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. 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 ordere
2. Offer iced fluids.
3. Ambulation and soft diet, as tolerate
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.


17. Hypothyroidism (myxedema): deficiency of circulating thyroid hormone; often a final consequence of Hashimoto’s thyroiditis and Graves’ disease.
1. Pathophysiology: atrophy, destruction of gland by endogenous antibodies or inadequate pituitary thyrotropin production —> insidious slowing of body processes, personality changes, and generalized, interstitial nonpitting (mucinous) edema - myxedema; pronounced involvement in systems with high protein turnover (e.g., cardiac, GI, reproductive, hematopoietic).
2. Risk factors:
1. Total thyroidectomy; inadequate replacement therapy.
2. Inherited autosomal recessive gene coding for disorder.
3. Hypophyseal failure.
4. Dietary iodine deficiencies.
5. Irradiation of thyroid gland.
6. Overtreatment of hyperthyroidism.
7. Chronic lymphocytic thyroiditis.
8. Postpartum thyroiditis.
9. Viral thyroiditis.
10. Medications, such as amiodarone HC1 (Cordarone), used to treat abnormal heart rhythms.
3. Assessment:
1. Subjective data:
1. Weakness, fatigue, lethargy.
2. Headache.
3. Slow memory, psychotic behavior.
4. Loss of interest in sexual activity.
2. Objective data:
1. Depressed basal metabolism rate (BMR).
2. Cardiomegaly, bradycardia, hypotension, anemia.
3. Menorrhagia, amenorrhea, infertility.
4. Dry skin, brittle nails, coarse hair, hair loss.
5. Slow speech, hoarseness, thickened tongue, Weight gain: edema, generalized interstitial; peripheral nonpitting; periorbital puffiness.
6. Intolerance to cold.
7. Hypersensitive to narcotics and barbiturates.
8. Lab data:
1. Elevated: thyroid-releasing hormone (TRH), thyroid-stimulating hormone (TSH), cholesterol (>220 mg/dL), lipids (>850 mg/dL), protein (>8g/dL).
2. Normal-low: serum thyroxine (T₄), serum triiodothyrinine (T₃).
3. Decreased: radioactive iodine up take (RAIU).
4. Analysis/nursing diagnosis:
1. Risk for injury related to hypersensitivity to drugs.
2. Altered nutrition, more than body requirements, related to decreased BMR.
3. Activity intolerance related to fatigue.
4. Constipation related to decreased peristalsis.
5. Decreased cardiac output related to hypotension and bradycardia.
6. Risk for impaired skin integrity related to dry skin and edema.
7. Social isolation related to lethargy.
5. Nursing care plan/implementation:
   1. Goal: provide for comfort and safety.
      1. Monitor for infection or trauma; may precipitate myxedema coma, which is manifested by: unresponsiveness, bradycardia, hypoventilation, hypothermia, and hypotension.
      2. Provide warmth; prevent heat loss and vascular collapse.
      3. Administer thyroid medications as ordered: levothyroxine (Synthroid) - most common drug used; liothyronine sodium (Cytomel); dosage adjusted according to symptoms.
   2. Goal: health teaching.
   1. Diet: low calorie, high protein.
   2. Signs and symptoms of hypothyroidism and hyperthyrodism.
   3. Lifelong medications, dosage, desired effects and side effects.
   4. Medication dosage adjustment: take onethird to one-half the usual dose of narcotics and barbiturates.
   5. Stress-management techniques.
   6. Exercise program.
6. Evaluation/outcome criteria:
1. No complications note Most common complications: atherosclerotic coronary heart disease, acute organic psychosis, and myxedema coma.
2. Dietary instructions followed.
3. Medication regimen followed.
4. Thyroid hormone balance obtained and maintained.


18. Cushing’s disease: an endogenous overproduction of adrenocorticotropic hormone (ACTH) that can be caused by pituitary-dependent adenomas. Cushing’s syndrome: condition marked by chronic excessive circulating cortisol with or without pituitary involvement. One of the most common causes of Cushing’s syndrome is the administration of cortisone-like medications for treatment of a variety of conditions.
1. Pathophysiology:
1. Excess glucocorticoid production, leading to:
1. Increased gluconeogenesis —> raised serumglucose levels —> glucose in urine, increased fat deposits in face and trunk.
2. Decreased amino acids —> protein deficiencies, muscle wasting, poor antibody response, and lack of collagen.
2. Risk factors:
1. Adrenal hyperplasia.
2. Excessive hypothalamic stimulation.
3. Tumors: adrenal, hypophyseal, pituitary, bronchogenic, or gallbladder.
4. Excessive steroid therapy.
3. Assessment:
1. Subjective data:
1. Headache, backache.
2. Weakness, decreased work capacity.
3. Mood swings.
2. Objective data:
1. Hypertension, weight gain, pitting edema.
2. Characteristic fat deposits, truncal and cervical obesity (buffalo hump).
3. Pendulous abdomen, purple striae, easy bruising.
4. Moon face, acne.
5. Hyperpigmentation.
6. Impotence.
7. Virilization in women: hirsutism, breast atrophy, and amenorrhea.
8. Pathological fractures, reduced height.
9. Slow wound healing
10. Lab data:
1. Urine: elevated 17-ketosteroids (>12 mg/24 hr) and glucose (>120 mg/dL).
2. Plasma: elevated 17-hydroxycorticosteroids, cortisol (> 10 >p.g/dL). Cortisol does not decrease during the day as it should.
3. Serum: elevated - glucose, RBC, WBC; diminished - potassium, chlorides, eosinophils, lymphocytes.
11. X-rays and scans to determine tumors/ metastasis.
4. Analysis/nursing diagnosis:
1. Body image disturbance related to changes in physical appearance.
2. Activity intolerance related to backache and weakness.
3. Risk for injury related to infection and bleeding.
4. Knowledge deficit related to management of disease.
5. Pain related to headache.
5. Nursing care plan/implementation.
1. Goal: promote comfort.
1. Assist with preparation of diagnostic workup.
2. Explain procedures.
3. Protect from trauma.
2. Goal: prevent complications; monitor for:
1. Fluid balance - I&O, daily weights.
2. Glucose metabolism - blood, urine for sugar and acetone.
3. Hypertension - vital signs.
4. Infection - skin care, urinary tract; check temperature.
5. Mood swings - observe behavior.
3. Goal: health teaching.
1. Diet: increased protein, potassium; decreased calories, sodium.
2. Medications:
   1. Cytotoxic agents: aminoglutethimide (Cytadren), trilostane (Modrastane), mitotane (Lysodren) - decrease cortisol production.
   2. Replacement hormones as needed.
3. Signs and symptoms of progression of disease as noted in assessment.
4. Preparation for adrenalectomy if medical regimen unsuccessful.
6. Evaluation/outcome criteria:
   1. Symptoms controlled by medication.
   2. No complications - adrenal steroids within normal limits.
   3. If adrenalectomy necessary, see following section.