Question

Surgery Assignment

A 25-year-old female client is being admitted to the postanesthesia care unit (PACU)
following a thyroidectomy for hyperthyroidism. The client had undergone three
months of preoperative treatment with antithyroid medications and iodine
preparations to establish euthyroid status prior to her surgery. At the client's bedside
the nurse has set up a tracheostomy set, endotracheal tube, laryngoscope, and suction
equipment. There are ampules of calcium gluconate on hand. The nurse places the
client in a semi-Fowler's position, and is supporting her head and neck with pillows
and sandbags. The nurse frequently checks the client's vital signs, and assesses her
suture line for strain or bleeding. Once the immediate postoperative period has passed,
the client will be transferred to the surgical ward where she will recuperate and learn
about lifelong thyroid replacement therapy.
a.  Why is it important to support the client's head and neck with sandbags and
pillows?

b. Develop a plan of care for this patient including two actual and two potential

Answer 1

Ans 1

Supporting head and neck by pillow makes the head and neck little elevated thus Prevent strain on the incision and thus prevent accidental bleeding or opening of incision and it also helps to keep the swelling down.

Ans 2

POST-OPERATIVE CARE

• The patient should be placed in Semi- Fowler’s position in order to reduce edema
• Limit the patient movement by providing sandbags at the side or side pillows.
• Avert tension on the suture line.
• Monitor the patient for the following:
  • Hypocalcemia – this may transpire due to removal of the parathyroid
    • Check Chvostek’s sign (taping the face and noting for facial spasm).
    • Trousseau’s sign (taking blood pressure while noting for spasm of the wrist).
    • Give calcium gluconate (usually always available at bedside).
  • Respiratory Distress – results from laryngeal edema
    • Check respiratory rate, pattern, and efforts
    • Keep tracheostomy set, suction equipment at the bedside
  • Thyroid Storm – acute episodes of thyroid hyperactivity brought by the release of thyroid hormone during surgery.
    • Observe for increase in temperature, delirium, extreme tachycardia, and marked respiratory distress
    • Hyperthermia is the earliest sign of thyroid storm. When checking for the vital signs, temperature should be taken rectally for post-op patients.
    • Thyroid storm is considered an emergency case for it can cause heart failure and lead to death.
    • Administer Lugol’s solution, anti-thyroid drugs such as Methimazole or Propythiouracil, and cardiac drugs such as propranolol.
    • Use of hypothermia mattress or blanket, ice packs, or expose in a cooler environment for elevated temperature. Patient may take medications such as acetaminophen or paracetamol, but they are not allowed to take in salicylates such as aspirin for it displace thyroid hormone from binding to proteins and worsens hypermetabolism.
  • The patient must be monitored for potential hemorrhage due to surgery. Always check the dressing and slide hands at the back of the head because this is where blood usually accumulates.
  • Check the patient for possible laryngeal damage. This could be assessed through hoarseness of voice or loss of voice. Hoarseness indicates unilateral damage while loss of voice indicates bilateral damage.

Nursing Priorities

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

Thyroidectomy Nursing Care Plan (Based on NANDA)

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

Maintain patent airway, with aspiration prevented.

Nursing Interventions	Rationales
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. Note quality of voice.	Indicators of tracheal obstruction/laryngeal spasm, requiring prompt evaluation and intervention.
Caution patient to avoid bending neck; support head with pillows.	Reduces likelihood of tension on surgical wound.
Assist with repositioning, deep breathing exercises, and/or coughing as indicated.	Maintains clear airway and ventilation. Although “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 characteristics of sputum.	Edema/pain may impair patient’s ability to clear own 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 oral secretions.	May indicate edema/sequestered bleeding in tissues 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: 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

Establish method of communication in which needs can be understood.

Nursing Interventions	Rationales
Communication Enhancement: Speech Deficit 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 appropriate, e.g., slate board, letter/picture board. Place IV line to minimize interference with written communication.	Facilitates expression of needs.
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 and answer call bell promptly.	Prevents patient from straining voice to make needs 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

Demonstrate absence of injury with complications minimized/controlled.

Nursing Interventions	Rationales
Independent Monitor vital signs noting elevating temperature, tachycardia (140–200 beats/min), dysrhythmias, respiratory distress, cyanosis (developing pulmonary edema/HF).	Manipulation of gland during subtotal thyroidectomy may result in increased hormone release, causing thyroid storm.
Evaluate reflexes periodically. Observe for neuromuscular irritability, e.g., twitching, numbness, paresthesias, positive Chvostek’s and Trousseau’s signs, seizure activity.	Hypocalcemia with tetany (usually transient) may occur 1–7 days postoperatively and indicates hypoparathyroidism, which can occur as a result of inadvertent trauma to/partial-to-total removal of parathyroid gland(s) during surgery.
Keep side rails raised/padded, bed in low position, and airway at bedside. Avoid use of restraints.	Reduces potential for injury if seizures occur.
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

Report pain is relieved/controlled.

Demonstrate use of relaxation skills and diversional activities appropriate to situation.

Nursing Interventions	Rationales
Pain Management Independent Assess verbal/nonverbal reports of pain, noting location, intensity (0–10 scale), and duration.	Useful in evaluating pain, choice of interventions, effectiveness of therapy.
Place in semi-Fowler’s position and support head/neck with sandbags or small pillows	Prevents hyperextension of the neck and protects integrity of the suture line.
Maintain head/neck in neutral position and support during position changes. Instruct patient to use hands to support neck during movement and to avoid hyperextension of neck.	Prevents stress on the suture line and reduces muscle tension.
Keep call bell and frequently needed items within easy reach.	Limits stretching, muscle strain in operative area.
Give cool liquids or soft foods, such as ice cream or popsicles.	Although both may be soothing to sore throat, soft foods may be tolerated better than liquids if patient experiences difficulty swallowing.
Encourage patient to use relaxation techniques, e.g., guided imagery, soft music, progressive relaxation.	Helps refocus attention and assists patient to manage pain/discomfort more effectively.
Collaborative Administer analgesics and/or analgesic throat sprays/lozenges as necessary.	Reduces pain and discomfort; enhances rest.
Provide ice collar if indicated.	Reduces tissue edema and decreases perception of pain.