ANGELES UNIVERSITY FOUNDATIONAngeles CityCollege of Nursing
CASE REPORT:COLLOID NODULAR GOITER (THYROIDECTOMY)
Submitted By:Bungay, Maria PaulaFabunan , Roman IIINapalit, Bea Nikkisia D.Group 10/ BSN III-3
Submitted To:Ma. Teresa Cabanayan, R.N., M.N.August 16, 2013I. IntroductionColloid nodular goiter is the enlargement of an otherwise normal thyroid gland. Colloid nodular goiters are also known as endemic goiters. They are usually caused by not getting enoughiodine in the diet. Colloid nodular goiters tend to occur in certain areas with iodine-poor soil. These areas are usually away from the sea coast. An area is defined as endemic for goiter if more than 10% of children ages 6 - 12 have goiters. Certain things in the environment may also cause thyroid enlargement. Small- to moderate-sized goiters are relatively common in the United States. The Great Lakes, Midwest, and Intermountain regions were once known as the "goiter belt." The routine use of iodized table salt now helps prevent this deficiency. (http://health.nytimes.com/health/guides/disease/colloid-nodular-goiter)Thyroid nodules are very common, with an estimated prevalence of approximately 4% by palpation (5% in women and 1% in men living in iodine-sufficient regions). A thyroid nodule larger than 1 cm in diameter is usually palpable. However, the detection of a nodule by palpation also depends on its location within the thyroid, on the structure of the patients neck and on the experience of the examiner. In the Framingham Study, clinically apparent thyroid nodules were present in 6.4% of the women and 1.6% of the men who participated, with an estimated annual incidence, by palpation, of 0.001.The lifetime risk of developing a thyroid nodule is reported to be 15%. Nevertheless, only 5% of the clinically apparent thyroid nodules are malignant. Thyroid carcinoma annual incidence is 1-2 per 100,000 population, which accounts for 90% of the malignancies of the entire endocrine system, 1% of total human malignancies and 0.5% of total deaths from malignancies. Although thyroid malignant tumors are not usually aggressive, thyroid malignancies are responsible for more deaths than all other malignancies of the endocrine system. (http://emedicine.medscape.com/article/127491-overview)The overall prevalence in the Philippines of iodine deficiency among patients with thyroid nodules is high at 63.4%.Despite of government efforts to eliminate iodine deficiency in our country, this remains as a significant health problem among adult Filipinos with thyroid nodules. It may be a risk factor for nodular thyroid disease and these results show that it may also play a crucial role in promoting the development of thyroid carcinoma, although more patients are needed to accurately evaluate the association between iodine exposure and risk of thyroid carcinoma. (R. Dejesus, et al., 2008)There are new trends regarding the treatment, Thyroidectomy. Thyroid surgery, which has traditionally been an overnight hospital procedure, can be done safely in an outpatient setting, and in fact is preferable because it is less expensive, according to a new study published in the April issue ofOtolaryngology-Head and Neck Surgery. The study's authors found not only were complications low, but conducting the procedure in an outpatient environment significantly lowered the cost by several thousand dollars. (http://www.medicalnewstoday.com/articles/67471.php) Another is that the scar less thyroid surgery was discovered as a new form of endoscopic surgery. The technique uses the latest Da Vinci three dimensional, high-definition robotic equipment to make a two-inch incision below the armpit that allows doctors to maneuver a small camera and specially designed instruments between muscles to access the thyroid. The diseased tissue is then removed endoscopically through the armpit incision.This techniquesafely removes thethyroid without leavingso much as a scratch on the neck. The benefits of this new technique go beyond aesthetics. Unlike other forms of endoscopic thyroid surgery, it doesn't require blowing gas into the neck to create space to perform the operation. Those techniques can risk complications if the gas is retained in the neck or chest after surgery, causing significant discomfort and postoperative complications. There is a reduced likelihood of laryngeal nerve damage andless risk of trauma to the parathyroid glands, which are near the thyroid. There is also significant faster recovery time and less discomfort on thepart ofthe patients. (http://www.sciencedaily.com/releases/2009/11/091124174735.htm)It is important for the student nurses to study about such disease and surgery since they will be future nurses. They can use their knowledge when they will encounter the disease condition or surgery as they go along with their career. This case report will help them understand and improve their skills, and they can give the best care possible to their patients having colloidal nodular goiter or some related diseases. New trends and technologies about the surgery can be discovered and be shared to other healthcare team especially to the surgeons and whole operating team.
II. Anatomy and PhysiologyThyroid Gland
The thyroid gland is an endocrine gland located inferior to the larynx. It is butterfly shaped and brownish-red in color, which lies on the trachea, in the anterior neck. It establishes a structural form consisting of two lobes connected in the middle by an isthmus, one on each side of the trachea, just inferior to the larynx. Internally, the thyroid gland consists of numerous follicles, which are small spheres filled with a sticky, gelatinous material called cuboidal epithelial cells. Each thyroid follicle is filled with proteins, called thyroglobulin, which are synthesized and secreted by the cells of the thyroid follicles. As part of the thyroglobulin molecules, large amounts of thyroid hormones are stored in the thyroid follicles. In between the delicate network of loose connective tissue between the follicles contains scattered parafollicular cells.
Thyroid HormonesThe thyroid hormones are triiodothyronine known as T3 and tetraiodothyronine known as T4. Another name for the T4 is thyroxin. T3 constitutes 90% of thyroid gland secretions and T4 10%. Although calcitonin is secreted by the Para follicular cells of the thyroid gland, T3 and T4 are considered to be thyroid hormones because they are more clinically important and because they are secreted from the thyroid follicles.T3 and T4 SynthesisThyroid stimulating hormone (TSH) from the anterior pituitary stimulates thyroid hormone synthesis and secretions. TSH causes increase in the synthesis if T3 and T4, which are then stored inside the thyroid follicles as part of the thyroglobulin. TSH also causes T3 and T4 to be released from the thyroglobulin and enter the circulatory system. An adequate amount of iodine is the diet is required for thyroid hormone synthesis because iodine is a component of T3 and T4. Transport in the BloodThyroid hormones are transported in combination with plasma proteins in the circulatory system. Approximately 70%-75% of circulating thyroid hormones are bound to thyroxin-binding globulin (TBG), which is synthesized by the liver, and 20%-30% are bound to other plasma proteins, including albumen. Thyroid hormones, bound to these plasma proteins, form a large reservoir of circulating thyroid hormones. Thyroid hormones are converted to other compounds and excreted in the urine.Effects of Thyroid HormonesThyroid hormones interact with their target tissues in a fashion similar to that of the steroid hormones. They readily diffuse through plasma membranes into the cytoplasm of cells. Within cells, they bind to receptor molecules in the nuclei. Thyroid hormones combined with their receptor molecules interact with DNA in the nuclei to influence genes and initiate new protein synthesis. The newly synthesized proteins within the targets cells mediate the cells response to thyroid hormones. It takes up to a week after the administration of thyroid hormones for a maximal response to develop, and new protein synthesis occupies much of that time.Thyroid hormones affect nearly every tissue in the body, but not all tissues respond identically. Metabolism is primarily affected in some tissues, and growth and maturation are influenced in others. The normal rate of metabolism depends on an adequate supply of thyroid hormone, which increases the rate at which glucose, fat, and protein are metabolized. The metabolic rate can increase 60%-100% when blood thyroid hormones are elevated. Maintaining normal body temperature depends on an adequate amount of thyroid hormones.Normal growth and maturation of organs also depend on thyroid hormones. Specifically, bone, hair, teeth, connective tissue, and nervous tissue require thyroid hormones for normal growth and development. Both normal growth and maturation of brain require thyroid hormones.Regulation of Thyroid Hormone SecretionThyroid hormone secretion is regulated by hormones produced in the hypothalamus and anterior pituitary. Thyrotropin-releasing hormone (TRH) is produced in the hypothalamus. Chronic exposure to cold increases TRH secretion, whereas stress, starvation, injury, and infections, decreases TRH secretion. TRH stimulates TSH secretion from the anterior pituitary. Small fluctuations in blood levels of TSH occur on daily basis, with a small nocturnal increase. TSH stimulates the secretion of thyroid hormones from the thyroid gland. TSH also increases the synthesis of thyroid hormones, as well as causing an increase in thyroid gland cell size and number. Decreased blood levels of TSH lead to decreased secretion of thyroid hormones and thyroid gland atrophy. Thyroid hormones have a negative feedback effect on the hypothalamus and anterior pituitary gland. As thyroid hormone levels increase in the circulatory system,