THYROIDECTOMY

Thyroidectomy, although rare, may be performed for patients with thyroid cancer, hyperthyroidism, and drug reactions
to antithyroid agents; pregnant women who cannot be managed with drugs; patients who do not want radiation therapy;
and patients with large goiters who do not respond to antithyroid drugs. The two types of thyroidectomy include:
Total thyroidectomy: The gland is removed completely. Usually done in the case of malignancy. Thyroid replacement
therapy is necessary for life.
Subtotal thyroidectomy: Up to five-sixths of the gland is removed when antithyroid drugs do not correct
hyperthyroidism or RAI therapy is contraindicated.

CARE SETTING
Inpatient acute surgical unit

RELATED CONCERNS
Cancer
Hyperthyroidism (thyrotoxicosis, Graves’ disease)
Psychosocial aspects of care
Surgical intervention

Patient Assessment Database

Refer to CP: Hyperthyroidisim (Thyrotoxicosis, Graves’ Disease), for assessment
information.
Discharge plan DRG projected mean length of inpatient stay: 2.4 days
considerations:
Refer to section at end of plan for postdischarge considerations.

NURSING PRIORITIES
1. Reverse/manage hyperthyroid state preoperatively.
2. Prevent complications.
3. Relieve pain.
4. Provide information about surgical procedure, prognosis, and treatment needs.

DISCHARGE GOALS
1. Complications prevented/minimized.
2. Pain alleviated.
3. Surgical procedure/prognosis and therapeutic regimen understood.
4. Plan in place to meet needs after discharge.

NURSING DIAGNOSIS: Airway Clearance, risk for ineffective

Risk factors may include
Tracheal obstruction; swelling, bleeding, laryngeal spasms
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Respiratory Status: Airway Patency (NOC)
Maintain patent airway, with aspiration prevented.
ACTIONS/INTERVENTIONS RATIONALE
Airway Management (NIC)

Independent
Monitor respiratory rate, depth, and work of breathing. Respirations may remain somewhat rapid, but
development of respiratory distress is indicative of
tracheal compression from edema or hemorrhage.

Auscultate breath sounds, noting presence of rhonchi. Rhonchi may indicate airway obstruction/accumulation of
copious thick secretions.

Assess for dyspnea, stridor, “crowing,” and cyanosis. Indicators of tracheal obstruction/laryngeal spasm,
Note quality of voice. requiring prompt evaluation and intervention.

Caution patient to avoid bending neck; support head with Reduces likelihood of tension on surgical wound.
pillows.

Assist with repositioning, deep breathing exercises, Maintains clear airway and ventilation. Although
and/or coughing as indicated. “routine” coughing is not encouraged and may be painful,
it may be needed to clear secretions.

Suction mouth and trachea as indicated, noting color and Edema/pain may impair patient’s ability to clear own
characteristics of sputum. airway.

Check dressing frequently, especially posterior portion. If bleeding occurs, anterior dressing may appear dry
because blood pools dependently.

Investigate reports of difficulty swallowing, drooling of May indicate edema/sequestered bleeding in tissues
oral secretions. surrounding operative site.

Keep tracheostomy tray at bedside. Compromised airway may create a life-threatening

situation requiring emergency procedure.
Collaborative

Provide steam inhalation; humidify room air. Reduces discomfort of sore throat and tissue edema and
promotes expectoration of secretions.

Assist with/prepare for procedures, e.g.:

Tracheostomy; May be necessary to maintain airway if obstructed by
edema of glottis or hemorrhage.

Return to surgery. May require ligation of bleeding vessels.

NURSING DIAGNOSIS: Communication, impaired verbal

May be related to
Vocal cord injury/laryngeal nerve damage
Tissue edema; pain/discomfort
Possibly evidenced by
Impaired articulation, does not/cannot speak; use of nonverbal cues such as gestures
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Communication Ability (NOC)
Establish method of communication in which needs can be understood.
ACTIONS/INTERVENTIONS RATIONALE
Communication Enhancement: Speech Deficit
(NIC)

Independent
Assess speech periodically; encourage voice rest. Hoarseness and sore throat may occur secondary to tissue
edema or surgical damage to recurrent laryngeal nerve
and may last several days. Permanent nerve damage can
occur (rare) that causes paralysis of vocal cords and/or
compression of the trachea.

Keep communication simple; ask yes/no questions. Reduces demand for response; promotes voice rest.

Provide alternative methods of communication as Facilitates expression of needs.

appropriate, e.g., slate board, letter/picture board. Place
IV line to minimize interference with written
communication.

Anticipate needs as possible. Visit patient frequently. Reduces anxiety and patient’s need to communicate.

Post notice of patient’s voice limitations at central station Prevents patient from straining voice to make needs
and answer call bell promptly. known/summon assistance.

Maintain quiet environment. Enhances ability to hear whispered communication and

reduces necessity for patient to raise/strain voice to be
heard.

NURSING DIAGNOSIS: Injury, risk for [tetany]

Risk factors may include
Chemical imbalance: excessive CNS stimulation
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Safety Status: Physical Injury (NOC)
Demonstrate absence of injury with complications minimized/controlled.

ACTIONS/INTERVENTIONS RATIONALE
Surveillance (NIC)

Independent
Monitor vital signs noting elevating temperature, Manipulation of gland during subtotal thyroidectomy may
tachycardia (140–200 beats/min), dysrhythmias, result in increased hormone release, causing thyroid
respiratory distress, cyanosis (developing pulmonary storm.
edema/HF).
ACTIONS/INTERVENTIONS RATIONALE
Surveillance (NIC)

Independent
Evaluate reflexes periodically. Observe for Hypocalcemia with tetany (usually transient) may occur
neuromuscular irritability, e.g., twitching, numbness, 1–7 days postoperatively and indicates
paresthesias, positive Chvostek’s and Trousseau’s signs, hypoparathyroidism, which can occur as a result of
seizure activity. inadvertent trauma to/partial-to-total removal of
parathyroid gland(s) during surgery.

Keep side rails raised/padded, bed in low position, and Reduces potential for injury if seizures occur. (Refer to
airway at bedside. Avoid use of restraints. CP: Seizure Disorders, ND: Trauma/Suffocation, risk
for.)

Collaborative

Monitor serum calcium levels. Patients with levels less than 7.5 mg/100 mL generally
require replacement therapy.

Administer medications as indicated:

Calcium (gluconate, lactate); Corrects deficiency, which is usually temporary but may
be permanent. Note: Use with caution in patients taking
digitalis because calcium increases cardiac sensitivity to
digitalis, potentiating risk of toxicity.

Phosphate-binding agents; Helpful in lowering elevated phosphorus levels associated

with hypocalcemia.

Sedatives; Promotes rest, reducing exogenous stimulation.

Anticonvulsants. Controls seizure activity until corrective therapy is

successful.

NURSING DIAGNOSIS: Pain, acute

May be related to
Surgical interruption/manipulation of tissues/muscles
Postoperative edema
Possibly evidenced by
Reports of pain
Narrowed focus; guarding behavior; restlessness
Autonomic responses
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Pain Control (NOC)
Report pain is relieved/controlled.
Demonstrate use of relaxation skills and diversional activities appropriate to situation.
ACTIONS/INTERVENTIONS RATIONALE
Pain Management (NIC)

Independent
Assess verbal/nonverbal reports of pain, noting location, Useful in evaluating pain, choice of interventions,
intensity (0–10 scale), and duration. effectiveness of therapy.

Place in semi-Fowler’s position and support head/neck Prevents hyperextension of the neck and protects integrity
with sandbags or small pillows. of the suture line.

Maintain head/neck in neutral position and support during Prevents stress on the suture line and reduces muscle
position changes. Instruct patient to use hands to support tension.
neck during movement and to avoid hyperextension of
neck.

Keep call bell and frequently needed items within easy Limits stretching, muscle strain in operative area.
reach.

Give cool liquids or soft foods, such as ice cream or Although both may be soothing to sore throat, soft foods
popsicles. may be tolerated better than liquids if patient experiences
difficulty swallowing.

Encourage patient to use relaxation techniques, e.g., Helps refocus attention and assists patient to manage
guided imagery, soft music, progressive relaxation. pain/discomfort more effectively.

Collaborative

Administer analgesics and/or analgesic throat Reduces pain and discomfort; enhances rest.
sprays/lozenges as necessary.

Provide ice collar if indicated. Reduces tissue edema and decreases perception of pain.

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, prognosis,

treatment, self-care, and discharge needs
May be related to
Lack of exposure/recall, misinterpretation
Unfamiliarity with information resources
Possibly evidenced by
Questions; request for information; statement of misconception
Inaccurate follow-through of instructions/development of preventable complications
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Knowledge: Disease Process (NOC)
Verbalize understanding of surgical procedure and prognosis and potential complications.
Knowledge: Treatment Regimen (NOC)
Verbalize understanding of therapeutic needs.
Participate in treatment regimen.
Initiate necessary lifestyle changes.
ACTIONS/INTERVENTIONS RATIONALE
Teaching; Disease Process (NIC)

Independent
Review surgical procedure and future expectations. Provides knowledge base from which patient can make
informed decisions.

Discuss need for well-balanced, nutritious diet and, when Promotes healing and helps patient regain/maintain
appropriate, inclusion of iodized salt. appropriate weight. Use of iodized salt is often sufficient
to meet iodine needs unless salt is restricted for other
healthcare problems, e.g., HF.

Recommend avoidance of goitrogenic foods, e.g., Contraindicated after partial thyroidectomy because these
excessive ingestion of seafood, soybeans, turnips. foods inhibit thyroid activity.

Identify foods high in calcium (e.g., dairy products) and Maximizes supply and absorption of calcium if
vitamin D (e.g., fortified dairy products, egg yolks, liver). parathyroid function is impaired.

Encourage progressive general exercise program. In patients with subtotal thyroidectomy, exercise can
stimulate the thyroid gland and production of hormones,
facilitating recovery of general well-being.

Review postoperative exercises to be instituted after Regular ROM exercises strengthen neck muscles,
incision heals, e.g., flexion, extension, rotation, and enhance circulation and healing process.
lateral movement of head and neck.

Review importance of rest and relaxation, avoiding Effects of hyperthyroidism usually subside completely,
stressful situations and emotional outbursts. but it takes some time for the body to recover.

Instruct in incisional care, e.g., cleansing, dressing Enables patient to provide competent self-care.
application.

Recommend the use of loose-fitting scarves to cover scar, Covers the incision without aggravating healing or
avoiding the use of jewelry. precipitating infections of suture line.

Apply cold cream after sutures have been removed. Softens tissues and may help minimize scarring.

Discuss possibility of change in voice. Alteration in vocal cord function may cause changes in
pitch and quality of voice, which may be temporary or
permanent.

Review drug therapy and the necessity of continuing even If thyroid hormone replacement is needed because of
when feeling well. surgical removal of gland, patient needs to understand
rationale for replacement therapy and consequences of
failure to routinely take medication.

Identify signs/symptoms requiring medical evaluation, Early recognition of developing complications such as
e.g., fever, chills, continued/purulent wound drainage, infection, hyperthyroidism, or hypothyroidism may
erythema, gaps in wound edges, sudden weight loss, prevent progression to life-threatening situation. Note: As
intolerance to heat, nausea/vomiting, diarrhea, insomnia, many as 43% of patients with subtotal thyroidectomy will
weight gain, fatigue, intolerance to cold, constipation, develop hypothyroidism in time.
drowsiness.
ACTIONS/INTERVENTIONS RATIONALE
Teaching; Disease Process (NIC)

Independent
Stress necessity of continued medical follow-up. Provides opportunity for evaluating effectiveness of
therapy and prevention of complications.

POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on patient’s age, physical

condition/presence of complications, personal resources, and life responsibilities)
Fatigue—decreased metabolic energy production, altered body chemistry (hypothyroidism)
Refer to Potential Considerations in Surgical Intervention plan of care.