CASE STUDY ON A

NODULAR NONTOXIC
GOITER
 INTRODUCTION
BACKGROUND OF THE STUDY
 Goiter or the enlargement of the thyroid gland is considered
prevalent in the Philippines. This disease in thyroid glands is
classified as an endemic, meaning present continuously in a
community, or sporadic goiter.
 Based on the studies on urinary iodine levels conducted by the
Department of Health, most goiter cases are found in the
mountainous provinces and other remote areas of the country,
where children and pregnant women are mostly affected.
 Some inland residents however, may have goiter because of
insufficient iodine intake in their diet aside from eating a lot of
goitrogenic foods, which are found in cabbage, soybeans,
peanuts, peaches, strawberries, spinach, and radishes. Other
people living in remote areas are discovered to have goiter
because of iron deficiency due to poverty.
 The most common cause of goiter in the country is iron
deficiency, but this condition is curable by mass food-
supplementation with iodine.
B. 5 SPECIFIC OBJECTIVES IN CHOOSING THE CASE

 We sought to be more familiarized about Goiter

 We wanted to use the knowledge that we have
acquired in promoting awareness to the people
more than ever to the poor that they seek for
medical care in order to put a stop the
development and progression of Goiter.
 We also wanted to focus on how to prevent and
treat this kind of disease.
 To enhance awareness about the importance of
having healthy lifestyle and good health
management.
 We want also to eradicate or reduce the number
of victims of this disease.
OVERVIEW OF THE DISEASE
 GOITER
 is an enlargement of the thyroid gland
 The thyroid can be enlarged due to generalized
enlargement of the thyroid or nodules (tissue
growths) within the thyroid
 The thyroid gland produces the hormones
thyroxine (also called T4) and a small amount
of triiodothyronine (also called T3). Most of the
T4 is converted to T3 outside of the thyroid.
These thyroid hormones influence such bodily
functions as a person’s body temperature,
mood and excitability, pulse rate, digestive
functions, and other processes necessary for
life.
SYMPTOMS
 A swelling, ranging in size from a small nodule to a massive lump, in the front of
the neck just below your Adam’s apple.

 A feeling of tightness in the throat area.

 Difficulty breathing (shortness of breath), coughing, wheezing (due to

compression of the windpipe).

 Difficulty swallowing (due to compression of the esophagus).

 Hoarseness.

 Neck vein distention.

 Dizziness when the arms are raised above the head.

 Coughing

 Difficulty swallowing

 Difficulty breathing
RISK FACTORS
 A lack of dietary iodine

 Sex

 Age

 Medical history

 Pregnancy and menopause

 Certain medications

 Radiation exposure
CAUSES
 Iodine deficiency
 Autoimmune thyroiditis - Hashimoto or postpartum thyroiditis
 Excess iodine (Wolff-Chaikoff effect) or lithium ingestion, which
decrease release of thyroid hormone
 Goitrogens
 Stimulation of TSH receptors by TSH from pituitary tumors,
pituitary thyroid hormone resistance, gonadotropins, and/or
thyroid-stimulating immunoglobulins
 Inborn errors of metabolism causing defects in biosynthesis of
thyroid hormones
 Exposure to radiation
 Deposition diseases
 Thyroid hormone resistance
 Infectious agents
 Acute suppurative - Bacterial
 Chronic - Mycobacteria, fungal, and parasitic
 Thyroid malignancy
POSSIBLE COMPLICATIONS
 Difficulty swallowing or breathing

 Hypothyroidism

 Hyperthyroidism

 Thyroid cancer

 Toxic Nodular Goiter

II. CLINICAL SUMMARY
PERSONAL DATA

Name: LS
Age: 34 y/o
Sex: female
Birthday: June 25, 1976
Address: San Isidro Cabuyao Laguna
Diagnosis: Nodular Nontoxic Goiter
Date of Admission: August 11, 2010
Attending physician: Dr. J. Bardonez, MD.
 
Chief Complaint: DOB and Dysphagia due to neck
mass.
 
PRESENT HEALTH HISTORY:

 This is a case of a 34 years old female brought

to the institution due to difficulty of
breathing and dysphagia due to neck mass.
 10 years PTA the patient notice enlargement
of her anterior neck with no accompanying
symptoms and no meds given.
 4 months PTA there is an increase size of
amount of neck mass with difficulty of
breathing and dysphagia experienced with
feeling of obstruction in while breathing and
swallowing.
 FNAB and neck ultrasound was done to rule
out thyroid cancer.
PAST MEDICAL HISTORY:
 General Health – Conscious and coherent
 Childhood Illnesses – Cough and colds,
chicken pox, mumps
 Accident and Injuries – She experienced
minor injuries during her childhood years.
 Hospitalization – First time to be hospitalized
 Immunization – Completed immunization
according to her mother.
 Allergies – Allergic to shrimp and “alamang”,
known allergy to amoxicillin
 Surgeries – Undergone subtotal
thryroidectomy.
FAMILIAL HISTORY
PHYSICAL ASSESSEMENT
 Area technique Norm Finding Analysis and
intervention

A.Skull
1. Size, shape Inspection , Smooth, Rounded head Rounded Normal
and Symmetry Palpation (normocephalic and head
of the Skull symmetrical) (Normoceph
alic)

2. Presence of Inspection , Smooth, uniform No presence Normal

nodules, masses Palpation consistence; Absence of nodules
and depressions of nodules and masses and masses

3. Facial Inspection , Symmetric or slightly Symmetrical Normal

Features Palpation asymmetric facial facial
features features
4. Presence of Palpation No edema and No edema Normal
edema and hollowness
hollowness in
the eye.
B.hair
Evenness of Inspection, Evenly equally Normal
growth, palpation Distributed, distributed
thickness, of covers the hair; color
thickness of whole black
hair scalp maybe
thick or thin
Texture and Inspection, Resilient hair Resilient hair Normal
oiliness over palpation
the scalp
Presence of Inspection, No infection and No infection Normal
infection and palpation infestation and
infestation infestation
in the hair
and scalp
C. Face
Facial features, inspection Symmetric facial Symmetric Normal
symmetry of movements facial
facial movements
movement
D. eye
1. EYEBROWS
Hair distribution, inspecti Symmetrical and in line Even Normal
alignment, skin on with each other; distribution
quality and maybe black, brown or of
movement blond depending on eyebrows,
race; evenly symmetrica
distributed l

2. EYELASHES
Evenness of distribution Even distributed; turned Evenly Normal
and direction of curl outward distributed,
turned
outward

Surface characteristics Upper eyelids cover the Slight protrude Normal

and position (in small portion of the and able to
relation to the iris, cornea and sclera close eyes
cornea, ability to when eyes are open; and to
blink, and frequency eyelids meet blink
of blinking) completely when the normally
eyes are close;
symmetrical
4.
CONJUNCTIVA
a. Color, texture, inspection Pinkish in color with Pinkish in color Normal
and the presence presence of small with presence of
of lesions in the capillaries; moist; no small
bulbar foreign bodies; no ulcer capillaries, no
conjunctiva ulcer
b. Color, texture, Inspection Pinkish in color with Pinkish in color Normal
and the presence presence of small with presence of
of lesions in the capillaries; moist; no small
palpebral foreign bodies; no ulcers capillaries; no
conjunctiva ulcers
5. SCLERA
Color and clarity Inspection White in color; clear; no White in color, Normal
yellowish discoloration; no yellowish
capillaries maybe visible discoloration;
6. CORNEA
Clarity and Inspection No irregularities on the Clear and Normal
texture surface; clear or smooth in
transparent texture
Iris
Shape and Inspection Anterior chamber is Black in color; Normal
color transparent; no noted anterior chamber
visible materials; is transparent
color depends on the
person’s race.
8. PUPILS
a. Color, shape Inspection Color depends on race; Black and equally Normal
and and are equally in round in shape
symmetry size; equally round
of size
b. Light Inspection Constricts when light is Constricts when Normal
reaction directed to the eye, there is light and
and both directly and dilates again if
accommod consensual light is off
ation
9. VISUAL
ACUITY
a. Near vision Inspection Able to read newsprint Able to read clearly; Normal
20/20 vision
10. LACRIMAL
GLAND
Palpability and Inspection No edema or No edema and Normal
tenderness of tenderness over tenderness
the lacrimal lacrimal gland
gland
11.
EXTRAOCUL
AR MUSCLE
Eye alignment and Inspection Both eyes are Both eyes are Normal
coordination coordinated, coordinated
move in unison,
with parallel
alignment
12. VISUAL
FIELDS
Peripheral visual Inspection looking straight Can see object Normal
fields ahead, the peripheral
patient can see field
object
Ears
1.auricle
a. Color, Inspection Color same as facial skin; Same color as of Normal
symmetry auricle aligned with the facial skin;
of size, outer canthus of the symmetrical;
and eye, about 10 degrees tip is aligned
position vertical at the outer
canthus of the
eye
b. Texture, Inspection Mobile, firm, and not Smooth in Normal
elasticity tender; pinna recoils texture;
and areas after it is folded flexible and
of elastic pinna;
tenderness no tenderness
2.HEARING
ACUITY
TESTS
Client’s Inspection Responds to normal Doesn’t respond Normal
response voice tones to normal
to normal voice tones
voice
tones
Nose
a. Any deviations in Inspection Symmetric and Symmetric Normal
shape, size or color straight; no and
and flaring or discharge or straight;
discharge from the flaring; uniform in
nares uniform in color
color
b. Nasal septum Inspection Nasal septum in midline Normal
(between the nasal intact in
chambers) midline
c. Patency of both Inspection Air moves freely moves freely Normal
nasal cavities as client breathes
breathes through
through the the nares
nares

d. Tenderness, masses, Inspection, Not tender; no No lesions Normal

and displacements Palpation lesions and
of bone and tenderness
cartilage
G. SINUSES
Identification of Inspection Not tender; frontal and Not tender; frontal Normal
the sinuses , sphenoid sinuses and sphenoid
and for Palpati not palpated sinuses not
tenderness on palpated
H. MOUTH
1. LIPS
Symmetry of Inspection Uniform pink in color; Dry and cracked lips Normal
contour, , soft, moist, smooth
color and Palpati in texture;
texture on symmetry of
contour; ability to
purse lips
2. BUCCAL
MUCOSA
Color, moisture, Inspection Uniform pink in color; Dry Normal
texture and moist, smooth,
the presence soft, glistening,
of lesions and elastic texture
3. TEETH
Color, number and Inspection Complete teeth; 32 teeth Complete Normal
condition and
presence of
dentures
4. GUMS
Color and condition Inspection Pink gums ; has no visible Pinkish in color Normal
retractions and no
retractions
5. TONGUE/FLOOR
OF THE MOUTH
a. Color and texture of Inspection Pink color; moist; slightly Pink in color; Normal
the mouth floor and rough; thin whitish moist;
frenulum coating; moves freely; moves freely
no tenderness and has no
tenderness
b. Position, color and Inspection Central position; pink Positioned in the Normal
texture, movement color; smooth tongue center
and base of the base with prominent
tongue veins
c. Any nodules, lumps, Inspection Smooth with no palpable No tenderness Normal
or excoriated areas Palpation nodules, or excoriated nor masses
areas
6. PALATES AND
UVULA
a. Color, shape, Inspection, Light pink, smooth, soft Light pink in Normal
texture Palpation palate; lighter pink color,
hard palate, more smooth in
irregular texture texture
b. Position of the Inspection Positioned on midline Positioned in Normal
uvula and of soft plate the middle
mobility ( while of the
examining the oropharynx
palates)
7. OROPHARYNX
AND TONSILS
a. Color and Inspection Pink and smooth Pinkish and Normal
texture posterior wall smooth
b. Size, color and Inspection Pink and smooth; no Has no Normal
discharge of the discharge; normal in discharge;
tonsils size pinkish in
color
c. Gag reflex Inspection Present Present gag Normal
reflex
I. THORAX
1. ANTERIOR
THORAX
a. Breathing Inspection Quiet, Soundless, Normal
patterns rhythmic, rhythmic and
and effortless
effortless breathing
respirations
b. Temperature, Palpation Skin intact; Normal Normal
tenderness, uniform temperature
masses temperatur temperature,
e; chest no masses. no
wall intact; tenderness
no
tenderness;
no masses
c. Auscultation Quiet and no Quiet and no Normal
Anterior thorax harsh harsh sounds
auscultation sounds
2. POSTERIOR
THORAX
a. Shape, Inspection, Anterioposterior Anterioposterior normal
symmetry, and Palpation and and transverse
comparison of transverse diameter are
anteroposterior diameter are equal
thorax to equal
transverse
diameter
b. Spinal alignment Inspection Spine vertically Has a vertical Normal
aligned alignment
c. Temperature, Palpation Skin intact; Skin is intact with Normal
tenderness and uniform no lesions,
masses temperature; tenderness and
chest wall no masses
intact; no
tenderness;
no masses
d. Posterior thorax Auscultation No Harsh sound No harsh sounds Normal
auscultation
J. CARDIOVASCULAR
a. Aortic and Palpation No pulsation No heaves Normal
Pulmonic
Areas
b. Tricuspid Area Palpation No pulsation; No heaves Normal
no lift or heard
heave
c. Apical Area Palpation Pulsation Palpable in the Normal
visible in 5th
50% of intercoastal
adults and space left
palpable in midclavicul
most PMI in ar loine
fifth LICS at
or medial to
MCL
d. Epigastric Area Slight Aortic pulsation Has pulsations Normal
Palpation
K. CAROTID ARTERIES
a. Carotid artery Palpation Has a With symmetric Normal
palpation symmetric pulse volume
pulse
volumes
L. AXILLAE
Axillary, Inspection, No No tenderness Normal
subclavicular, Palpation tenderness, nodules and
supraclavicular masses, or masses
lymph nodes nodules
M. ABDOMEN
a. Skin integrity Inspection Unblemished Unblemished Normal
skin; uniform skin;
color
b. Abdominal Inspection and Flat, Normal
contour osculated rounded(conv Flat
ex), or
scaphoid(con
cave)
c. Abdominal Inspectio Symmetric movements Symmetrical normal
movements n caused by respiration; movement on
associated with visible peristalsis in the abdomen,
respirations, very lean people;
peristalsis or aortic aortic pulsations in
pulsation.admonal thin persons at
sounds epigastric area
N. MUSCOLOSKELETAL SYSTEM
1. MUSCLES
a. Muscles size Inspection Proportionate to the Proportionate to normal
and comparison body; even in both the body, even
on the other side sides in both sides

b. Fasciculation Inspection No fasciculation and No tremors Normal

and tremors in the tremors
muscles

c. Muscle tonicity Palpation Even and soft fats Even and soft Normal
fats
2. JOINTS

Joint swelling Inspection, No No swelling of Normal

Palpation swelling, no joints, no
warmth, no warmth, no
redness, no redness, no
pain, pain

3. Inspection, No There’s Abnormal

EXREMITIES Palpation swelling, no weakness
warmth, no
redness, no
pain
•Nursing History (Based on the Functional Health Pattern by Gordon)

A.HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

1. Client’s description of her/his health:

Before admission, the client perceives her health as well. She feels that she is okay. The
client said that she would take daily baths, brush her teeth after eating, and wash her hands
regularly. She has allergy in seafoods. She said that whenever she sick she’s not consult
her doctor.
She was aware about her disease 10 years ago. But she does not taking medication.
Upon admission, the client feels difficulty in talking.

1. Health Management:

The client verbalized that the interventions she would do to relieve her symptoms
whenever she would be sick were: adequate rest and sleep, and sometimes drinking of
medications.
 Expectations of hospitalization:

According to the client, her expectation is to regain the health that she had before she
was hospitalized. She expects that the hospital will ensure the recovery and satisfaction of
her needs.

Knowledge

The client is knowledgeable about the condition, treatment plan and prognosis.
According to the client, the doctor handling her frequently provides information regarding
her condition and the procedures to be undergone.

Reaction to above prescriptions:

The client does not have any reactions regarding the prescriptions given. The main
concern is for the client fast recovery. Furthermore, she is entrusting her health and
medical management to the medical health team especially the health care providers.
NUTRITION AND METABOLIC PATTERN
2.1 Usual food intake (before admission)

BREAKFAST LUNCH DINNER

Before 1 to 2 cup of rice and 1 to 2 cup of rice and 1 to 2 cup of rice and
usually fish of any of sometimes meat: which comprises of
kind or processed chicken or fish and vegetables, meat:
meat. comprises of veggies chicken, fish.
2-3 glasses of water 2-3 glasses of water 2-3 glasses of water

After Food given by the Food given by the Food given by the
hospital hospital hospital

Table 1.1 Food Intakes during Breakfast, Lunch and Dinner

Before admission, the client said that she could eat everthing except seafoods. She always uses
condiment for her food.
 2.2 Usual fluid intake (type, amounts)

Type of Fluid Amount

Water 12-15 glasses per day

Before admission

Upon admission Water 6 glasses per day

Table 1.3. Usual fluid intake of client before admission and at present
Preferences: The client prefers water as her usual source of fluids.

2.3 Any food restrictions:

Before admission, the client said that she could eat everthing except seafoods. She
always uses condiment for her food.
 2.4 Any problems with ability to eat:
The client has problems regard to ability to eat because of its difficulty in swallowing after the surgery.

2.5 Any supplements (vitamins, feedings)

The client said that she is not taking any vitamins or supplements.

3. ELIMINATION PATTERN
3.1 Bladder

Complaints on
Frequency per
Color the usual pattern Home remedies
day
of elimination

The client has no

3 to 6 times a day complaints or
No home
Clear yellow and at night she problems on the
Before Admission remedies used
void 2 times usual pattern of
urination.
Table 1.4 Bladder elimination pattern before admission
Before admission, the client urinated 5-8 times a day and at night she void 2 times with clear yellow output.
The client had no complaints or problems on the usual pattern of urination; there were no home remedies used.
 3.2 Bowel:

Complaints of
Frequency usual pattern
Color Consistency Remedies
per day of bowel
movement

Not- No home
brown every evening Semi-solid
Before constipation remedies

Not
At Present brown Everyday Semi solid None
constipated

Table 1.6 Bowel elimination pattern before admission and at present

The client verbalized that she defecates everyday with brown and semi-solid stool.
The client does not have constipation.
ACTIVITY EXERCISE PATTERN

•SLEEP-REST PATTERN

•COGNITIVE-PERCEPTUAL PATTERN

6.2 Ability to read and write. Any difficulty in learning?

6.1 Any deficits in sensory perception (hearing, sight, touch)

1.Memory

6.3 Any complaints? (e.g. pain)

ACTIVITY EXERCISE PATTERN

•SLEEP-REST PATTERN

•COGNITIVE-PERCEPTUAL PATTERN

6.2 Ability to read and write. Any difficulty in learning?

6.1 Any deficits in sensory perception (hearing, sight, touch)

1.Memory

6.3 Any complaints? (e.g. pain)

7. SELF-PERCEPTION PATTERN
7.1 What the client is most concerned about
7.2 Present health goals
7.3 Effect of present illness to self:

1.8. ROLE-RELATIONSHIP PATTERN

8.2 Manner of Speaking
8.3 Significant person to client
8.1 Language spoken
•SEXUALITY-SEXUAL FUNCTION

COPING-STRESS MANAGEMENT PATTERN

VALUE BELIEF SYSTEM
10.1 Decision making ability
11.1 Source of strength or meaning:
11.2 Importance of God to client:
11.3 Religious practices (type and frequency):
NURSING THEORY

Florence Nightingale
Environmental Theory

External influences can prevent, suppress or contribute to disease or death

Nightingale’s Concepts

Person 
•Patient who is acted on by nurse
•Affected by environment
•Has reparative powers

Environment
•Foundation of theory.  Included everything, physical, psychological, and social

Health
•Maintaining well-being by using a person’s powers
•Maintained by control of  environment

Nursing
•Provided fresh air, warmth, cleanliness, good diet, quiet to facilitate person’s reparative process
DEVELOPMENTAL STAGES

THE DEVELOPMENTAL STAGES OF ERIK ERIKSON

Young adulthood: 18 to 35
Ego Development Outcome: Intimacy and Solidarity vs. Isolation
Basic Strengths: Affiliation and Love
In the initial stage of being an adult we seek one or more companions and love. As we try to find mutually
satisfying relationships, primarily through marriage and friends, we generally also begin to start a family, though
this age has been pushed back for many couples who today don't start their families until their late thirties. If
negotiating this stage is successful, we can experience intimacy on a deep level.
If we're not successful, isolation and distance from others may occur. And when we don't find it easy to create
satisfying relationships, our world can begin to shrink as, in defense, we can feel superior to others.
Our significant relationships are with marital partners and friends.

FREUD’S DEVELOPMENTAL STAGE

Genital stage: post puberty
Physical focus: genitals
Psychological theme: maturity and creation and enhancement of life.  So this is not just about creating new life
(reproduction) but also about intellectual and artistic creativity. The task is to learn how to add something
constructive to life and society.
Adult character: The genital character is not fixed at an earlier stage. This is the person who has worked it all out.
This person is psychologically well-adjusted and balanced. According to Freud to achieve this state you need to
have a balance of both love and work.
KOHLBERG’S DEVELOPMENTAL STAGE
Stage 5: Prior Rights And Social Contract
Moral action in a specific situation is not defined by reference to a checklist of rules, but from logical application of
universal, abstract, moral principles. Individuals have natural or inalienable rights and liberties that are prior to
society and must be protected by society. Retributive justice repudiated. Justice distributed proportionate to
circumstances and need. "Situation ethics." The statement, "Justice demands punishment," which is a self-
evident truism to the Stage 4 mind, is just as self-evidently nonsense at Stage 5. Retributive punishment is neither
rational nor just, because it does not promote the rights and welfare of the individual. Only legal sanctions that
fulfill that purpose are imposed-- protection of future victims, deterrence, and rehabilitation. Individual acts out of
mutual obligation and a sense of public good. Right action tends to be defined in terms of general individual
rights, and in terms of standards that have been critically examined and agreed upon by the whole society--e.g.
the Constitution. The freedom of the individual should be limited by society only when it infringes upon someone
else's freedom.

PIAGET'S COGNITIVE STAGES

Formal Operations: (adolescence)
This stage brings cognition to its final form. This person no longer requires concrete objects to make rational
judgements. At his point, he is capable of hypothetical and deductive reasoning. Teaching for the adolescent may
be wideranging because he'll be able to consider many possibilities from several perspectives.
LABORATORY
 Hematology
Test Result Reference
Hemoglobin 139 Female (120 – 150)

Hematocrit 0.41 Female (0.39 – 0.47)

WBC 7.1 5-10 x 10^9/L

RBC 4.6 4-4.5 x 10^12/L

Differential

Segmenters 0.62 0.55-0.65

Lymphocytes 0.38 0.25-0.35

Platelet 222 150-400 x 100^9/L

URINALYSIS
Test Result

Color Light Yellow

Transparency SL Turbid

Specific Gravity 1.005

Ph 6.5

Albumin Negative

Sugar Negative
ULTRASOUND – THYROID
 Result:

 There is a cystic nodule in the right lobe measuring 2.6

x 1.1 x 1.5cm with a thick soft tissue rind. No septations
aseen. Minimal flow seen on the soft tissue. No
clarification seen.
 
 No focal nodule seen in the left lobe and isthmus. The
thyroid strap muscles are unremarkable

 No enlarged central neck lymph nodes seen.

 Conclusion: Cystic nodule in the right lobe. Consider a

hyperplastic nodule with cystic degeneration. Biopsy
recommended
ANATOMY AND PHYSIOLOGY
THE THYROID GLAND IS A BUTTERFLY-SHAPE ORGAN AND IS
COMPOSED OF TWO CONE-LIKE LOBES OR WINGS, LOBUS DEXTER
(RIGHT LOBE) AND LOBUS SINISTER (LEFT LOBE), CONNECTED
VIA THE ISTHMUS.
THE ORGAN IS SITUATED ON THE ANTERIOR SIDE OF THE NECK,
LYING AGAINST AND AROUND THE LARYNX AND TRACHEA,
REACHING POSTERIORLY THE OESOPHAGUS AND
CAROTID SHEATH. IT STARTS CRANIALLY AT THE OBLIQUE LINE
ON THE THYROID CARTILAGE (JUST BELOW THE LARYNGEAL
PROMINENCE, OR 'ADAM'S APPLE'), AND EXTENDS INFERIORLY TO
APPROXIMATELY THE FIFTH OR SIXTH TRACHEAL RINGIT IS
DIFFICULT TO DEMARCATE THE GLAND'S UPPER AND LOWER
BORDER WITH VERTEBRAL LEVELS BECAUSE IT MOVES POSITION
IN RELATION TO THESE DURING SWALLOWING.
 The thyroid gland is covered by a fibrous sheath, the capsula
glandulae thyroidea, composed of an internal and external
layer. The external layer is anteriorly continuous with the
lamina pretrachealis fasciae cervicalis and posteriorolaterally
continuous with the carotid sheath. The gland is covered
anteriorly with infrahyoid muscles and laterally with the
sternocleidomastoid muscle. On the posterior side, the gland is
fixed to the cricoid and tracheal cartilage and cricopharyngeus
muscle by a thickening of the fascia to form the posterior
suspensory ligament of Berry. In variable extent, Lalouette's
Pyramid, a pyramidal extension of the thyroid lobe, is present
at the most anterior side of the lobe. In this region, the
recurrent laryngeal nerve and the inferior thyroid artery pass
next to or in the ligament and tubercle.

 Between the two layers of the capsule and on the posterior

side of the lobes there are on each side two parathyroid glands
.
 The thyroid isthmus is variable in presence and size, and can
encompass a cranially extending pyramid lobe (lobus pyramidalis or
processus pyramidalis), remnant of the thyroglossal duct. The
thyroid is one of the larger endocrine glands, weighing 2-3 grams in
neonates and 18-60 grams in adults, and is increased in pregnancy.

 The thyroid is supplied with arterial blood from the

superior thyroid artery, a branch of the external carotid artery, and
the inferior thyroid artery, a branch of the thyrocervical trunk, and
sometimes by the thyroid ima artery, branching directly from the
brachiocephalic trunk. The venous blood is drained via
superior thyroid veins, draining in the internal jugular vein, and via
inferior thyroid veins, draining via the plexus thyroideus impar in
the left brachiocephalic vein.
 Lymphatic drainage passes frequently the
lateral deep cervical lymph nodes and the pre- and parathracheal
lymph nodes. The gland is supplied by parasympathetic nerve input
from the superior laryngeal nerve and the recurrent laryngeal nerve
.
 The primary function of the thyroid is production
of the hormones triiodothyronine (T3), thyroxine
(T4), and calcitonin. Up to 80% of the T4 is
converted to T3 by peripheral organs such as the
liver, kidney and spleen. T3 is several times
more powerful than T4, which is largely a
prohormone, perhaps four or even ten times
more active
 Thyroxine (T4) is synthesised by the follicular cells
from free tyrosine and on the tyrosine residues of
the protein called thyroglobulin (Tg). Iodine is
captured with the "iodine trap" by the
hydrogen peroxide generated by the enzyme thyroid
peroxidase (TPO) and linked to the 3' and 5' sites of
the benzene ring of the tyrosine residues on Tg, and
on free tyrosine. Upon stimulation by the
thyroid-stimulating hormone (TSH), the follicular
cells reabsorb Tg and cleave the iodinated tyrosines
from Tg in lysosomes, forming T4 and T3 (in T3, one
iodine atom is absent compared to T4), and releasing
them into the blood. Deiodinase enzymes convert T4
to T3Thyroid hormones that are secreted from the
gland is about 80-90% T4 and about 10-20% T3.
 Cells of the brain are a major target for the
thyroid hormones T3 and T4. Thyroid
hormones play a particularly crucial role in
brain maturation during fetal development A
transport protein that seems to be important
for T4 transport across the
blood-brain barrier (OATP1C1) has been
identified.[] A second transport protein (MCT8
) is important for T3 transport across brain
cell membranes.[
 Non-genomic actions of T4 are those that are not initiated
by liganding of the hormone to intranuclear thyroid
receptor. These may begin at the plasma membrane or
within cytoplasm. Plasma membrane-initiated actions begin
at a receptor on the integrin alphaV beta3 that activates
ERK1/2. This binding culminates in local membrane actions
on ion transport systems such as the Na(+)/H(+) exchanger
or complex cellular events including cell proliferation. These
integrins are concentrated on cells of the vasculature and on
some types of tumor cells, which in part explains the
proangiogenic effects of iodothyronines and proliferative
actions of thyroid hormone on some cancers including
gliomas. T4 also acts on the mitochondrial genome via
imported isoforms of nuclear thyroid receptors to affect
several mitochondrial transcription factors. Regulation of
actin polymerization by T4 is critical to cell migration in
neurons and glial cells and is important to brain
development.
 T3 can activate phosphatidylinositol 3-kinase
by a mechanism that may be cytoplasmic in
origin or may begin at integrin alpha V
beta3.
 In the blood, T4 and T3 are partially bound to
thyroxine-binding globulin (TBG), transthyretin
, and albumin. Only a very small fraction of
the circulating hormone is free (unbound) - T4
0.03% and T3 0.3%. Only the free fraction has
hormonal activity. As with the
steroid hormones and retinoic acid, thyroid
hormones cross the cell membrane and bind to
intracellular receptors (α1, α2, β1 and β2),
which act alone, in pairs or together with the
retinoid X-receptor as transcription factors to
modulate DNA transcription
 PATHOPHYSIOLOGY
follicular epithelial hyperplasia (diffuse
goiter) is present

Predisposing Factor:
Gender
Age increase in thyroid mass
Familial history

development of areas of involution and

Precipitating Factor:
fibrosis
Diet

results in multiple nodules
Aggravating Factor:
Exposure to radiation
Signs and symptoms:

·Swelling on the neck

· Breathing difficulties, coughing, or wheezing with

large goiter
· Difficulty swallowing with large goiter
· Feeling of pressure on the neck
·Hoarseness
 Generic/ Action Classificatio Indication Contraindic Side Effects Nursing Intervention
Brand n ation
Name
Inhibits Anti-biotic Peritonitis Allergy to Adverse Assess patient’s previous
Generic cell-wall and other penicillins effects: sensitivity reaction to
name: synthesis, intra- & Phlebitis & penicillin
Cefoxitin promoting abdominal cephalosp inflammati Assess for signs &
Brand osmotic and orins & on at the symptoms of infection
Name: instability intrapelvic people site of before & during
Mefoxin, infections, with injection & treatment: fever,
Panafox septicemia allergic GI earache
, drug reactions. Assess for allergic
endocardi backgroun Allergic reaction & anaphylaxis:
tis d signs, skin rash, urticaria, pruritus
reactions, Assess renal function
digestive before & during therapy:
reactions urine output, BUN &
creatinine. Monitor
nephrotoxicity
 Generic/ Action Classification Indication Contraindicati Side Effects Nursing
Brand Name on Intervention

Inhibit Analgesic To relieve Contraindica adverse Instruct

Generic prostaglandi Antipyretic signs and ted in effects: patient to
name: n synthesis, symptoms patients headache, promptly
Celecoxib impeding of hypersensiti abdominal signs of GI
Brand cyclooxygen osteoarthriti ve to drug, pain bleeding
Name: ase-2 to s sulfomides, hypertensio such as
Mefoxin, produce Acute pain aspirin or n, chest vomit,urine,
Panafox anti- and primary other pain, stool.
Celebrex inflamatory, dysmenorrh nsaids. Instruct
analgesic ea patient to
and take drug
with food is
stomach
upset
occurs.
Advise
patient to
immediately
report rash,
unexplained
weight gain
or swelling.
DISCHARGE PLANNING
Medication  Advise patient to take the prescribed
medications continuously at home
 Always check the expiration date of
the medicine before taking
Environment/Exercise  Avoid crowded areas, especially during
cold and flu season.
 Avoid close contact with anyone who is
ill.
 Provide safety measure to promote safe
environment and individual safety.
 Sanitary handling of food and water.
 Avoid strenuous activities.
Treatment  Eating a healthy diet (eating more fruits,
vegetables, and low fat dairy products,
less saturated and total fat).
 Reducing the amount of sodium in your
diet to 2,300 milligrams (about 1
teaspoon of salt) a day or less.
Hygiene  Ask for help if can’t do activities of
daily living.
 Always perform daily hygiene routine