Thyroidectomy is a surgery involving the removal of part or all of the thyroid gland. The delicate procedure is commonly performed to treat malignancy, benign disease or hormonal disease that is unresponsive to medications. These notes will outline the Thyroidectomy Post-Operative Nursing Care, but before getting into that, make sure that you’ve read:
Thyroidectomy Post-Operative Nursing Care Part 1: Assessment
The Post-Operative Nursing Assessment is carried out to identify the patient’s medical and psychological needs and anticipate any future needs, particularly regarding the patient’s continued recovery upon discharge.
Examining the Respiratory System for signs of airway obstruction should be your first priority when assessing post-thyroidectomy patients. The location of the thyroid gland, and the nature of the surgery, leave patients at risk of airway obstruction. This could arise from oedema of the epiglottis, swelling and haematoma formation or injury to the recurrent laryngeal nerve. To assess the respiratory system, start by measuring the respiratory rate and evaluating the breathing pattern. Next, check the patient’s oxygen saturation levels and look out for any signs of cyanosis. Assess the patient’s neck for oedema, and ensure that the patient is seated at a 45-degree angle or more to avoid swelling.
When assessing post-thyroidectomy patients, the next thing on your priority list should be looking out for signs of low calcium levels in the blood, also known as Hypocalcaemia. This condition occurs if the patient’s parathyroid glands have been injured or removed during surgery. Manipulating the parathyroid glands disturbs the calcium metabolism, and eventually, the imbalance leads to a decreased production of calcium. At first, patients with Hypocalcaemia will be asymptomatic, but as the blood calcium levels drop, they will experience hyperirritability of the nerves. This causes spasms in their hands and feet and muscle twitching. If the condition is left untreated, the symptoms will become progressively worse, including:
Prolonged QT interval
To avoid the occurrence of Hypocalcaemia, you should regularly monitor your patient’s Ionized Calcium levels, including both the total calcium and albumin levels. By comparing them to the patient’s pre-operative and intra-operative values, you’ll determine any discrepancies that can indicate Hypocalcaemia. Another test that has recently become the standard for monitoring blood calcium levels is the PTH blood test.
Hypocalcaemia is not the only condition that can cause cardiovascular complications in the post-operative phase, so the third step in your assessment should be to monitor your patient’s cardiovascular status for signs of Haemorrhage. You can do this by first checking their vital signs, including the temperature, SpO2, respiration rate, blood pressure, heart rate and level of consciousness. In addition, if the patient has a history of cardiovascular disease or had cardiac problems during the surgery, they will need regular ECG monitoring.
You should also note the patient’s skin colour, whether they seem adequate, pale, flush red, or cyanotic, and check if their skin is cold and clammy or warm and moist. Look at their fingers and toes, and assess their circulation by checking their capillary refill.
Apart from the regular presentation of these complications, haematoma formation and Haemorrhage can sometimes present as a sensation of pressure or fullness close to the incision site. So as you go around the patient, take a good look at their incision site. Note down the type of dressing and sutures used, and ensure that it’s kept clean and has no additional strain (for example, having the patient lying on it).
But more importantly, lookout for any signs of bleeding and swelling surrounding the area. Minor bleeding from the surgical site is a common occurrence in the post-op phase, but in rare instances, the bleeding can become severe and causes a life-threatening condition known as Haemorrhage.
Bleeding can also occur internally, which means that it would not be visible, but you can still detect it because it presents with several symptoms, including:
Tachypnoea and laboured breathing
Oliguria (low urine output)
Pallor and cyanosis of the lips, gums, and tongue
Disorientation and restlessness
If you notice any signs of Haemorrhage, you should inform the surgical team right away. And if possible, take an ABG sample to determine the patient’s haemoglobin and haematocrit levels.
After completing the first three priority assessments, you can continue carrying out the general post-operative assessment. This will assess their:
You can find more information about the general assessment here.
Thyroidectomy Post-Operative Nursing Care Part 2: Diagnoses
Having completed the Thyroidectomy Post-Operative Nursing Assessment, you’re likely to come across some of the following diagnoses:
Risk of Hypocalcaemia
Risk of Deficient Fluid Volume
Risk of Injury
Uncontrolled nausea and vomiting
Unregulated body temperature
Impaired skin integrity
The goal of identifying these post-op issues is to improve all physiological aspects of the patient, regain independence and provide them with the necessary knowledge to continue their rehabilitation once discharged.
Thyroidectomy Post-Operative Nursing Care Part 3: Interventions
1 Managing Ineffective Respirations
The majority of post-op patients will be receiving opioids to manage their pain, and they will most likely be spending extended periods in bed. While the two are necessary for the patient’s recovery, they also put the patient at risk of developing respiratory complications such as Atelectasis, Pneumonia and Hypoxemia. In addition, post-thyroidectomy patients have an increased risk of airway obstruction due to oedema of the epiglottis, swelling and haematoma formation in the neck, or injury to the recurrent laryngeal nerve.
As in any other care plan, prevention and early recognition of symptoms are crucial to avoiding pulmonary complications. While assessing the patient’s respiratory system, look out for any changes in their breathing pattern, unusual breath sounds or sputum production. Moreover, regularly evaluate their neck for swelling or increased pressure. Document the findings, and compare them with future assessments to determine any decline in function.
Advise your patient to keep the head of the bed elevated at a 45-degree angle or more to avoid swelling. If your patient has suction drains close to the incision, you must check the patency of the drain as if it gets blocked, it might cause a build-up of blood in the neck area.
Encourage your patient to cautiously change their position in bed frequently and regularly mobilise throughout the day. Decrease the risk of injury by keeping the bed’s side rails up, securing all the lines, and providing walking assistance until the patient regains full consciousness and independency.
Explain to your patient how to perform deep breathing exercises and their importance in allowing the patient to expel any residual anaesthetic agents and expand the lungs fully. Lastly, prolonged oxygen therapy may be prescribed in some patients to prevent hypoxia.
2 Risk of Hypocalcaemia
Hypocalcaemia is one of the major complications in post-thyroidectomy patients, particularly those who had a total thyroidectomy. If it’s not treated immediately, Hypocalcaemia can become a life-threatening complication.
As their nurse, it’s your responsibility and the surgical team to monitor the patient regularly and identify any signs of Hypocalcaemia. Once identified, the surgical team will prescribe calcium supplementation, and you need to administer this as prescribed. They can either be prescribed orally along with Vitamin D, or they can be prescribed intravenously. Before administering IV Calcium, you need to ensure that a continuous cardiac monitor is attached to the patient. IV Calcium may cause cardiac arrhythmias, syncope, bradycardia and hypotension. Hence the patient must be monitored at regular intervals. Moreover, it can also cause necrosis or abscess formation if the solution infiltrates the muscle or surrounding tissues. Making it vital for you to regularly check the IV cannula’s patency and lookout for signs of phlebitis.
You could also encourage the intake of foods high in calcium, such as spinach, cheese and sardines.
3 Risk of Deficient Fluid Volume
Thyroidectomy requires the patient to be fully anaesthetised, so the surgical team will ask them to be starved for a minimum of 6 hours before the surgery. However, in most cases, the surgical team advises the patient to starve from midnight, extending the period of starvation and leaving the patient at risk of dehydration. In addition, post-thyroidectomy patients are at risk of nutritional deficiencies because:
Hyperthyroidism causes weight-loss
Some post-thyroidectomy patients are scared to eat and drink not to injure the surgical site
Most post-thyroidectomy patients will have one or two suction drains attached at the incision site to remove access blood.
Ensure that the intake/output sheet is updated regularly, including all IV or oral fluids consumed before, during and after the surgery. As well as the volume of fluid lost through urine, drains and bleeding. This will allow you to identify any discrepancies in fluid volume and adjust accordingly. In addition, you should also continue to monitor the vital signs regularly and look out for a decrease in blood pressure and an increase in heart rate, both of which can indicate fluid deficiency. Lastly, you could also take a blood sample to check the patient’s electrolytes.
If the patient does have a fluid deficiency, you should inform the surgical team and administer hydrating fluids as prescribed. Typically, these would come in IV form, consisting of 0.9% sodium chloride solution or Ringer Lactate’s solution. The type of surgery and anaesthesia will determine when the patient can consume oral intake, and IV hydration is kept until the patient returns to a regular diet.
Once oral consumption is resumed, encourage your patient to eat a high calorie and high protein diet. Specially concentrated shakes can be administered to achieve the daily required caloric intake. You should also look out for factors that might be affecting your patient’s intake and adjust them accordingly. These might include:
Difficulty with chewing or swallowing (refer your patient to a speech and language pathologist or dentist, and provide soft or liquid foods)
Nausea and vomiting (administer prescribed antiemetics)
Depressed mood (refer your patient for a psychological assessment, and provide emotional support)
Difficulty with handling eating utensils (refer your patient to an occupational therapist and assist them during feeding time)
Diet restrictions due to allergies, personal preferences such as vegans/vegetarians or religious restrictions (provide your patient with food that is within their diet)
4 Reducing the Risk of Injury
While most patients in the surgical unit will be awake from general anaesthesia, they would still have a level of residual which can alter their level of consciousness and their gait, leaving them at a greater risk of falls and injury. Additionally, post thyroidectomy patients can accidentally pull out their suction drains or IV lines which can cause trauma.
When you first admit your patient into the surgical unit, keep both of the bed’s side rails up and keep the bed at the lowest level possible. Assess the patient’s level of consciousness and orientation, and ideally admit the patient to a bed close to the nurse’s station for closer monitoring. Keep all the necessary items within the patient’s reach to avoid unnecessary movements and show them how to use the nursing call bell whenever they need assistance.
It’s vital to keep the back elevated at 45 degrees or more following a thyroidectomy, decreasing swelling and the risk of airway obstruction. Secure the drain safely to avoid accidental pulling, and advise the patient to talk as little as possible during the first few hours to reduce oedema to the vocal cords.
5 Managing Acute Pain
Post-operative pain management focuses on preventing pain rather than treating pain already at a severe stage. Analgesia treatments are often prescribed at regular intervals to keep the patient on an effective therapeutic dose. The most common approaches for post thyroidectomy pain management include:
Opioid Analgesics, such as codeine, morphine and fentanyl
Patient-Controlled Analgesia (PCA), which usually contains opioid analgesics
Ask your patient to locate their pain and give it a score from a range of 1-10, with 10 being very severe pain. This will allow you to monitor the effectiveness of the chosen pain management approach.
If your patient is receiving opioid analgesics, you’ll need to check their vital signs and evaluate their level of consciousness before every administration. This is because analgesics have a sedating effect, which might decrease the patient’s heart rate, respiratory rate and level of consciousness. The Pasero Opioid-Induced Sedation Scale (POSS) and the Glasgow Coma Scale are two of the most commonly used tools to determine the patient’s level of consciousness and, ultimately, the safety of administering more analgesics.
Follow all the standard treatment administration guidelines, and explain the expected side effects to your patient. In addition, if the patient has a PCA, explain how to use it and reassure them that it is safely programmed to maintain a therapeutic drug level and avoid overdose. If the analgesics are being administered in IV form, you’ll need to assess the cannula for any signs of infection and patency. And the same approach can be taken when evaluating the insertion site for an epidural or intrapleural infusion.
6 Managing Post-Operative Nausea and Vomiting (PONV)
PONV is a widespread occurrence, and apart from causing discomfort to the patient, it can also cause several complications, including:
Dehydration, hypotension and electrolyte imbalance
Stress on the suture lines and incision dehiscence.
Hence, you need to administer prescribed antiemetic medications or GI stimulants at the first signs of nausea to avoid the stress of vomiting. You should also position the patient upright to decrease the risk of aspiration and provide them with a vomiting bag if necessary.
7 Managing an Imbalanced Body Temperature
The risk of hypothermia during the surgery is increasingly high. This is because the operating rooms are kept at a relatively low temperature, and, more so, the patients have to lay still on the theatre table with their light hospital gowns.
To manage hypothermia, start by obtaining a temperature reading and evaluating the patient’s environment. Change their soiled gown and sheets with a new clean and warm pair, and use a lightweight blanket to cover their body. If the patient remains cold or has a severely low temperature, you can use patient warming devices such as the Bair Hugger and the Foil sheet. You can also use a fluid warmer when administering IV fluids.
On the other hand, the patient might have been overheated in the operating room or had an ongoing infection that could cause hyperthermia.
In this case, start by adjusting the patient’s environment. Remove any unnecessary blankets and sheets and lower the room temperature. Apply cold packs or cold towels to help the patient cool down and continue to administer the fluids at room temperature. If the patient has a fever secondary to an infection, administer paracetamol and antibiotics as prescribed.
8 Improving skin Integrity
Impaired skin integrity in post-operative patients results from inadequate moving and handling, pressure points, decreased ambulation and decreased nutrition.
Keep the patient’s gown and sheets dry and uncreased, and avoid friction whenever you ambulate the patient. Next, check that your patient meets their daily fluid and nutritional requirements, and administer any supplemental nutrition as prescribed. Regularly assess their incision site and clean it using an aseptic non-touch technique to avoid surgical site infections.
Advise your patient to consume a high protein diet to aid the natural process of skin repair and stay hydrated to help the skin’s elasticity. Moreover, it’s essential to explain how they should care for their incision after leaving the hospital.
In most cases, a thyroidectomy incision is closed using absorbable sutures, which would naturally dissolve within the body after a couple of days. Advise your patient to keep the area clean and dry and avoid using harsh soaps, perfumes, and jewellery until the incision site has completely healed. They could opt to use a soft cotton scarf to protect the incision from environmental dust and sun rays.
9 Managing Deficient Knowledge
Educating the patient about their surgery and recovery has been linked to improving the post-operative outcomes.
Start by introducing yourself, and ask the patient what they’ve understood about the thyroidectomy surgery and why it was done. Such information should have been given in the pre-operative stage, but some patients might have new concerns or questions about the surgery. Next, explain the expected recovery, what diet they can consume and what level of exercise they can be expected to tolerate. Explain what treatment they’re receiving and why it has been prescribed.
Discuss the care of their surgical incision and any additional devices they might go home with, such as catheters, stomas, drains or pacemakers. If necessary, provide them with community care or outpatient appointments to clean and monitor their incisions and devices. Explain the signs of infection, and provide a contact number that they can call to seek medical assistance.
Evaluate the patient’s support system at home and provide community care as needed. Go over their regular treatment, and highlight any additional medications or changes in their prescriptions. Update their treatment chart and provide them with written information to ensure they continue their care at home. Encourage your patient to seek support groups and address their psychological and spiritual needs as required.
10 Managing Anxiety
Experiencing anxiety and fear after a thyroidectomy is extremely common, and in most cases, this stress stems from a lack of understanding. Patients often feel anxious because they have no control over their situation, and similarly, they experience fear because they cannot anticipate what is about to happen. However, these factors can be controlled through adequate education, support and anxiety stemming techniques.
Start by creating a safe space where your patient feels comfortable voicing their feelings and expressing their concerns. While talking to your patient, evaluate their body language, constant fidgeting, avoidance, crying or not talking are all signs that the patient is uncomfortable. Ask the patient what they know about their situation and move on from there, educating as necessary. Moreover, assure the patient that the surgical team is professional and they will do their utmost to ensure the best possible outcome.
Encourage your patient to join a support group or look out for other individuals who have previously had the same surgery. Sharing experiences can provide a greater sense of support and motivation for the patient. Lastly, you can use deep breathing techniques, music therapy or imagery to distract the patient and reorient their focus onto something more pleasant.
Thyroidectomy Post-Operative Nursing Care References