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ATI Med-Surg: Chp 79: Hyperthyroidism

Terms in this set (22)

A thyroidectomy is the surgical removal of part or all of the thyroid gland.
☐ A subtotal thyroidectomy may be performed for the treatment of hyperthyroidism when medication therapy fails or radiation therapy is contraindicated. It may also be used to correct diffuse goiter and thyroid cancer. After a subtotal thyroidectomy, the remaining thyroid tissue usually supplies enough thyroid hormone for normal function.
☐ If a total thyroidectomy is performed, the client will need thyroid hormone replacement therapy.

■ Nursing Actions
☐ Preprocedure
> Explain the purpose of the thyroidectomy to the client. Tell the client that there will be an incision in the neck, a dressing, and possibly a drain in place. Tell the client that some hoarseness and a sore throat from intubation and anesthesia may be experienced.
> The client is usually prescribed propylthiouracil or methimazole 4 to 6 weeks before surgery.
> The client should receive iodine for 10 to 14 days before surgery. This reduces the gland's size and prevents excess bleeding.
> Propranolol (Inderal) may be given to block adrenergic effects.
> Notify the provider immediately if the client fails to follow the medication regimen.

☐ Postprocedure
> Keep the client in a high-Fowler's position. Support head and neck with pillows. Avoid neck extension.
> Check surgical dressing and back of neck for excessive bleeding. Be aware that respiratory distress can occur from compression of trachea due to hemorrhage.
> Respiratory distress also can occur due to edema. Ensure that tracheostomy supplies are immediately available. Humidify air, assist to cough and deep breathe, and provide oral and tracheal suction if needed.
> Check for laryngeal nerve damage by asking the client to speak as soon as awake from anesthesia and every 2 hr thereafter.
> Administer medication to manage pain. Reassure the client that discomfort will resolve within a few days.
> Hypocalcemia and tetany can occur if parathyroid glands are damaged or removed. Indications are tingling of toes or around mouth, and muscle twitching. Check for positive Chvostek's and Trousseu's signs. Ensure that IV calcium gluconate or calcium chloride are immediately available.
> If no drain is in place, prepare the client for discharge the day following surgery as indicated. However, if a drain is in place, the surgeon will usually remove it, along with half of the surgical clips, on the second day after surgery. The remaining clips are removed the following day before discharge.

■ Client Education
☐ Instruct the client to cough and breathe deeply while stabilizing her neck.
☐ Show the client how to change positions while supporting the back of the neck.
☐ Remind the client to be careful of the incisional drain if applicable.
☐ Advise the client that the voice will become hoarse, and to expect pain.
☐ Advise the client to notify the nurse of any tingling sensation of the mouth, tingling of the distal extremities, or muscle twitching.
☐ Remind the client that talking at intervals will be expected to check for nerve damage.
☐ Instruct the client to notify the surgeon of incisional drainage, swelling, or redness that may indicate infection.
☐ Advise the client and family to monitor for manifestations of hypothyroidism, such as hypothermia, lethargy, and weight gain.
☐ Instruct the client to take all medications as directed.
☐ Instruct clients who have had a total thyroidectomy that lifelong thyroid replacement medications will be required.
☐ Advise the client to check with the surgeon/provider prior to taking over-the-counter medications.
☐ Instruct the client to keep all follow-up appointments.
> Advise the client to notify the surgeon of fever, increased restlessness, palpitations, or chest pain.
◯ Thyroid storm/crisis results from a sudden surge of large amounts of thyroid hormones into the bloodstream, causing an even greater increase in body metabolism. This is a medical emergency with a high mortality rate.
◯ Precipitating factors include infection, trauma, emotional stress, diabetic ketoacidosis, and digitalis toxicity, all of which increase demands on body metabolism. It also can occur following a surgical procedure or a thyroidectomy as a result of manipulation of the gland during surgery.
◯ Findings are hyperthermia, hypertension, delirium, vomiting, abdominal pain, hyperglycemia, and tachydysrhythmias. Additional findings include chest pain, dyspnea, and palpitations.

◯ Nursing Actions
■ Maintain a patent airway.
■ Provide continuous cardiac monitoring for dysrhythmias.
■ Administer acetaminophen to decrease the client's temperature.
☐ Caution - Salicylate antipyretics are contraindicated because they release thyroxine from protein-binding sites and increase free thyroxine levels.
■ Provide cool sponge baths, or apply ice packs to decrease fever. If fever continues, obtain a prescription for a cooling blanket for hyperthermia.
■ Administer thionamides - methimazole or propylthiouracil (PTU) - to prevent further synthesis and release of thyroid hormones.
■ Administer propranolol to block sympathetic nervous system effects.
■ Administer glucocorticoids to treat shock.
■ Administer IV fluids to provide adequate hydration and prevent vascular collapse. Fluid volume deficit may occur because of increased fluid excretion by the kidneys or excessive diaphoresis. Monitor intake and output hourly to prevent fluid overload or inadequate replacement.
■ Administer sodium iodide as prescribed, 1 hr after administering PTU.
☐ Caution - If given before PTU, sodium iodide can exacerbate manifestations in susceptible clients.
■ Administer small doses of insulin as prescribed to control hyperglycemia, which can occur because of the hypermetabolic state.
■ Administer supplemental O2 to meet increased oxygen demands.

◯ Client Education
■ Provide the client and family support and information about the client's condition and all procedures. Advise the client to notify the provider of fever, increased restlessness, palpitations, and chest pain.