I. LEARNING OBJECTIVES a.

For the student to identify the underlying factors that contributes the development of the said problem. b. For the readers to be able to understand the said problem and give them precautionary steps in their lifestyle to avoid its occurrence. II. OVERVIEW AND ANATOMY AND PHYSIOLOGY

The thyroid gland is butterfly shaped and sits on the trachea, in the anterior neck. It is comprised of two lobes connected in the middle by an isthmus. Inside, the gland is made up of many hollow follicles, whose epithelial cell walls (also known as follicle cells) surround a central cavity filled with a sticky, gelatinous material called colloid. Parafollicular cells are found in the follicle walls, protruding out into the surrounding connective tissue. The thyroid is the largest exclusively endocrine gland in the body. The endocrine system is the bodys communication hub, controlling cell, and therefore organ, function. A primary goal of the endocrine system is to maintain homeostasis within the organism, despite external fluctuations of any sort. Hormones, which act as chemical messengers, are the mechanism for this communication. The hormones secreted by the thyroid gland are essential in this process, targeting almost every cell in the body (only the adult brain, spleen, testes, and uterus are immune to their effects.) Inside cells, thyroid hormone stimulates enzymes involved with glucose oxidation, thereby controlling cellular temperature and metabolism of proteins, carbohydrates, and lipids. Through these actions, the thyroid regulates the bodys metabolic rate and heat production. Thyroid hormone also raises the number of adrenergic receptors in

blood vessels, thus playing a major role in the regulation of blood pressure. In addition, it promotes tissue growth, and is particularly vital in skeletal, nervous system, and reproductive development. III.DEFINITION AND DSCRIPTION OF THE DISEASE A goiter is simply a thyroid gland that has grown to an abnormally large size. Some patients with goiter have a thyroid gland that is making too little thyroid hormone. An example of this would be Hashimoto's thyroiditis. Other patients with an abnormally large thyroid may have a gland that is overactive. For instance, patients with Graves' disease usually have an enlarged thyroid. However, many people have a goiter and yet have perfectly normal thyroid hormone levels in their blood. The thyroid is enlarged but it is making a normal amount of thyroid hormone. Goiter is the enlargement of the thyroid gland. It is usually a response to a thyroid hormone deficiency (primary hypothyroidism) that results in the hypersecretion of thyroidstimulating hormone (TSH) from the anterior pituitary gland. Oversecretion leads to subsequent thyroid hypertrophy and hypervascularity. The bodys response may compensate for thyroid hormone deficiency, leaving the patient asymptomatic. Goiter may also occur in conjunction with hyperthyroidism, known as Graves disease. Finally, goiter may occur with the growth of thyroid tumors. Secondary hypothyroidism occurs with TSH deficiency in the pituitary gland and is not associated with goiter. Goiter becomes a problem only when the enlargement exerts pressure on other neck structures, such as the trachea, or when the enlargement is unsightly, causing the patient to become concerned. Goiter caused by thyroid nodules, a common condition, may also cause no symptoms. Although thyroid nodules or tumors may be either benign or malignant, more than 75% of thyroid nodules are benign. Goiter associated with hyperthyroidism wherein too much thyroid hormone is produced that speeds up metabolism or hypothyroidism which is opposite hyperthyroidism may present with symptoms of the underlying disorder although the symptoms are often unspecific and hard to diagnose. Goiter not associated with hormonal abnormalities will not cause any symptoms aside from the presence of anterior neck mass. However, for particularly large masses, compression of the local structures may result in difficulty in breathing or swallowing. In those presenting with these symptoms, malignancy must be considered. Toxic goiters will present with symptoms of thyrotoxicosis such as palpitations, hyperactivity, weight loss despite increased appetite, and heat intolerance. IV.TYPES AND CLASSIFICATION They are classified in different ways: Class I - palpation Struma - in normal posture of the head, it cannot be seen; it is only found by palpation. Class II - the Struma is palpative and can be easily seen. Class III - the Struma is very large and is retrosternal; pressure results in compression marks.

Other types of goiter are as follows: Diffuse Small Goiter- This is the place where the entire thyroid gland swells to a larger size. It also feels smooth to touch. Nodular Goiter- This is the place where the certain sections of nodules of thyroid gland swells, it feels lumpy to touch. V. CAUSES/ETIOLOGY and RISK FACTORS Worldwide, the most common cause for goitre is iodine deficiency. Other causes are overproduction or unproduction of hormones but there could be many different causes of goiters in people who do not have thyroid problems. The patient could have a mild case of Hashimoto's thyroiditis that has not yet caused the thyroid to become underactive. They may have inherited a "weak" thyroid gland, which has to be stimulated excessively by thyroid stimulating hormone in order to make a normal amount of thyroid hormone. They may have an autoimmune diseases in which the body's immune system produces immune globulins that stimulate the thyroid to grow without either destroying it or stimulating it to make too much thyroid hormone. They may have conditions in which white blood cells in the body produce substances called "cytokines" that stimulate the thyroid to grow. Often, when a patient has a goiter with normal thyroid hormone levels, the doctor is never really able to find out the exact cause of the goiter. VI. PATHOPHYSIOLOGY The thyroid gland is controlled by thyroid-stimulating hormone (TSH; also known as thyrotropin), secreted from the pituitary gland, which in turn is influenced by the thyrotropinreleasing hormone (TRH) from the hypothalamus. TSH permits growth, cellular differentiation, and thyroid hormone production and secretion by the thyroid gland. Thyrotropin acts on TSH receptors located on the thyroid gland. Serum thyroid hormones levothyroxine and triiodothyronine feed back to the pituitary, regulating TSH production. Interference with this TRH-TSH thyroid hormone axis causes changes in the function and structure of the thyroid gland. Stimulation of the TSH receptors of the thyroid by TSH, TSH-receptor antibodies, or TSH receptor agonists, such as chorionic gonadotropin, may result in a diffuse goiter. When a small group of thyroid cells, inflammatory cells, or malignant cells metastatic to the thyroid is involved, a thyroid nodule may develop. A deficiency in thyroid hormone synthesis or intake leads to increased TSH production. Increased TSH causes increased cellularity and hyperplasia of the thyroid gland in an attempt to normalize thyroid hormone levels. If this process is sustained, a goiter is established. Causes of thyroid hormone deficiency include inborn errors of thyroid hormone synthesis, iodine deficiency, and goitrogens.

A goiter may result from a number of TSH receptor agonists. TSH receptor stimulators include TSH receptor antibodies, pituitary resistance to thyroid hormone, adenomas of the hypothalamus or pituitary gland, and tumors producing human chorionic gonadotropin The histopathology varies with etiology and age of the goiter. Initially, uniform follicular epithelial hyperplasia (diffuse goiter) is present, with an increase in thyroid mass. As the disorder persists, the thyroid architecture loses uniformity, with the development of areas of involution and fibrosis interspersed with areas of focal hyperplasia. This process results in multiplenodules (multinodular goiter). On nuclear scintigraphy, some nodules are hot, with high isotope uptake (autonomous) or cold, with low isotope uptake, compared with the normal thyroid tissue (as demonstrated in the images below). The development of nodules correlates with the development of functional autonomy and reduction in thyroid-stimulating hormone (TSH) levels. Clinically, the natural history of a nontoxic goiter is growth, nodule production, and functional autonomy (resulting in thyrotoxicosis in a minority of patients). VII. LABORATORY AND DIAGNOSTIC EXAM The most important part of the evaluation of a goiter is the doctor's examination. Commonly the doctor will evaluate a goiter using some or all of the following techniques: Feeling the thyroid Blood test Thyroid scan Ultrasound 1. Feeling the Thyroid By feeling the thyroid, the doctor can estimate the size of the gland, tell whether it is growing or not, and tell if it has any lumps in it that might be suspicious for cancer. 2. Blood Test Measurement of the levels of thyroid stimulating hormone (TSH) and T4 in the blood stream are important because they help the doctor determine whether or not the goiter is making a normal amount of thyroid hormone. If the gland has a lump in it, the doctor may order a thyroid scan or an ultrasound to see if there are any masses in the thyroid that might be suspicious for a thyroid cancer. 3. Thyroid Scan A thyroid scan is performed by having the patient take oral capsules that contain a harmless radioactive tracer (which is a tiny quantity of radioactive iodine). After four to twenty-four hours (depending on the institution) a detector is placed over the thyroid gland. The amount of

radioactive iodine that wound up in the thyroid gland is measured and a picture is taken of the distribution of radioactive iodine in the thyroid. 4. Ultrasound Ultrasound is a way of taking a picture of the inside of the thyroid. Ultrasound bounces sound waves off the thyroid and makes a picture out of the returning echoes. If the ultrasound shows a large mass that is suspicious for cancer, then the ultra-sonographer can use the ultrasound to guide a needle into the mass to perform a fine needle aspiration biopsy. If there are no large lumps in the thyroid gland that are suspicious for cancer, then no biopsy needs to be done. VIII. MEDICAL/SURGICAL MANAGEMENT Levothyroxine, used to treat hypothyroidism, can also be used in euthyroid patients for the treatment of goiter. Levothyroxine suppressive therapy decreases the production of TRH and TSH and may reduce goiter, thyroid nodules, and thyroid cancer. Blood tests are needed to ensure that TSH is still in range and the patient has not become sub clinically hyperthyroid. Subtotal thyroidectomy. This is an operation in which most of the thyroid gland is removed. There are some research studies suggesting that putting a patient on a thyroid hormone pill everyday may help to shrink goiters or keep them from growing. However, there are other studies suggesting that this may not work. There are also studies suggesting that even a mild overdose of thyroid hormone, if taken for many years, can result in osteoporosis and may put older individuals at risk for abnormal heart rhythms. IX. NURSING DIAGNOSTICS Pain on swallowing related to Nodular and Non Toxic Goiter Risk for ineffective airway clearance related to tracheal compression or obstruction. Acute pain related to postoperative surgical procedure. Risk for Fluid Volume loss: Bleeding related to post-neck surgery. Risk for injury: Tetany related to possible stimulation of parathyroid gland. Risk for infection related to postoperative surgical incision. Risk for Altered Body Nutrition: Less than body requirements. X. NURSING MANAGEMENT Asses for presence or description of pain. Assess neck incision for approximated skin edges, redness, swelling, and drainage. Use relaxation techniques as appropriate. Protect the neck incision by instructing patient to: Avoid neck flexion/hyperextension. Avoid rapid head movements

Administer analgesic to prevent unnecessary pain. Advise client to have adequate rest and not to strain. Monitor for signs of infection. redness, swelling, increased pain and purulent drainage at incision Provide small and frequent feedings followed by water. Promote a pleasant environment for eating. Advice client about proper hygienic measures to avoid infection at the incision site. XI. BIBLIOGRAPHY
http://netwellness.org/healthtopics/thyroid/thyroidgoiter.cfm http://www.ayushveda.com/dietfitness/goiter/ http://encyclopedia.thefreedictionary.com/Goiter http://www.ohlonecenter.org/research-papers/the-thyroid-gland-anatomy-physiology/

CASE ANALYSIS In OR-DR

(GOITER)
Submitted to: Mrs. Susan Barbero, Rn, Man Clinical Instructor Submitted by: Dianne April A. Alvarez SN IV, DWCB

Twin
A twin is one of two offspring produced in the same pregnancy. Twins can either be identical (in scientific usage, "monozygotic"), meaning that they develop from one zygote that splits and forms two embryos, or fraternal ("dizygotic") because they develop from two separate eggs that are fertilized by two separate sperm. In contrast, a fetus which develops alone in the womb is called a singleton, and the general term for one offspring of a multiple birth is multiple. It is theoretically possible for two singletons to be identical if all 23 chromosomes in both gametesfrom the mother and father were to be exact matches from one birth to the next. While this is statistically improbable (less than one in one billion-billion-billion chance) under natural conditions, a controlled pairing may someday be possible. A less complex way to engineer genetically identical offspring is through the process of cloning, a procedure that has successfully been accomplished with several species of mammals.

Zygosity
Zygosity is the degree of identity in the genome of twins. There are five common variations of twinning. The three most common variations are all fraternal (dizygotic):

Malefemale twins are the most common result, 50 percent of fraternal twins and the most common grouping of twins. Femalefemale fraternal twins (sometimes called "sororal twins") Malemale fraternal twins

The other two variations are identical (monozygotic) twins:

Femalefemale identical twins Malemale identical twins (least common)

Among non-twin births, male singletons are slightly (about five percent) more common than female singletons. The rates for singletons vary slightly by country. For example, the sex ratio of birth in the US is 1.05 males/female, while it is 1.07 males/female in Italy. However, males are also more susceptible than females to death in utero, and since the death rate in utero is higher for twins, it leads to female twins being more common than male twins.

Fraternal (dizygotic) twins

Fraternal or dizygotic (DZ) twins (also referred to as "non-identical twins", "dissimilar twins", "biovular twins", and, in cases of females, occasionally sororal twins) usually occur when

two fertilized eggs are implanted in the uterus wall at the same time. When two eggs are independently fertilized by two different spermcells, fraternal twins result. The two eggs, or ova, form two zygotes, hence the terms dizygotic and biovular. Fraternal twins, like any other siblings, have an extremely small chance of having the same chromosome profile. Like any other siblings, fraternal twins may look similar, particularly given that they are the same age. However, fraternal twins may also look very different from each other. They may be of different sexes or the same sex. The same holds true for brothers and sisters from the same parents, meaning that fraternal twins are simply brothers and/or sisters who happen to be the same age.

Identical (monozygotic) twins

Identical or monozygotic (MZ) twins occur when a single egg is fertilized to form one zygote (hence, "monozygotic") which then divides into two separate embryos. Regarding spontaneous or natural monozygotic twinning, a recent theory posits that identical twins are formed after a blastocyst essentially collapses, splitting the progenitor cells (those that contain the body's fundamental genetic material) in half, leaving the same genetic material divided in two on opposite sides of the embryo. Eventually, two separate fetuses develop. Spontaneous division of the zygote into two embryos is not considered to be a hereditary trait, but rather a spontaneous or random event. Identical twins may also be created artificially by embryo splitting. It can be used as an expansion of IVF to increase the number of available embryos for embryo transfer.

Semi-identical twins
Half-identical or semi-identical twins (also referred to as "half twins") are the result of a very rare form of twinning in which the twins inherit exactly the same genes from their mother but different genes from their father. Although examples of half-identical twins have been found, the exact mechanism of their conception is not well-understood, but could theoretically occur in polar body twinning where sperm cells fertilize both the ovum and the second polar body. Types There are two mechanisms by which this might happen:

Polar twins (or "polar body twins"), where two sperm fertilize an ovum, one of the two fertilizing a polar body;[22] or where an ovum splits into identical copies, one containing a polar body, prior to fertilization, allowing it to be fertilized by two different sperm.

Sesquizygotic twins, where two sperm fertilize the one ovum, forming a triploid, and then splitting.