The thyroid gland plays a major role in the metabolism, growth and development of the human body, regulating body functions by constantly releasing a steady amount of thyroid hormones into the bloodstream. At times however, an individual may require a thyroidectomy, which is the surgical removal of all or part of the thyroid gland. This may happen due to thyroid-related conditions such as Goitre and Carcinomas.
Hypothyroidism vs Hyperthyroidism
In hypothyroidism, the thyroid gland is underactive, hence it doesn’t produce enough thyroid hormone. On the other hand, in hyperthyroidism, the thyroid gland is overactive, hence it produces too much thyroid hormone.
Thyroidectomy Indications
Goitre
A goitre a.k.a. goiter refers to swelling of the thyroid gland which causes a lump located at the front of the neck which moves up and down with swallowing. Nodules are lumps located within the thyroid gland.
- Solitary Nodular Goitre (single swelling) – most commonly benign, solitary nodular goitres are often left untreated. If upon examination cancer is not excluded, surgery is usually recommended. An overactive nodule a.k.a. hot nodule can be treated by pharmacological medication, radioactive iodine treatment, or surgery.
- Multi-Nodular Goitre (multiple swellings) – common multiple swellings which usually do not require surgery unless breathing and/or swallowing become compromised, or in case of rapidly growing nodules, or the individual prefers to undergo surgery for aesthetic purposes (unsightly goitre).
Carcinoma
Thyroid cancer is a rare type of cancer affecting the thyroid gland. Types of thyroid cancers include:
- papillary carcinoma – the most common type, affecting mostly females under 40; papillary carcinomas appear as irregular solid or cystic masses or nodules
- follicular carcinoma – affecting mostly middle-aged females, these malignant epithelial tumors account for about 15% of malignant thyroid tumors
- rare carcinomas – include thyroid teratomas, lymphomas, and squamous cell carcinomas.
Thyroidectomy Types
- Hemi-Thyroidectomy – removal of half of the thyroid gland
- Lobectomy – removal of either the right or the left thyroid gland lobe, commonly done in the case of solitary goitre
- Total Thyroidectomy – removal of the whole thyroid gland, commonly done in cases of malignant thyroid tumors
- Subtotal Thyroidectomy – removal of almost whole thyroid gland, commonly done in multi-nodular goitre (some thyroid tissue surrounding one parathyroid gland is preserved)
- Near-Total Thyroidectomy – removal of almost whole thyroid gland, commonly done in multi-nodular goitre (some thyroid tissue surrounding one parathyroid gland is preserved)
- Isthmusectomy – removal of the thyroid isthmus
Thyroidectomy Perioperative Nursing Care
Thyroidectomy Preoperative Care
BLOOD INVESTIGATIONS:
- CBC
- Urea, Electrolytes, & Creatinine
- T3, T4, & TSH (Thyroid Stimulating Hormone)
SCANS:
- Thyroid Gland ultrasound scan
- Radio-Iodine Thyroid Scan
- Neck X-ray
- Chest X-ray
OTHER INVESTIGATIONS:
- FNAC (Fine Needle Apiration Cytology) of thyroid nodule, if palpable
- Indirect Laryngoscopy for pre-operative assessment of vocal cords functioning
CARE:
- patient reassurance through answering of any questions in relation to surgery so as to help reduce patient anxiety and fear; this also helps in acquiring informed consent
- patient education regarding neck support in preparation for post-operative self-care
- administration of anti-thyroid medication eg. Methimazole to promote a euthyroid (normal thyroid function) state
- preparation of Potassium Iodide (Iodine) which helps to decrease thyroid gland vascularity, thus reducing risk for haemorrhage
- avoid prophylactic antibiotic administration in such a clean elective surgery unless indicated
Thyroidectomy Postoperative Care
PATIENT CARE ON DAY OF SURGERY:
- monitor patient’s vital signs and document accordingly
- keep patient NBM (nil-by-mouth)
- administer between 2.5l-3l of supplemental IV fluid
- administer analgesics as prescribed to reduce severe post-operative pain
- in case of excessive blood loss during surgery, blood transfusion may be required
PATIENT CARE FROM DAY 2:
- encourage initial sips of clear fluid; move on to free fluids, to a soft diet, and finally to a normal diet once each phase is tolerated
- maintain vital signs monitoring – temperature rise following 3rd day of surgery indicates infection
- monitor surgical site for signs of infection; change initial dressing after 48-72hrs following surgery (unless it’s soaked beforehand, in which case should be changed earlier); use dry dressings every alternate day if suture line is clean and dry; removal of sutures is recommended for the 5th day post-op to avoid scarring as much as possible
- monitor daily output from Redivac Drain – remove drain after 48 hours OR when drainage is reduced to a few milliliters in a 24hr period
- keep on administering prescribed analgesics, monitoring their effectiveness and taking necessary measures in case of inefficacy
Redivac Drain
Thyroidectomy Complications
- haemorrhage – assess surgical wound area for drainage, monitor blood pressure and pulse to notice possible hypovolaemic shock earlier on; risk of haemorrhage is at its peak in the first 24 hours post-op
- respiratory distress – assess respiratory rate, rhythm, depth, and strength; prepare suction equipment, oxygen, and tracheostomy set at hand since possible haemorrhage and oedema may result in tracheal compression
- wound infection
- voice hoarseness and aphonia (total vocal cord paralysis due to nerve damage which causes sounds to come out as just whispers) – assess speaking tone and ability; hoarseness, which eventually subsides, happens due to oedema or endotracheal tube used during surgery
- hypocalcemic tetany (low calcium levels in the blood caused by accidental parathyroid glands removal in total thyroidectomy) – this complication may occur in up to 7 days post-op; signs and symptoms include tingling of toes, fingers, and lips; prepare calcium gluconate or calcium chloride in case it’s needed for IV use
Further Related Information
Graves’ Disease
Graves’ disease is an immune system disorder that causes overproduction of thyroid hormones a.k.a. hyperthyroidism. Signs and symptoms of Graves’ disease can be wide ranging.
Hashimoto’s Disease
Hashimoto’s Thyroiditis a.k.a. Hashimoto’s Disease is an autoimmune disease that causes the body to produce antibodies which attack thyroid cells, leading to the under-production of the thyroid hormone. Symptoms of Hashimoto’s Disease may include goitre, lethargy, weight gain, and muscle weakness.
Thyroid Storm
Thyroid storm a.k.a. thyrotoxic crisis is an acute, life-threatening, hypermetabolic state caused by excessive release of thyroid hormones in individuals with thyrotoxicosis. Thyroid storm may be the initial presentation of thyrotoxicosis in undiagnosed paediatric patients, especially neonates.
Myxedema Coma
Myxedema coma, which is considered to be a medical emergency with a high mortality rate, is defined as severe hypothyroidism that causes decreased mental status, hypothermia, and other organs to slow down their functions.
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