A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL

THYROIDECTOMY) I. INTRODUCTION Papillary thyroid cancer or Papillary carcinoma is the most common type (about 80% of thyroid cancer cases), and usually affects women of childbearing age. It spreads slowly and is the least dangerous type of thyroid cancer. (https://www.healthbase.com/hb/cm/thyroid-cancer-treatment-surgery-hormone-therapyradioactive-iodine-therapy-RAI-america-india-abroad-medical-tourism-top-cancercenter.html) Despite its well-differentiated characteristics, papillary carcinoma may be overtly or minimally invasive. In fact, these tumors may spread easily to other organs. Papillary tumors have a propensity to invade lymphatics but are less likely to invade blood vessels. Papillary carcinoma appears as an irregular solid or cystic mass in a normal thyroid parenchyma. T2 categorized for papillary carcinoma means that the tumor is between 2 cm and 4 cm (slightly less than 2 inches) across and has not grown out of the thyroid. (http://emedicine.medscape.com/article/282276-overview#showall) Papillary or follicular (differentiated) thyroid cancer in patients 45 years and older categorized as Stage I (T1, N0, and M0), the tumor is 2 cm or less across and has not grown outside the thyroid (T1). It has not spread to nearby lymph nodes (N0) or distant sites (M0). (http://www.cancer.org/cancer/thyroidcancer/detailedguide/thyroid-cancerstaging) Thyroid cancers are more often found in patients with a history of low- or highdose external irradiation. Papillary tumors of the thyroid are the most common form of thyroid cancer to result from exposure to radiation. The life expectancy of patients with this cancer is related to their age. The prognosis is better for younger patients than for patients who are older than 45 years. Of patients with papillary cancers, about 11% present with metastases outside the neck and mediastinum. Some years ago, lymph node metastases in the cervical area were thought to be aberrant (supernumerary) thyroids because they contained well-differentiated papillary thyroid cancer. http://emedicine.medscape.com/article/282276-overview#showall In the United States,approximately 74-80% of the thyroid cancers diagnosed each year are of the papillary type. Internationally, thyroid cancers are quite rare, accounting for only 1.5% of all cancers in adults and 3% of all cancers in children, but the rate of new cases is increasing in the last decades. The highest incidence of thyroid carcinomas in the world is found among female Chinese residents of Hawaii. During the last few years, the frequency of papillary cancer has increased, but this increase in frequency is related to an improvement in diagnostic techniques and the information campaign about this

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY) carcinoma. Of all thyroid cancers, 74-80% of cases are papillary cancer. Follicular carcinoma incidences are higher in regions where incidence of endemic goiter is high. In contrast to other cancers, thyroid cancer is almost always curable. Most thyroid cancers grow slowly and are associated with a very favorable prognosis. The mean survival rate after 10 years is higher than 90% and is 100% in very young patients with minimal non-metastatic disease. This cancer occurs more frequently in whites than in blacks. The 5-year relative survival rates by race increased from 1975 to 2003, as follows:

Whites: Increase from 93% to 97% African American: Increase from 91% to 94% All races: Increase from 93% to 97%

(http://emedicine.medscape.com/article/282276-overview#showall)

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY) II. SCOPE AND LIMITATIONS OF THE STUDY This case study tackles about left thyroid, status post fine needle aspiration biopsy stage 1 T2 NOMO and the operation performed to improve the condition specifically on the case of patient RG. It includes essential concepts in relation to the said condition such as the patients profile and health history, nursing assessment and clinical manifestations, drug study and diagnostic exams done. The anatomy and physiology is also included as well as the pathophysiology of the above said diagnosis with its associated factors. The Medical and Nursing Management along with the discharge plans and other relevant data are also being covered. The scope of the plan encompasses during the course of duty and date of operation last August 12, 2011 wherein the assigned students who have assessed the client with cumulative interaction postoperatively and established good rapport to the patient and significant other. Nursing Management covers the above mentioned dates which encompasses the clients Recovery Phase. Data gathering about the Laboratory results covers from August 4 2011 to August 12, 2011 and other previous laboratory results, the date and time of operation is also included and how it was performed. The areas of concerns are limited to the discussions of left thyroid papillary carcinoma status post fine needle aspiration biopsy stage 1 T2 NOMO and the quality of nursing care to the patient. The quantity and quality of the information are limited to the data gathered from the client, significant others and his medical records. OBJECTIVES OF THE STUDY The study aims to explore the concepts about the condition and the quality of nursing care being rendered to our client postoperatively that was diagnosed with papillary carcinoma left thyroid status post fine needle aspiration biopsy stage 1 T2 NOMO. In order to learn more about the health condition of the patient, the study wants to fathom about the predisposing and precipitating factors, anatomy and physiology and the pathophysiology of the condition experienced by the client. Basically, the main goal of this study in relation to knowledge is to identify the nursing interventions after the patient undergone an operation. The study aims to critically analyze the qualitative and quantitative data gathered in order to establish connection between the different manifestations experienced by the patient with that of the disease process. To be able to improve skills, the students also endeavors to come up with nursing care plans that will alleviate patients condition. The presentors also intend to compare and contrast the ideal management for papillary
3

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY) carcinoma left thyroid status post fine needle aspiration biopsy stage 1 T2 POMO with that of the actual management. In addition, the study seeks to disseminate essential information to everybody for awareness. Furthermore, by this study, the provider will be able to exercise that attitude of determination and in order to come up with a successful study.

SIGNIFICANCE OF THE STUDY The study is significant to the following people: the client, the clients family, and nursing students. The study is significant to the client, because it enlightens the clients queries and doubts regarding her condition. Allowing him to understand the situation of his present state, this would allow him to be more aware of the importance of following the treatment regimen. Clients family must also be aware of the condition of the client. With the study, the clients family will be able to participate in the clients continuous treatment, and they will be able to realize the importance of the support system in participating in the clients care. The study is also important to the nursing students, since it allows them to explore the clients condition, giving them firsthand experience in observing the manifestations of the disease condition and allowing them to apply theoretical knowledge regarding nursing managements for the manifested signs and symptoms.

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY) III. CLIENTS PROFILE This is a case of a 51 years old female Filipino, a resident of Patag Cagayan de Oro City. Patient X was born on September 09 , 1959.She is married but is separated for 20 years already. She has eight children all are in good health. Patient X only reached 2nd year high school. She was a housekeeper. Patient X was admitted on August 07, 2011 for the first time in Northern Mindanao Medical Center in Female Surgical ward for elective surgery of thyroidectomy. A.VITAL SIGNS Upon assessment, the following data was obtained from Patient X: BP: 110/70mmHg, HR: 18cpm, HR: 85, Temp.36.8. Patient X weighs 63 kg from her previous weight of 68 kg and is 52 in tall. B.CHIEF COMPLAINT Patient X sought hospitalization for surgery due to presence of anterior neck mass C. Family Health Illness History According to patients daughter they have known genetic disease that runs in the family such as hypertension, diabetes mellitus and goiter on the mother side and prostate cancer on the father side. D.HISTORY OF PRESENT ILLNESS Two years prior to admission, patient noted anterior neck mass associated with heat intolerance, insomnia and weight loss. Patient sought medical attention on 2008 at Polymedic General Hospital and biopsy was taken with results of solid masses on left lobe with complex nodules. She was given thyrax 50 g once daily with good compliance. One year prior to admission, still with anterior neck mass with no notable change in size, she had onset of odynophagia with solid food associated with occurrence dysphagia. Three months prior to admission she sought consult with biopsy taken showing atypical thyrocytes suspicious of papillary cancer and was advised surgery. She was worked up with OPD with subsequent admission.

E.HISTORY OF PAST ILLNESS Patient had subsequent admissions in different hospitals. She undergone an operation on her left eye due to cataract last 2008 and on her right eye on 2009.
5

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY)

F.STATEMENT OF THE PATIENTS GENERAL APPERANCE Patient X looked weak, she cant talk due to surgery but she can do sign language. Patient has known allergies to metformin. G. NUTRITIONAL AND METABOLIC PATTERN Pre-hospitalization: Patient X eats more than three times a day. She consumes 1/ 2 share of served food with good appetite. She drinks 3.6 liters of water a day. Hence Patient X is a tobacco user since she was 25 years old consuming 3 sticks of cigarette per day, but on 2007 patient had already stopped smoking. During hospitalization(pre surgery): Patient X still has a good appetite she was advised to eat Quaker oats with wheat bread, milk and fruits and vegetables and she only drinks 2 liters of water a day. Patient X lost weight from 68 kg to 63 kg as she was advised to go on diet. Post surgery: Patient is still on an NPO state Patient X has a diabetes mellitus type 2 with a HGT result of 164mg/dl on August 12, 2011@ 2pm.She has started having her insulin injection since May 26, 2011 up to present. Patient was hooked in an Intravenous fluid of PNSS 1 liter regulated at 30gtts ACTIVITIES OF DAILY LIVING Feeding Bathing DRESSING Grooming Meal preparation Cleaning Laundry Toileting Bed mobility Chair/toilet transfer Ambulation R.O.M 4 - Total dependence 4 - Total dependence 4 - Total dependence 4 - Total dependence 4 - Total dependence 4 - Total dependence 4 - Total dependence 4 - Total dependence 4 - Total dependence 4 - Total dependence 4 - Total dependence 4 - Total dependence

H.ELIMINATION
6

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY)

Pre hospitalization: Patient X usually defecates once a day, with yellowish to brownish stool and soft in consistency and no discomfort felt during defecation but whenever she cannot defecate in a day she uses suppository. She urinates three times daily with dark yellow colored urine in variable amount. During hospitalization: Patient X has defecated only once for four days. Her last bowel movement was last August 10, 2011. She urinates three times daily with dark yellow urine in variable amount and sometimes patient would choose not to void because of the dirty C.R. Prior to surgery she was inserted with a foley catheter attached to urobag. Post surgery: Patient was still hooked with a catheter attached to urobag draining well to dark yellow colored urine @ 200cc for 7 hours. I.ACTIVITY AND EXERCISE PATTERN Patient X considered walking up and down their house as her form of exercise and reading books as her leisure activity. J.COGNITIVE AND PERCEPTUAL PATTERN Patient X speaks tagalog and visayan language but her primary language is tagalog. She has no learning difficulties. She has change of memory lately, whenever she was told of something in just a minute she can already forget what was told to her according to her daughter. She was oriented to time, place and person. She was conscious and is able to understand but she still cant able to speak, she can only do sign language. According to her daughter she felt worried about her condition. K.SLEEP REST PATTERN Pre- hospitalization: Patient X sleeps 8 hours a day. For her it is adequate. During hospitalization: Patient X has sleep disturbances due to noisy environment, like the slam of the door of the C.R and the cries of babies in the ward. L.ROLE RELATIONSHIP PATTERN Patient X has been separated with her husband for 20 years however she has a good and sound relationship with her children. It was her children who had helped her during these days. Patient X family was worried about her condition and on how they can sustain her financial needs in terms of her hospitalization as they lack financial support.

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY) M.SEXUALITY-REPRODUCTIVE PATTERN Patient X sexual life was inactive as she has been separated with her husband for 20 years. She is menopausal. She had her last menstrual flow in the year 2009 but just this year she experienced vaginal bleeding for 7 days last three weeks and according to her it was profuse. She doesnt have her regular monthly breast examination she only does it when she like to do it so according to her daughter. N.COPING- STRESS TOLERANCE Patient X was worried about her condition especially on financial matters. She was very compliant to medication regimen although she doesn't usually have her follow up check up. O.VALUES BELIEF PATTERN Patient X is a Roman Catholic. According to her daughter she goes to church every Sunday and prays as part of her religious practices. Hospitalization interferes with her religious activities like going to church but she is constantly praying even hospitalized.

PHYSICAL ASSESSMENT Together with medical history, the physical examination aids in determining the correct diagnoses and devising the treatment plan. This part of the study will present the normal and regressed health function of Patient X pointing out the salient, manifestations of the disease.

I.COGNITIVE-PERCEPUAL PATTERN Level of consciousness Orientation Emotional state Appropriate behavior conscious oriented Worried cooperative

HEAD Head Normocephalic

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY) Facial movement Fontanels Hair Scalp Symmetrical Closed Fine; evenly distributed Clean

EYES Lids Periorbital region Conjunctiva Cornea & lens Sclera Pupils Symmetrical Normal Pale Opacity to Right Anicteric Equal size:4mm;brisk reaction to light left eye; uniform accommodation Visual acuity Peripheral vision EARS External Pinnae External canal Tympanic membrane Gross hearing Normoset No discharges Intact Normal Nearsighted Decreased

NOSE Septum Mucosa Patency Gross mell Midline Pallor Both patent Normal sinuses

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY) Sinuses No tenderness

MOUTH Lips Mucosa Tongue Teeth Gums Pinkish Pallor Midline Missing teeth Pale

PHARYNX Uvula Tonsils Posterior pharynx Midline Not inflamed Not inflamed

NECK Trachea Thyroids Midline Removed

SKIN General color Texture Turgor Temperature Pink Smooth Supple Warm

10

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY)

ABDOMEN General Configuration Bowel sounds Percussion Superficial Symmetrical Normoactive( 13 count) Tympanitic

II. CARDIOVASCULAR Point of maximum impulse Heart sounds Peripheral pulses Capillary refill 5thintercostal space Regular Regular 2 seconds

II.RESPIRATORY STATUS Breathing pattern Shape of chest Lung expansion Vocal/tactile fremitus Breath sounds Cough Regular Ap:1:2 Symmetrical Symmetrical Vesicular None

11

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY) BACK AND EXTREMITIES Range of motion Muscle tone and strength Spine Gait Decreased ROM due to surgery Symmetrical in size Not assessed Not assessed

III.REPRODUCTIVE SYSTEM Vagina Breast No discharges Equal in size

12

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY)

REVIEW OF SYSTEMS

Pale Pale oral mucosa conjunctiva Impaired CBG shows gag reflex abnormal increase of blood Missing teeth glucose of 13 164mg/dl

Near sighted, decreased peripheral vision

Decreased range of motion

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY) IV. ANATOMY AND PHYSIOLOGY The thyroid gland is a soft, butterfly shaped gland that lies wrapped around the windpipe below the Adam's apple. It is located in the front of the neck, below the larynx or voice box. The small, two-inch gland consists of two lobes; one on each side of the windpipe, connected by tissue called the isthmus. The thyroid tissue is made up of two types of cells: follicular cells and parafollicular cells. Most of the thyroid tissue consists of the follicular cells, which secrete iodine-containing hormones called thyroxine (T4) and triiodothyronine (T3). The parafollicular cells secrete the hormone calcitonin. The thyroid needs iodine to produce the hormones. There's no much difference between T3 and T4. The numbers refer to the amount of atoms of iodine contained in the hormones. T3 is the more powerful while T4 is released by the thyroid in larger amounts, but is mostly converted to T3 in the liver and kidneys. The effect of T3 and T4 is to:

increase the basal metabolic rate of almost all the cells in the body increase the fat and carbohydrate metabolism boost protein synthesis; and increase heart rate and blood flow to other organs. Thyroid hormones

are also needed for normal development of organs such as the heart and the brain in children and for normal reproductive functioning. When the gland is healthy, it releases as much thyroid hormone as we need to keep our metabolism on an even keel. It knows just how much to release because of the feedback mechanisms between a gland in the base of the brain, called the pituitary, and a small part of the brain above the pituitary, called the hypothalamus. The pituitary contains special cells that are very sensitive to levels of thyroid hormone in the blood. If they are too low, it secretes a hormone called thyrotropin stimulating hormone (TSH).
14

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY) This in turn stimulates the thyroid to produce more thyroid hormone. When the level of thyroid hormone in the blood goes back to normal, the pituitary stops producing extra TSH. It works the other way if there's too much thyroid hormone in the blood: the pituitary releases less TSH, and the thyroid makes less thyroid hormone. The hypothalamus has a hand in this too. It can stimulate or suppress TSH production from the pituitary, by means of a hormone released from the hypothalamus in response to environmental changes from the brain, called thyroid releasing hormone (TRH). The whole system is sometimes called the 'hypothalamic -pituitary -thyroid axis'. The thyroid gland makes thyroid hormone from the amino acid tyrosine that it gets from proteins in the diet. But it requires a regular supply of iodine in the diet too. Adults need about 150g (millionths) of a gram each day and almost double this amount during pregnancy otherwise it can't make enough thyroid hormone to keep metabolism at normal levels. Iodine is found in most foods and is especially prevalent in seafood and dairy products. It's often added to foods in the form of salt too. However, some mountainous areas have soil that is low in iodine. As a result, foods grown there are iodine deficient. The thyroid also makes the hormone calcitonin, which is involved in calcium metabolism and stimulating bone cells to add calcium to bone.

15

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY) Predisposing Factors: V. PATHOPHYSIOLOGY Family history of cancer in maternal side Age: 51 years old Gender: Female Smoker for 22 years Precipitating Factors: Existence of Goiter LEGEND: Predisposing Factors Precipitating Factors Disease Process Treatment (either through medication or surgery) Diagnostic Examination Surgery effects Mutation in DNA mismatches repair genes Activation of trk and ret Proto-oncogens Signs and symptoms

Alteration in the normal cell

Transforms cells into oncogene Negatively affects the DNA repair Tumor suppressor genes is turned off inactivation of the thyrocytes ability to stop replication

Proliferation of affected cell

Quick abnormal cell growth and division

Allows unchecked cellular replication at the follicular epithelium surface

16

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY)

Inability to control proliferation of affected cells

DNA repair genes is inactivated

Increased cell division causing further mutations

Increases survival and proliferation of cancer cells

Activation of the k-ras oncogene

P53 mutations which prevent apoptosis Spreads out to follicular cells of the thyroid, left Prolong lifespan of affected cancer cells

Continuous replication of affected cells

Increases number of malignant cells

Invades the follicular epithelium

17

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY)

Initial damage of the thyrocytes

Forms epithelium composed of genetically altered cells located in the superficial surface of the follicular thyrocytes

Transformation takes place among the stem cell population at the epithelium of the follicular base

Cancerous cells migrate from the follicular surface to the isthmus undergoes differentiation and maturation abnormal cells spreads covering the left thyroid

Transformed stem cell replicated

loss of proliferation control

Biopsy and ultrasound show presence of possible papillary carcinoma

Connects to pre-existing of follicular cells and replaces them with cancer cells

monoclonal conversion produces the monopapillary adenoma

expands early by papillary fission Anterior mass noted on the neck

Affects the whole left thyroid gland

Formation of malignant tumor in the thyroid epithelial tissue

TOTAL THYROIDECTOMY (August 12, 2011; AM)

18

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY) VI. SURGICAL PROCEDURE Total Thyroidectomy History of Thyroidectomy Modern thyroid surgery, as we know it today, began in the 1860s in Vienna with the school of Billroth.1 The mortality associated with thyroidectomy was high, recurrent laryngeal nerve injuries were common, and tetany was thought to be caused by hysteria. The parathyroid glands in humans were not discovered until 1880 by Sandstrom, and the fact that hypocalcemia was the definitive cause of tetany was not wholly accepted until several decades into the twentieth century. Kocher, a master thyroid surgeon who operated in the late nineteenth and early twentieth centuries in Bern, practiced meticulous surgical technique and greatly reduced the mortality and operative morbidity of thyroidectomy for goiter. He described cachexia strumipriva in patients years after thyroidectomy. Kocher recognized that this dreaded syndrome developed only in patients who had total thyroidectomy. As a result, he stopped performing total resection of the thyroid. We now know, of course, that cachexia strumipriva was surgical hypothyroidism. Kocher received the Nobel Prize for this very important contribution, which proved beyond a doubt the physiologic importance of the thyroid gland. What is Total Thyroidectomy? A total thyroidectomy is surgery to take out all of your thyroid gland. Your thyroid gland is important for making hormones that help your body work right. Your thyroid gland is in the front lower part of your neck. It is made up of two sections. Each section has two parathyroid glands. The parathyroid glands control the calcium level in your body, and are an important part of your thyroid gland. Your thyroid may grow too big or it may make too many hormones. This can lead to conditions such as hyperthyroidism, benign multinodular goiter, or cancer. Benign means that the goiter is not cancer, but it may turn into cancer if it is not treated. Certain medicines may also cause your thyroid gland to stop working right. Total thyroidectomy surgery may be needed to correct certain thyroid conditions. The nerves to the larynx run close to the thyroid gland. Removal of thyroid tumors requires care to prevent injury to these nerves. There are two nerves on each side of the neck. One, the superior laryngeal nerve approaches the upper end of the thyroid and provides tension to the vocal cords thus allowing higher pitched singing and speaking. The more crucial nerve to speech is the recurrent laryngeal nerve that passes just deep to the thyroid lobe as it courses up from the chest to the larynx. Injury to this
19

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY) nerve causes a paralysis of the vocal cord. The effect of this vocal cord weakness varies considerably between individuals as some patients demonstrate no detectable voice change and others become hoarse. If hoarseness does result, it is usually temporary. Corrective procedures can be performed for either temporary or permanent vocal fold weakness. If you have cancer, your thyroid gland, as well as tissue and lymph nodes around the gland may be removed. Your parathyroid glands may also be removed, and then put back into another place in your neck during surgery. Putting your parathyroid glands back into your neck will help the calcium level in your blood stay at the level it should be. After this surgery, swallowing and breathing problems may go away. Removing your thyroid gland and tissue and lymph nodes may also prevent certain thyroid problems from returning or getting worse. The procedure is done under general anesthesia through a transverse incision below the collar line. This incision heals well with minimal scarring and provides safe access to identify the recurrent laryngeal nerves and remove all tumor tissue. Total thyroidectomy is a 3-4 hour procedure. The incision is usually closed with nylon sutures that are removed 4-6 days after surgery. A drain is usually placed which is removed in 1-2 days after surgery.

Indication for

Thyroidectomy Thyroidectomy is usually performed for the following reasons: 1. As therapy for some individuals with thyrotoxicosis, both those with Graves disease and others with hot nodules.

20

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY) 2. To establish a definitive diagnosis of a mass within the thyroid gland, especially when cytologic analysis after fine-needle aspiration (FNA) is either nondiagnostic or equivocal. 3. To treat benign and malignant thyroid tumors. 4. To alleviate pressure symptoms or respiratory difficulties associated with a benign or malignant process. 5. To remove an unsightly goiter. 6. To remove large substernal goiters, especially when they cause respiratory difficulties.

Preparation for Surgery Most patients undergoing a thyroid operation are euthyroid and require no specific preoperative preparation related to their thyroid gland. Determination of serum calcium and parathyroid hormone (PTH) levels may be helpful, and endoscopic or indirect laryngoscopy should definitely be performed in those who are hoarse and in others who have had a prior thyroid, parathyroid, or cervical disc operation in order to detect the possibility of a recurrent laryngeal nerve injury. Figure 1. Common operations on the thyroid. In near-total thyroidectomy, a small amount of thyroid tissue is left to protect the recurrent laryngeal nerve and upper parathyroid gland. (From Kaplan EL: Surgical endocrinology. In Polk HC, Stone HH, Gardner B [eds]: Basic Surgery, 4th ed. St. Louis, Quality Medical Publishing, 1993, pp 162195.)

21

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY)

Operative Technique for Thyroidectomy Under general endotracheal anesthesia, the patient is placed in a supine position with the neck extended. A low collar incision is made and carried down through the subcutaneous tissue and platysma muscle (Fig. 2A). Currently, small incisions are the rule unless a goiter is present. Superior and inferior subplatysmal flaps are developed, and the strap muscles are divided vertically in the midline and retracted laterally (Fig. 15B). Figure 2. A, Incision for thyroidectomy. The neck is extended and a symmetrical, gently curved incision is made 1 to 2 cm above the clavicle. In recent years the author has used a much smaller incision except when a large goiter is present; B, The sternohyoid and sternothyroid muscles are retracted to expose the surface of the thyroid lobe; C, The surgeons hand retracts the gland anteriorly and medially to expose the posterior surfaces of the thyroid gland. The middle thyroid vein is identified, ligated and divided; D,The superior thyroid vessels are ligated on the thyroid capsule of the superior pole to avoid inadvertent injury to the external branch of the superior laryngeal nerve. This nerve can be seen in many cases

22

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY)

LOBECTOMY OR TOTAL THYROIDECTOMY The thyroid isthmus is usually divided early in the course of the operation. The thyroid lobe is bluntly dissected free from its investing fascia and rotated medially. The middle thyroid vein is ligated (Fig. 2C). The superior pole of the thyroid is dissected free, and care is taken to identify and preserve the external branch of the superior laryngeal nerve. The superior pole vessels are ligated adjacent to the thyroid lobe, rather than cephalic to it, to prevent damage to this nerve (Fig. 2D). This nerve can be visualized over 90% of patients if it is carefully dissected. The inferior thyroid artery and recurrent laryngeal nerves are identified (Fig. 2E). To preserve blood supply to the parathyroid glands, the inferior thyroid artery should not be ligated laterally; rather, its branches should be ligated individually on the capsule of the lobe after they have supplied the parathyroid glands (Fig. 2F). The parathyroid glands are identified, and an attempt is made to leave each with an adequate blood supply while moving the gland off the thyroid lobe. Any parathyroid gland that appears to be devascularized can be minced and implanted into the sternocleidomastoid muscle after a frozen section biopsy confirms that it is in fact a parathyroid gland. Care is taken to try to identify the recurrent laryngeal nerve along its course if a total lobectomy is to be done. The nerve is gently unroofed from surrounding tissue, with care taken to avoid trauma to it. The nerve is in greatest danger near the junction of the trachea with the larynx, where it is adjacent to the thyroid gland. Once the nerve and parathyroid glands have been identified and preserved, the thyroid lobe can be removed from its tracheal attachments by dividing the ligament of Berry (Fig. 2G). The contralateral thyroid lobe is removed in a similar
23

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY) manner when total thyroidectomy is performed. A near-total thyroidectomy means that a very small amount of thyroid tissue is left on the contralateral side to protect the parathyroid glands and recurrent nerve. Careful hemostasis and visualization of all important anatomic structures are mandatory for success. Some surgeons utilize the harmonic scalpel or electrothermal bipolar vessel sealing system and believe that they decrease the time of operation. However, one must be careful not to cause damage. Figure 2. E, With careful retraction of the lobe medially, the inferior thyroid artery is placed under tension. This facilitates exposure of the recurrent laryngeal nerve and the parathyroid glands; F, The inferior thyroid artery is not ligated as a single trunk, but rather its tertiary branches are ligated and divided on the thyroid capsule. This preserves the blood supply to the parathyroid glands, which can be moved away from the thyroid lobe; G, The ligament of Berry is then ligated and divided and the thyroid lobe is removed. (Courtesy of Drs. Alan P. B. Dackiw and Orlo H. Clark.)

When closing, we do not tightly approximate the strap muscles in the midline; this allows drainage of blood superficially and thus prevents a hematoma in the closed deep space. Furthermore, we obtain better cosmesis by not approximating the platysmal muscle. Rather, the dermis is approximated by interrupted 4-0 sutures, and the epithelial edges are approximated with a running subcuticular 5-0 absorbable suture. Sterile paper tapes (Steri-strips) are then applied and left in place for about a week. When it is needed, a small suction catheter is inserted through a small stab wound; it is generally removed within 12 hours.

24

A Case Study on Left Thyroid Papillary Carcinoma, Status Post Fine Needle Aspiration Biopsy Stage 1 T2N0M0 (TOTAL THYROIDECTOMY)

25

VII. LABORATORY RESULTS Hematology Report (August 11,2011) TEST WBC RBC Hgb RESULTS 7,400 5.66 13.0 REFERENCE VALUES 5,000-10,000 cell/mm3 4.7-6.1 10^6/uL 13.7-16.7 g/dL INTERPRETATION Within Normal Range Within Normal Range A decrease in rbc may also decrease hemoglobin since rbc carries oxygen to the blood. A Low hemoglobin may also indicate anemia. Within Normal Range A low MCV number might indicate the presence of anemia, but other factors will be measured as well before making this diagnosis. The mean corpuscular volume indicates the size of the red blood cells in a person's body. A low MCH number might indicate the presence of anemia. The Mean Corpuscular Hemoglobin indicates the weight of hemoglobin in each cell. Within Normal Range

Hct MCV

39.4 69.6

37.0- 47.0 gm% 80.0-96.0 fL

MCH MCHC Differential Count Lymphocytes Monocytes Platelet count

23.0 33.0

27.0-31.0 pg 32.0-36.0%

37.2 5.6 235, 000

18-45% 4-8% 144,000-372,000 cell/mm3

Within Normal Range Within Normal Range Within the normal range which connotes the clotting factor is good.

Radiographic Report (August 4, 2011) Shows slight thickening of the bronchovascular markings hilar area. Trachea is at midline. Heart is not enlarged. Diaphragm is distinct. Thorax is unremarkable Impression: Bronchitis suggest follow up after 3 weeks. Interpretation: There is a slight thickening of bronchovascular markings specifically in the hilar area which means that an infection is developing.

Fine Needle Aspiration Cytology Report (5-11-11) Source/Organ : Left Thyroid Gross description of aspirated material Aspirated scanty blood tinged brown turbid fluid Cytologic Descripion Aspirated smears show few atypical thyrocytes arranged in overlapping clusters. These cells have round to oviod folded and regular nuclie, fine coarse chromatin, occasional prominent nucleoli and moderate distinct cytoplasm some of these cells exhibit nuclear grooving. The background shows abundant foamy histiocytes and red blood cells and some colloid. Cytopathologic Interpretation Few atypical thyrocytes present. Suspicious of papillary carcinoma in background of colloid cyst. Interpratation: The findings indicate few atypical thyrocytes which suggest papillary carcinoma.

Ultrasound (07-01-2008) Findings: The thyroid gland is not enlarged. Right Lobe: 4.4 x 1.5 x 1.2 cm Left Lobe: 4.3 x 1.6 x 1.5 cm There is a solid echogenic nodule seen at the mid-segment of the left lobe measuring 1.4 x 1.1 x 1.1 cm Nodules seen at the right lobe of the gland. A solid nodule at the upper segment, 0.6 x 0.6 cm, solid nodule at the mid-segment, 0.5 x 0.5 cm, and complex nodule at the mid segment, 0.4 x 0.5 cm Normal sized left lobe with solid mass, as described Normal sized right lobe with solid and complex nodules Interpretation: Both the left and right lobes are normal sized. Thyroid mass and nodules indicate presence of abnormal growth in the thyroid gland. A fine needle aspiration biopsy is needed to get information on the thyroid nodules.

Blood Chemistry Date August 4, 2011 Electrolyte Glucose Potassium Creatinine Sodium August 11, 2011 Calcium Result 92.0 3.6 0.90 142.3 8.9 Reference Value 59.9-110.1mg/dL 3.4-5.4mmol/L 0.59-1.21mg/dL 134.0-149.0 mmol/L 8.1 10.4 mg/dL Interpretaion Within Normal Range Within Normal Range Within Normal Range Within Normal Range Within Normal Range

August 12, 2011

Calcium

9.2

8.1- 10.4 mg/dL

Within Normal Range

Serology Immunology (May 13, 2011) Analyte Thyroid Function T3 T4 2.08 117.50 nmol/L nmol/L [1.30-3.10] [66.0-181.00] Within Normal Range Within Normal Range Result Unit Flag Normal Range Interpretation

RADIO IMMUNO ASSAY (RIA) Result (May 13, 2011) Test FT3 FT4 FSH 0.68uIU/mL Result Normal Range 2.5-5.8pmol/L 11.5-23.0pmol/L 0.27 -3.75uIU/mL Within Normal Range Interpretation

Previous Result (October 2, 2009) Test FT3 FT4 Result Normal Range 2.5-5.8pmol/L 11.5-23.0pmol/L Interpretation

FSH

1.03uIU/mL

0.27 -3.75uIU/mL

Within Normal Range

RIA Performance Calibration Range Analytical Sensitivity Specificity

FT3 0.544 pmol/L 0.5 pmol/L Highly Specific

FT4 2.5-5.8pmol/L 11.5-23.0pmol/L Higly Specific

FSH 0.01-100 uIU/mL 0.01 uIU/mL Highly Specific

Interpratation: T3, T4, TSH are within the normal range.

VIII. DRUG STUDY

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency)

MECHANISM OF ACTION

INDICATON

CONTRAINDICATION

ADVERSE EFFECT OF THE DRUG

NURSING RESPONSIBILTIES/ PRECAUITION

GENERIC NAME: Ketorolac tromithamine BRAND NAME: Kortezor CLASSIFICATION: Nonsteroidal antiinflammatory drug (NSAID) Analgesic, antipyretic, anti-inflammatory DOSAGE: 30mg ROUTE: IVTT FREQUENCY: every 6hrs x 4doses

Interferes with Post operative pain prostaglandin biosynthesis by inhibiting cyclooxygenase pathway of arachidonic acid metabolism; also acts as potent inhibitor of platelet aggregation

Hypersensitivity to drug, its components, aspirin, or other NSAIDs Concurrent use of aspirin, other NSAIDs, or probenecid Peptic ulcer disease GI bleeding or perforation Advanced renal impairment, risk ofrenal failure Increased risk of bleeding, suspected or confirmed cerebrovascular bleeding, hemorrhagic diathesis, incomplete hemostasis Prophylactic use before major surgery, intraoperative use when hemostasis is critical Labor and delivery Breastfeeding

CNS: drowsiness, headache, dizziness CV: hypertension EENT: tinnitus GI: nausea, vomiting, diarrhea, constipation, flatulence, dyspepsia, epigastric pain, stomatitis Hematologic: thrombocytopenia Skin: rash, pruritus, diaphoresis Other: excessive thirst, edema, injection site pain

Monitor for adverse reactions, especially prolonged bleeding time and CNS reactions. Advise patient to minimize GI upset by eating small, frequent servings of healthy foods. Monitor fluid intake and output. Monitor Vital signs especially blood pressure for possible bleeding Caution female patient not to take drug if she is breastfeeding.

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) GENERIC NAME: Tramadol hydrochloride

MECHANISM OF ACTION

INDICATON

CONTRAINDICATION

ADVERSE EFFECT OF THE DRUG

NURSING RESPONSIBILTIES/ PRECAUTION

Inhibits reuptake of serotonin and norepinephrine in CNS

Moderate to moderately severe pain

Hypersensitivity to drug, its components, or opioids Acute intoxication

CNS: dizziness, vertigo, headache, drowsiness, anxiety,

Assess patients response to drug 30 minutes after

BRAND NAME: Milador CLASSIFICATION: Pharmacologic class: Opioid agonist Therapeutic class: Analgesic DOSAGE: 50mg ROUTE: IVTT FREQUENCY: every 8hrs x 2doses and PRN

with alcohol, sedativehypnotics, centrally acting analgesics, opioid analgesics, or psychotropic agents Physical opioid dependence

stimulation, confusion, incoordination, euphoria, nervousness, sleep disorder, asthenia, hypertonia, seizures CV: vasodilation EENT: visual disturbances GI: nausea, vomiting, diarrhea, constipation, abdominal pain, dyspepsia, flatulence, dry mouth, anorexia GU: urinary retention and frequency, proteinuria, menopausal symptoms. Respiratory: respiratory depression (with large doses, concomitant anesthetic use, or alcohol ingestion)

administration. Monitor respiratory status. Withhold drug and contact prescriber if respirations become shallow or slower than 12 breaths/minute. Withhold the drug if hypotension noted administer IVTT drug slowly to avoid nausea and vomiting.

Skin: pruritus, sweating

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) GENERIC NAME: ranitidine

MECHANISM OF ACTION

INDICATON

CONTRAINDICATION

ADVERSE EFFECT OF THE DRUG

NURSING RESPONSIBILTIES/ PRECAUTION

Reduces gastric acid secretion and increases gastric mucus and

Prevent gastric ulcer

Hypersensitivity to

CNS: headache,

Confirm patient through asking his

BRAND NAME: Ramadine CLASSIFICATION: Pharmacologic class: Histamine2receptor antagonist Therapeutic class: Antiulcer drug DOSAGE: 50mg ROUTE: IVTT FREQUENCY: every 8hrs. x 2doses

bicarbonate production, creating a protective coating on gastric mucosa

drug or its components agitation, anxiety Alcohol intolerance (with some oral products) History of acute porphyria GI: nausea, vomiting, diarrhea, constipation, abdominal discomfort or pain Hematologic: reversible granulocytopenia and thrombocytopenia Hepatic: hepatitis Skin: rash Other: pain at I.M. injection site, burning or itching at I.V. site, hypersensitivity reaction

name and looking on his name bracelet. Explain to the patient what the drug is for. Assess vital signs. Monitor CBC and liver function tests. Tell patient smoking may decrease drug effects. Tell patient drug caan cause constipation.

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) GENERIC NAME:

MECHANISM OF ACTION

INDICATON

CONTRAINDICATION

ADVERSE EFFECT OF THE DRUG

NURSING RESPONSIBILTIES/ PRECAUTION

Interferes with

Surgical prophylaxis

Hypersensitivity to

CNS: headache,

Confirm patient

Cefazolin sodium BRAND NAME: Fonvisol CLASSIFICATION: Pharmacologic class: First-generation cephalosporin Therapeutic class: Anti-infective DOSAGE: 1gm ROUTE: IVTT FREQUENCY: every 8hrs.

bacterial cell-wall synthesis, causing cell to rupture and die

cephalosporins or penicillins

lethargy, confusion, hemiparesis, paresthesia, syncope, seizures CV: hypotension, palpitations, chest pain, vasodilation EENT: hearing loss GI: nausea, vomiting, diarrhea, abdominal cramps, oral candidiasis, pseudomembranous colitis GU: vaginal candidiasis, nephrotoxicity Hematologic: lymphocytosis, eosinophilia, bleeding tendency, hemolytic anemia, hypoprothrombinemia, neutropenia, thrombocytopenia, agranulocytosis, bone marrow depression Hepatic: hepatic failure, hepatomegaly Musculoskeletal: arthralgia Respiratory: dyspnea Skin: urticaria, maculopapular or

through asking his name and looking on his name bracelet. Explain to the patient what the drug is for. Assess vital signs. If patient is receiving high doses, monitor for extreme confusion, tonic clonic seizures, and mild hemiparesis. Be aware that crosssensitivity to penicillins may occur.

erythematous rash

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) GENERIC NAME:

MECHANISM OF ACTION

INDICATON

CONTRAINDICATION

ADVERSE EFFECT OF THE DRUG

NURSING RESPONSIBILTIES/ PRECAUTION

Reduces gastric acid

Prevent gastric Ulcer

Hypersensitivity to

CNS: dizziness,

Assess vital signs.

omeprazole BRAND NAME: Losec CLASSIFICATION: Pharmacologic class: Proton pump inhibitor Therapeutic class: Antiulcer drug DOSAGE: 40mg ROUTE: P.O FREQUENCY: STAT / PRN

secretion and increases gastric mucus and bicarbonate production, creating protective coating on gastric mucosa and easing discomfort from excess gastric acid

drug or its components headache, asthenia Precautions GI: nausea, vomiting, diarrhea, constipation, abdominal pain Musculoskeletal: back pain Respiratory: cough, upper respiratory tract infection Skin: rash

Check for abdominal pain, emesis, diarrhea, or constipation. Evaluate fluid intake and output. Watch for elevated liver function test results (rare). Tell patient to take 30 to 60 minutes before a meal, preferably in morning. Instruct patient to swallow capsules or tablets whole and not to chew or crush them.

IX. NURSING CARE PLAN

ASSESSMENT

NURSING DIAGNOSIS

GOALS AND

NURSING INTERVENTION

EVALUATION

OBJECTIVES SUBJECTIVE: ACUTE ANTERIOR hand gesture when he was INJURY asked if he is experiencing NERVE pain. PAIN SCALE OF SURGICAL (Assessed gestures) OBJECTIVES: Irritability Fatigue Facial grimace through hand IN PAIN

/RATIONALE GOALS MET. interventions, the patient was pain from 7 by to 0 as

AT At the end of 15 minutes Independent: temperature and vital signs. Demonstrate acute pain.

LOWER of nursing care, patient will PAIN 1. TO decreased level of pain from 7 to 0 as evidenced adequate manner cannot due to by rest/ (patient verbalize R: fear

1. Monitor the skin color and After 15 minutes of nursing R: Which are usually altered in able to decreased level of 2. Provide comfort measures evidenced adequate

Patient said yes through NECK RELATED TO be able to: ENDINGS INCISION

SECONDARY

such as touch,repositioning, rest/sleep and demonstrate use of heat or cold packs relaxed manner. and nurses presence, quiet environment activities To promote pain rest and calm

7/10 (THYROIDECTOMY)

sleep and relaxed

of nonpharmacological management. 3. Encourage periods R: To prevent fatigue adequate

dehiscence)

4. Instruct and encourage use of relaxation techniques, such as listening to music (e.g., white noise)

R:

To

distract

attention

and

reduce tension. Dependent: 1. Administer analgesics such as Tramadol 50mg IVTT and Ketorolac 30 mg IVTT. R: To decrease level of pain. Notify physician if regimen is inadequate to meet pain control goal.

ASSESSMENT

NURSING DIAGNOSIS

GOALS AND OBJECTIVES

NURSING INTERVENTIONS/ RATIONALE

EVALUATION

RISK FACTORS: Inadequate primary defenses (broken skin) Invasive procedure (Thyroidectomy)

RISK FOR INFECTION RELATED TO TRAUMATIZED TISSUE SECONDARY TO SURGICAL INCISION (THYROIDECTOMY)

At the end of 8 hours of nursing interventions, patient will be able to: 1. Identify interventions to prevent risk of infection 2. Patients post-operative wound remains dry and intact.

INDEPENDENT: 1. Observe for localized sign of infection at site of surgical incision R: To assess causative or contributing factor. 2. Encourage early ambulation, deep breathing, coughing, and position changes. R: For mobilization of respiratory secretions and prevention of aspiration 3. Stress proper hand hygiene by all caregivers between therapies and client. R: A first line defense against healthcare-associated infection. 3. Instruct patient and SO to do handwashing before and after eating and to avoid touching the

GOALS MET. After 8 hours of nursing interventions, the patient was able to identify interventions to prevent risk of infection as evidenced by patient was able to express his thoughts through writing, sign language and answering closed-ended questions through facial expressions and hand gestures. GOALS MET After 8 hours of nursing interventions, the patients wound remained dry and intact.

patients wound or dressing. R: To prevent crossing of microorganisms from hands to surgical site; this is also a means of portal of entry. DEPENDENT: 1. Administer prophylactic antibiotics such as Cefazolin 1g IVTT as indicated.

ASSESSMENT DATA (Subjective & Objective)

NURSING DIAGNOSIS (Problem and Etiology)

GOALS AND OBJECTIVE

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Risk Factors: Neck surgery (Thyroidectomy) Impaired swallowing due to depressed gag reflex

RISK FOR ASPIRATION RELATED TO DEPRESSED GAG REFLEX SECONDARY TO TOTAL THYROIDECTOMY

After 8 hours of nursing interventions, the patient will be able to: Experience no aspiration as evidenced by noiseless respirations, clear breath sounds, clear odorless secretions

Independent: > Assist with postural drainage R: To mobilize thickened secretions that may interfere with swallowing > Auscultate lung sounds frequently R: To determine presence of secretions > Elevate client to best possible position during eating and drinking Dependent:

GOALS MET After 8 hours of nursing interventions, the patient was able to experience no aspiration as evidenced by noiseless respirations, clear breath sounds, clear odorless secretions.

> Provide soft foods as ordered by the physician R: To aid in swallowing effort.

ASSESSMENT DATA (Subjective & Objective)

NURSING DIAGNOSIS (Problem and Etiology)

GOALS AND OBJECTIVE

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective: Patient said yes through hand gesture when he was asked if he is experiencing pain. PAIN SCALE OF 7/10 (Assessed through hand gestures) Objective: Disruption of skin surface (epidermis) Disruption of skin

IMPAIRED SKIN INTEGRITY RELATED TO SURGICAL INCISION AT ANTERIOR LOWER NECK

After 10 days of nursing interventions, the patient will be able to: Display timely healing of operative wound without complications

Independent: > Identify underlying condition (diabetes mellitus type II and surgical incision) > inspect skin on a daily basis and describe changes > Keep the area clean and dry, carefully dress wounds and prevent infection R: To assist bodys natural process of repair.

Goals met After 10 days of nursing interventions, the patient was able to display timely healing of operative wound without complications

layers (dermis) Invasion of body structures

> Use appropriate wound dressing R: To protect the wound and surrounding tissues > Encourage early ambulation R: Promotes circulation and reduces risk associated with immobility Collaborative: > Refer to certified diabetes educator as indicated R: To enhance healing, reduce risk of recurrence of diabetes ulcers.

ASSESSMENT

NURSING DIAGNOSIS

GOALS AND OBJECTIVES

NURSING INTERVENTIONS/ RATIONALE Independent: 1. Assessed speech periodically; encouraged voice rest. R - Hoarseness and sore throat may occur secondary to tissue edema or surgical damage to recurrent laryngeal nerve and may last several days. Permanent nerve damage can occur that causes paralysis of of the trachea. 2. Kept communication simple; asked yes or no question.

EVALUATION

Subjective cues: Dili pa siya ka storya as verbalized by the significant other.

IMPAIRED VERBALCOMMUNICATIO N RELATED TO POSSIBLE ALTERATION OF PHONATORY APPARATUS SECONDARY TO TOTAL THYROIDECTOMY

After 2 hours of nursing care and interventions the patient will be able to establish communication in which needs can be understood through writing, sign language and answering closedended questions.

GOALS MET. After 2 hours of nursing interventions, the patient was able to identify interventions to prevent risk of infection as evidenced by patient was able to express his thoughts through writing, sign language and questions through facial expressions and hand gestures.

Objective cues: Does not speak Used cues gestures non such verbal as

vocal cords and/or compression answering closed-ended

R - Reduces demand for response; promotes voice rest. 3. Provided alternative methods of communication as appropriate such as notes. R - Facilitates expression of needs. 4. Anticipated needs as possible. R - Reduces anxiety and patients need to communicate. 5. Maintained quite environment. R - Enhances ability to hear whispered communication and reduces necessity for patient raise/strain voice to be heard.

X. DISCHARGE PLANNING MEDICATIONS Discuss to the patient and family the dosage, frequency, and adverse effects of the drugs. Explain that the drugs used for effective control of elevated BP will likely produce adverse effect. Explain to the patient and family members the importance of taking medicines. The patient will able to take medications as what had been prescribed by the physician religiously and be able to follow directions as instructed by the nurse. In patients with self-administer insulin, demonstrate patient the appropriate preparation and administration techniques.

ECONOMIC STATUS Inform the patient to avail to some government programs such as philhealth. Explain to significant others that the rehabilitation may be prolonged to be able to for the family to prepare financial needs. Have occupational therapist to help re-learn everyday activities or ADL and for early recovery from the surgery.

TREATMENT
Emphasized the importance of regular follow-up check-ups and as instructed by

physician.
Advised patient and family members to seek medical advise if any unusuality

arises
Reinforced the importance of having blood sugar checked every day.

Admit patient in cardiac rehabilitation, this is a monitored exercise and education program that can help the patient return to an active lifestyle.

HEALTH TEACHING

 Encouraged client to do at least 30 minutes of walking a day as a form of exercise. Encouraged client to quit smoking and offered nicotine replacement. Cessation of cigarette smoking reduces the progression of disease, as shown by lower rates of amputation and lower incidences of rest ischemia in patients who quit, and it reduces the risks of myocardial infarction and death from other vascular causes. Instructed to monitor blood sugar regularly. Adjustments in diet, medication and exercise can be made accordingly. Encouraged to stick to the monitoring protocol prescribed by the doctor. Generally, blood is monitored before meals and at bedtime. Safety precaution should be maintained to prevent foot injury such as do not wear open shoes or walk barefoot Teach to the patient signs and symptoms of diabetic neuropathy and emphasize the need for safety precautions because neuropathy decreased sensation can hide sense injuries. Adjust of activities to avoid over exertion and fatigue, allow rest periods No heavy lifting or straining for 2 weeks following the surgery. Instructed not to wash or manipulate the neck wound for 48 hours following the thyroidectomy (except to apply ointment).

OUT-PATIENT The patient could avail his medication from government hospitals that he could get some benefits. She will also avail the services offered by the barangay health center and at the botikang bayan Instruct patient to seek regular medical check-up DIET
Eat a variety of foods as recommended in the Diabetes Food Pyramid to get a

balanced intake of the nutrients your body needs - carbohydrates, proteins, fats, vitamins, and minerals.

 Reduce the amount of fat you eat by choosing fewer high-fat foods and cooking with less fat. Eat more fiber by eating at least 5 servings of fruits and vegetables every day. Eat fewer foods that are high in sugar like fruit juices, fruit-flavored drinks, sodas, and tea or coffee sweetened with sugar. Use less salt in cooking and at the table. Eat fewer foods that are high in salt, like canned and packaged soups, pickles, and processed meats. Eat foods rich in calcium content.

SPIRITUALITY
Encouraged patient and Family members to go to church every Sunday and to

continue to seek Gods guidance and enlightenment.

Emphasized the importance of prayers in healing Encouraged

to

ask

for

divine

assistance

in

everything

and

to

encouragecontinuing to pray to God.

Encouraged to continue to have a positive outlook in life. Encouraged to keep faith in God and not to give up easily when hard times come

XI. RELATED LEARNING EXPERIENCE Taking up nursing course have entitled the group to become disciplined in everything that we do. As much as we want to think that the nursing life is easy to somehow lessen the stress and sometimes burden but its not working. This have made us realize that its better to accept the idea that nothing is easy and hence, molding ourselves to become disciplined is one way of passing this difficult road to success.

Our duty at the operating room of Northern Mindanao Medical Center is probably the busiest duty weve ever had unlike in any other institutions, its opposite due to fewer patients operation that was performed. But despite it, we have taken it as an opportunity to take advantage of our duty time in improving our clinical skills and as well as improving our knowledge in the operating room. Weve learned a lot in the clinical area and so its definitely worth our exhaustion and above all, we enjoyed working with the professional individuals in the field. We learned and at the same time enjoyed thats the best related learning experience as we nursing students could have.

The entire process of making this case study may have not been easy for all of us but fortunately, weve manage to deal with the problems properly and thus, we were able to finish this case study in the best way we could. Whether the outcome of this case study is good or bad, we must take it as a lesson and a parameter to continue seeking knowledge and improving our skills for we never stop learning.

This case study enabled the group to identify nursing intervention which are appropriate to promote the well-being of the patient and as well as the medical management for the case.

We would like to thank Mr. Enrico Galang Jr, for giving his best to teach us and to mold us in becoming good and competent nurses in the future. Furthermore, this rotation would have not been successful without the guidance of our almighty God!

XII. REFERENCE

BOOKS:
Doenges, M.E., Moorhouse, M.F., & Geissler, A.C, (2002). Nursing Care

Plans Guidelines for Individualizing Patient Care, (6th ed.). Thailand

Doenges, M.E., Moorhouse, M.F., & Geissler, A.C (2006). Nurses pocket

Guide; Diagnoses, Prioritized Interventions, and Rationales. (10thed.). Philadelphia, Pennsylvania

Smeltzer, Suzanne C., RN, Edd, FAAN, & Bare, Brenda G., RN, MSN,(2004).

Textbook of Medical-Surgical Nursing, (10th ed.), Philadelphia

Karch, Amy M. ; 2006 Lippincotts Nursing Drug Guide, 8th edition. Lippincott

Williams & Wilkins. Nurses Pocket Guide, 10th edition F.A. Davis. Nursing Care Plans, 7th edition F.A. Davis Doeuger, Moorhouse, Murr. Patients Chart
Black, Joyce M. et. al, Medical-Surgical Nursing: Clinical Management for

Positive outcome. 7th edition. Philadelphia, W.B. Saunders. 2005 Malseed, Roger T. ; Springhouse Nurses Drug Guide 2004, 5th edition.
Davis drug handbook, 10th edition

Drug handbook by Saunders

Medical-Surgical Nursing (Clinical Management for Positive Outcomes) 8th

edition By: Joyce Black and Jane Hokanson Hawks Nursing Care of Infants and Children by Wong

INTERNET:

http://cpmcnet.columbia.edu/dept/gi/.html http://www.drstandley.com/labvalues www.cureresearch.com/c/cerebral_palsy/stats-country.htm?ktrack=kcplink http://www.tuberculosistextbook.com/tb/tbchild.htm http://www.scribd.com/doc/2068251/The-Pathophysiology-of-Cancer http://ocw.tufts.edu/Content/14/lecturenotes/266736 http://www.thyroidmanager.org/Chapter21/21-frame.htm

http://emedicine.medscape.com/article/282276-overview#a0104 http://www.abc.net.au/health/library/stories/2005/06/16/1831822.htm http://www.medterms.com/script/main/art.asp?articlekey=16051 http://www.umm.edu/endocrin/thygland.htm