Posted in Med Surg

No thyroid? No problem. Taking care of patients with a thyroidectomy.

One of the things I love most about being a nurse is that I learn something new every single time I show up for work. Recently this involved learning about the nursing care of patients who’ve had a thyroidectomy. But before we get into the details, let’s first talk a little bit about why a patient would have their thyroid removed.

One of the most common reasons a patient may have their thyroid removed is because of thyroid cancer, but can also be due to the presence of nodules on the thyroid, goiter or hyperthyroidism (which you can read about here). In the old-old days, a thyroidectomy was a dangerous surgery with a lot of risks, but improvements in surgical technique have drastically reduced complications and surgical blood loss. These days it’s a pretty common procedure that has good outcomes overall. These patients still require specialized care, so let’s get started using the Straight A Nursing LATTE method.

L: How will the patient LOOK?

After the procedure, the patient will leave the surgical suite with a dressing at the anterior of the neck and an incision approximately 5.5 cm for a total thyroidectomy (smaller for partial removal of the thyroid). 

If the patient had hyperthyroidism prior to surgery, they may have had a goiter which basically looks like localized swelling at the anterior neck. In some cases, it can be quite large!

A: How will you ASSESS the patient? 

Anytime you have a patient who has had neck surgery you are always always always thinking AIRWAY. Tracheal collapse and mucus accumulation, laryngeal edema, and paralysis of the vocal cords can all lead to sudden respiratory failure. Many hospitals have a protocol of keeping a tracheostomy tray at the bedside for the first 24-hours after surgery, just in case. Hopefully you won’t ever need it.

You will be watching that surgical site like a hawk for any signs of hematoma formation, which could become so severe it impedes the patient’s ability to ventilate. Patients can hemorrhage, with or without hematoma formation, leading to airway obstruction and aspiration of blood. When assessing for bleeding, it’s important to assess the back of the neck as well, as this is where blood tends to pool. 

Another common complication of thyroidectomy is hypocalcemia due to damage inflicted on the parathyroid gland. Think about the signs/symptoms of hypocalcemia and base your assessments on that. For example, you would want to monitor your patient for tetany, which would be assessing for Chvostek and Trousseau as well as other signs of tetany such as laryngospasm. 

To assess for Chvostek’s sign, tap on the patient’s facial nerve to observe a twitching of the facial muscles. If twitching is present, this indicates a positive Chvostek’s sign and hypocalcemia. To assess for Trousseau’s sign, inflate a blood pressure cuff and observe the patient for a carpopedal spasm…if it is present, this is also a sign of hypocalcemia. 

An additional potential complication is damage to the accessory nerve, which would impede the patient’s ability to shrug their shoulders effectively. So, a simple assessment in the postoperative period is to simply ask the patient to shrug their shoulders. Easy! Any patient at risk for hypocalcemia should receive continuous ECG monitoring, as this electrolyte deficiency can lead to serious arrhythmias.

Thyroid storm is also a risk during or after surgery in patients who have hyperthyroidism. It’s a result of the thyroid gland being manipulated during removal, and includes signs/symptoms such as tachycardia, hyperthermia, nausea and altered LOC. 

But wait, there’s more! Laryngeal nerve damage can also occur. To assess for this, you’ll want to assess the quality of the patient’s voice.  Hoarseness or difficulty forming sound could be an indicator of laryngeal nerve damage. In addition to damage to the laryngeal nerve, hypoglossal nerve damage can also occur. To assess for this, have the patient extend their tongue. If they are able to do so without any difficulty or deviation to the side, this nerve is likely to be intact.

T: What TESTS will be conducted?

  • Serum calcium level to assess for hypocalcemia
  • If partial thyroidectomy, anticipate collecting blood for thyroid hormone levels
  • Prior to surgery for hyperthyroidism, the patient will likely be taking medications to help prevent thyroid storm during/after the procedure. These patients will need thyroid levels checked prior to surgery.

T: What TREATMENTS will be provided?

  • After surgery, keep the patient in high-Fowler’s position to help prevent any excess edema from forming and to minimize bleeding or oozing from the incision. 
  • Patients experiencing hypocalcemia will receive calcium gluconate.
  • Pain medication and/or ice pack to the affected area as needed.

E: How will you educate the patient? 

After a total thyroidectomy, the patient will need to be instructed to take exogenous thyroid hormone for life (levothyroxine). This medication must be taken on an empty stomach, typically first thing in the morning. You can read more about thyroid replacement medication here.

Patients should also be instructed to monitor themselves for signs of hypothyroidism which can include: lethargy, brain fog, hair loss, weight gain, hoarse voice, and others. They should also be aware of signs of hyperthyroidism, which typically include tachycardia, anxiety, restlessness.

If the patient has parathyroid damage, instruct him that he will need to take calcium supplements and how to recognize signs of hypocalcemia. 

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So there you have it.  Your down and dirty guide to taking care of patients undergoing thyroidectomy using the Straight A Nursing LATTE method.

Get this on audio in Podcast Episode 100.

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References: 

Hofflich, H. (2011). Implications of long-term hypocalcemia with normal PTH levels following thyroid surgery. Clinical Thyroidology, 1.

Wang, T., Lyden, M., & Sosa, J  (2020). Thyroidectomy. UpToDate. https://www.uptodate.com/contents/thyroidectomy

Mayo Clinic. (n.d.). Thyroidectomy—Mayo Clinic. https://www.mayoclinic.org/tests-procedures/thyroidectomy/about/pac-20385195

Mayo Clinic. (n.d.). What is the Trousseau sign in patients with hypocalcemia?https://www.medscape.com/answers/241893-20151/what-is-the-trousseau-sign-in-patients-with-hypocalcemia

Medscape. (n.d.). What is the Chvostek sign in patients with hypocalcemia?Retrieved April 29, 2020, from https://www.medscape.com/answers/241893-20150/what-is-the-chvostek-sign-in-patients-with-hypocalcemia

Mills, E. (n.d.). Handbook of Medical-Surgical Nursing(Fourth). Lippincott Williams & Wilkins.