INTRODUCTION: The thyroid gland is a butterfly-shaped organ and is composed of two cone-like lobes or wings, lobus dexter (right

lobe) and lobus sinister (left lobe), connected via the isthmus. The organ is situated on the anterior side of the neck, lying against and around the larynx and trachea, reaching posteriorly the oesophagus and carotid sheath. It starts cranially at the oblique line on the thyroid cartilage (just below the laryngeal prominence, or 'Adam's Apple'), and extends inferiorly to approximately the fifth or sixth tracheal ring. It is difficult to demarcate the gland's upper and lower border with vertebral levels because it moves position in relation to these during swallowing. Hormones produced by the thyroid gland have an enormous impact on your health, affecting all aspects of your metabolism. It produces two main hormones, thyroxine (T-4) and triiodothyronine (T-3). They maintain the rate at which your body uses fats and carbohydrates, help control your body temperature, influence your heart rate, and help regulate the production of protein. Your thyroid gland also produces calcitonin, a hormone that regulates the amount of calcium in your blood. When your thyroid doesn't produce enough hormones, the balance of chemical reactions in your body can be upset. There can be a number of causes, including autoimmune disease, treatment for hyperthyroidism, radiation therapy, thyroid surgery and certain medications. Hypothyroidism is the underproduction of the thyroid hormones T3 and T4. Hypothyroid disorders may occur as a result of congenital thyroid abnormalities, autoimmune disorders such as Hashimoto's thyroiditis, iodine deficiency, especially in poorer countries, or the removal of the thyroid following surgery to treat severe hyperthyroidism. Typical symptoms are abnormal weight gain, tiredness, baldness, cold intolerance, and

bradycardia. Hypothyroidism is treated with hormone replacement therapy, such as levothyroxine, which is typically required for the rest of the patient's life. Thyroid hormone treatment is given under the care of a physician and may take a few weeks to become effective.[16] Negative feedback mechanisms result in growth of the thyroid gland when thyroid hormones are being produced in sufficiently low quantities as a means of increasing the thyroid output; however, where the hypothyroidism is caused by iodine insufficiency, the thyroid is unable to produce T3 and T4 and as a result, the thyroid may continue to grow to form a non-toxic goiter. It is termed non-toxic as it does not produce toxic quantities of thyroid hormones, despite its size.

Hypothyroidism upsets the normal balance of chemical reactions in your body. It seldom causes symptoms in the early stages, but, over time, untreated hypothyroidism can cause a number of health problems, such as obesity, joint pain, infertility and heart disease. The National Health and Nutrition Examination Survey (NHANES 1999-2002) of 4,392 individuals reflecting the US population reported hypothyroidism (defined as TSH levels >4.5 mIU/L) in 3.7% of the

population.2 Hypothyroidism is more common in women with small body size at birth and low body mass index during childhood. Iodine deficiency as a cause of hypothyroidism is more common internationally. The prevalence is reported as 2-5% depending on the study, increasing to 15% by age 75 years.

NHANES 1999-2002 reported that the prevalence of hypothyroidism (including subclinical) was higher in whites (5.1%) and Mexican Americans than in African Americans (1.7%). African Americans tend to have lower TSH values. Generally, thyroid disease is much more common in females than in males, with reports of prevalence 2-8 times higher in females. The frequency of hypothyroidism, goiters, and thyroid nodules increases with age. Hypothyroidism is most prevalent in elderly populations, with 2% to as much as 20% of older age groups having some form of hypothyroidism. The Framingham study found hypothyroidism (TSH >10 mIU/L) in 5.9% of women and 2.4% of men older than 60 years.4 In NHANES 1999-2002, the odds of having hypothyroidism were 5 times greater in persons aged 80 years and older than in individuals aged 12-49 years.2 Hyperthyroidism is a overactive thyroid, is the overproduction of the thyroid hormones T3 and T4, and is most commonly caused by the development of Graves' disease an autoimmune disease in which antibodies are produced which stimulate the thyroid to secrete excessive quantities of thyroid hormones. The disease can result in the formation of a toxic goiter as a result of thyroid growth in response to a lack of negative feedback mechanisms. It presents with symptoms such as a thyroid goiter, protruding eyes (exopthalmos), palpitations, excess sweating, diarrhea, weight loss, muscle weakness and unusual sensitivity to heat.

Increased production of thyroid hormone in Graves' disease leads to a stimulation or quickening of the body's metabolism. This results in symptoms of Hyperthyroidism that include

nervousness, anxiety, irritability, weight loss, bulging eyes, and hypertension. Hyperthyroidism may also lead to serious, potentially life-threatening complications

Hyperthyroidism is more common in women than in men. People over the age of fifty who have hypertension or atherosclerosis are at risk for developing Hyperthyroidism. Hyperthyroidism can also be caused by the growth of a thyroid nodule on the thyroid gland. A thyroid nodule is a noncancerous cyst that produces additional thyroid hormone, resulting in hyperthyroidism (high levels of thyroid hormone). It affects about 5 per 10,000 people (NWHIC). A number of conditions, including Graves' disease, toxic adenoma, Plummer's disease (toxic multinodular goiter) and thyroiditis, can cause Disorders of thyroid function, whether hyperthyroidism or hypothyroidism are medical conditions that can have a significant impact on public health and can even shorten the lifespan of individuals of any age. Thyroid disorders, goitrous and non goitrous forms, occur with great frequency in the adult population ranging from 0.5 to 5% in overt disease and 3 to10% in the subclinical forms depending on the population, age and sex examined. Lack of dietary iodine is an important underlying cause of thyroid disorders, excess iodine, genetic background, and other geographical and dietary factors can trigger thyroid disorders. Children, pregnant women and lactating mothers are most at risk to iodine deficiency as this may result in permanent damage to the developing brain. In the general adult population which is the backbone of the labor force of a country, deficient and excessive iodine can cause subtle thyroid abnormalities with considerable consequences. Small aberrations in thyroid function have been associated with overweight and blood pressure problems.

In modern technology, thyroidectomy is being improved. Nowadays, we have a latest kind of method. It is being done by a robot. According to the article, this method is useful, simple, safer, and easier. Surgeons gain

access through a two-to-three-inch armpit incision, and then work their way through skin and fat and finally in between two big neck muscles. "It's a long way down a big tunnel to get to that thyroid through the armpit that would not be possible without telescopes and long instruments. One of the advantages of this method is that scarring will be avoided. After the surgery, there will no scarring in the site of the incision. And it was being proven that patients undergoing this method have a faster recovery period than of those used the traditional method. (http://www.sciencedaily.com/releases/2010/07/100706112607.htm)

Being a nurse in the society requires characteristics to be a productive member of the society. Three characteristics that entail a nurse include: knowledge, skills and attitude. A nurse needs the knowledge to function well and to render care from those suffering from diseases. Through this information contains in this case report may help him/her to give the appropriate care for these patients. Also, this information may set as a guide to the nurse as he/she goes along with his/her profession.

Chapter II ANATOMY AND PHYSIOLOGY

ANATOMY OF THE THYROID GLAND A large, highly vascular endocrine gland situated in the base of the neck. The thyroid consists of two lobes, one on

each side of the trachea, just below the larynx or voice box. The two lobes are connected by a narrow band of tissue called the isthmus. Internally, the gland consists of follicles, which produce thyroxine and triiodothyronine hormones. Both these hormones contain iodine. The thyroid controls how quickly the body burns energy, makes proteins, and how sensitive the body should be to other hormones. The thyroid participates in these processes by producing thyroid hormones, principally thyroxine (T4) and triiodothyronine (T3). These hormones regulate the rate of metabolism and affect the growth and rate of function of many other systems in the body. Iodine is an essential component of both T3 and T4. The thyroid also produces the hormone calcitonin, which plays a role in calcium homeostasis. Thyroid hormones also help maintain normal blood pressure, heart rate, digestion, muscle tone, and reproductive functions.

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.

About 95 percent of the active thyroid hormone is thyroxine, and most of the remaining 5 percent is triiodothyronine. Both of these require iodine for their synthesis. Thyroid hormone secretion is regulated by a negative feedback mechanism that involves the amount of circulating hormone, the hypothalamus, and the anterior pituitary gland (adenohypophysis).

The thyroid is controlled by the hypothalamus and pituitary. The gland gets its name from the Greek word for "shield", after the shape of the related thyroid cartilage. Hyperthyroidism (overactive thyroid) and hypothyroidism (underactive thyroid) are the most common problems of the thyroid gland. The thyroid gland is butterfly-shaped organ and is composed of two cone-like lobes or wings: lobus dexter (right lobe) and lobus sinister (left lobe), connected with the isthmus. The organ is situated on the anterior side of the neck, lying against and around the larynx and trachea, reaching posteriorly the oesophagus and carotid sheath. It starts cranially at the oblique line on the thyroid cartilage (just below the laryngeal prominence or Adam's apple) and extends inferiorly to the fourth to sixth tracheal ring. It is difficult to demarcate the gland's upper and lower border with vertebral levels as it moves position in relation to these during swallowing.

The normal thyroid gland is easily palpable. Palpation is carried out from behind using the digits to feel for the cricoid cartilage and for the 1st tracheal ring directly below it. The isthmus of the thyroid overlies the 2nd through the fourth tracheal rings, to which the pretracheal fascia (a fibrous sheath that contains the thyroid and allows it to glide smoothly over the nearby contents) firmly attaches through suspensory ligaments (extensions of the fascia). This attachment allows the thyroid to move with the larynx during swallowing, an important fact in palpating the thyroid as it is appropriate to ask the patient to sip a glass of water while palpating the gland, as to allow the inferior portion to be better felt when it elevates with the larynx.

The thyroid isthmus is variable in presence and size, and can encompass a cranially extending pyramid lobe (lobus pyramidalis or processus pyramidalis), remnant of the thyroglossal duct. The thyroid is one of the larger endocrine glands, weighing 2-3 grams in neonates and 18-60 grams in adults, and is increased in pregnancy.

The thyroid is supplied with arterial blood from the superior thyroid artery, a branch of the external carotid artery, and the inferior thyroid artery, a branch of the thyrocervical trunk, and sometimes by the thyroid ima artery, branching directly from the aortic arch. The venous blood is drained via superior thyroid veins, draining in the internal jugular vein, and via inferior thyroid veins, draining via the plexus thyroideus impar in the left brachiocephalic vein. Lymphatic drainage passes frequently the lateral deep cervical lymph nodes and the pre- and parathracheal lymph nodes. The gland is supplied by sympathetic nerve input from the superior cervical ganglion and the cervicothoracic ganglion of the sympathetic trunk, and by parasympathetic nerve input from the superior laryngeal nerve and the recurrent laryngeal nerve.

PHYSIOLOGY OF THE THYROID GLAND The primary function of the thyroid is production of the hormones thyroxine (T4), triiodothyronine (T3), and

calcitonin. Up to 80% of the T4 is converted to T3 by peripheral organs such as the liver, kidney and spleen. T3 is about ten times more active than T4.

T3 and T4 Production and Action

Thyroxine (T4) is synthesised by the follicular cells from free tyrosine and on the tyrosine residues of the protein called thyroglobulin (TG). Iodine is captured with the "iodine trap" by the hydrogen peroxide generated by the enzyme thyroid peroxidase (TPO) and linked to the 3' and 5' sites of the benzene ring of the tyrosine residues on TG, and on free

tyrosine. Upon stimulation by the thyroid-stimulating hormone (TSH), the follicular cells reabsorb TG and proteolytically cleave the iodinated tyrosines from TG, forming T4 and T3 (in T3, one iodine is absent compared to T4), and releasing them into the blood. Deiodinase enzymes convert T4 to T3. Thyroid hormone that is secreted from the gland is about 90% T4 and about 10% T3. Cells of the brain are a major target for the thyroid hormones T3 and T4. Thyroid hormones play a particularly crucial role in brain maturation during fetal development. A transport protein (OATP1C1) has been identified that seems to be important for T4 transport across the blood brain barrier. A second transport protein (MCT8) is important for T3 transport across brain cell membranes. In the blood, T4 and T3 are partially bound to thyroxine-binding globulin, transthyretin and albumin. Only a very small fraction of the circulating hormone is free (unbound) - T4 0.03% and T3 0.3%. Only the free fraction has hormonal activity. As with the steroid hormones and retinoic acid, thyroid hormones cross the cell membrane and bind to intracellular receptors ( 1, 2, 1 and 2), which act alone, in pairs or together with the retinoid X-receptor as transcription factors to modulate DNA transcription.

T3 and T4 Regulation

The production of thyroxine and triiodothyronine is regulated by thyroid-stimulating hormone (TSH), released by the anterior pituitary (that is in turn released as a result of TRH release by the hypothalamus). The thyroid and thyrotropes form a negative feedback loop: TSH production is suppressed when the T4 levels are high, and vice versa. The TSH production itself is modulated by thyrotropin-releasing hormone (TRH), which is produced by the hypothalamus and secreted at an increased rate in situations such as cold (in which an accelerated metabolism would generate more heat). TSH production is blunted by somatostatin (SRIH), rising levels of glucocorticoids and sex hormones (estrogen and testosterone), and excessively high blood iodide concentration.

Calcitonin

An additional hormone produced by the thyroid contributes to the regulation of blood calcium levels. Parafollicular cells produce calcitonin in response to hypercalcemia. Calcitonin stimulates movement of calcium into bone, in opposition

to the effects of parathyroid hormone (PTH). However, calcitonin seems far less essential than PTH, as calcium metabolism remains clinically normal after removal of the thyroid, but not the parathyroids.

Significance of Iodine

In areas of the world where iodine (essential for the production of thyroxine, which contains four iodine atoms) is lacking in the diet, the thyroid gland can be considerably enlarged, resulting in the swollen necks of endemic goitre. Thyroxine is critical to the regulation of metabolism and growth throughout the animal kingdom. Among amphibians, for example, administering a thyroid-blocking agent such as propylthiouracil (PTU) can prevent tadpoles from metamorphosing into frogs; conversely, administering thyroxine will trigger metamorphosis. In humans, children born with thyroid hormone deficiency will have physical growth and development problems, and brain development can also be severely impaired, in the condition referred to as cretinism. Newborn children in many developed countries are now routinely tested for thyroid hormone deficiency as part of newborn screening by analysis of a drop of blood. Children with thyroid hormone deficiency are treated by supplementation with synthetic thyroxine, which enables them to grow and develop normally. Because of the thyroid's selective uptake and concentration of what is a fairly rare element, it is sensitive to the effects of various radioactive isotopes of iodine produced by nuclear fission. In the event of large accidental releases of such material into the environment, the uptake of radioactive iodine isotopes by the thyroid can, in theory, be blocked by saturating the uptake mechanism with a large surplus of non-radioactive iodine, taken in the form of potassium iodide tablets. While biological researchers making compounds labelled with iodine isotopes do this, in the wider world such

preventive measures are usually not stockpiled before an accident, nor are they distributed adequately afterward. One consequence of the Chernobyl disaster was an increase in thyroid cancers in children in the years following the accident.

The use of iodized salt is an efficient way to add iodine to the diet. It has eliminated endemic cretinism in most developed countries, and some governments have made the iodination of flour mandatory. Potassium iodide and Sodium iodide are the most active forms of supplemental iodine.

Chapter III The Patient and his Illness PATHOPHYSIOLOGY (Book- Centered) a. Schematic diagram HYPERTHYROIDISM

Modifiable Factors y y y y y Diet Toxic nodular goiters/ adenomas thyroiditis Amiodarone Autoimmune disorder

Non- modifiable Factors y y Gender (female) Age

Over functioning of the thyroid gland

Loss of the normal regulatory controls of TH secretion

Excessive amount of thyroid hormone

sympathetic nervous system

Body Metabolism

Cardiac system Negative nitrogen balance Number of beta adrenergic receptors

heart contraction Metabolism of CHO Fat, and CHON Cardiac output and stroke volume Hyperactivity Resting hand tremors Weight loss Weakness

Lipid depletion

Fatigue

Depression

GI motility

Loose bowel movement

Diarrhea

Absorption of glucose in the intestine

glyconeolysis

Hyperglycemia

Release of insulin in bloodstream

Blood glucose

Male - gynecomastia

Reproductive system

or sexual desire

fertility

Female oligomenorrhea or amenorrhea

Unable to tolerate heat

Dilate superficial capillaries

Cardiac output

Warm and moist skin

appetite PALPITATION TACHYCARDIA

Retraction of upper eyelid

Sclera exposure

Exophthalmos

Mood cyclic

Mild euphoria

Extreme hyperactivity

Delirium

b. Synthesis of the disease Hyperthyroidism is the term for overactive tissue within the thyroid gland causing an overproduction of thyroid hormones (thyroxine or "T4" and/or triiodothyronine or "T3"). Hyperthyroidism is thus a cause of thyrotoxicosis, the clinical condition of increased thyroid hormones in the blood. It is important to note that hyperthyroidism and thyrotoxicosis are not synonymous. For instance, thyrotoxicosis could instead be caused by ingestion of exogenous thyroid hormone or inflammation of the thyroid gland, causing it to release its stores of thyroid hormones. Thyroid hormone is important at a cellular level, affecting nearly every type of tissue in the body. Thyroid hormone functions as a controller of the pace of all of the processes in the body. This pace is called metabolism. If there is too much thyroid hormone, every function of the body tends to speed up. It is therefore not surprising that some of the symptoms of hyperthyroidism are nervousness, irritability, increased perspiration, heart racing, hand tremors, anxiety, difficulty sleeping, thinning of the skin, fine brittle hair, and muscular weaknessespecially in the upper arms and thighs. More frequent bowel movements may occur, but diarrhea is uncommon. Weight loss, sometimes significant, despite a good appetite may occur, vomiting, and, for women, menstrual flow may lighten and menstrual periods may occur less often. Thyroid hormone is critical to

normal function of cells. In excess, it both overstimulates metabolism and exacerbates the effect of the sympathetic nervous system, causing "speeding up" of various body systems and symptoms resembling an overdose of epinephrine (adrenaline). These include fast heart beat and symptoms of palpitations, nervous system tremor such as of the hands and anxiety symptoms, digestive system hypermotility (diarrhea), considerable weight loss and unusually low lipid panel (cholesterol) levels as indicated by a blood test. Hyperthyroidism usually begins slowly. At first, the symptoms may be mistaken for simple nervousness due to stress. If one has been trying to lose weight by dieting, one may be pleased with weight loss success until the hyperthyroidism, which has quickened the weight loss, causes other problems. Etiology Modifiable factor 1. Diet This risk factor has something to do with the intake of iodine where in due to low level of Iodine it may lead to thyroid causing adenoma resulting to hyperthyroidism. 2. Toxic nodular goiters/ adenomas This risk factor is the most common etiology in Switzerland, 53%, thought to be atypical due to a low level of dietary iodine in this country that may lead to overstimulation of the thyroid gland causing increased release of thyroid hormone. 3. Thyroiditis When it comes to this risk factor it has something to do with the inflammation of the thyroid gland resulting to excessive secretion of thyroid hormone.

4. Amiodarone An anti-arrhythmic drug is structurally similar to thyroxine and may cause either under- or over activity of the thyroid. 5. Autoimmune disorder The immune system incorrectly treats self-antigens as foreign antigens; thereby due to this mechanism it may lead to over stimulation of the thyroid gland causing excessive secretion of thyroid hormone.

Non-modifiable factors 1. Gender (female) 2. Age

Signs and symptoms 1. Fatigue and depression -due to increased stimulation in the sympathetic nervous system and increase blood flow in the brain leading to hyperactivity in turn leads to extreme fatigue and depression, again followed by episodes of over activity. 2. Palpitation and tachycardia -due to increased sympathetic nervous system activity excessive amount of TH stimulate the cardiac system and increase number of beta- adrenergic receptors. 3. Exopthalmos

-because the eyes are surrounded by unyielding bone, fluid accumulation in the fat pads and muscles behind the eyeballs causes protruding eyes and a fixed stare in the client. Also it is due to increased adrenergic activity results in the retraction of the upper eyelids which presents with increased sclera exposure or exophthalmos. 4. Delirium -the clients emotions are adversely affected by the turbulent activity within the body. Moods maybe cyclic, ranging from mild euphoria to extreme hyperactivity to delirium. 5. Increased appetite -There is elevation in metabolic rate manifesting in elevation in metabolism of protein, fat and carbohydrate. The accelerated protein and fat metabolism lead to weight loss and muscular weakness. The body attempts to remedy the weight loss and so the patient's appetite is increased in the process. 6. Lipid depletion and nutritional deficiency - Due increased metabolism, leading to a negative nitrogen balance causing lipid depletion and state of nutritional deficiency 7. Warm, moist skin and diaphoresis -Patient is unable to tolerate hot weather as a result of the increase in the body metabolism. The superficial capillaries dilate leading to increased peripheral blood flow and also an increase in cardiac output as the body tries to eliminate excess heat from the system. This accounts for warm and moist skin and also for the perspiration. 8. Thin and soft hair -brought about by increase thyroid hormone leading to increased in the metabolism

9. Decreased fertility -Noticeable changes occur in the reproductive systems. There is either increase sexual desire orlow sex drives in both sexes. In the hyperthyroid males gynaecomastia is sometimes present, whereas there is oligomenorrhoea or amenorrhoea in the females. However, there may be decrease in fertility in severe hyperthyroidism. 10. Decreased glucose -The increase in metabolism also brings about an increase in the absorption of glucose from the intestines. This excessive absorption of glucose triggers off glyconeolysis which in combination with the glucose absorption leads to hyperglycaemia. Excessive glucose in the blood leads to the release of insulin into the blood stream which brings about a rapid fall in blood glucose level. This glyconeolysis and insulin release lead to rapid rise and fall in blood glucose level as well.

Pathophysiology: Book-based HYPORTHYROIDISM Non-modifiable:  Genetic  Age  Gender  Autoimmune disease  Congenital disease Modifiable:  Treatment for hyperthyroidism  Radiation therapy  Thyroid surgery  Medications  Pituitary disorder  iodine deficiency  Pregnancy

Decrease Thyroid Stimulating Hormone from pituitary gland

Decrease Thyroid Hormone Decrease Metabolism and heat formation

Compensation: Enlarged thyroid gland

Hoarseness of voice

Decrease energy, constant tiredness

Weight gain

Intolerance to cold

Raised blood cho lesterol

Anemia

Dry scaly skin, brittle nails and hair loss

Constipation

Dizziness, Fatigue, sluggishness

Muscle weakness , cramps

Menstrual irregularities Headach e, nape pain, increase blood pressure

Swollen abdomen

Inability to concentrate

Impaired coordination

Synthesis of the disease: hypothyroidism Hypothyroidism is a common endocrine disorder resulting from deficiency of thyroid hormone. It usually is a primary process in which the thyroid gland produces insufficient amounts of thyroid hormone. It can also be secondarythat is, lack of thyroid hormone secretion due to inadequate secretion of either thyrotropin (ie, thyroid-stimulating hormone [TSH]) from the pituitary gland or thyrotropin-releasing hormone (TRH) from the hypothalamus (secondary or tertiary hypothyroidism). The patient's presentation may vary from asymptomatic to, rarely, coma with multisystem organ failure (myxedema coma). The most common cause in the Unites States is autoimmune thyroid disease (Hashimoto thyroiditis).

Cretinism

refers

to

congenital

hypothyroidism,

which

affects

per

4000

newborns.

Subclinical hypothyroidism, also referred to as mild hypothyroidism, is defined as normal serum free T4 levels with slightly high serum TSH concentration.

Pathophysiology Localized disease of the thyroid gland that results in decreased thyroid hormone production is the most common cause of hypothyroidism. Under normal circumstances, the thyroid releases 100-125 nmol of thyroxine (T4) daily and only small amounts of triiodothyronine (T3). The half-life of T4 is approximately 7-10 days. T4, a prohormone, is converted to T3, the active form of thyroid hormone, in the peripheral tissues by 5-deiodination. Early in the disease process, compensatory mechanisms maintain T3 levels. Decreased production of T4 causes

an increase in the secretion of TSH by the pituitary gland. TSH stimulates hypertrophy and hyperplasia of the thyroid gland and thyroid T4-5'-deiodinase activity. This, in turn, causes the thyroid to release more T3.

Because all metabolically active cells require thyroid hormone, deficiency of the hormone has a wide range of effects. Systemic effects are due to either derangements in metabolic processes or direct effects by myxedematous infiltration (ie, accumulation of glucosaminoglycans in the tissues).

The myxedematous changes in the heart result in decreased contractility, cardiac enlargement, pericardial effusion, decreased pulse, and decreased cardiac output. In the GI tract, achlorhydria and decreased intestinal transit with gastric stasis can occur. Delayed puberty, anovulation, menstrual irregularities, and infertility are common. Decreased thyroid hormone effect can cause increased levels of total cholesterol and low-density lipoprotein (LDL) cholesterol and a possible change in high-density lipoprotein (HDL) cholesterol due to a change in metabolic clearance. In addition, hypothyroidism may result in an increase in insulin resistance. Frequency United States The National Health and Nutrition Examination Survey (NHANES 1999-2002) of 4,392 individuals reflecting the US population reported hypothyroidism (defined as TSH levels >4.5 mIU/L) in 3.7% of the population. Hypothyroidism is more common in women with small body size at birth and low body mass index during childhood.

International Iodine deficiency as a cause of hypothyroidism is more common internationally. The prevalence is reported as 2-5% depending on the study, increasing to 15% by age 75 years. Mortality/Morbidity In developed countries, death caused by hypothyroidism is uncommon. History Hypothyroidism commonly manifests as a slowing in physical and mental activity but may be asymptomatic. Symptoms and signs of this disease are often subtle and neither sensitive nor specific. Classic signs and symptoms, such as cold intolerance, puffiness, decreased sweating, and coarse skin, previously reported in 9097% of patients, may actually occur in only 50-64% of younger patients. Many of the more common symptoms are nonspecific and difficult to attribute to a specific cause. Individuals can also present with obstructive sleep apnea (secondary to macroglossia) or carpal tunnel syndrome. Women can present with galactorrhea and menstrual disturbances. Consequently, the diagnosis of hypothyroidism is based on clinical suspicion and confirmed by laboratory testing.

Myxedema coma is a severe form of hypothyroidism that results in an altered mental status, hypothermia, bradycardia, hypercarbia, and hyponatremia. Cardiomegaly, pericardial effusion, cardiogenic shock, and ascites may be present. Myxedema coma most commonly occurs in individuals with undiagnosed or untreated

hypothyroidism who are subjected to an external stress, such as low temperature, infection, or medical intervention (eg, surgery or hypnotic.

High Risk group Race NHANES 1999-2002 reported that the prevalence of hypothyroidism (including subclinical) was higher in whites (5.1%) and Mexican Americans than in African Americans (1.7%). African Americans tend to have lower TSH values. Sex Community studies use slightly different criteria for determining hypothyroidism; therefore, female-to-male ratios vary. Generally, thyroid disease is much more common in females than in males, with reports of prevalence 2-8 times higher in females. Age The frequency of hypothyroidism, goiters, and thyroid nodules increases with age. Hypothyroidism is most prevalent in elderly populations, with 2% to as much as 20% of older age groups having some form of

hypothyroidism. The Framingham study found hypothyroidism (TSH >10 mIU/L) in 5.9% of women and 2.4% of men older than 60 years. In NHANES 1999-2002, the odds of having hypothyroidism were 5 times greater in persons aged 80 years and older than in individuals aged 12-49 years. Causes/ predisposing factors

Primary hypothyroidism  Autoimmune: The most frequent cause of acquired hypothyroidism is autoimmune thyroiditis (Hashimoto thyroiditis). The body recognizes the thyroid antigens as foreign, and a chronic immune reaction ensues, resulting in lymphocytic infiltration of the gland and progressive destruction of functional thyroid tissue. Up to 95% of affected individuals have circulating antibodies to thyroid tissue. Antimicrosomal or antithyroid peroxidase (anti-TPO) antibodies are found more commonly than antithyroglobulin antibodies (95% vs 60%). These antibodies may not be present early in the disease process and usually disappear over time.6  Postpartum thyroiditis: Up to 10% of postpartum women may develop lymphocytic thyroiditis in the 2-10 months after delivery. The frequency may be as high as 25% in women with type 1 diabetes mellitus. The condition is usually transient (2-4 mo) and can require a short course of treatment with levothyroxine (LT4), but postpartum patients with lymphocytic thyroiditis are at increased risk of permanent hypothyroidism. The hypothyroid state can be preceded by a short thyrotoxic state. High titers of anti-TPO antibodies during pregnancy have been reported to be 97% sensitive and 91% specific for postpartum autoimmune thyroid disease.

 Subacute granulomatous thyroiditis: Inflammatory conditions or viral syndromes may be associated with transient hyperthyroidism followed by transient hypothyroidism (de Quervain or painful thyroiditis, subacute thyroiditis). These are often associated with fever, malaise, and a painful and tender gland.  Drugs: Medications such as amiodarone, interferon alpha, thalidomide, lithium, and stavudine have also been associated with primary hypothyroidism.  Iatrogenic o Use of radioactive iodine for treatment of Graves disease generally results in permanent hypothyroidism within 1 year after therapy. The frequency is much lower in patients with toxic nodular goiters and those with autonomously functioning thyroid nodules. Patients treated with radioiodine should be monitored for clinical and biochemical evidence of hypothyroidism. o Thyroidectomy o External neck irradiation (for head and neck neoplasms, breast cancer, or Hodgkin disease) may result in hypothyroidism; patients who have received these treatments require monitoring of thyroid function.  Rare: Rare causes include inborn errors of thyroid hormone synthesis.  Iodine deficiency or excess: Worldwide, iodine deficiency is the most common cause of hypothyroidism. Excess iodine, as in radiocontrast dyes, amiodarone, health tonics, and seaweed, inhibits iodide organification and thyroid hormone synthesis. Most healthy individuals have a physiologic escape from this effect; however those with abnormal thyroid glands may not. These include patients with autoimmune thyroiditis, surgically treated Graves hyperthyroidism (subtotal thyroidectomy) and prior radioiodine therapy.

 Worldwide, iodine deficiency remains the foremost cause of hypothyroidism. In the United States and other areas of adequate iodine intake, autoimmune thyroid disease is most common. The prevalence of antibodies is higher in women, and increases with age.

Central

hypothyroidism

Central hypothyroidism (secondary or tertiary) results when the hypothalamic-pituitary axis is damaged. Various causes should be considered.
 Pituitary adenoma  Tumors impinging on the hypothalamus  History of brain irradiation  Drugs (eg, dopamine, lithium)  Sheehan syndrome  Genetic disorders

The following are symptoms of hypothyroidism:  Fatigue, loss of energy, lethargy decrease heat production and metabolism of the body resulting from decrease thyroid hormone.

 Weight gain decrease use of nutrients supplied by foods or breakdown of nutrients used for activities.  Decreased appetite there is a feeling of fullness  Cold intolerance decrease heat production.  Dry skin and hair loss decrease supply of nutrients in the skin and in the hair.  Sleepiness -decrease/slowed metabolism.  Muscle pain, joint pain, weakness in the extremities decreased heat, metabolism and supply of adequate nutrients in the body.  Emotional lability, mental impairment  Forgetfulness, impaired memory, inability to concentrate- thyroid hormone acts as a medium for faster activities and mental alertness, when these hormones are inadequate, forgetfulness, impaired memory and inability to concentrate may occur.  Constipation there is gastric stasis because of slowed meatabolism.  Menstrual disturbances, impaired fertility thyroid hormone is essential in the regulation of other hormones of the body including menstruation.  Decreased perspiration decrease heat production  Fullness in the throat, hoarseness- as a compensation of the thyroid gland, it may be possible that it will atrophy and enlarge as a result, it may affect the vocal cords. o Additional signs specific to different causes of hypothyroidism, such as diffuse or nodular goiter or pituitary tumor, can occur.

Metabolic abnormalities associated with hypothyroidism include anemia, dilutional hyponatremia, hyperlipidemia, and reversible increase in creatinine.
source: http://emedicine.medscape.com/article/122393-overview

Chapter IV CLINICAL INTERVENTION (HYPERTHYROIDISM)

Description of Prescribed Surgical Treatment Performed

Thyroidectomy is a surgical procedure in which all or part of the thyroid gland is removed. Located in the forward (anterior) part of the neck just under the skin and in front of the Adam's apple. The thyroid is one of the body's endocrine glands, it secretes its products inside the body, into the blood or lymph. The thyroid produces several hormones that have two primary functions: they increase the synthesis of proteins in most of the body's tissues, and they raise the level of the body's oxygen consumption.

Types of Thyroidectomy:

1. Total Thyroidectomy (Complete Removal of the Thyroid) - This is the most common type of thyroid surgery and preferred by most surgeons for cases of hyperthyroidism, often used for thyroid cancer, and in particular, aggressive cancers, such as medullary or anaplastic thyroid cancer. It is used for goiter and Graves. 2. Subtotal/Partial Thyroidectomy (Removal Half of the Thyroid Gland) - For this operation, cancer must be small and non-aggressive -- follicular or papillary -- and contained to one side of the gland. When a subtotal or partial thyroidectomy is performed, typically, surgeons perform a bilateral subtotal thyroidectomy which leaves from 1 to 5 grams on each side/lobe of the thyroid. 3. Thyroid Lobectomy (Removal of Only About a Quarter of the Gland) - This is less commonly used for thyroid cancer, as the cancerous cells must be small and non-aggressive.

Preparation and Positioning of the Patient The patient may lie either in the half sitting position with slightly reclined head, (Fig 1.1a) or be lying with the head

hanging (Fig. 1.1b). The advantage of the lying position is that the venous pressure is positive preventing an air embolus. The pressure in the cervical veins in the sitting position is on average 2.4cm and, in the lying position with the head hanging, 8.1 cm. however, it must not be overlooked that a pressure in the venous system is dangerous even under positive pressure if the vein is opened (Keminger and Maager 1969).

Fig. 1.1a

Fig. 1.1b

Skin preparation Using iodine solution with soap and sterile water, begin at the anterior neck extending upward to just below the

infra-auricular border and lower lip, and down-ward to 2.5 to 5 cm (1 to 2 inches) above the nipples; continue down to the table at the neck, around the shoulders, and at the sides. y Preparation of Surgical Instruments  Draping

Simple and effective draping of the head can be achieved with Kaspars goiter towel (Fig.1.2a). The tapes are tied behind the patients neck (Fig. 1.2a). Before the head and the lateral parts of the neck are covered with the goiter towel, the patients body is covered with a sterile folded linen drape. Four towel clips are used to fix the towels and ensure a rectangular operative field (Fig 1.2b). After the skin has been incised, and the cervical fascia and the strap muscle have been dissected the remaining free parts of the skin are covered with 2 further drapes (Fig. 1.2c). The upper drape is folded over several times but the long one simple lay on.

Fig. 1.2a

Fig. 1.2b

Fig. 1.2c

Operative Procedure  The Skin Incision It should lay two fingers breadth above the suprasternal notch. The incision should be carried out in one straight stroke through skin and platysma. A band may be mark out the incision (Fig. 1.3a). Bleeding intracutaneous vessels are clamped but if possible are not covered. The flap of skin and platysma is elevated above and below.

Fig. 1.3a - Band being used for marking out incision

Fig. 1.3b Kochers Collar Incision

Operative Technique The fascia is divided on both sides of veins, held up with the forceps, clamped (Fig 1.4) and then divided between

two clamps (Fig 1.5). The fascia bridges lying between the veins are divided from left to right. Veins should also be dealt with along the medial edge of both the sternocleidomastoid muscles. The upper fascia and platysmal flap is elevated as far as the laryngeal eminence (Fig 1.6) and the superior fascial flap is elevated using a pair of forceps. The superior stumps of the vein are ligated and the superior stumps transfixed (Fig 1.7).

Fig. 1.4

Fig 1.5

Fig. 1.6 The deep strap muscles are divided in the mid line with scissors or scalpel up to the cricoid (Fig 1.7). As rule the muscles should not be divided. Division of the sternohyoid and sternothryroid muscles may lead to rapid tiring of the voice and reduction of its range. However it should be remembered that more damage may caused by blunt forceful retraction than by deliberate division.

Fig 1.7

Fig 1.8

Division of the Isthmus The division of the isthmus, beginning at its superior or inferior edge, thus allowing the trachea to be located. It is

elevated from the trachea by spreading movements with artery forceps. (Fig 1.9), bringing the delicate connective tissue sheath of the trachea into view.

Fig 1.9

A voluminous, adenomatous, and parenchymatous isthmus is divided between clamps with scissors from below upwards. A small artery usually runs along the superior edge from one pole to the other, and this should also be clamped and divided (Fig.1.10)

Fig. 1.10

Fig. 1.11a

Fig 1.11b Figures 1.11a and 1.11b, Babcock are applied to inferior and superior (not shown) aspects of the thyroid lobe to facilitate medial retraction on the gland. This exposes the area when the parathyroid glands and recurrent laryngeal nerve are located.

Fig. 1.12 Figure 1.12, downward traction on the superior Babcock clamp exposes the superior pole vessels, including the branches of the superior thyroid artery. The external laryngeal nerve courses along the cricothyroid muscle just medial to the superior pole vessels. To avoid injury to this nerve, which controls tension of the vocal cords, the superior pole vessels are divided individually as close as possible to the point where they enter the thyroid.

Fig 1.13 Figure 1.13, as the thyroid is retracted medially; gentle dissection with a Hoyt clamp is used to expose the parathyroid glands, inferior thyroid artery, and recurrent laryngeal nerve. The recurrent nerve usually passes behind the inferior thyroid artery but occasionally lies anterior to it. They nerve can then be traced upward, and its position in relation to the thyroid can be determined. Parathyroid glands that lie on the thyroid surface can be mobilized with their vascular supply and thus preserved.

Fig 1.14 Figures 1.14, to perform total lobectomy, the branches of the inferior thyroid artery are divided at the surface of the thyroid gland. The inferior thyroid veins can now be ligated and divided. Superiorly, the connective tissue (ligament of Berry), which binds the thyroid to the tracheal rings, is carefully divided. Division of ligament allows the thyroid to be mobilized medially.

Fig. 1.15 Figure 1.15, the dissection of the thyroid from the trachea can be performed with the cautery by division of the loose connective tissue between these structures. Dissection is extended under the Isthmus, and the specimen is divided, so that the isthmus is included with the resected lobe.

Fig 1.16 Figure 1.16, subtotal lobectomy necessitates identification of the parathyroid glands inferior thyroid artery, and recurrent laryngeal nerve, as previously described. The line of resection is selected to preserve the parathyroid glands and their blood supply and to protect the recurrent laryngeal nerve. It should be based on the inferior thyroid artery or its major branches.

Fig 1.17a

Fig 1.17b Figures 1.17 A and B, clamps are placed along the line of resection, and the thyroids gland is divided. The divided tissue is ligated or suture-ligated with 3-0 silk. The dissection is extended to the trachea. (Sabiston, D.C., Jr. [Ed]: Atlas of General Surgery Philadelphia, WE.B. Sauders, 1995.)

Fig 1.18 At the end of the resection the remnant of capsule and parenchyma is closed by individual horizontal suture (Fig 1.18) to achieve good homeostasis. This procedure is facilitated by traction to the opposite side on the capsule sutures which have been left long, and by lateral displacement of the common carotid artery with a hook.

Before closing the neck it is advisable to increase positive pressure respiration for a brief period to increase the pressure in the superior vena cava and thus show any venous bleeding points or potential points of entry for air emboli which have been overlooked. Then a pyramidal lobe if present is removed and aberrant adenomas in the region of the upper and lower pole are looked for. The cavity is drained for 24 hours by penrose drain (Fig. 1.19)

Fig 1.19

Fig 1.20a Wound closure is limited to suture of the strap muscles (Fig 1.19) and the placing of skin clips (Fig 1.20a and b) which are removed 3 days later.

Fig. 1.20b

Fig 1.21 1.2 Indication of Prescribed Surgical Treatment Thyroidectomy is usually performed for the following reasons: 1. As therapy for some individuals with thyrotoxicosis; those with Graves disease; and others with a hot nodule or toxic nodular goiter.

2. To establish a definitive diagnosis of a mass within the thyroid gland, especially when cytologic analysis after fine needle aspiration (FNA) is either non-diagnostic 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 (Figure 9). 6. To remove large substernal goiters, especially when they cause respiratory difficulties. 7. Young patients and are free from any condition that makes them poor operative risks (DM, heart disease, renal disease) Specific: o A small thyroid nodule or cyst o A thyroid gland that is so overactive it is dangerous (thyrotoxicosis) o Benign (noncancerous) tumors of the thyroid o Cancer of the thyroid o Thyroid swelling (nontoxic goiter) that makes it hard for you to breathe or swallow

Thyroid surgery (Thyroidectomy) is a common operation, but one which needs to be taken seriously because of the potential complications which may occur. Commonly, this surgery is done because of suspected cancer. Patient risk factors, appearance on ultrasound examination or needle biopsy results may cause your surgeon to recommend surgical removal of the thyroid.

If there is a vocal cord paralysis or rapid growth of a solid mass also indicates a cancer. Unfortunately, one of the forms of thyroid cancer, follicular carcinoma, can appear benign on needle biopsy and may also be read as benign on frozen section during surgery.

If the thyroid becomes so large that it compresses the trachea or esophagus surgical removal is indicated. A thyroid cyst that recurs after a single or repeated needle drainage is also an indication for removal. Rarely, a thyroiditis will cause scaring in the neck which also compresses the airway. The thyroid must also be removed in this case. However, cases of thyroiditis have an increased complication rate due to bleeding and scarring. 2 Risk and Benefits of Undergoing Treatment Risk 1. Hypoparathyroidism or recurrent lesion, have not been systematically. Benifits 1. As therapy for some individuals disease; and others with a hot nodule or toxic nodular goiter. 2. Recurrent laryngeal nerve injuries. 2. To establish a definitive diagnosis of a mass within the thyroid gland, 3. Cervical hematomas. especially when cytologic analysis after fine needle aspiration (FNA) is either non-diagnostic or equivocal.

investigated with thyrotoxicosis; those with Graves

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.

3 Risks and Benefits of Not Undergoing Treatment Risk 1. A small thyroid nodule or cyst. 2. A thyroid gland that is so overactive it is dangerous (thyrotoxicosis). Benefits 1. The patient may have decreased risk of developing any postoperational complications.

3. Benign (noncancerous) tumors of the thyroid 4. Cancer of the thyroid

5. Thyroid swelling (nontoxic goiter) that makes it hard for you to breathe or swallow

1.3 Required Instruments, Devices, Supplies, Equipment and Facilities y Retractors: 1.) DOUBLE-ENDED RICHARDSON RETRACTOR used to retract deep incisions

2.) ARMY-NAVY RETRACTOR used to retract shallow or superficial incisions

3.) WEITLANER ends can be blunt or sharp; has rake tips; ratchet to hold tissue apart

4.) GELPI has single point tips; ratchet to hold tissue apart

Clamping Instruments: 5.) MOSQUITO used to clamp blood vessels

6.) KELLY is used to clamp larger vessels and tissue. Available in short and long sizes.

7.) LAHEY thyroid forceps used to deliver the thyroid in thyroidectomy.

8.) KOCHER a heavy, straight hemostat with interlocking teeth on the tip

9.) CRILE a clamp for temporary stoppage of blood flow.

10.) TOWEL CLIPS used to hold towels and drapes in place.

Grasping Instruments:

11.) BABCOCK CLAMP used to grasp delicate tissue

12.) ADSON a small thumb forceps with two teeth on one tip and one tooth on the other.

13.) CUSHING FORCEPS

14.) PLAIN TISSUE FORCEPS used to grasp tissue.

15.) DEBAKEY FORCEPS nontraumatic forceps used to pick up blood vessels; also known as magics.

16.) ALLIS a straight grasping forceps with serrated jaws, used to forcibly grasp or retract tissues or structures.

Dissecting/ Cutting Instruments:

17.) MAYO SCISSORS used to cut heavy tissue.

18.) METZENBAUMS "Mets" used to cut delicate tissues.

19.) #3 KNIFE HANDLES -

20.) BLADES NO. 10 the flat part of a tool or weapon that (usually) has a cutting edge.

21.) TENOTOMY The surgical division of a tendon for relief of a deformity caused by congenital or acquired shortening of a muscle, as in clubfoot or strabismus

22.) CURVED IRIS

Suturing Instruments:

23. ) NEEDLE HOLDER used to hold needles when suturing. They may also be placed on the sewing category.

Equipments:

24.) CAUTERY UNIT This may be a separate apparatus or it may be part of an electrosurgery system. It employs a probe with a hot metal tip or wire which is used to stop bleeding and in some cases for cutting. In its very simplest form it may be a hand-held unit containing a large electrical cell which heats up a small wire loop at its tip on pressing a button. Such a unit may be used to remove very small polyps and to stop bleeding. Larger units use a low voltage source from a transformer connected to the cautery probe via a flexible lead.

Supplies:

25.) BASIN SET

26.) SUCTION TUBING An apparatus for removing fluid from a body cavity, consisting usually of a hollow needle and a cannula, connected by tubing to a container in which a vacuum is created by a syringe or a suction pump.

27.) PENROSE DRAIN is a surgical device placed in a wound to drain fluid. It consists of a soft rubber tube placed in a wound area to prevent the build up of fluid.

28.)

ELECTROSURGICAL PENCIL A novel dual mode electrosurgical pencil is provided for conventional

tissue cutting/coagulation use in a first mode of operation, and gas-enhanced coagulation by fulguration in a second mode of operation.

29.) STERI STRIPS

30.) ADENOID SUCTION 1.4 Perioperative Tasks and Responsibilities of The Nurse DUTIES OF SCRUB NURSE y y y y y y Ensures that the circulating nurse has checked the equipment. Ensures that the theater has been cleaned before the trolley is set. Prepares the instruments and equipment needed in the operation. Uses sterile technique for scrubbing, gowning and gloving. Receives sterile equipment via circulating nurse using sterile technique. Performs initial sponges, instruments and needle count, checks with circulating nurse.

 When Surgeon Arrives After Scrubbing: y Perform assisted gowning and gloving to the surgeon and assistant surgeon as soon as they enter the operation suite.

Assemble the drapes according to use. Start with towel, towel clips, draw sheet and then lap sheet. Then, assist in draping the patient aseptically according to routine procedure.

y y y y

Place blade on the knife handle using needle holder, assemble suction tip and suction tube. Bring mayo stand and back table near the draped patient after draping is completed. Secure suction tube and cautery cord with towel clips or allis. Prepares sutures and needles according to use.

 During an Operation y y y y Maintain sterility throughout the procedure. Awareness of the patients safety. Adhere to the policy regarding sponge/ instruments count/ surgical needles. Arrange the instrument on the mayo table and on the back table.

 Before the Incision Begins y y Provide 2 sponges on the operative site prior to incision. Passes the 1st knife for the skin to the surgeon with blade facing downward and a hemostat to the assistant surgeon. y y y y Hand the retractor to the assistant surgeon. Watch the field/ procedure and anticipate the surgeons needs. Pass the instrument in a decisive and positive manner. Watch out for hand signals to ask for instruments and keep instrument as clean as possible by wiping instrument with moist sponge.

y y y y y y

Always remove charred tissue from the cautery tip. Notify circulating nurse if you need additional instruments as clear as possible. Keep 2 sponges on the field. Save and care for tissue specimen according to the hospital policy. Remove excess instrument from the sterile field. Adhere and maintain sterile technique and watch for any breaks.

 End of Operation y y y y y y y y y Undertake count of sponges and instruments with circulating nurse. Informs the surgeon of count result. Clears away instrument and equipment. After operation: helps to apply dressing. Removes and siposes of drapes. De-gown. Prepares the patient for recovery room. Completes documentation. Hand patient over to recover room.

 Scrub Duties y y y Perform surgical hand scrub. Gown and glove using closed glove technique. Regown and glove when breaks in technique occur.

Assist the 1st scrub in setting up case (back table, mayo stand and O.R. basins).The tasks include: o Arrange instruments and supplies (back table, mayo stand and O.R.). o Count needles, instruments and sponges. o Check instruments for proper functions. o Prepare irrigating solution. o Draw medications properly. o Gown and glove surgeon and assistant. o Assist with draping. o Prepare electric cautery, suction and light handles for proper use. o Prepare necessary sutures. o Pass instruments to surgeon and assistant. o Retract, sponge, and suction during case as necessary. o Proper identification and handling of specimen. o Prepare instruments for decontamination at completion of case. o Dispose of sharps properly. o Discard soiled drapes and trash properly. o Transport soiled drapes and trash properly. o o Anticipate the surgeon and assistant needs. Anticipate the operative procedure needs.

DUTIES OF CIRCULATING NURSE  Before an Operation

y y y y y y y y y

Checks all equipment for proper functioning such as cautery machine, suction machine, OR light and OR table. Make sure theater is clean. Arrange furniture according to use. Place a clean sheet, arm board (arm strap) and a pillow on the OR table. Provide a clean kick bucket and pail. Collect necessary stock and equipment. Turn on aircon unit. Help scrub nurse with setting up the theater. Assist with counts and records.

 During the Induction of Anesthesia y y y y y Turn on OR light. Assist the anesthesiologist in positioning the patient. Assist the patient in assuming the position for anesthesia. Anticipate the anesthesiologists needs. If spinal anesthesia is contemplated: o Place the patient in quasi fetal position and provide pillow. o Perform lumbar preparation aseptically. o Anticipate anesthesiologists needs.  After the Patient is Anesthetized y Reposition the patient per anesthesiologists instruction.

y y y y y

Attached anesthesia screen and place the patients arm on the arm boards. Apply restraints on the patient. Expose the area for skin preparation. Catheterize the patient as indicated by the anaesthesiologist. Perform skin preparation.

 During Operation y y y y y y y Remain in theater throughout operation. Focus the OR light every now and then. Connect diatherapy, suction, etc. Position kick buckets on the operating side. Replenishes and records sponge/ sutures. Ensure the theater doors remain closed and patients dignity is upheld. Watch out for any break in aseptic technique.

 End of Operation y y y Assist with final sponge and instruments count. Signs the theater register. Ensures specimen are properly labeled and signed.

 After an Operation y Hands dressing to the scrub nurse.

y y y y

Helps remove and dispose of drapes. Helps to prepare the patient for the recovery room. Assist the scrub nurse, taking the instrumentations to the service (washroom). Ensures that the theater is ready for the next case.

 Circulating Duties y y y y y y y y y y y y y y Clean operating room and discard suction prior to case. Gather all supplies, instruments and equipment necessary for case. Arrange O.R. furniture properly. Open and flip sterile supplies for the surgical procedure. Assist with IV therapy. Assist the anaesthesiologist. Assist with the skin preparation. Tie gowns of the scrub nurse and surgeon. Provide scrub personnel with sitting stools and foot stools as necessary. Turn and help adjust lights as necessary. Supply the scrub nurse with necessary supplies. Receive and label specimen properly. Log and deliver specimen to pathology properly. Help apply wound dressing.

1.5 Expected Outcome of Surgical Treatment Performed

After a thyroidectomy, the patient may experience neck pain and a hoarse or weak voice. This doesn't necessarily mean there's permanent damage to the nerve that controls the vocal cords. These symptoms are often temporary and may be due to irritation from the breathing tube (endotracheal tube) that's inserted into the windpipe (trachea) during surgery, or as a result of nerve irritation but not permanent damage caused by the surgery. The long-term effects of thyroidectomy depend on how much of the thyroid is removed. If only part of the thyroid is removed, the remaining portion typically takes over the function of the entire thyroid gland, and the patient doesn't need thyroid hormone therapy. If the entire thyroid is removed, the body can't make thyroid hormone and may develop signs and symptoms of underactive thyroid (hypothyroidism). As a result, the patient need to take a pill every day that contains the thyroid hormone thyroxine (levothyroxine). This hormone replacement is identical to the hormone normally made by the thyroid gland and performs all of the same functions. The Doctor will determine the amount of thyroid hormone replacement the patient need based on blood tests.

The patient may experience some short-term, less serious side effects after surgery. These can include: Pain when swallowing, or in the neck area pain can come from the Tracheal tube after surgery or from the surgery itself. This should subside within a few days; an over-the-counter non-steroidal pain reliever, like ibuprofen, can relieve discomfort. Neck tension and tenderness there will be a tendency to hold the head stiffly in one position after surgery, and this can cause neck and muscle tension. It's good to do gentle stretching and range of motion exercises to

prevent muscle stiffness in the neck area. Simply turning the head to the right, then rolling the chin across the chest until the head is facing left can help loosen tight muscles. Voice problems the voice may be hoarse, whispery, or tired. Some people find that periods of hoarseness can last as long as two to three months. Irritated windpipe if the patient had a Tracheal tube during general anesthesia, it can irritate the windpipe and may make the patient feel as if he have something stuck in his throat. This feeling usually goes away within five days. Thyroidectomy is generally a safe surgical procedure. However, some people have major or minor complications. Possible complications include: Hemorrhage (bleeding) beneath the neck wound if this occurs, the wound bulges and the neck swells, possibly compressing structures inside the neck and interfering with breathing. This is an emergency. Thyroid storm. If a thyroidectomy is done to treat a very overactive gland (thyrotoxicosis), there may be a surge of thyroid hormones into the blood. This is a very rare complication because medications are given before surgery to prevent this problem. Injury to the recurrent laryngeal nerve because this nerve supplies the vocal cords, injury can lead to vocal cord paralysis and can produce a husky voice. In rare cases, if both vocal cords are paralyzed, the opening of the throat may be obstructed, causing breathing problems.

Injury to a portion of the superior laryngeal nerve If this occurs, patients who sing may not be able to hit high notes, and the voice may lose some projection. Hypoparathyroidism. If the parathyroid glands are mistakenly removed or unintentionally damaged during a thyroidectomy, the patient may suffer from hypoparathyroidism, a condition in which the levels of parathyroid hormone (a hormone that helps regulate body calcium) are abnormally low. Hypothyroidism: Transient hypothyroidism is seen in 2% to 4% of all patients after thyroidectomy and in 20% to 22% of those who undergo total or repeated thyroidectomy. Permanent hypothyroidism occurs in under 0.6% of patients. Wound infection.

1.6 Medical Management of Physiologic Outcomes Usual Postoperative Course. Outpatient procedures are appropriate for solitary benign nodules and have been performed for thyrotoxicosis and thyroid cancer in some centers; otherwise, the hospital stay is 1 to 2 days. Special monitoring required. Respiratory status should be carefully monitored if early postoperative stridor or difficulty in clearing secretions occurs. Patients with thyrotoxicosis who receive appropriate preoperative preparation should undergo routine monitoring.

Patient activity and positioning. The head should be elevated 30 to 45 degrees (Semi-Fowler) when client is conscious unless client is hypotensive to minimize edema and venous oozing. Support head and neck with pillows. Full activity is resumed the morning after operation. Neck Exercises. First, teach the client how to support the weight of the head and neck when sitting up in bed. Show the client how to place the hands at the back of the head when flexing the neck or moving. The client will probably be able to perform this maneuver by the first postoperative day. Second, as the wound heals (about the 2nd to 4th postoperative day); demonstrate range-of-motion exercises to prevent contractures. With the surgeons permission, teach the client to flex the head forward and laterally, to hyperextend the neck, and to turn the head from side to side. Have the client perform these exercises several times every day. Medications. Give meperidine (Demerol) or morphine sulfate every 1-2 hours as needed for pain in throat area. Give continuous mist inhalation until chest is clear. If a total thyroidectomy has been performed, explain selfadministration of thyroid replacement medications (T4) used to treat hypothyroidism: Levothyroxine sodium (Synthroid, Levothroid, Levoxine). Teach client the medication regimen and the need for lifelong replacement therapy. Alimentation: Full liquids are permitted on the day of operation and a soft diet can be started on afternoon of day 2. Drains: Closed suction drains are removed on the first postoperative day.

Postoperative Complications  In the Hospital Hemorrhage: Although it is extremely rare (less than 0.5%), a hematoma in the area of resection may cause

airway obstruction early in the postoperative period. Removal of the skin and strap muscle sutures and evacuation of the hematoma in the recovery room is preferable to tracheostomy. Patients are then returned to the operating room for irrigation of the operative site, control of hemorrhage, and repeated closure of the wound. Hypothyroidism: Transient hypothyroidism is seen in 2% to 4% of all patients after thyroidectomy and in 20% to 22% of those who undergo total or repeated thyroidectomy. Permanent hypothyroidism occurs in under 0.6% of patients. Symptomatic hypocalcemia (less than 7.5mg/dl) is characterized by anxiety, perioral or finger tingling, and a positive Chvosteks sign, and usually develops 16 to 24 hours after surgery. Intravenous calcium is given to relieve acute symptoms in the hospital and oral calcium therapy is prescribed at the time of discharge. Recurrent laryngeal nerve injury: Paralysis of one vocal cord causes hoarseness and difficulty in clearing secretions. This almost always is related to traction on the recurrent nerve and may also resolve over a period of days to months. Permanent recurrent nerve palsy occurs in as many as 4.5% of all thyroidectomies, usually resulting from intended sacrifice of a nerve involved with carcinoma.

Thyroid storm: Thyroid storm should not occur after surgery for thyrotoxicosis in adequately prepared patients, but it may be seen in patients with untreated thyrotoxicosis who are undergoing other operations. Symptoms of tremor, agitation, tachycardia, and hyperthermia are treated with intravenous fluids, propranolol, potassium iodide, and steroids.  After Discharge Recurrent benign nodule or goiter: Recurrence of a benign nodule or goiter can be prevented by the lifelong administration of thyroid hormone. Recurrent thyroid cancer: To decrease the incidence of recurrent cancer in the neck, lungs, or bone, thyroid hormone replacement is delayed until radioactive iodine is administered. Late or recurrent hyperthyroidism: Annual thyroid function tests are indicated in patients who are receiving thyroid hormone after operation for goiter or cancer and in those who are originally euthyroid after operation for Graves disease. Permanent hypothyroidism: Vitamin D is added to calcium replacement to enhance absorption. In serial parathyroid hormone levels begin to raise, first the vitamin D and then the calcium supplement should be tapered.

Clinical Interventions (Hypothyroidism) Pharmacological Management Desired Outcome:  To correct TH deficiency  Reverse the manifestations  Prevent further cardiac and arterial damage Thyroid Replacement Therapy  Levothyroxine sodium Drug of choice converted in the body to both T3 and T4 The majority of people with hypothyroidism are treated with one of the synthetic forms of the T4 thyroid hormone (Levoxyl, Synthroid). This is a more stable form of thyroid hormone and requires once a day dosing, whereas preparations containing T3 (the most active thyroid hormone) are much shorter-acting and need to be taken multiple times a day. Synthetic T4 is readily and steadily converted to T3 naturally in the bloodstream in the great majority of people, and this conversion is appropriately regulated by the body's tissues. A brand name preparation of L-thyroxine is recommended over generic preparations, and individuals should use the same brand of levothyroxine throughout treatment  Cytomel  Thyrolar  Thycar

Nursing Management  Problem #1: Acute Pain Assessment Diagnosis Scientific Explanation Patient experiences operative procedure Expected Planning Intervention Rationale outcome/ Evaluation Short term: > Establish > To gain the trust Short term: and cooperation of The the client >To shall provide use relaxation skills > and > Perform To assess activities indicated individual situation. and as for diversional patient have of

S > Patient Acute pain may report

After 5 hours rapport nursing interventions, the patient will able to > Monitor signs of

pain on the operative site

pain due to the of

demonstrated

done. As the be O > Patient may manifest: facial anesthetic sensation returns pain other of incision, agent wear off, use

vital baseline data.

demonstrate relaxation and skills the diversional and activities indicated

grimaces - restlessness - irritability reduced

a etiology/ precipitating of contributory factors

comprehensive as assessment for pain to include

interaction with people - change in respiration, blood pressure, and pulse

manipulations done body into awareness. The on

individual

location, characteristics, onset/duration,

Long term: The shall reported feeling well-being and comfort. > This of can the pain influence amount of patient have

the situation.

comes Long term:

frequency, severity (1 to 10), and precipitating or

After 4 days of quality,

injured nursing

tissue releases interventions, pain substances such

the patient will aggravating report feeling factors as of well-being

prostaglandins, and comfort. histamine and kinin. transmit These pain substances

> Note location of experienced surgical procedures > To ensure despite comfort > Observe body impaired language for communication > To assist client > Provide quiet for environment pain alleviation of evidence of pain

impulse to the spinal From cord. the

spinal cord, the pain message is sent to the brain where it

is and

processed is as The is > Encourage use of as relaxation > soft music, Promotes rest, > Encourage > To prevent

perceived pain. message transmitted

adequate periods

rest fatigue

back to the site of injury then through the spinal cord. In the spinal cord and brain, such endorphins, serotonin involved modulation and transmission of and in adrenaline are in the many as

techniques

such redirects attention

focused breathing

> Take time to listen contact patient and > with and attention, Helpful in maintain frequent alleviating anxiety

chemicals

refocusing which

may relieve pain >Administer analgesic medications ordered. >To provide

pharmacologic as treatment of pain.,

pain. > Monitor > To promote timely of intervention/revision of plan of care

effectiveness

pain medications

 Problem # 2: Ineffective Airway Clearance Related to Bleeding and/ or Laryngeal Edema Assessment S > Diagnosis Scientific Explanation If hemorrhage (bleeding) beneath to neck the wound the Objectives Short Term: After 1 hour of the to nursing patient > Monitor level Interventions > Establish rapport Rationale Desired Outcomes

the Ineffective may airway clearance related the or

> To gain the trust Short Term: and cooperation The patient

patient verbalize dyspnea O >

of the client vital > note To

will be able to maintain

interventions, will be able signs,

bleeding and/ occurs, patient manifest: - presence of surgical wound on the low collar may edema

provide airway deviations Long Term: The patient

laryngeal wound bulges and the neck swells, possibly compressing structures inside the neck and interfering with breathing. This is an

of baseline data and patency.

maintain consciousness, orientation

airway patency.

from normal

> Auscultate breath >To Long Term:

ascertain will be able to

sounds and assess status and note maintain vital progress signs, respirations, breath for profuse of bleeding sounds within

After 3 days air movement of the nursing patient site

area of neck - adventitious breath

interventions, > Check dressing > To identify signs and

sounds wheezes, crackles)

emergency. Laryngeal edema to may surgical

will be able bleeding (side of to vital and maintain neck and back of signs, head) every 15 after

normal limits.

- changes in respiratory rate rhythm restlessness - cyanosis difficulty vocalizing and

also occur due manipulation. Bilateral recurrent nerve with paralysis both cords occur injury acute of vocal may during

respirations, sounds within normal limits.

minutes for 1 hour surgery

breath immediately

>

Keep

dressing >

To

prevent

size minimized

impaired view of incision site

> Position patient > of bed elevated 30 to 45 degrees

To

promote

on back with head ease in breathing

surgery which may the cause of

obstruction

> Monitor for signs > To identify early of distress respiratory signs or respiratory caused tracheal of

airway

because of the adduction cords. of

obstructed airway q distress 1 : stridor, by coarse edema wheezing,

the true vocal

airway

crackles,

dyspnea, cyanosis, labored respirations > Teach and assist > patient to To prevent

turn, pulmonary and to take advantage of decreasing pressure on the diaphragm enhancing drainage ventilation different segments of / to lung and gravity

cough, and deep complications and breathe q2h prn

> If indicated, keep > To clear airway suction equipment when at bedside; gently are secretions blocking

suction oropharynx airway only necessary > environment allergen free > To use if patient > tracheostomy and immediately available bedside > To mobilize at Have experiences tray severe respiratory Keep > To maintain when

patent airway

oxygen distress

> Encourage use of secretions warm versus cold liquids appropriate > > opportunities for To prevent as

Provide fatigue

rest

> Hoarseness and sore throat to

> Encourage voice secondary speech swallowing periodically

rest, but do assess edema or damage and to laryngeal nerve may last several days. difficulty indicate impending obstruction > > changes in sleep pattern > Observe > To identify infectious for process/ promote signs/ symptoms of timely intervention infection > To promote timely intervention To assess Increased may

Evaluate changes

> Note physician if / revision in plan dressing requires of care

reinforcement more than one time  Problem #3: Altered Tissue Perfusion r/t Excessive Blood Loss Secondary to Surgery Assessment Diagnosis Scientific Explanation The decreased hemoglobin concentration Expected Planning Intervention Rationale outcome/ Evaluation Short term: > Establish > To gain trust and Short term: to have a good The patient have to

S>

Altered Tissue

in After 3 hours rapport. of nursing interventions,

O > The patient Perfusion may manifest: r/t Generalized excessive

relationship to the shall SO.

patient and to the demonstrated measures improve > To have a circulation. Long term: > To prevent further The > Instruct patient complications. to have complete patient Monitor and baseline data.

in the blood of the patient will may be able to to >

weakness pallor - Altered BP - Dizziness - Vomiting - Headache - Body malaise -

blood loss client to surgery perfusion

- Paleness and secondary

lead to tissue demonstrate measures improve ineffective. record vital signs

The level of circulation. the hemoglobin of Long term: the

shall able to demonstrate increased

patient After 3 days of bed rest. > Compliance

may give the nursing

to perfusion

as

Hypoventilation - Cold skin

outcome decrease oxygen resulting failure nourish

of interventions,

> Stress out the and of the patient to individually of the regimen will appropriate.

in the patient will importance be able

to compliance to the result in effective therapeutic as healing process. treatment process. and healing regimen to hasten faster

in demonstrate to increased the perfusion

tissues at the individually capillary level. appropriate This may exist without decreased cardiac output: however, there may be a relationship between cardiac output and tissue > Encourage > To know what the and patient is trying to of voice out and what the patient feelings. perfusion. > Provide > For patient environment conducive resting. for comfortability. > Encourage > To prevent relaxation technique such as deep breathing aspiration.

exercise.

expression verbalization feelings.

>Administer

IV >

To

maintain

fluids as ordered.

electrolyte balance.

>Evaluate nursing > To identify what interventions given. needs reinforced assess effectiveness of interventions given. to be and

 Problem # 4: Impaired Verbal Communication Related to Damage and/or Manipulation of Laryngeal Nerves Secondary to Surgery Assessment S > Diagnosis Scientific Explanation Injury results Objectives > Interventions Rationale Desired Outcomes

the Impaired may verbal

that Short Term: nursing interventions,

Establish > To gain the Short Term: trust cooperation the client vital > To baseline and and The patient will of be able to use alternative communication provide methods data which note can in needs be

patient verbalize dyspnea O >

from After 4 hours of rapport

communication severing, related the manipulation may of to clamping, or

damage and/or compressing, patient manifest: surgical wound on the low collar impaired laryngeal either recurrent to laryngeal nerve superior laryngeal nerve during

the patient will > Monitor

stretching be able to use signs the alternative communication methods or which can expressed. > Monitor in be quality q2h

nerves surgery

- presence of secondary

deviations from expressed. Long Term: > To evaluate The patient will damage at to be able to for laryngeal nerves communicate verbally

needs > Monitor voice normal

area of neck articulation

thyroid surgery Long Term:

may result in After 6 days of edema

- inability to speak use of

severe untoward sequelae the The

nursing interventions, for the patient will able

surgical incision > To assess and glottis contributing factors of draining tubes blocks > To assess

without change.

voice

nonverbal cues/ gestures difficulty or

patient. be

to > Note presence

recurrent communicate

laryngeal nerve

verbally without that lies voice change. speech >If provide alternative means

speaking verbalizing

adjacent to the postero-medial aspect of the thyroid. Unilateral recurrent laryngeal nerve causes ipsilateral vocal cord to remain in the median paramedian position, thus > or >Keep call bell within reach at all times injury the

causative indicated factors

of >To minimize

communication

such as use of patients need to pad and pencil speak or slate board

>To

minimize

reduce patients need to

immediate hoarseness occurs. voice The may

environmental stimuli

speak

> > meaning nonverbal communication of may

To

lessen which worsen

validate anxiety problem

never recover its timbre and focus, though effective phonation can eventually achieved. Bilateral recurrent nerve injury with be even

> because they > increasing hoarseness physician > > patients to promote / anticipate timely needs intervention to report may be wrong

acute paralysis of both vocal cords adducts the true vocal cords. Permanent debilitating

as indicated

revision in plan of care >to minimize

patients need to speak

hoarseness may follow.

Damage to the superior laryngeal nerve voice is affects pitch. to and the and in

Since the cord unable

lengthen tense, pitch breathy quality.

voice is low in

 Problem # 5: Impaired Skin and Tissue Integrity Secondary to Surgery Assessment S> O > Diagnosis Impaired skin the tissue may integrity secondary patient Scientific Explanation In an incision will be through made the Objectives Short Term: After 2 hours of nursing interventions, the patient will > be able verbalize understanding of condition > Record > To Monitor vital > To Interventions > Establish rapport Rationale Desired Outcomes

> To gain the trust Short Term: and cooperation of The the client patient will be able to verbalize provide understanding of condition and causative provide factors.

and thyroidectomy,

manifest: surgical wound on

- presence of to surgery

skin in the low collar area of the neck. Next, a vertical cut will be made through strap-like muscles located and just these below the skin, the

to signs

baseline data

the low collar area of neck damaged tissue

size comparative width), baseline Long Term: The patient

and causative (depth, factors. color, temperature, Long Term:

location,

will be able to display progressive improvement > To assess extent in wound

texture, consistency

After 3 days of wound/ lesion if of nursing possible interventions,

muscles will be spread aside

the patient will >Inspect be able to surrounding skin for erythema, induration, maceration

of involvement

healing.

to reveal the thyroid and deeper structures. Then, part thyroid all of or the gland gland other

display progressive improvement in wound

> To assess early progression of

healing.

> Note odors and wound healing or drains emitted from development the skin/ area of hemorrhage injury infection of or

will be cut free from surrounding tissues and > Assess adequacy of blood supply and innervation of the > To promote timely affected tissue intervention/revision of plan of care > Inspect skin on a daily describing basis, lesions > To assist bodys removed. After the gland removed, thyroid is one > To identify contribution factors

or two stitches will be used to bring the neck muscles

together again. Then the

and observed

changes natural process of repair

deeper layer of the incision will be closed with stitches, and > Keep the area clean/dry, carefully dress support and infection > To prevent skin > Use appropriate breakdown due to wound coverings moisture wounds, > To protect the incision, wound and/or

the skin will be closed sterile tapes. with paper The

prevent surrounding tissues

incision can be an entry for bacteria.

>

Avoid

use

of >

To

provide

plastic material and positive remove promptly wet/wrinkled linens healing

nitrogen and to

balance to aid in facilitate healing

>

Rrovide

good with

nutrition

adequate

protein >

To

prevent

and calorie intake, fatigue and mineral supplements indicated as > To promote and risks with vitamin/

circulation > sleep Encourage reduce immobility adequate rest and associated

>Encourage ambulation mobilization

early >

To

prevent tissue

and excessive pressure

> To reduce risk of cross> Provide position contamination changes

> Practice aseptic

technique

in >

To

prevent

cleansing/dressing and lesions > Instruct

spread of infectious

medicating agent

proper >

To

enhance

disposal of soiled healing dressing >Refer to dietician as appropriate

V.Conclusion:

Hyperthyroidism is a disease of the thyroid gland. Hyperthyroidism results in an abnormal over activity of the thyroid gland. While Hypothyroidism (underactive thyroid) is a condition in which your thyroid gland doesn't produce enough of certain important hormones. There are many different factors that may result to these conditions so, people who are at high risk must be knowledgeable about these factors .Both conditions are lifethreatening when prompt medical intervention is not given attention. Proper prevention of these conditions

must be the priority goal. Prevention of these conditions may decrease the risk of a person to acquire hypothyroidism or hyperthyroidism.