lymphoma, sarcoma and carcinosarcoma) can be found in the thyroid gland. Some thyroid
cancers are caused by exposure to radiation and some medullary carcinomas are associated with an
inherited condition (multiple endocrine neoplasia).Papillary carcinoma typically arises as a solid, irregular
or cystic mass that comes from otherwise normal thyroid tissue. Cervical metastases (spread to lymph
nodes in the neck) are present in 50% of small papillary carcinomas and in more 75% of the larger
papillary thyroid carcinomas. The presence of lymph node metastasis in the neck area typically has a
more frequent recurrence rate but not a higher mortality rate. Distant spread of papillary thyroid cancer is
called metastasis. Distant metastasis of papillary thyroid cancer is uncommon, but when it does occur, it
may spread to the lungs, liver, and bone. Papillary thyroid cancer that invade the surrounding tissues next
to the thyroid gland have a much worse prognosis because of a high local recurrence rate.

OBJECTIVE:

 This case study aims to identify and determine the general health problems and needs of the
client with proper an admitting diagnosis of Throat Cancer
 This presentation also intends to help patient promote health and medical understanding of such
condition through the application of the nursing skills.
 To review management of papillary thyroid cancer

SUBJECTIVE:

 To raise the level of awareness of patient on health problems that she my encounter.
 To facilitate patient in taking necessary actions to solve and prevent the identification problem on
her own
 To help patient in motivating her to continue the health care provided by the health workers.
 To render nursing care and information to patient through the application of the nursing skill.
 Overview Thyroid CA

Papillary carcinoma typically arises as a solid, irregular or cystic mass that comes from otherwise normal
thyroid tissue. Cervical metastases (spread to lymph nodes in the neck) are present in 50% of small
papillary carcinomas and in more 75% of the larger papillary thyroid carcinomas. The presence of lymph
node metastasis in the neck area typically has a more frequent recurrence rate but not a higher
mortality rate. Distant spread of papillary thyroid cancer is called metastasis. Distant metastasis of
papillary thyroid cancer is uncommon, but when it does occur, it may spread to the lungs, liver, and
bone. Papillary thyroid cancer that invade the surrounding tissues next to the thyroid gland have a much
worse prognosis because of a high local recurrence rate.

Demographic data

Patient Name: Patient X

Age: 65 Y/O
Address: San Idelfonso, Bulacan
Date of Birth: June 10, 1954
Gender: Female
Hospital No.: 246339
Nationality: Filipino
Date of Admission: Sept. 2, 2019
 Nursing History
History of past illness/Family History
(+) DM
(-) HPN
(-) Heart Disease
(-) No prev. Hosp.
(-) No Allergy in Food and Drugs
(-) Of travel domestic and International

History of present
illness
 Jan 2019- X-ray was done and revealed present of neck mass on right anterior measuring 5cm
in size. Advised to take thyroid drugs for 3 mos. (NIL)

 March 2019- started to take the thyroid drugs up to month of June (unrecalled)

 3 weeks after- Had underwent tissue biopsy and revealed Papillary Thyroid CA (Malignant)

 Sept. 2, 2019- Admitted in the institution for thyroid surgery.

 Sept 3, 2019- Underwent total thyroidectomy

 Anatomy and Physiology

 Hyoid bone- U-shaped bone situated at the root of the tongue in the front of the neck and
between the lower jaw and the largest cartilage of the larynx, or voice box.
 The primary function of the hyoid bone is to serve as an anchoring structure for the
tongue.

 Superior thyroid artery- delivers oxygenated blood to the thyroid and surrounding
tissues.

 Carotid arteries- are major blood vessels in the neck that supply blood to the brain, neck,
and face.
 There are two carotid arteries: one on the right and one on the left.
 In the neck, each carotid artery branches into two divisions: The internal carotid artery,
supplies blood to the brain and the external carotid artery supplies blood to the face and neck.
 Thyroid cartilage- which forms the Adam's apple, is the largest and uppermost of nine
cartilages within the larynx, or voice box. (Cartilage is a strong but flexible tissue.) It
houses the vocal folds, also known as the vocal cords.

 Isthmus- is the central but relatively very small part of the thyroid gland that connects
the right and left thyroid lobes. It is directly anterior to the trachea and is covered by the
strap muscles, fascia, and skin in the middle of the neck.

 Trachea- (Windpipe)- is a wide, hollow tube that connects the larynx (or voice box) to
the bronchi of the lungs.
 It is an integral part of the body's airway and has the vital function of providing air flow
to and from the lungs for respiration.
 Pathophysiology

PREDISPOSING FACTORS PRECIPITATING FACTORS

Sex: Female Occupation
Age: 65 Diet
Family History Life style
FNAB Smoking

Exposure to carsinogen

Mucation in the genetic matrial (DNA)

Activation of growth Inactivation of tumor

Promoting oncogenes suppressor genes (p53)

Alteration in mechanism
that control

Ungenerated cell
Alteration and growth

Neoplasm in the thyroid S/SX

Gland -mass, non movable at
right lateral neck
Angeneosis -Dysphagia

Papillary Carcinoma

Patient Risk

High Low

Lobectomy with
Total thyroidectomy
thyroidectomy
neck dissection for
(controversial)
palp. disease
Vs
Total thyroidectomy neck
dissection sac palp disease
 Physical Examination
Examination of Neck
 Firm, Solitary or dominant nodule in MNG
 Movement of swelling on swallowing
 Mobility
 Consistency
 Extent
 Cervical limp node
Examination of Pharynx and Larynx
 Firm, Solitary or dominant nodule in MNG
 Movement of swelling on swallowing
 Mobility
 Consistency
 Extent
 Cervical limp node
 LABORATORY OR DIAGNOSTIC STUDY
Name: Patient X Dept: Surgery Date: 9/2/2019

NAME OF DATE NORMAL ACTUAL ANALYSIS/INTERPRETATION INTERPRETATION

TEST OR DONE VALUES RESULTS AND
PROCEDURE RESULTS OR OR SIGNIFICANCE OF
FINDINGS THE RESULTS OR
FINDING Normal FINDINGS
COMPLTE 9/2/2019
Hemoglobin:
BLOOD 129 g/L
117-157 g/L
COUNT Normal
Hematocrit:
0.37 g/L
0.48-0.68 10^12L
Normal
RBC Count: 3.97/L
4.70-6.10 10^3/uL
Normal
WBC: 6.3/uL
9.0-30.0 L Normal
Neutrophil: 0.48
0.30-0.60
↑
Lymphocyte: H 0.43 May indicate chronic
0.30-0.60 infection or
Normal
inflammation.
Monocyte: 0.05
0.02-0.10 Normal
Eosinophils: 0.04
0.01-0.04

Band:
0.05-0.10
Normal
PLATELET
COUNT: 218
150-400 10^9/L Normal
MCV: 94
95-125 fT Normal
MCH: 32.5
30.00-42.00 pg

Normal
MCHC: 0.35
0.30-0.42 pg Normal
↓
RDW: 14.5
11.50-14.50 % Low platelets.
L 7.23 Normal
MPV:
8.00-10.00 fL Normal
100%
Patient activity Normal
13.0 seconds
Test (s)
Normal
INR 1.00

Control 13.0
 Drug Study
Name of Action Indication Side Effect Adverse Nursing
Drug Effect Responsibilities
Generic Analgesic Thought to Prevention *hypersensitive * Fatigue
Name Para- produce of adverse to drug. IV *Anxiety
aminophen-ol analgesic by reactions form is *Insomnia
Paracetamol derivative inhibiting with contraindicated *Headache
prostaglandin papillary to patients with *
and other thyroid hepatic
substances that CA impairment or
sensitize pain severe liver
receptors. Drug disease.
may relieve * Use
fever through cautiously in
central action in Other patients with
the Indication: long-term
hypothalamic alcohol use
heat-regulating because
center. *Mild to therapeutic
moderate doses
pain hepatoxicity
*Fever
*arthritis
Brand
Name

Calpol

Dose /
Frequency

300 mg / q4

Route

TIV
Generic
Name

Remitidine

Brand
Name

Dose /
Frequency
Route

Generic
Name

Declofenal

Brand
Name

Dose /
Frequency

Route

Problem list

PROB. RANK JUSTIFICATION

1 This is the 1st prioritized nursing prob. because patient

Impaired skin integrity discomfort when not addressed immediately this will increases
the chances that without proper physical treatment and
medication. Physiological needs are thought to be the most
important and they should be met first.
Risk for infection 3 This is the 3rd prioritized nursing prob. because this is a risk
problem and should be prioritized least after actual problems
have been resolved. The fact that the patient has incision site
wound make him more vulnerable in developing infection
directly to her systemic circulation and in her Pharynx and
Larynx.
Risk of injury (fall) 2 This is classified as the 2nd priority due to the discomfort
brought by pain, normal functions of the patient couldn’t be
performed. It also limits her range of motion and mobility since
it also triggers the wounds after surgery in her neck. In
Maslow’s hierarchy of needs, physiologic needs that are basic to
life receive higher priority than security. No immediate
interventions are needed at present, except for continued
assessment and reassurance of client’s safety.
 NURSING CARE PLAN
CUES NURSING SCIENTIFIC PLANNING INTERVEN RATIO EVALUATION
DIAGNOSIS EXPLANATION OR TIONS NALE FOR PARAMETERS
BACKGROUND EACH
INTER
VENTION
Objective:
*Temp: Risk for The creation of a STG: Assess Fever may indicate Goal met:
37.0 C infection surgical wound Within the signs and infection. Patient was free
related to disrupts the shift, the symptoms from any signs and
*BP: post integrity of the patient of infection symptoms of
140/90 operative skin, bypassing will be especially infections as
mmHg incision the body’s able to temperatur manifested by
primary defense identify e. absence of fever.
*PR: and protection ways to It serves as a first
89bpm against infection. reduce risk Emphasize line of defense
Exposure of deep for the against infection.
*RR: body tissue to infection. importance
23cpm pathogens in the of hand
environment LTG: washing Regular wound
*Weak in places the patient At the end technique. dressing promotes
appearanc at riskfor of fast healing and
e infection of the hospitaliza Maintain drying of wounds.
surgical, site and tion, aseptic
*Clean a potentially life- patient technique
and intact threatening will not when Wet area can be
wound complication manifest changing lodge area of
dressing such as infection any signs dressing/ bacteria.
can increase the of caring
length of hospital infection. wound.
stay, cost of care,
and risk for Keep area Premature
further around discontinuation of
complication. wound treatment when
clean and client begins to feel
dry. well may result in
Reference:Brunn return of infection.
er & Suddarth’s Emphasize
Textbook of necessity
Medical and of taking
Surgical Nursing antibiotics
14th Edition by as ordered.
Hinkle and
Cheever
 CUES NURSING SCIENTIFIC PLANNING INTERVEN RATIO EVALUATION
DIAGNOSIS EXPLANATION OR TIONS NALE FOR PARAMETERS
BACKGROUND EACH
INTER
VENTION

NEEDS RISK FOR GOAL OBSERVE TO ENSURE CLIENTS AFTER 2 TO 3 HOURS

ASSISTANCE FALL AFTER 7 INDIVIDUALS SAFETY OF PROPER NURSING
IN RELATED TO DAYS OF GENERAL INTERVENTION THE
AMBULATIO PHYSICAL NURSING HEALTH TO IDENTIFY DEFECITS PATIENT WILL BE FREE
N IMMOBILITY INTERVENTI STATUS THAT PROVIDES FROM FALL AS
ON OPPORTUNITIES EVIDENCED BY ABILITY
THE CLIENT FOR INTERVENTION TO EXPLAIN THE
WILL BE CONSIDER AND INTERACTION SAFETY PRECAUTIONS
FREE FROM ENVIRONME
INJURY NTAL TO PREVENT THE
HAZARDS IN PATIENT FROM
THE CARE FALLING ON BED
INABILITY LONG TERM SETTINGS
TO MOVE GOAL
AFTER 8 ASSES THE TO REDUCE THE RISK
HOURS OF PATIENT OF FALLING
IRRITABLE NURSING ABILITY TO
INTERVENTI AMBULATE
ON THE SAFETY WITH
WEAKNESS CLIENT WILL OR
UNDERSTAN WITHOUTH
D ASSISTIVE
ABSENCE THE RISK DEVICE
OF SIDE FACTORS
THE
RAILS PUT SIDE
CONTRIBUTE
POSSIBILTY RAILS
TO FALLS
THROUGHLY
DEMONSTRA ORIENT THE
TE PATIENT TO
BEHAVIORS ENVIRONME
THAT NT
REDUCE RISK
FACTORS INSTRUCT
AND THE PATIENT
PROTECTION TO CALL FOR
FROM SELF ASSISTANCE
INJURY OF MOVING

MODIFY
ENVIRONME
NTAS
INDICATED
TO ENHANCE
SAFETY
 CUES NURSING SCIENTIFIC PLANNING INTERVEN RATIO EVALUATION
DIAGNOSIS EXPLANATION OR TIONS NALE FOR PARAMETERS
BACKGROUND EACH
INTER
VENTION

Objectives: Impaired Impaired skin STG: Note skin To assess of injury. After 2 hours of
Pale in Skin integrity increases After 2 color, intervention, the
skin color Integrity the chance of hours of texture and patient was able to
related to infection, impaired interventio turgor To asses for maintain or develop
Disruption post mobility, and n, the complications and clean and dry skin.
of skin operative decreased patient will Inspect infection.
layers surgery function. Skin is maintain or surrounding
affected by both develop skin for After 4 days of
Invasion of intrinsic and clean and erythema or intervention, the
body extrinsic factors. dry skin. inflammatio patient was able to
structures Intrinsic factors n and note display progressive
can include altered LTG: the odors improvement in
nutritional status, After 4 days emitted wound healing.
vascular disease of from the To promote optimal
issues, and interventio surgical wound healing.
diabetes. Extrinsic n, the incision.
factors include patient will
falls, accidents, display Inspect skin
pressure, progressive on daily
immobility, and improveme basis, To monitor progress
surgical nt in wound describing of wound healing.
procedures. healing. wound
characteristi
2007 Elsevier Inc cs and
changes Tp assist body’s
observed. natural process of
repair
Periodically
measure a
wound and
observe for
complicatio
ns like
infection.

Keep the
area clean
and dry,
carefully
dress.