I.

INTRODUCTION

During the student nurse exposure to the operating room, the student nurse may encounter common and unique surgical cases. A surgical case of Left thyroid lobectomy was chosen to be further studied by the student nurse because of its ideal contribution to the field of nursing, most especially to the student nurses which may use this as a guide and reference to broaden their knowledge regarding the disease. This is also an opportunity for the student nurse to explore and expand what has been learned in theory and apply it on the actual patient. After the completion of this case study, student nurse will expect a better understanding on the pathophysiology, immediate and appropriate nursing interventions on the said condition. The student nurse will learn more about the patients condition on why it occurred to the said patient. The student nurse would be able to expand the knowledge of the disease and how the said disease disrupts the normal functioning of the body. Student nurse would also have a better understanding on how to prevent the disease. Hopefully, the gained knowledge, attitude and skills will be implemented to future patients with the same condition. Some thyroid glands are nodular because of areas of hyperplasia. No symptoms may arise as a result of this condition, but not uncommonly these nodules slowly increase in size, with some descending into the thorax, where they cause local pressure symptoms. Some nodules become malignant, and some are associated with a hyperthyroid state. Therefore, the patient with may thyroid nodule may eventually require surgery. Thyroid lobectomy is one of the surgical management done for nodular goiter. The half of the thyroid gland that contains the nodule is removed (Smeltzer,et.al,2004).

II. OBJECTIVES Student Nurse-centered General Objectives: After 2 days of student nurse- patient and significant others interaction, the student nurse will be able to gain more knowledge and enhances skills in managing a patient with nodular goiter. Specific Objectives: After 8 hours of student nurse patient interaction, the student nurse will be able to: 1. 2. 3. 4. 5. establish rapport with the client gain information regarding reason of patients admission define nodular goiter determine the possible causes of nodular goiter list down the clinical manifestation of nodular goiter, manifested by the patient 6. 7. 8. 9. 10. 11. review the anatomy and physiology of the organs affected by nodular goiter trace the pathophysiology of nodular goiter compare the classical and clinical manifestations of nodular goiter develop a plan of care necessary in the management of nodular goiter enumerate the risk factors that can cause nodular goiter impart information to the patient and significant others about the prevention and management of nodular goiter

Client-centered General objectives: After 2 days of student nurse-patient and significant others interaction, the patient and significant others will be able to gain information for the management and prevention of appendicitis.

Specific Objectives: After 8 hours of student nurse- patient interaction, the patient will be able to: 1. 2. 3. 4. 5. 6. 7. establish trust and rapport with the student nurse understand her condition/disease process verbalize feeling and concerns about the nodular goiter show willingness to communicate with the student nurse maintain skin integrity as evidenced by absence of laceration of suture verbalize relief of pain as evidenced by a pain scale of 3 to 1 out of 10 maintain the wound that is free from infection as evidenced by absence of discharges 8. show hygienic ways of handling objects like the use of alcohol and proper hand washing 9. show willingness to participate in nursing routines especially with vital signs monitoring 10. modify behaviors to a healthy lifestyle/to improve the health condition

III. NURSING ASSESSMENT 3.1. Personal History 3.1.1. Patients Profile

Name Age Sex Civil Status Religion Date of Admission Room No. Complaints

: Teleron, Jo-ann Covero : 32 years old : female : Married : Roman Catholic : January 31,2011 : SM 23 : Difficulty in swallowing

Impression/Diagnosis: Nodular goiter Physician : Dr. Ed Barcelona

1.2. Family and Individual Information, Social and Health History

Mrs. Teleron, 32 years old, a common housewife who has 3 children and lives in Hibonaon, Ormoc City. 11 years ago, an unusual mass was noticed in her neck. She was bothered with the increase in size and decided to consult a physician of this unusuality. The gradual enlargement of her neck mass was diagnosed with nodular goiter. For 11 years, she hasnt done any intervention for her condition due to financial constraints until a medical mission was held in Ormoc City and she was fortunately chosen for a free surgery. She was then scheduled for Left Thyroid Lobectomy last February 1,2011.

1.3. Level of Growth and Development 1.3.1. Normal Development at Particular Stage Young Adults: 20 to 40 years The age at which a person is considered and adult depends on how adulthood is described in the social context of the individual, and this defining age is changing. The legal age for alcohol consumption outside the home varies among states from 18 to 21 years. Another criterion of adulthood is financial independence, which is also highly variable. Some adolescents support themselves as early as 16 years of age, usually because of family circumstances. By contrast, some adults are financially dependent on their families for many years, for example, during prolonged periods of education (Kozier & Erbs,2008). Adulthood may also be indicated by moving away from home and establishing ones own living arrangements. Yet this independence also varies greatly. Some adolescents leave home because of family problems. In recent years, however, Bommerang Kids have evolved, as young adults have moved back into their parents homes after an initial period of independent living. In 2003,13% of young men(ages 24-34 years) and 7% of young women were living with one or both of their parents(Fields, 2004). The factors contributing to this trend include high housing costs, high divorce rates, high unemployment rates, and the problems resulting from substance abuse and maladaptive behaviors. Some young people who are employed full time receive only minimum wage and are unable to earn enough money to be self-supporting (Kozier & Erbs,2008). Young adults are typically busy people who face many challenges. They are expected to assume new roles at work, in the home, and in the community, and to develop interests, values, and attitudes related to these roles (Kozier & Erbs,2008).

Physical Development People in the early 20s are in their prime physical years. The musculoskeletal system is well developed and coordinated. This is the period when athletic endeavors reach their peak. All other systems of the body (e.g., cardiovascular, visual, auditory, and reproductive) are also functioning at peak efficiency (Kozier & Erbs,2008). Although physical changes are minimal during this stage, weight and muscle mass may change as a result of diet and exercise (Kozier & Erbs,2008).

Psychosocial Development In contrast to the minimal physical changes, psychosocial development of the young adult is great. Young adults face a number of new experiences and changes in life style as they progress toward maturity. Choices must be made about education and employment, about whether to marry or remain single, about starting a home, and about rearing children. Social

responsibilities include forming new friendships and assuming some community activities (Kozier & Erbs,2008). Occupational choice and education are largely inseparable. Education influences occupational opportunities; conversely, an occupation, once chosen, can determine the education needed and sought. Education enhances employment opportunities and usually ensures economic survival. As the role of women has changed, many women now choose to assume active careers and civic roles in society in addition to their roles as mother and/or wife (Kozier & Erbs,2008). Remaining single is becoming the lifestyle of more young adults. Many people choose to remain single, perhaps to pursue on education and then to have the freedom to pursue their chosen vocation. Some unmarried individuals choose to live with another person of the

opposite or same sex and share living agreements and certain expenses. Some people who are gay or lesbian commit themselves legally to a partner in a marriage (Kozier & Erbs,2008).

Cognitive Development Young adults are able to use formal operations, characterized by the ability to think abstractly and employ logic. For example, young adults are able to generate hypotheses about what will happen, give a set of circumstances, and do not have to engage in trial-and-error behavior. Most adults identify strongly with the values and norms of their social group and will act in ways that are consistent with those norms (Kozier & Erbs,2008).

Moral Development Young adults who have mastered the previous stages of Kohlbergs theory of moral development now enter the post-conventional level. At this time, the person is able to separate self from the expectations and rules of others and to define morality in terms of personal principles. When individuals perceive a conflict with societys rules and laws, they judge according to their own principles. For example, a person may intentionally break the law and join a protest group to stop hunters from killing wild animals, believing that the principle of wild life conservation justifies the protest action. This type of reasoning is called principled reasoning (Kozier & Erbs,2008). Gilligan argues that as individuals approach young adulthood, men and women tend to be defining moral problems somewhat differently. Men often use an ethnic of justice and define moral problems in terms of rules and rights. Women, by contrast, often define moral problems in terms of obligation to care and to avoid hurt (Kozier & Erbs,2008).

Spiritual Development According to Fowler, the individual enters the individuating-reflective period somewhat after 18 years of age. During this period, the individual focuses on reality. The religious teaching that the young adult had as a child may now be accepted or redefined (Kozier & Erbs,2008). In this stage, young adults move away from the conforming peer group and clarify boundaries of selfhood and commitment.An encounter with people or groups other than those that provided
8

support in the previous stage often precipitates this shift. Values, beliefs and attitudes change as a result of interacting in more diverse, pluralistic settings, which can be stressful and frightening. Some situations precipitating this shift include new jobs, international travel,

advanced study or education, or new religious affiliations possibly intertwined with achieving intimate relationships choosing careers, and starting families. The challenge during this stage is to establish ones sense of faith and commitment based on personal experience and reflection on meaning in life (Kozier & Erbs,2008).

Sexual Development In young adulthood, many people begin to form intimate relationships with long-term implications. These relationships may take the form of dating, cohabitation, or marriage. Note, however, that some people do not form intimate relationships until late adulthood and that some never form these types of relationships (Kozier & Erbs,2008). Young adults, men and women, are often concerned about normal sexual responses, for both themselves and their partners. In heterosexual relationships, problems may arise because of basic differences in male and female expectations and responses. Gay and lesbian couples often fare better in this respect. Couples need to communicate their needs to one another early in their courtship so that a successful intimate relationship can develop and grow. Young adults should also be aware that because sexual needs and responses may change, each partner should listen and respond to the needs of the others (Kozier & Erbs,2008).

1.3.2. The Ill Person at a Particular Stage Acute illness is often more of an annoyance than of serious consequence. If hospitalized, a young adults motivation to recover and to resume normal activities is strong. Because independence and self-sufficiency are important to young adults, they will not easily accept the dependent sick role. Although chronic illnesses are less common, their occurrence can lead to delayed development, loss of independence, and permanent changes in personal and career goals. Prolonged hospitalization, long term care, or home care increases the young adults feelings of isolation and may disrupt normal development. In relation to the patients actual status during her hospitalization in OSPA-FMC, the patient manifested a little bit of nervousness but still, she is very eager to undergo the said operation.

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2. Diagnostic Results Diagnostic Test Normal Values Patients Result Hematology Hemoglobin 14 17.5 g/dl 13.7 g/dl Decreased; Anemia caused by impaired haemoglobin synthesis (decreased EPO levels), impaired intestinal iron and folate absorption or B12 deficiency Hematocrit 41.5 50.4% 40.8% Decreased; Anemia caused by impaired haemoglobin synthesis (decreased EPO levels), impaired intestinal iron and folate absorption or B12 deficiency RBC WBC MCV MCH MCHC 4.5 5.9 m/uL 4.4 11.0 80 96 fl 27 31 pg 32 36 g/dL 4.86m/uL 7.8 84 fl 28.2pg 33.6 g/dL Normal Normal Normal Normal Normal Significance

PLT

140,000 480,000/uL

310,000/uL

Normal

Neutrophils

40 70%

32.6%

Decreased; may indicate viral infection

Eosinophils Lymphocytes

1 5% 20 40%

2.7% 7.0%

Normal Decreased; Aplastic anemia caused by impaired haemoglobin synthesis (decreased EPO levels), impaired intestinal iron and folate absorption or B12 deficiency

11

Basophils

0 1%

0.3%

Normal

Radiologic findings: >Soft tissue density in the imaged left lower neck region probably of thyroid in origin Cytopathologic Dx: > Cellular findings consistent with colloid goiter, anterior neck mass.

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3. Present profile of functional health patterns

3.1 Health Perception/Health Management

She said that she was very healthy; she never thought that she would have a nodular goiter before she was diagnosed, and she was very depressed when her doctor told her with the result. Due to financial constraints she did not undergo a surgery immediately. For 11 years she developed positive attitude about her condition, until a medical mission was held in Ormoc and made her prayers answered. After the operation the patient was worried for complication, she feel the pain in her incision site.

3.2 Nutritional and metabolic pattern

The patient eats all different kinds of foods. She is not on a diet. She eats whatever her family could afford for meal. She eats 3 times daily (major meals) and snacks in between. After the operation, her physician ordered her diet to be diet as tolerated. Due to her incision, she eats a little bit less than the usual.

3.3 Elimination Pattern

The patient had normal elimination pattern prior to operation. She usually defecates daily and has a normal urination. After the surgery, the patient could freely urinate and defecate. She did not experience any difficulty in urination and defecation.

3.4 Activity/Exercise

Prior to admission the patient states that she does not have any exercise regimen. Her usual activity is the household chores and taking care of her kids. That includes sending and fetching her children to their school. After the operation, she has activity intolerance because of the post operative incision; she feared that it would bleed if she moves too much.
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3.5 Cognitive/Perceptual Pattern

Prior to admission patient already knew there was something unusual to her body thats why she rest most of the time, she doesnt take the condition for granted, upon hospitalization patient was aware when the physician explained everything to her and she ask for the thing she should do.

3.6 Rest/Sleep Pattern

The patient usually sleeps around 11pm or 12 mn and wakes up early because of the chores she does at home. During free time she naps but most of the time she uses her free time to wash the laundry. Presently, she rests almost all of the time of the day and usually sleeps.

3.7 Self-perception Pattern

She feels contented with her family and her 3 children. Shes also happy that her husband has always stood for her and her family. She feels anxious about her condition and her operation.

3.8 Role Relationship Pattern

The patient has a good relationship with her family. She is a good wife and also a good mother. She has also built good relationship with her husbands family. During her hospitalization, her children were taken care of her mother and her sister. Her husband goes to work everyday and visits her at the hospital after work.

3.9 Sexuality-Reproduction Pattern

The patient and his husband is a happy couple. They already have 3 children, as of this time they dont have any plan to have another child.

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3.10 Coping-Stress Tolerance Pattern

On the first day of student nurse-patient interaction, she has difficulty in expressing herself. She was hesitant express herself fully because of her post operative incision. The patient copes with stress through expressing her feelings to her husband, mother, and sister or through her friends so as to God. Her ways of coping problem is by praying and be with God in times whenever she has serious problems. She asks guidance to God and prays that God will protect her always.

3.11 Value-Beliefs system

Mrs. Teleron and her family is a Roman Catholic. Before she was admitted, she usually goes to church every Sunday together with her family. For now as she is in the hospital, she always pray and asks protection and guidance for her family. She is a kind and loving person, she cares for her children and her husband. She has the perseverance and is willing to sacrifice for the sake of her family.

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Physical Assessment (Post- Op.) Body Part Head And Neck Head The head is normocephalic , the size is proportionate to the body, no lesions and scars The hair is short and curly with even hair distribution Pale white without lesions and scars, not swollen No pimple, fair in color and shiny. No lesions noted or found. Symmetrical, color match with the exposed body parts, no involuntary movements in the facial muscle Symmetrically aligned, no involuntary movements Bilateral, even distribution of thick black hairs Even distribution of hair on the lid margins, He skull is smooth, no tenderness palpated Inspection Palpation Percussion Auscultation

Hair

Scalp

No lesions noted Temporal pulse are felt

Forehead

Face

Eyes

Brows

Lashes

Lids: Upper Smooth in texture, no lesions and scars, brown in color Smooth in texture, no lesions and scars, brown in color White with the
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Lower

Sclera

Conjunctiva Cornea Iris Pupil

Muscle Function

Muscle Balance Peripheral Vision Nose

Frontal Sinuses

presence of superficial arteries Pale pink and free of discharges Clear, smooth and reacts with light Round, black in color, no lesions Are equal, round and reacts to light and accommodation Cover test: uncovered eye reacts every time the cover is removed the same as the eye Both eyes are equal in movements The patient can see my finger without moving his head No lacerations and scars symmetrical with face Transilluminate with diffused red appearance

Maxillary sinuses

Patients doesnt complain of pain when palpated Patients doesnt complain of pain when palpated Dry and crack

No pain felt

No pain felt

Mouth Lips

Gums Teeth

Tongue Frenulum

Pinkish and dry, close symmetrically of free lesions Pinkish, no swelling and bleeding Yellow in color and has 28 teeth with 2 decayed molars White taste buds Light pink, no lesions, moistened

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Sublingual Hard palate Soft palate Uvula

Tonsils Ears

External Internal Auditory canal Neck Lymph nodes Trachea Thyroid gland

Soft, pale, pink, no lesions, moistened Pale pink, no lesions, moistened Soft, pale pink no lesions, moistened Centrally located, no lesions, pink in color, hangs freely Not swollen, pink in color, pink Presence of earwax, smooth without lesions Bilateral; symmetric No perforations Able to hear whispered words Presence of incision Non palpable Located in the midline Makes up and down as the patient swallows Chest is symmetric rises and falls during respiration Smooth, good, skin turgor

Thorax

Chest anterior

No tenderness, palpable, no pain felt No tenderness, palpable, no pain felt No scars, no lesions, no swelling

Lungs

Heart

Chest posterior

Symmetrical, spine is vertically aligned, spinal column is

Nonpalpable beats are felt No pain felt

Vibrations on Resonance the right side is the same as he left side Vibrations on RR of 23 bpm the right side is the same as he left side Dull sound Apical pulse (80 bpm)

Vibrations on the right side is similar as

Resonance

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straight Diaphragmatic excursion Chest rises during inhalation and falls when exhaling Fair in color; umbilicus is at midline Non palpable Non palpable Non palpable Bilateral, even distribution of fine hairs, no abrasions, no lesions Bilateral, even distribution of fine hairs, no abrasions, no lesions, no scars Warm extremities

the left side

Abdomen

Liver Spleen Kidney Extremities Upper

BP of 100/70 mmHg

Lower

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4. Pathophysiology 4.1 Normal anatomy and physiology of organ or system affected

The thyroid gland is a butterfly-shaped organ located in the lower neck, anterior to the trachea. It consists of two lateral lobes connected by an isthmus. The gland is about 5cm long and 3cm wide and weighs about 30g. the blood flow to the thyroid is very high(about 5ml/min per gram of thyroid tissue), approximatetly five times the blood flow to the liver. This reflects the high metabolic activity of the thyroid gland. The thyroid gland produces three hormones: thyroxine(T4), triiodothyronine(T3) and calcitonin. T4 and T3 are referred to collectively as thyroid hormone.

T4 and T3 the two separate hormones produced by the thyroid gland that make up thyroid hormone, are amino acids with eh unique property of containing iodine molecules bound to the amino acid structure. T4 contains four iodine atoms in each molecule, and T3 contains three. These hormones are synthesized and stored bound to proteins in the cells of the thyroid gland until needed for release into the bloodstream. About 75% of bound thyroid hormone is bound to thyroxine-binding globulin(TBG); the remaining bound thyroid hormone is bound to thyroid-binding pre-albumin and albumin.

The secretion of T3 and T4 by the thyroid gland is controlled by TSH from the anterior pituitary gland. TSH controls the rate of thyroid hormone release. In turn, the level of thyroid hormone in the blood determines the release of TSH. If the thyroid hormone
20

concentration in the blood decreases, which causes increased output of T3 and T4. This is an example of negative feedback. The term euthyroid refers to thyroid hormone production that is within normal limits.

Thyrotropin-releasing hormone, secreted by the hypothalamus, exerts a modulating influence on the release of TSH from the pituitary. Environmental factors, such as a decrease in temperature, may lead to increased secretion of TRH, resulting in elevated secretion of thyroid hormones (Smeltzer,et. al.,2008).

21

4.2 Schematic Drawing to Show the Pathophysiology of the Disease

Predisposing Factors: Family history Gender Race age

Precipitating Factors: y y y Stress Iodine deficiency Side effects of psychosocial therapy pregnancy

y y y y

Nodular Goiter

Signs and Symptoms: y y y y y y y y y Sensory deficit difficulty breathing A tight feeling in your throat gross bulging of anterior neck mass upon palpation of neck Coughing Enlargement of your thyroid gland, resulting in swelling of your neck Behavioral changes Difficulty in swallowing

Medical mgmt: Radiodine therapy Synthetic thyroid stimulating hormone

Nursing mgmt: Vital signs monitoring Check and change dressing frequently 22

Surgical mgmt: thyroidectomy

4.3 Disease process and its effects on different organ/system 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 multiple nodules (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 (see Images 1-2). 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. The thyroid gland is controlled by thyrotropin (TSH), secreted from the pituitary gland, which, in turn, is influenced by the thyrotropin-releasing 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. 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.

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4.4 Classical and clinical symptoms of the disease Classical Symptoms Clinical Symptoms Enlarged thyroid gland (swollen neck) manifested Constant demand to produce thyroid hormone causes the thyroid gland to enlarge Tightness in throat manifested Due to enlarged thyroid gland; increase in pressure Coughing manifested Due to tightness in throat, with thyroid gland growing Difficulty in swallowing manifested
Constant demand to produce thyroid hormone causes the thyroid gland to enlarge. It then takes up more than its allotted space, infringing on the tissue around it. This causes a deep, hoarse voice and difficulty swallowing

Rationale

source: http://www.livestrong.com/article/108005complete-list-hypothyroidsymptoms/#ixzz1JUtsJPJF

Dysphagia

manifested

Constant demand to produce thyroid hormone causes the thyroid gland to enlarge. It then takes up more than its allotted space, infringing on the tissue around it. This causes a deep, hoarse voice and difficulty swallowing

source: http://www.livestrong.com/article/108005complete-list-hypothyroidsymptoms/#ixzz1JUtsJPJF

24

Hoarse voice

manifested

Vocal cord weakness or paralysis may be caused by swelling, stretching, or injury to the recurrent laryngeal nerve which passes very close to the thyroid gland. Temporary hoarseness may result

Slow speech

manifested

Constant demand to produce thyroid hormone causes the thyroid gland to enlarge. It then takes up more than its allotted space, infringing on the tissue around it. This causes a deep, hoarse voice and difficulty swallowing. Speech slows and slurs as the tongue thickens.

source: http://www.livestrong.com/article/108005complete-list-hypothyroidsymptoms/#ixzz1JUulCxNz

Fatigue

manifested

Muscles weaken and become tender and stiff or cramp painfully. Fluid leaks into joints, causing localized pain. Less commonly, the neck feels painful or stiff with limited range of motion.

source:

http://www.livestrong.com/article/108005complete-list-hypothyroidsymptoms/#ixzz1JUu5hrJ7

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IV. Nursing intervention 1. CARE GUIDE: NURSING CARE FOR A POST THYROIDECTOMY The patient is moved and turned carefully so as to provide support and avoid tension on the sutures. The patient is positioned in semi-Fowlers with the head elevated and supported by pillows. Narcotics, pain relievers are administered as prescribed by the physician. Intravenous fluid was also administered during the immediate post-operative periods; Water maybe given by mouth as soon as nausea subsides. Cold fluids and ice chips may be given. Surgical dressing should be checked periodically and reinforced when necessary. Observe for signs of bleeding: check sides and back of the neck as well as the anterior dressing. Monitor pulse and blood pressure for any indications of internal bleeding. Be alert for sensation of pressure or fullness at the incision site such symptoms may indicate hemorrhage subcutaneously and should be reported. Keep a tracheostomy set on patients bed side at all times. Advise patient to talk a little as possible note any voice changes that might indicate injury on the recurrent laryngeal nerve which lies just behind the thyroid next trachea. A well balanced, high caloric diet is prescribed to promote weight gain. Keep materials needed within easy reach like; paper, tissues, water, pitcher, glass and emesis basin so that t patient the will not need to turn his head in search of the item.

26

Patients name: Teleron, Jo-ann Room No: SM23 Chief complaints: difficulty in swallowing
Needs/cues/ problems Nursing Diagnosis Scientific Basis Objectives of Care Intervention

Age: 32

Rationale

Evaluation

Objective cues: >facial gimace >pain scale of 3 out of 10 >slow, guarded movements >OLDCART O-intermittent pain L-on anterior neck D-1 to 2 mins C-gnawing pain A-excessive mobilization R-repositining and deep breathing T-Advil

Alteration in comfort: Acute pain related to surgical incision secondary to left thyroid lobectomy

Most patients experience some pain after a surgical procedure. The degree and severity of post operative pain and the patients tolerance for pain depends on the incision site, the nature of the surgical procedure, the extent of surgical trauma, the type of anesthetic agent and how the agent was administered. When pain impulses are transmitted, muscle tension increases, as

After 8 hours of holistic nursing care, the patient will be able to verbalize relief of pain.

1. accept the patients description of pain

-pain is subjective experience and cannot be felt by others

After 8 hours of holistic nursing care, the patient was able to

2. provide comfort measures

-to promote nonpharmacolo gical pain management

verbalize relief of pain.

3.instruct/encour age use of relaxation techniques

-to distract attention and reduce tension

4. encourage deep breathing technique

- to distract attention and reduce tension

Subj cues: Sakit pa gamay ako samadas verbalized by the patient

5. assist client in activities of daily living

-to assist clients needs

27

does local vasoconstriction . The ischemia in the affected area causes further stimulation of pain receptors. 7. administer medication as ordered by the physician Brunner and Suddarth, MedicalSurgical Nursing, pp.446 -to relieve acute pain 6. encourage adequate rest periods -to prevent fatigue

Source: (Nurses pocket guide by Doenges, et.al., 2008)

Source: (Nurses pocket guide by Doenges, et.al., 2008)

28

Needs/cues/ problems

Nursing Diagnosis

Scientific Basis

Objectives of Care

Intervention

Rationale

Evaluation

Physiolo-gic deficit: wound

Impaired skin integrity: post

An incision or wound is a break in the continuity of the skin. The tissues are remarkably resistive to injury. When skin is damaged, it can repair itself but may take a long period of time. Infection may occur because first line barriers are

After 8 hours of nursing care the patient will be able to verbalize feeling of comfort.

1. inspect wound on a daily basis

- monitor progress of wound healing

After 8 hours of nursing care the

Objective cues:
- recent operation -presence of bandage on neck - bandage a little bloody - neck wrapped firmly to prevent unnecessary mobilization

operative wound related to post operative procedure

2.keep the area clean/dry,carefully dress wounds, support incision

- to assist bodys natural process of repair

patient was able to verbalize feeling of comfort.

3. use appropriate barrier dressings and skin-protective agents for open/draining wounds

-to protect the wound and surrounding tissues

4. ecourage early ambulation/mobilization

- promotes circulation and reduces risks associated with immobility

Subjective cues:

destroyed and pathogens gain an

kuyawan ko day, tingale dugay ni maayo ako samad as verbalized by the patient

entrance. Scars are marks of a wound already healed. Fundamentals of nursing by Wolff p 636 5. Provide optimum nutrition and increase protein intake - to provide a positive nitrogen balance to aid in skin/tissue healing and to maintain general good health

29

6. encourage adequate rest periods

- prevent fatigue

7. administer medications as prescribed by the physician Source: (Nurses pocket guide by Doenges, et.al., 2008)

-fastens wound healing

Source: (Nurses pocket guide by Doenges, et.al., 2008)

30

Needs/cues/ problems Physiologic deficit: risk for infection

Nursing Diagnosis Risk for Infection: presence of wound related to post

Scientific Basis Infection may occur because first line barriers are destroyed and pathogens gain an entrance. Scars are marks of a wound already healed.

Objectives of Care After 8 hours of holistic nursing care patient will be able to prevent infection as evidenced by absence of signs and symptoms of infection.

Intervention

Rationale

Evaluation

1. monitor changes in color and discharges of wound

- to note infection

After 8 hours of holistic nursing care patient was able to prevent

Objective cues:
- recent operation -presence of bandage on neck - bandage a little bloody - neck wrapped firmly to prevent unnecessary mobilization

operative procedure

2. instruct patient not to touch the wound

- minimizes contamination

infection as evidenced by absence of signs and symptoms of infection.

3. encourage regular handwashing

- to reduce transfer of bacteria

Fundamentals of nursing by Wolff p 636 4. promote a clean and well ventilated environment - to have an environment conducive to healing

5. provide protective wound barrier

- to protect wound from external injury

6. apply aseptic wound care

- fasten wound healing

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7. administer antibacterial creams as ordered by the physician

- kills bacteria

Source: (Nurses pocket guide by Doenges, et.al., 2008)

Source: (Nurses pocket guide by Doenges, et.al., 2008)

32

Drug/dosage/ route/ frequency

Classification/ mechanism of action

Indication/ contraindication/ side effects

Principle of care

Treatment

Evaluation

Advil

Nonsteroidal

Indications: - acute pain, primary dysmenorrhea, osteoarthritis,

>Watch for signs and symptoms of overt and occult bleeding >Monitor patient for

>tell patient to report history of allergic reactions. >Instruct patient to promptly

Medicatio ns given are followed and consumed with the right time, dosage and expected effects of medicatio ns obtained.

1 cap q 6hours antiPRN for pain inflammatory drug

Mechanism of action: Thought to inhibit prostaglandin synthesis

rheumatoid arthritis

Contraindications: - hypersensitivity to drugs; severe hepatic impairment; women in the third trimester of pregnancy; history of ulcer or GI bleeding

hypertension, report signs edema or heart failure >Drug may be hepatotoxic; watch for signs and symptoms of liver toxicity >Before and symptoms of GI bleeding such as blood in stools, vomit, urine. >Report immediately if rash, unexplained weight gain occur.

Side Effects: - dizziness, headache, peripheral edema; pharyngitis; abdominal pain,

starting drug therapy, rehydrate dehydrated patients

diarrhea, dyspepsia, back pain; rash

>Drug can be >Instruct given without regard to meals, but food may decrease GI upset - Watch carefully for GI bleeding especially those with history of ulcer patient take to drugs

with food if stomach upsets occur >Monitor vital signs of the patient as well as I/O. - Encourage ambulation

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SOAPIE CHARTING 7-3 shift S- Sakit-sakit pa gamay ako samad O- Seen patient lying on bed, awake, conscious and coherent without IVF. Complains of intermittent pain, duration of pain is 1-2 mins. Characterized by gnawing pain. Aggraviated by excessive mobilization, relieved by repositioning and deep breathing and treated by Advil as ordered. With pain scale of 3 in which 10 is the highest and 0 is the lowest. With baseline vital signs of T-34.8C , P-73 bpm, R-21cpm, BP- 120/90 mmHG A- Alteration in comfort: Acute pain related to surgical incision secondary to thyroid lobectomy P- To reduce pain felt from 3 to 1 I- monitored vital signs and input and output - encouraged verbalization of pain -encouraged rest periods - instructed patient on deep breathing - assisted in repositioning - encouraged diversional techniques such as socialization and listening to music - encouraged increase nutritional intake such as protein for faster healing - administered Tramadol as ordered E- Patient verbalizes a decrease of pain as evidenced by a pain scale of 1 from 3

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SOAPIE CHARTING 7-3 shift S- Kuyawan man ko ani ako samad as verbalized by the patient O- Seen patient on a supine position awake, conscious, and coherent without IVF. Baseline vital sign of T-36.8C , P- 76bpm, R-19cpm, BP- 110/70mmHg A- Anxiety related to surgical incision secondary to thyroid lobectomy P- To alleviate anxiety I- identify clients perception of the threat represented by the situation -assist the client to identify precipitating factors and new methods of coping - identify actions/activities for the client - provide accurate information about her situation - review dos and donts to prevent complications of her surgery - be available to client for listening and talking - assist client to develop self- awareness E- patients anxiety level has decreased

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4.2.9 Health Teaching Plan

Objective

Content

Methodology

Time Allotted

Resources

Evaluation

General Objectives:

At the end of 2 days in providing a holistic nursing care, the patient and the significant others will be able to gain knowledge, develop beginning skills and positive attitude on the care of patient with postthyroidectomy state.

Specific objectives:

Specific objectives:

After 45 minutes of student nurse37

After 45 minutes of

patient and significant others interaction, the patient and significant others will be able to:

nurse patient interacton, the patient and significant others was able to:

a. identify the purpose of wound dressing

Purpose of wound dressing: a.to prevent hemorrhage

Lecture

10 minutes

Fundamental s of Nursing, 7th ed. by: Kozier, Barbara

a. identify the purpose of wound dressing

b.to splint or immobilize the wound site and thereby facilitate healing and prevent injury

pp.874

c.to absorb drainage

d.to provide or maintain high humidity of the wound

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b. enumerate the

Phases of

Informal discussion

10 minutes

MedicalSurgical Nursing by: Black, J. pp.398

b. enumerate the different phases of wound dressing

different phases of wound dressing wound dressing a.vascular response phase b.inflammation c.proliferation or resulotion d.maturation or reconstruction

c. state the

Sequentials

Informal discussion

10 minutes

Fundamentals of Nursing, 7th ed. by: Kozier, Barbara pp.924

c. state the sequential signs of healing

sequential signs of signs of healing: healing a.absence of bleeding and the appearance of a clot binding the wound edges

b.inflammation at the wound edges for 1 to 3 days

c.reduction in inflammation when the clot diminishes

d.scar formation

e.diminished
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scar size

d. demonstrate

Basic procedure

demonstration and return demonstration

15 minutes

Fundamentals of Nursing, 7th ed. by: Kozier, Barbara pp.869

d.demonstrate the beginning skills in wound care

beginning skills in of Wound Care: wound care 1.cleanse in a direction from the least contaminated area such as from the wound incision to the surrounding skin or from an isolated drain site to the surrounding skin 2.use gentle friction when applying solutions locally to the skin 3.when irrigating, allow the solution to flow from the least to the most contaminated area

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e. shows interest to the discussed health teaching plan by asking related question

e. show interest to the discussed health teaching plan

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V. EVALUATION AND RECOMMENDATION The patient has no fever or signs of infection and is able to do wound care with aseptic technique. The patient is able to identify signs of infection and could cite the importance of adequate iodine intake. The prognosis is good because the patient has a good response to surgical and medical treatment. The patient has been able to follow the prescribed medical regimen. So far the patient doesnt have any complications in 3 days of care. The patient is able to ambulate with assistance at first but manage to ambulate later all by herself. Patient who had undergone thyroidectomy needs to know that recovery at home takes 2-3 weeks. The patient is instructed to do follow-up.

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VI. EVALUTAION AND IMPLICATION A. NURSING PRACTICE This case study on thyroidectomy will enable the student nurse to provide appropriate care to patients with said or similar cases. This guide will enable not only the student nurse, but all members to the healthcare team to improve care for all patients. Through this case study, the student nurse has improved and gained more knowledge, proper attitude, and has rendered holistic nursing care.

B. NURSING EDUCATION This case study called serve as a guide to nursing educators in teaching student nurses appropriate care to post thyroidectomy patients. Furthermore, this case study also offers adequate knowledge about toxic goiter as well as corresponding treatment given pre operatively or post operatively.

C. NURSING RESEARCH This case study is directed towards broadening the scope and extent of facts related to thyroidectomy. It is also useful and handy to nursing research for important facts and details (i.e. related literature). This will also serve as supplement to the body of knowledge that already exists regarding the said case.

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D. BIBLIOGRAPHY Black, Joyce M., et al. Medical-Surgical Nursing: Clinical Management for Positive Outcomes, 7th ed., W.B. Saunders Company, Philadelphia PA 2003

Black, Joyce M., et al. Medical-Surgical Nursing: Clinical Management for Positive Outcomes, 6th ed., W.B. Saunders Company, Philadelphia PA 2001

Smeltzer, Suzanne & Bare, Brenda: Medical-Surgical Nursing 11th Edition, Lippincott Williams and Wilkins, 2004. Kozier, Barbara, et al. Fundamentals of Nursing: Concepts, Process and Practice, Updated 5th edition. Philippines: Addison Wesley Longman, Inc. 1998

Lippincott Williams and Wilkins, Inc., 227 East Washington Square, Philadelphia. PA, 9106; 2004. Lippincott, Williams and Wilkins: Nursing Drug Handbook 2003, 23rd Edition, Idaho, Springhouse 2002

Marrilynn E. Doenges, Mary Frances Moorehouse, & Alice Geissler-Murr: Nursing Care Plans, CA, FA Davis Company 2008

Microsoft Encarta Encyclopedia 2002. 1993-2001 Microsoft Corporation

http://www.livestrong.com/article/108005-complete-list-hypothyroid-symptoms/#ixzz1JUtsJPJF

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