thyroidectomynursingstudentssnow-090304072631-phpapp02.pptx

Nursing College

1. Thyroidectomy BY: Dr. Raafat Al- Awadhi

2. Thyroid gland surgical anatomy Location : Thyroid is situated in the neck in relation to 2 nd 3 rd and 4 th tracheal rings Two lobes : Right and left, joined by an ‘isthmus’ Arteries : Supplied by superior and inferior thyroid arteries Veins : Drained by superior, middle and inferior thyroid veins

3. Thyroidectomy – Indications Goitre (any non-neoplastic swelling of the thyroid gland is classified as a goitre) Single swelling (Solitary nodular goitre) Multiple swellings (Multi-nodular goitre) Carcinoma Follicular carcinoma Papillary carcinoma Rare varieties

4. Thyroidectomy – Types Hemi-thyroidectomy : Removal of half of thyroid gland (Hemi = Half) Lobectomy : Removal of either right of left lobe of thyroid gland Both these are done in solitary goitre Total thyroidectomy : Removal of whole thyroid gland This is done in cases of malignancy

5. Thyroidectomy types – cont’d Subtotal thyroidectomy : Removal of a little less than total; done in multi-nodular goitre Near-total thyroidectomy : Almost same as total, but a little thyroid tissue around one parathyroid gland is preserved Isthmusectomy : Dividing the isthmus

6. Pre-operative investigations Full blood count (CBC) Serum Urea, Electrolytes, Creatinine Thyroid Profile: T3, T4, TSH Ultrasound thyroid gland Radio-iodine ( 99m Tc / 131 I) scan of thyroid

7. Pre-operative investigations X-ray neck X-ray chest (Both AP / lateral) Fine Needle Aspiration Cytology (FNAC) of thyroid nodule, if any palpable Indirect laryngoscopy to assess pre-operative function of both vocal cords.

8. Pre operative care Administer ordered antithyroid medications and iodine preparations, and monitor their effects. These drugs promote a euthyroid state. Iodine preparations are given to the client before the surgery to decrease vascularity of the gland and there by decreasing the risk of hemorrhage

9. Pre operative care Teach the patient to support the neck by placing both hands behind the neck when sitting up in bed, while moving about, and while coughing. Placing the hands behind the neck provides support for the suture line

10. Post-operative management Patient is kept NPO/NBM (Nil Per Oral / Nil By Mouth) on the day of surgery. Supplemental IV fluid usually given on day of surgery; usually between 2.5 to 3 litres. Compatible blood may be transfused if there had been excessive blood loss during surgery.

11. Post-operative management Oral intake initiated from next day, starting with ‘clear fluids’, going on to ‘free fluids’, then to soft diet and finally to normal diet Analgesics essential in post-operative period; there is invariably severe pain during first night. Antibiotics avoided in clean elective surgeries

12. Post-operative management Daily vital (PTR, BP) chart is maintained. Rise of temperature after 3 rd post-operative day indicates infection. This may require inspection of suture line. Careful note is made of daily output from Redivac drain. Drain removed after 48 hours or when drainage falls to few ml during last 24-hour period, whichever is earlier.

13. Post-operative management Initial dressing changed after 48-72 hours (to inspect for infection of suture line), Unless there is soakage, when it should be removed earlier. Dry dressings sufficient every alternate day, if suture line is clean and dry. Sutures usually removed on 5 th post-operative day. This gives minimum scarring.

14. Thyroidectomy – Possible complications Hemorrhage Respiratory distress or stridor Hoarseness of voice Total vocal cord paralysis – aphonia Hypocalcemic tetany (due to accidental removal of parathyroid glands during total thyroidectomy) Wound infection: This may manifest after 48 hours of surgery

15. Parathyrodectomy nursing care

16. SURGICAL MANAGEMENT: PRE-OPERATIVE CARE -Check doctor’s order. -Identify the patient. -Explain the procedure to the patient. -Prepare the patient for surgery.

17. INTRA-OPERATIVE CARE Assess the condition of the patient Vital signs monitoring Assesses the amount of blood loss Ensures that the surgical team maintains sterile technique and a sterile field Anticipates the client's and surgical team's needs, pro­ viding supplies and equipment as needed Communicates information regarding the client's status with family members during long and unique procedures Documents care, events, interventions, and findings

18. POST-OPERATIVE CARE -A irway management -Monitor serum calcium -Assess symptoms- anxiety, hyperventilation, Chvostek’s and Trousseau’s signs, paresthesias . -Administer oral calcium carbonate 1 g per oral q6h, or IV calcium gluconate for severe hypocalcemia (<7.0) -Vitamin D supplementation -Watch out for bleeding and infection

19. NURSING MANAGEMENT: Intake and output Observe for signs of urinary calculi, flank pain and decreasing urine output Monitor serum potassium, calcium, phosphate and magnesium levels. Encourage a large volume of fluid. Encourage the patient to regular exercise. Assess the patient with walking, keep bed at its lowest position and raised side rails. Lift immobilized patient carefully to minimize bone stress. Provide rest periods and monitor fatigue

20. Adrenalectomy Nursing care

21. Surgical Management The definitive treatment of pheochromocytoma is surgical removal of the tumor, usually with adrenalectomy. Bilateral adrenalectomy may be necessary if tumors are present in both adrenal glands.

22. Surgical Management……. Manipulation of the tumor during surgical excision may cause release of stored epinephrine and norepinephrine, with marked increases in blood pressure and changes in heart rate. Therefore, use of sodium nitroprusside (Nipride) and alpha-adrenergic blocking agents may be required during and after surgery

23. Surgical Management……. Corticosteroid replacement is required if bilateral adrenalectomy or for the first few days or weeks after removal of a single adrenal gland. IV administration of corticosteroids (methylprednisolone sodium succinate begin on the evening before surgery and continue during the early postoperative period to prevent adrenal insufficiency.

24. Surgical Management……. Oral preparations of corticosteroids (prednisone) are prescribed after the acute stress of surgery diminishes. Hypotension and hypoglycemia may occur because of the sudden withdrawal of excessive amounts of catecholamines. Therefore, careful attention is directed toward monitoring and treating these changes.

25. Surgical Management……. Blood pressure is expected to return to normal with treatment; one third of patients continue to be hypertensive after surgery if not all pheochromocytoma tissue was removed, pheochromocytoma recurs, or if the blood vessels were damaged by severe and prolonged hypertension.

26. Surgical Management……. Several days after surgery, urine and plasma levels of catecholamines and their metabolites are measured to determine whether the surgery was successful.

27. Complications of Pheochromocytoma Cardiac : CHF, MI, arrhythmias, orthostasis from volume contraction Metabolic : Increased metabolic rate, weight loss Endocrine : Hyperglycemia from suppression of insulin production by the excessive catecholamines

28. Nursing processes Assessment vital signs Blood pressure Hypertension (before and during surgery) Hypotension (after surgery) Blood sugar Hypoglycemia (after surgery) Hyperglycemia (before and during surgery)

29. Nursing asst……. hemodynamic parameters fluid and electrolyte status—including intake and urinary output and urine catecholamine levels. Assess the patient for bleeding and infection Assess the patient for pain

30. Possible Nursing DX Anxiety related to potential seriousness and Sudden onset sign and symptoms of the problem. Ineffective renal tissue perfusion related to adverse effects of high blood pressure in renal vascular system. Risk for injury related to potential for hypertensive crisis.

31. Nursing Management preoperative Patient preparation includes control of blood pressure and blood volumes; usually this is carried out over 4 to 7 days. Nifedipine and nicardipine may be used safely without causing undue hypotension.

32. preoperative…….. the nurse informs the patient about the importance of follow-up monitoring to ensure that pheochromocytoma does not recur undetected Several IV lines are inserted for administration of fluids and medications.

33. postoperative phase nursing care The patient is monitored for several days in the intensive care unit with special attention given to ECG changes, arterial pressures, fluid and electrolyte balance, and blood glucose levels.

34. postoperative phase nursing care…….. Teaching Patients Self-Care After adrenalectomy, use of corticosteroids may be needed. Therefore, the nurse instructs the patient about their purpose, the medication schedule, and the risks of skipping doses or stopping their administration abruptly.

35. postoperative phase nursing care…….. It is important to teach the patient and family how to measure the patient's blood pressure and when to notify the health care provider about changes in blood pressure. provides verbal and written instructions about the procedure for collecting 24-hour urine specimens to monitor urine catecholamine levels.

36. postoperative phase nursing care…….. Continuing Care A follow-up visit from a home care nurse may be indicated to assess the patient's postoperative recovery, surgical incision, and compliance with the medication schedule. This may help reinforce previous teaching about management and monitoring.

37. postoperative phase nursing care…….. nurse also obtains BP measurements and assists the patient in preventing problems that comes from long-term use of corticosteroids. Because of the risk for recurrence of hypertension , periodic checkups are required, for young patients and families history of pheochromocytoma. The patient should have appointments to observe urine levels of catecholamine.