INTRODUCTION Goiter Goi ter is an enl enlarg argeme ement nt of th thee thy thyroi roid d gla gland. nd. The thy thyroi roid d can be en enlar larged ged due to gen genera eraliz lized ed enlargement of the thyroid or nodules (tissue growths) within the thyroid. The thyroid gland produces the hormones thyroxine (also called T4) and a small amount of triiodothyronine (also called T3). These thyroid hormones influence such bodily functions as a person’s body temperature, mood and excitability, pulse rate, digestive functions, and other processes necessary for life. Goiters have different ca uses depending on their type. Goiters can be classified as simple, hereditary, or due to other causes. Simple goiters are caused by an inadequate supply of thyroid hormone to meet the body’s need. The thyroid gland tries to make up for this deficiency by enlarging. Endemic goiters occur in people within certain geographic areas who do not get enough iodine in their diet (iodine is necessary to make thyroid hormone). Sporadic goiters in most cases have no known cause. Sometimes certain types of drugs, such as lithium or aminoglutethimide, can cause this type of goiter. Risk factors for goiter development include gender mostly to female with an age 40 and above, family histor his tory y of go goite iterr oth other er dis diseas eases es and con condit dition ionss can als also o cau cause se a goi goiter ter.. The These se inc includ ludee gra grave’ ve’ss dis diseas ease, e, hashimoto’s disease, nodular goiter, goiter, thyroid cancer, pregnancy, thyroiditis, and exposure to radiation. Main symptoms include swelling, ranging in size from a small nodule to a massive lump, in the front of the neck just below your Adam’s apple, a feeling of tightness in the throat area, difficulty breathing, coughing, wheezing, dysphagia, hoarseness, distended neck vein. Other symptoms includes signs of hyperthyroidism -- a condition in which the thyroid is overactive includes an increased resting pulse rate, rapid heartbeat, diarrhea, nausea, vomiting, sweating without exercise or increased room temperature, shaking, and agitation. On the other hand symptoms includes signs of hypo hypothyro thyroidism idism are fatig fatigue, ue, const constipati ipation, on, dry skin, weigh weight, t, menst menstrual rual irregularities Several testing methods can be used to diagnose and evaluate the goiter, including: Physical exam ; it may be able to determine enlargement of the thyroid gland by feeling your neck area for nodules and signs of tenderness tende rness,, hormon hormonee test test,, a bloo blood d test to deter determine mine thyroid hormone hormone leve levels. ls. anti antibody body test, ultrasound ultrasound of the thyroid, Thyroid scan , and CT scan or MRI Treatment options depend on the size of the enlargement, your symptoms, and the underlying cause. Medications; Levothyroxine is a thyroid hormone replacement therapy. Aspirin or a corticosteroid corticosteroid medication might be prescribed if the underlying cause of your goiter is inflammation. Small doses of iodine can be prescribed if the goiter is due to iodine deficiency. deficiency. Radioactive iodine treatment, is another another treatment, used in cases of an overactive thyroid gland. Biopsy may be required if you have large nodules in the thyroid to exclude cancer. Thyroidectomy surgery,to remove all or part of the thyroid gland, may be necessary if the goiter is large and causing difficulty with breathing and swallowing.
Disorders of thyroid function, whether hyperthyroidism or hypothyroidism are medical conditions that can have a significant impact on public health and can even shorten the lifespan of individuals of any age. Thyroid disorders, goitrous and non goitrous forms, occur with great frequency in the adult population ranging from 0.5 to 5% in overt disease and 3 to 10% 10% in the subclinical forms depending depending on the population, population, age and sex examined. While, lack of dietary iodine is an important important underlying cause of thyroid thyroid disorders, excess iodine, genetic background, other geographical and dietary factors can trigger thyroid disorders.
NURSING HISTORY
Biography Data
This is the case of Z.D. 58 years of age, born on July 30 1953, widow,and Roman Catholic who is currently residing at Panginay, Balagtas, Bulacan.she was admitted at Bulacan Medical Center on November 20, 2011, 10:19 in the morning of Dr. Alfonso Reiner. Chief Complain: Enlarged Thyroid PRESENT HEALTH HISTORY
4 Years PTA, the patient was experiencing uncontrolled cough daily she always feel irritable and quite abdominal pain. No medication taken or consultation was sought. 3 Years PTA the patient still experience persistent cough and Nausea and vomiting. But still she didn’t seek for consultations due to lack of financial problem. Eventhough she felt that there is mass palpated on her neck. 2 years PTA the patient felt difficulty of breathing specially during lying on the bed still cough is present. She is also experience difficulty a swallowing. 1year PTA the patient sought consultation to a physician with her daughter. She was offer for an operation but they refuse because they were not yet prepared. 1 month PTA ZD due to enlarged neck mass they again sought for consultation and undergone a hormone examination and electrolyte exam. Then they wait for result. 1 day PTA, ZD was waiting for her schedule for surgical operation and preparing for the things she needed. PAST HEALTH HISTORY
ZD was hospitalized when she as 38 years old also due to goiter. She was already legated before turning 40 years old. No past record of accident or injuries. No allergy.
LIFE STYLE
ZD is living with her daughter and son-in-law with her grandchildren. She spends her day doing household chores daily (laba, luto, linis bahay). She was difficulty in sleeping, 5 hours of sleep pattern. The patient is taking vitamins enervon, sometimes centrum. She was take 8 glasses of water a day. Non- smoker and non- alcoholic drinker. Do not like to eat repolyo, sitaw, and sayote, and seafood’s like seaweeds. FAMILY HISTORY
The patient’s mother –side have a history siblings died from Breast Cancer. On her father- side, they have history of hypertension.
PHYSICAL ASSESSMENT & FINDINGS
Area to be
Technique
examined Vital signs:
Findings
Significance
Findings
Nov 22,2011 BP:150/90
Nov 28,2011 BP:140/80
PR:99
PR:86
RR:29
RR:21
TEMP:38.1
TEMP:37.2
Significance
HEAD
Inspection Palpation
-Round & Symmetric -no masses -hairs are equally distributed with many visible white hairs -with freckles surrounding her face
- Findings are normal
-Round & Symmetric -no masses -hairs are equally distributed with many visible white hairs -with freckles
- Findings are normal
EYES
Inspection Palpation
-asymmetrically aligned -no edema -narrowed visual acuity -pupil reacts to stimuli
- Findings are normal
-asymmetrically aligned -no edema -narrowed visual acuity -pupil reacts to stimuli
- Findings are normal
NOSE
Inspection Palpation
-intact nasal mucosa -no nodules nor masses - nares are symmetrical
- Findings are normal
-intact nasal mucosa -no nodules nor masses - nares are symmetrical
- Findings are normal
EARS
Inspection Palpation
-symmetrically aligned -auricles with outer canthus of the eye -mobile and firm -no tenderness - contain some cerumen
-uncleaned external ear canal
-symmetry of countour - uniform in color -dry lips -missing teeth -tongue moves freely -no palpable nodules
-Due to old age
-head centered -with enlarged lymph node -with jackson’s pratt drainage -with intact dressing -complain for
-The patient undergone complete thyroidectomy last Nov 21, 2011
MOUTH
NECK
Inspection Palpation
Inspection palpation
-other findings are normal
-Other findings are normal
-other findings
-symmetrically aligned -auricles with outer canthus of the eye -mobile and firm -no tenderness - clean ear canal; absence of cerumen
-uncleaned external ear canal
-symmetry of countour - uniform in color -dry lips -missing teeth -tongue moves freely -no palpable nodules
-Due to old age
-head centered -with dry and intact dressing - gland is not visible even in swallowing
-The patient undergone complete thyroidectomy last Nov 21, 2011
-other findings are normal
-Other findings are normal
-other findings
Conclusion: The gathered data through Physical Assessment mostly shows normal findings except to the incision site on the neck part. Because , the patient Z.D. was undergone a surgery of Complete Thyroidectomy, last November 21, 2011.
ANATOMY & PHYSIOLOGY
The thyroid is a butterfly-shaped gland that sits low on the front of the neck. Your thyroid lies below your Adam’s apple, along the front of the windpipe. The thyroid has two side lobes, connected by a bridge (isthmus) in the middle. When the thyroid is its normal size, you can’t feel it. Brownish-red in color, the thyroid is rich with blood vessels. Nerves important for voice quality also pass through the thyroid. The thyroid secretes several hormones, collectively called thyroid hormones. The main hormone is thyroxine, also called T4. Thyroid hormones act throughout the body, influencing
metabolism, growth and development, and body temperature. During infancy and childhood, adequate thyroid hormone is crucial for brain development.
PATHOPHYSIOLOGY
NON-MODIFIABLE Gender: Female Age: 58 y/o Hyperthyroidism
MODIFIABLE Lifestyle; low iodine
Iodine deficiency
Decrease synthesis of thyroid
Decrease release of
Sends signal to pituitary
Increase release of
Increase cellularity of thyroid
Hyperplasia of Thyroid Pain
Visible neck mass
Wheezing &
Coughing & DOB Fatigue Dysphagia & weight
GOITE
LABORATORY EXAMINATIONS
Chemistry Result Form October 25, 2011
Constipation & Dry
Test Name
Result
Interpretation
Ranges
Significance
Biochem Glucose Hexoki
5.5 mmo / L
Normal
3.8 – 6.0
Normal
81.3
Normal
35.4 – 123.8
Normal
Creatinine Kinetic 2
GOITER Sodium
141.9
135-148mmol/L
Normal
Potassium
4.59
3.5-5.3 mmol/L
Normal
Calcium
-
1.1-1.32
None
Chloride
107.7
96-107
Thyroid Profile October 26, 2011 Test T3 T4 TSH FT4 FT3
Electrolytes Result November 23, 2011
Results 5.4 22.7 0.1
Normal None None 0.4-5.5 uiu/mL 9.0-23.0 pmol/L 3.5-6.5 pmol/L
Sodium
138.1
135-148mmol/L
Normal
Potassium
3.09
3.5-5.3 mmol/L
Normal
Calcium
1.15
1.1-1.32
Normal
Chloride
-
96-107
None
Radiologic Report October 21, 2011 Lung is clear. The heart is enlarged, the aorta is tortuous and calcified. The hemidiaphragms & costophrenic sulci is intact.
Impression: CARDIOMEGALY ATHEROMATOUS AORTA
HEALTH TEACHINGS
M
-Instruct the patient to take the prescribe medications. -Teach the patient on how to take the medicine in the right time, right dose and right route as prescribed by the physician. -Educate the client about the effect of her medication.
E
-Promote a calm and clean environment. -Encourage the relative to promote good ventilation and free from pollution environment. -Promote an infection-free environment by cleaning the surroundings.
T
-Advise the patient and as well as the relatives to have a healthy lifestyle. -Advise the patient to avoid smoking area and avoid alcohol beverages intake. -Instruct the patient to use povidone solution in cleaning her wound incision site.
H
-Encourage the patient to have a daily wound care. -Encourage the patient to have a proper hygiene by taking a bath and hand washing using water and mild soap. -Encourage the patient to have a clean and aseptic dressing technique to her wounds to prevent contamination.
O
-Advise the patient to have a monthly check-up to a physician. -Encourage the patient for the compliance of her take home medications. -Encourage the patient to maintain her healthy condition.
D
-Advise the patient to eat foods rich in iodine, like sea foods & nutritious foods that will make her healthy. -Advise the client to have a proper diet and adequate fluid intake.
S
-Provide safety by keeping things in the right place specially those which can injured. -Encourage the relatives to be sensitive enough about the things that can harm the patient. -Be careful all the time.
OBJECTIVE
This case study aims to identify & determine the needs of the patient. This is also intends to help patient promote healthy lifestyle and understand such condition through application of the nursing skills and for the students to gain knowledge, skill & attitude.
At the end of this case study, the students will be able to:
•
Discuss about Goiter
•
Analyze the Pathophysiology of Goiter
•
Interpret laboratory result of the patient with Goiter
•
Formulate the Nursing Care Plan & Health teachings to promote wellness of the client.
•
Evaluates Physical Assessment Findings.
EVALUATION This study enables the students to identify& determine the needs of the patient with Goiter who undergone Complete Thyroidectomy. It is also helped the patient to promote his healthy lifestyle through understanding his condition and through the application of the nursing skills, the students gained knowledge, skills and enhance good attitude.
Specifically the student nurses now able to:
•
Discuss the Goiter
•
Analyze the Pathophysiology of Goiter
•
Interpret laboratory result of the patient with Goiter
•
Formulate the Nursing Care Plan and health teachings promote wellness of the client .
•
Evaluates Physical Assessment Findings
Dr. Yanga’s Colleges Inc. Wakas, Bocaue, Bulacan
A CASE STUDY
(SURGICAL WARD)
Submitted by: PRINCESS JOY T. CORTEZ
Group 9
