O.R.

WARD CLASS

TOPIC DESCRIPTION: This concept deals with the concepts and principles of perioperative care on OR client who will undergo thyroidectomy. It includes a discussion of related terms, indications as well as the principle and techniques of nursing care management for this surgery.

CENTRAL OBJECTIVES: At the end of 1 hour and 30 mins, the level III students shall gain adequate knowledge, develop basic and competent nursing skills, and demonstrate desirable attitudes on perioperative care of OR client who will undergo thyroidectomy. TIME-ALLOTMENT: 1 hour and 30 mins PLACEMENT: Level III, 2nd semester, SY 2011-2012 VENUE: DJRMH/ ABC-ST

THYROIDECTOMY

WHAT IS THYROIDECTOMY?

 A transverse collar incision is made in a natural skin crease about inch (2cm) above the clavicle. The cervical fascia is incised vertically in the midline.

 Throughout the surgical procedure, meticulous hemostasis is maintained. Blood supply arises from the external carotid arteries to the upper poles of the thyroid gland and from subclavian arteries to the lower poles.

 The superior laryngeal nerves, which innervate the cricothyroid muscles, and recurrent laryngeal nerves, which innervate the vocal cords, are identified.

 Trauma to these nerves can result in temporary or permanent laryngeal paralysis. Voice disturbances with hoarseness occur with paralysis of one vocal cord.

TYPES OF THYROIDECTOMY

TOTAL THYROIDECTOMY
Excision of both lobes plus the isthmus may be the procedure of choice for palpable disease in both lobes. Is the removal of the entire thyroid gland. It last about an hour and a half.

 It is the most common type of thyroid surgery, and often use for thyroid cancer, such as medullary or anaphylactic thyroid cancer. It is also indicated for certain carcinomas, to relieve tracheal or esophageal compression

SUBTOTAL THYROIDECTOMY

The usual procedure for hyperthyroidism is removal of approximately 5/6 of the thyroid gland. This procedure generally relieves symptoms permanently, because the remaining thyroid tissue secretes sufficient hormone for normal function. It is the removal of half of the thyroid gland

 For this operation, cancer must be small and non-aggressive-follicular or papillary and contained one side of the gland, and when this is performed, typically, surgeons perform bilateral subtotal thyroidectomy which leaves from 1-5 grams on each side/lobe of the thyroid.

 A Harley Dunhill procedure is also used in which theres a total lobectomy on one side, and a subtotal on the other, leaving 4-5 grams of thyroid tissue remaining. This procedure usually takes about 45 minutes to an hour.

THYROID LOBECTOMY

An entire lobe is removed, especially for toxic diffuse goiter which is usually benign. In case of malignant growth, the lobe and lymph nodes in the neck and drain into the involved area may be dissected.

 It is the removal of only about a quarter of the thyroid gland It is less commonly used for thyroid cancer, as the cancerous cells must be small and non-aggressive.

INTRATHORACIC THYROIDECTOMY

Invasion of the gland into substernal and intrathoracic regions can cause tracheal obstruction. The sternum may have to be split to remove a large, adherent intrathoracic goiter.

Thyroid hormones the rate of glucose metabolism, oxidation and conversion to body heat and chemical energy. Calcitonin decreases the calcium levels in the blood by depositing calcium into the bones.

ANATOMY AND PHYSIOLOGY

Thyroid Gland
The thyroid gland is located in the neck, just below the cricoids cartilage, and somewhat Hshaped. The thyroid is composed of two pear shaped lobes which extend from the thyroid cartilage to the 6th tracheal ring on the anterior side of the neck.

 It lies over the trachea and is covered by layers of pretracheal fascia (allowing it to move), muscle and skin. The two lobes are joined by the isthmus which overlies tracheal rings 2, 3 and 4.

 Each lobe is composed of irregularly shaped lobules, which consist of a multitude of tiny sacs (follicles) filled with jelly-like, iodine-containing substance called colloid. The main component of colloid is thyroglobulinthe storage form of the hormone thyroxine. The parathyroid gland s are four glands near, attached to, or embedded in the thyroid gland.

 Thyroxine or T4, triiodothyronine or T3 are actually two iodine-containing hormones. Thyroid hormone controls the rate at which glucose is burned, and converted to chemical energy to power their activities.

INDICATIONS
Thyroid cancer Goiter Multiple nodules cause by cosmetics, breathing, or swallowing problems

 Hyperthyroidism-only when not controlled by antithyroid drugs, and requires immediate treatment Benign and malignant thyroid tumors

NURSING RESPONSIBILITIES

PREOPERATIVE
Asses the clients demographic data Obtain the clients health history The client must be euthyroid before the operation Check the clients vital signs.

 Allow the client to verbalize his/her concerns to reduce anxiety. Make sure that the client had adequate rest periods and in good health before entering the operating room.

 Teachings include demonstrating to the patient how to support the neck to the hands after the surgery to prevent stress on the incision.

INTRAOPERATIVE
Monitor the clients vital signs in the absence of anesthesiologist. Observe and maintain clients safety. Maintain sterility to avoid introducing microorganisms during the procedure.

OR instruments used
Needle holder Mayo straight Baby metzenbaum scissors Curved mosquito straight Curved mosquito curved

OR instruments used
Kelly clamp straight Kelly clamp curved Freer elevator Regular metzenbaum Ochnser Adenoid suction Fiberoptic headlight

OR instruments used
Sterile strips Army-navy retractors Richardson-Eastman retractor McCabe nerve dissector Babcock clamp Double skin hooks Green retractors

OR instruments used
Bullets (peanuts) KI Gardlok dissector Vein retractor Criles

POSTOPERATIVE
Observe for any complications after the surgery Hemorrhage Hypocalcemia Laryngeal nerve damaged Tetany

 Infection Respiratory obstructon Thyroid storm

 Take vital signs q15 minutes until stable; then qh for next 24hr Periodically assess the surgical dressing Use semi-fowler position when client is conscious unless client is hypotensive. Support head and neck with pillows and sandbags

 Water may be given by mouth as soon as nausea subsides Initially clod fluids and ice may be taken better than other liquids The patient advised to talk as little as possible to reduce edema to vocal cords

 A well balanced, high caloric diet may be prescribed to promote weight gain Ambulation on day 2 as tolerated Give fluids by mouth as tolerated If nausea and vomiting, notify physician Start soft diet on afternoon of day 2.

 Give Morphine sulfate other opioid agent q12hr as needed for pain in throat area Cough and deep breath qh Suction mouth and trachea as necessary

 Have tracheostomy set, endotracheal tube, laryngoscope and oxygen on hand. Give continuous must inhalation until chest is clear

 Take temperature q4h for 24hr, then routinely Assess client for hypocalcemia and monitor Ca, Mg, Phosphate

BIBLIOGRAPHY Marieb, E.N. (2004). Essentials of anatomy and physiology. 6th ed. First Lok Yang Road Singapore: Pearson Education Asia Pte Ltd. Smeltzer, S.C. & Bare, B. (2004). Brunner and Suddarths textbook of medical surgical nursing. 10th ed. J.B.U.S.A.: Lippincott Company. Black, J. & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes. 7th ed. Philadelphia: W.B. Saunders Company. Phillips, N. F. (2004). Berry and Kohns operating room technique. 10th ed. Singapore: Mosby Elsevier.