16. Thyroidectomy: partial removal of thyroid gland (for hyperthyroidism) or total removal (for malignancy of thyroid).
1. Risk factor: unsuccessful medical treatment of hyperthyroidism.
2. Analysis/nursing diagnosis:
   1. Risk for injury related to possible trauma to parathyroid gland during surgery.
   2. Ineffective breathing pattern related to neck incision.
   3. Pain related to surgical incision.
   4. Altered nutrition, less than body requirements, related to difficulty in swallowing because of neck incision.
   5. Impaired verbal communication related to possible trauma to nerve during surgery.
   6. Risk for altered body temperature related to thyroid storm.
3. Nursing care plan/implementation: Prepare for surgery (see Preoperative preparation, p. 500). Postoperative:
   1. Goal: promote physical and emotional equilibrium.
      1. Position: semi-Fowler’s to reduce edema.
      2. Immobilize head with pillows/sandbags.
      3. Support head during position changes to avoid stress on sutures, prevent flexion or hyperextension of neck.
   2. Goal: prevent complications of hypocalcemia and tetany, due to accidental trauma to parathyroid gland during surgery; signs of tetany indicate necessity of calcium gluconate IV
      1. Check Chvostek’s sign - tapping face in front of ear produces spasm of facial muscles.
      2. Check Trousseau’s sign - compression of upper arm (usually with BP cuff) elicits carpal (wrist) spasm.
      3. Monitor for respiratory distress (due to laryngeal nerve injury, edema, bleeding); keep tracheostomy set/suction equipment at bedside.
      4. Monitor for elevated temperature, indicative of thyroid storm (see objective assessment data for thyroid storm).
      5. Monitor vital signs, check dressing and beneath head, shoulders for bleeding qlh and pm for 24 hr; hemorrhage is possible complication; if swallowing is difficult, loosen dressin If patient still complains of tightness when dressing is loosened, look for further signs of hemorrhage.
      6. Check voice postoperatively as soon as responsive after anesthesia and every hour (assess for possible laryngeal nerve damage)-, crowing voice sound indicates laryngeal nerves on both sides have been injured; respiratory distress possible from swelling.
         1. Avoid unnecessary talking to lessen hoarseness.
         2. Provide alternative means of communication.
   3. Goal: promote comfort measures.
      1. Narcotics as ordered.
      2. Offer iced fluids.
      3. Ambulation and soft diet, as tolerated.
   4. Goal: health teaching.
      1. How to support neck to prevent pressure on suture line: place both hands behind neck when moving head or coughing.
      2. Signs of hypothyroidism; needs supplemental thyroid hormone if total thyroidectomy.
      3. Signs and symptoms of hemorrhage and respiratory distress.
      4. Importance of adequate rest and nutritious diet.
      5. Importance of voice rest in early recuperative period.
4. Evaluation/outcome criteria:
   1. No respiratory distress, hemorrhage, laryngeal damage, tetany.
   2. Preoperative symptoms relieved.
   3. Normal range of neck motion obtained.
   4. States signs and symptoms of possible complications.