CLINICAL REPORT:

NURSING CLIENT CARE OF A PATIENT WITH LEFT THYROID ENLARGEMENT

(GOITRE).
Ushi, E. Precious and Shiaka N. Michael
School of Nursing, ABU Teaching Hospital, Zaria, Kaduna State, Nigeria.
Abstract
Goitre, a disease characterised by the enlargement of the thyroid gland can result from
insufficient levels of iodine in the diet. Much effort has been made by the World Health
Organization in collaboration with different health agencies and countries to eradicate gotire
using various interventions, particularly the consumption of iodised salt. However, there are still
cases of goitre in our society, though the incidence has greatly reduced. This client care was
carried out on a patient who presented with goitre at the Ahmadu Bello University Teaching
Hospital, Shika. She had surgery done and was given adequate nursing and medical care which
all proved effective and was discharged without any complication. Health education and
surveillance should be intensified to eradicate the disease.

Key words: Client care, Multi-nodular, goitre, Patient

INTRODUCTION
This client care study was carried out on a 30 year old lady, who was not in distress, not
pale, anicteric, acyanosed, nil pedal oedema, and not dehydrated. She came into the surgery
outpatient department of Ahmadu Bello University Teaching Hospital, Shika on 6th January, 2014
for a medical appointment. After series of examination, a clinical diagnosis of Left Thyroid
Enlargement (Goitre) was made and she was admitted into Female Surgical ward on 17th March,
2014 for surgery and further management.
The normal thyroid is a fairly homogenous structure, but nodules often form within its
substance. These nodules may be only the growth of localised colloid-filled follicles, or more or
less discrete adenomas or cyst. Nodules less than 1cm in diameter not clinically detectable unless
located on the surface of the gland are much more frequent (Neto, 2013).
Studies have shown that in areas of iodine deficiency, goitre prevalence is very high.
Females are commonly affected probably due to a higher secretion of thyroid hormones to meet
up metabolic demands during reproductive cycles (Thyroid Manager.org, 2012).
Goitre can be managed using different approaches. This includes thyroid hormone replacement,
radioactive iodine and surgery (thyroidectomy) (Wisse, 2013).

LITERATURE REVIEW
Review of Goitre
According to Smeltzer et al (2010), goitre is defined as an enlargement of the thyroid
gland, usually caused by an iodine-deficient diet. Goitre is an enlargement of the thyroid gland
without signs of hyperthyroidism caused by a relative lack of thyroxine and triiodothyronine
(Waugh and Grant, 2010).
Goitre has many associated possible causes. As a result, there are different types of goitre.
These types according to Healthline Networks (2014) include; endemic or colloid goitre, non-
toxic or sporadic goitre and toxic or multi-nodular goitre

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 According to NHS Choices (2013), there are several causes of goitre, these include iodine
deficiency, overactive thyroid gland, underactive thyroid gland, smoking, pregnancy and puberty,
exposure to radiation, ingestion of lithium, hereditary factors and infection.
On the incidence, goitre and thyroid disease in general are very much more common in
females than in males. The World Health Organisation (WHO) estimated that goitre affects 12%
of the population worldwide, with the figure being slightly lower across Europe (WHO, 2010).
According to the Punch Newspaper (17th June, 2012), there is a link between the consumption of
iodine deficient foods, including improperly processed cassava products and goitre. Goitre is
usually endemic in mountainous regions. It can also occur in low-lying areas of the world. In
Nigeria, Ondo, Enugu, Plateau, Kano, Adamawa and Abeokuta are places where high rate of the
disease has been recorded due to their rocky and mountainous terrain. Goitre rate in Nigeria,
which was 20% in 1993, was found to have dropped to 11% in 1999. UNICEF however reported a
total goitre rate (TGR) of 7.7% in 2004.

Clinical Manifestations
Some of the signs and symptoms present in simple or non-toxic goitre.
1. A visible swelling on the neck due to hyperplasia and hypertrophy (the swelling is often
painless).
2. Dysphagia (difficulty in swallowing) from pressure on the oesophagus.
3. Hoarseness of the voice due to pressure on the nerve controlling the vocal cords (recurrent
laryngeal nerve).
4. Tremor, nervousness and irritation due to disturbance in nerve stability.
5. Sweating as a compensatory mechanism to raised body temperature.
6. Increased blood pressure due to over activity of the thyroid gland.
7. Increased body temperature due to increase heat production in the body etc (Usha, 2009).

Pathophysiology of Goitre
The deficiency of iodine in the diet or in the blood stream causes deficient production of
thyroid hormones by the thyroid gland. The deficiency of these hormones in the blood stream
stimulates the anterior lobe of the pituitary gland to produce its hormone called thyroid-
stimulating hormone (TSH). The increase production of TSH is to stimulate the thyroid gland to
produce adequate thyroid hormone. The effect of this thyroid stimulation leads to the increase in
the number and size of the follicles in the thyroid gland, as well as the accumulation of viscid fluid
called colloid within the gland. Thus leading to the enlargement of the thyroid gland called
SIMPLE GOITRE. The prolonged iodine deficiency and excessive stimulation of the thyroid
gland by the TSH lead to the development of nodules containing grossly distended follicles, hence
multinodular goitre. The compression of the larynx and trachea gives rise to manifestations of
respiratory obstruction like cough, dyspnoea, stridor, cyanosis and restlessness. The compression
of the oesophagus leads to dysphagia, while a compression of the recurrent laryngeal nerves may
lead to hoarseness of the voice (Mustapha, 2010).

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Investigations
a. Physical Examination: this includes inspection, palpation, and auscultation
b. Laboratory and Diagnostic Studies: this include serum thyroid stimulating hormone,
serum free thyroxine, serum triiodothyronine (T3) and Thyroxine (T4), Triiodothyroxine
Resin Uptake Test, Thyroid Antibodies, Radioactive Iodine Uptake, Thyroid Scan,
Laryngoscopy (Brickley, 2007; Usha, 2009; Smeltzer et al 2010).

Medical-Surgical and Nursing Management

Medical Management
The medical management depends on the severity or the level of the goitre.
i. Iodine Therapy: Iodised salt can be administered as prophylactic treatment of simple
goitres. Also, treatment with thyroid hormone may prevent further thyroid enlargement (Wilson,
2005).
ii. Drug Therapy: Antithyroid drugs are usually used short term prior to radioactive iodine
therapy for toxic multinodular goitre. Antithyroid medication inhibit one or more stages in thyroid
hormone synthesis or hormone release. They include propylthiouracil (PTU), methimazole,
sodium iodide, potassium iodide, saturated solution of potassium iodide (SSKI), dexamethasone,
beta-blocker e.g propanolol (Morton and Fontaine, 2009).

Surgical Management
Surgery is primary or necessary when there is a marked symptom and also to avoid
malignancy. Thyroidectomy is the surgical operation performed. Thyroidectomy either sub-total
(partial) or total entails removal of about five-sixths of the thyroid tissue or removal of the entire
gland respectively. Sub-total thyroidectomy is usually performed in benign cases such as non-
toxic or simple multinodular goitre (Usha, 2009). Following surgical intervention, proper
nursing care as for a post-operative patient is instituted

Prognosis and Complications

The prognosis for goitre is good if detected and treated early. Complications include recurrent
laryngeal nerve injury, Haemorrhage, Tetany, Respiratory obstruction, Thyroid infection and
Oedema (tissue swelling) (Medscape, 2013).

DETAILED MANAGEMENT OF THE CLIENT

The patient was admitted into the Female Surgical Ward of ABUTH on 17th March, 2014
at about 11am after she was seen at Surgical Outpatient Department (SOPD) and booked for an
elective surgery (thyroidectomy). She was welcomed, introduced into the ward and admitted on a
comfortable bed.
The nursing process approach was used to assess the patient; through this process, the
health history, and physical examination (inspection, palpation, percussion and auscultation) were
collected and the following nursing diagnoses were made;
1. Anxiety related to fear of outcome of surgery, evidenced by verbalization.
2. Disturbed body image related to potential swelling on the neck evidenced by verbalization.
3. Deficient knowledge (regarding cause of disease condition) related to insufficient
knowledge on the disease condition evidenced by patient asking questions.

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Vital Signs on Admission: - Temperature 36.20C, - Pulse 76b/m, Respiration 22c/m, BP
120/80mmHg

Investigations and Result

- Urinalysis: urinalysis was negative for glucose and protein.
Laboratory Investigation: Haematology, chemical pathology and radiology results are shown
below out,
Serum Urea and Electrolyte Result Normal Range
Urea 3.1mMol/L 2.5 – 6.5mMol/L
Sodium 142mMol/L 136 – 145mMol/L
Potassium 4.0 mMol/L 3.6 – 5.2 mMol/L
Chloride 103 mMol/L 94 - 108 mMol/L
Bicarbonate 26 mMol/L 24 - 32 mMol/L
Creatinine 71 mMol/L 9 - 126 mMol/L

Serum Hormones Result Normal Range

Triiodothyronine (T3) 0.8ng/ml 0.5 – 2.0ng/ml
Thyroxine (T4) 60ng/ml 46 – 112ng/ml
Thyroid stimulating hormone 2.0 µMol/L 0.3 – 6.5 µMol/L

Liver Function Test Result Normal Range

AST 7 IU/L 5 – 22 IU/L
ALT 5 IU/L 16 – 40 IU/L
ALK Phos 27 IU/L 21 – 92 IU/L
Total Bilirubin < 17 mMol/L 4 - 17 mMol/L

Serum Glucose Result Normal Range

Fasting 4.1 mMol/L 2.5 – 6.5mMol/L
Random 4.1 mMol/L 3.0 – 8.3 mMol/L

Neck Ultrasound Result: The result revealed that the left thyroid lobe is grossly enlarged when
compared with the right thyroid lobe. It measures 67cm 3 in volume compared with the right lobe
which measures 2.6cm3 in volume. The parenchymal echocentre is distorted by multiple
coalescing cystic lesions. However, no solid nodular lesion seen within it. No calcification seen
within it as well. The right thyroid lobe, isthmus, strap muscles and the neck vessels are within
normal limits.
Conclusion on the Neck ultrasound: Left Thyroid Enlargement (Goitre).

Pre-operative Nursing Care

The patient was mobile and been walked up for surgery. She was health educated, physical
care (personal hygiene) was ensured while psychological care was provided. On the third day of
admission, she was reassured by the Nursing and Surgical team. The nature of the surgery was
explained to her. She asked many questions which were answered by the Surgical and Nursing
team.
At 10am, the anaesthetic unit came to review her. Thereafter, consent form was signed by
her in the presence of the Nurses and Doctors. She was counselled on anaesthesia and told to
commence nil per os (not to eat or drink anything) from 10pm which she complied to.
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 On the 4th day of admission (the operation day), she had a warm bath during the early
hours of the morning, urinary catheter was inserted and IV line was set, jewelleries removed, her
urine was collected and tested for glucose and protein. The result read negative. She was
encouraged to pray for a successful surgery, she was also reassured that all would turn out well.
Relatives were also reassured. She was then drapped in theatre gown. Her laboratory results and
other vital documents were placed in her folder which would go along with her to the theatre. Her
vital signs was assessed at 8.15am which reads as follows; Temperature 36.00C, Pulse 76b/m,
Respiration 22c/m, Blood pressure 120/80mmHg
She was wheeled to the theatre at about 8.20am and was handed over to the theatre Nurse,
with her folder and some prescribed drugs (IV metronidazole and ciprofloxacin). She was planned
to undergo sub-total thyroidectomy.

Post-operative Nursing Care

On returning back to the ward, a post-operative bed was made with the following by the
bedside; a drip stand, observation tray, suction machine, and oxygen cylinder. At about 11.25am,
she was received from the theatre conscious after a successful thyroidectomy. She was oriented to
time, place and person. Operation and drain sites were dry and covered. No abnormal bleeding.
She was wheeled into the ward at 11.40am and placed on the already made post-operative bed on
a supine position so as to reduce strain and pressure on the surgical site. The post-operative vital
signs at 11.45am reads thus; Temperature 36.00C, Pulse 80b/m, Respiration 20c/m, Blood pressure
130/80mmHg.
The following drugs were prescribed; IV. Ciprofloxacin 200mg 12hourly, IVF Dextrose Saline
5% 1L 8hourly, IV PCM 300mg 8hourly, IV Pentazocine 30mg 6hourly x 2/7. The drugs were
commenced immediately, precisely at noon.
Specific nursing cares provided post-operatively include;
 Physical care: assisted bed bath was done 48 hours (2days) post-operative, subsequently, she
resumed bathroom bath while necessary assistant was provided. Oral care was also ensured
using soft brush; this was done by the patient herself. Care of pressure areas was also done
using soap and water as well as talcum powder within the 48hours post-operative; she was
encouraged to ambulate subsequently.
 Administration of prescribed medications: the prescribed drugs as listed above were
administered using the rights of drug administration (right drug, right dose, right patient, right
time, right route and right documentation).
 Elimination (intake and output) care: The patient’s intake and output were strictly
monitored, the intake during the first 48 – 72hours was mostly IVF Dextrose saline. The
output was the sum of the urine passed and the drains from the operated site. The intake and
output chart was balanced each day.
 Psychological care: Good rapport was created with the patient and her relatives, they were
reassured, questions were answered, while the likely outcome of the condition was explained.
They were encouraged not to entertain any fear.
 Observation: Patient vital signs were closely observed, precisely quarter-hourly immediately
she was admitted from the theatre. The IV infusion was closely monitored along the intake
and output. The operated site was also observed and there was no discharge noticed, the site
look clean, no swelling was also noticed.

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 Wound care: On the 2nd day post-operative, the operated site was opened and inspected
alongside the surgical team. It was observed to be clean and the dressing changed using sterile
technique. The wound was cared for on alternate days.
 Health education: It is believed that, patients on bed tend to assimilate and appreciate
information or instructions provided and adhere more to such instructions. It is on this basis
that the patient and her relatives were health educated on ways to prevent goitre, prevention of
malaria, living a positive mental health life and the need for regular exercise and medical
check-up among others.
On the 9th day of admission (5th day post op), at 10am, her team doctors came for review.
On examination, drain was out and operation site appeared dry and clean. They found that the vital
signs was stable, she and her relatives did not present any complain and appeared cheerful.
Plan: Her stitches were to be removed and consider for discharge. She was asked to do histology
and come back in two (2) weeks time with the result to the SOPD.
The stitches were removed, the operated site was intact, no opening seen, no bleeding and
discharge. At about 3pm, she was discharged home on drugs.

Advice on Discharge
Patient was advised on the importance of personal and environmental hygiene so as to
promote her wellbeing and prevent infection. She was health educated on the advantage and
importance of good nutrition (balanced diet) and the use of iodised cooking salt so as to promote
healing and good health respectively. She was also health educated on the importance of rest and
sleep so as not to overwork her body and also the need for exercise to help build body immunity
against diseases.
Finally, she was advised on the need to take her prescribed drugs, watch out for any
change in her body, follow-up and reporting any complication immediately to the hospital.

HOME VISIT
The patient was paid a home visit at her residence on 30th March, 2014. She was in a state
of quick convalescence. She was health educated on the importance of iodised salt in diet and the
need to reduce intake of goitrogenous substances like cabbage, cauliflower, etc. She was also
advised on the importance of personal and environmental hygiene, intake of nutritional diets,
fruits and vegetables.

FOLLOW-UP
She came back on 8th April, 2014 for follow-up. She was looking stronger and healthy.
She had nil fresh complaint. The physician observed the surgical site and it was healing already.
She was observed and her vital signs were stable.

NURSING DIAGNOSES

Pre-operative Nursing Diagnosis

1. Anxiety related to fear of surgery outcome evidenced by verbalisation.
2. Disturbed body image related to protruded swelling on the neck evidenced by
verbalisation.

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3. Deficient knowledge (regarding disease condition) related to insufficient knowledge on
disease condition evidenced by patient’s asking questions.

Post-operative Nursing Diagnoses

1. Ineffective airway clearance related to effect of anaesthesia evidenced by grunting
respiration.
2. Acute pain related to surgical incision on the neck evidenced by verbalization.
3. Risk for infection related to surgical incision on the neck.
4. Impaired physical mobility related to surgical incision on the neck evidenced by inability
to move the neck.
5. Impaired comfort related to surgical incision on the neck evidenced by verbalisation.
(NANDA 2012 – 2014).

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 NURSING CARE PLAN OF A PATIENT WITH SIMPLE MULTINODULAR GOITRE
Pre-operative
Nursing Nursing Objective Nursing Intervention Scientific Rationale Evaluation
Diagnosis
Anxiety related to Patient will verbalise i. Patient s anxiety was assessed i. Assessment serves as a baseline Patient verbalised less
fear of surgery less anxiety within 1 – ii. Nature of surgery/reason and anticipated ii. Knowledge on surgery and anxiety at the end of 1
outcome 2hours of nursing outcomes of surgery, risks, type of anticipated outcome of surgery will hour of nursing
evidenced by intervention. anaesthesia to be used and prognosis were reduce apprehension. intervention.
verbalisation explained to Patient. iii. Verbal expression of ideas
iii. Level of Patient’s understanding of helped clarify thought thus calming
surgical procedure was assessed by asking the client.
her questions. iv. Magazine serve as diversional
iv. Patient was provided with fashion therapies thus reducing anxiety.
magazine to read.
Disturbed body Patient will verbalise i. Patient was encouraged to express i. Expression of self gives room for Patient verbalised less
image related to less disturbance as feelings, especially about the way she feels, correction of misconceptions thus disturbance as regards
protruded regards body image thinks, or view self. improving self-worth and image. body image at the end
swelling on the within 45 minutes – ii. Patient was encouraged to acknowledge ii. Acknowledgement of weakness of 1 hour of nursing
neck evidenced 1hour of nursing feelings of grief, fear, hospitality and gives room for working on intervention.
by verbalisation intervention. dependency. strengths thus improving self-
iii. Patient was taught strategies for coping image.
with emotions such as interaction with iii. Engagement in gainful
family and friends, involvement in unit interactive and activities help to
activities. improve self-image.
iv. Patient belief was explored and iv. Areas of cloudiness clarified
misconceptions about self, care givers enhances belief and body image.
clarified. v. Avenue to express self enhances
v. Patient was provided opportunity to share body image.
with people going through similar
experiences.

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 Post-operative
Nursing Nursing Objective Nursing Intervention Scientific Rationale Evaluation
Diagnosis
Ineffective airway Patient will breathe i. Patient was placed on a recumbent i. Positioning enhances breathing Patient breathed without
clearance related without grunting position. ii. Suctioning clears airway thus grunting at the end of 30
to effect of within 15 – 30 ii. She was suctioned. enhancing breathing. minutes of nursing
anaesthesia minutes of nursing iii. Adequate ventilation was ensured. iii. Helps in easy breathing. intervention.
evidenced by intervention iv. She was encouraged and reassured that iv. Reassurance fosters hope and
grunting she would be better. compliance.
respiration
Acute pain related Patient will verbalise i. Patient was placed in a recumbent i. Positioning enhances comfort and Patient verbalised less
to surgical less pain within 15 – position. alignment of body thus relieving pain. pain at the end of 30
incision on the 30 minutes of nursing ii. Patient level of pain was assessed. ii. Assessment serves as a baseline. minutes of nursing
neck evidenced intervention. iii. She was reassured that the pain would iii. Reassurance and diversional intervention.
by verbalisation. subside, and diversional therapy created therapies serve as non-
through playing cool music. pharmacological methods of relieving
iv. She was served with prescribed pains.
analgesic e.g IV Acetaminophen 300mg. iv. Analgesics interfere with the
transmission of pain.
Risk for infection Patient will not i. Her wound dressing was done with i. Aseptic technique serves as Patient did not develop
related to surgical develop infection strict aseptic technique. infection control measure. any sign and symptom of
incision on the during the period of ii. She was health educated on the need to ii. Reduces the spread of infection. infection throughout the
neck. hospitalization. maintain personal and environmental iii. Proteinous diets and fruits increase period of hospitalization.
hygiene. body immunity and facilitates wound
iii. She was encouraged to eat high healing thus preventing the spread of
proteinous diets and to take much fruits. infection.
iv. She was served her prescribed iv. Antibiotics are bactericidal thus
antibiotics e.g IV ciprofloxacin 200mg interfering with DNA replication in
and IV metronidazole 400mg. susceptible bacteria preventing cell
replication.

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DISCUSSION
This discussion focused mainly on the differences and similarities between the literature
review and what was obtained from the care rendered to the patient. The areas of focus include;

Clinical Presentation:
On presentation to ABUTH, the patient presented with a visible swelling on the neck which
was painless and was diagnosed with simple goitre. However, she did not manifest all the clinical
presentations as stated by Usha (2009) in the literature probably as result of the stage of her goitre
and early presentation to the hospital for proper management.

Investigations
The following investigations were carried out on the patient; physical examination
(inspection, palpation and auscultation), serum thyroid stimulating hormone, serum
triiodothyronine and thyroxine, thyroid ultrasound, liver function test, serum glucose, serum urea
and electrolyte, pack cell volume, urinalysis and laryngoscopy. These investigations are in line with
what is obtainable in literature review as stated by (Brickley, 2007; Usha 2009; and Smeltzer et al
2010).

Treatment
Treatments for an enlarged thyroid include; thyroid hormone replacement pills, if the goitre
is due to an underactive thyroid. Some doses of Lugol’s iodine or potassium iodine solution if the
goitre is due to a lack of iodine. Radioactive iodine to shrink the gland, especially if the thyroid is
producing too much thyroid hormone. Surgery (thyroidectomy) to remove all or part of the gland
(Wisse, 2013).
However, the patient was not on any antithyroid medication as her condition was simple
goitre, but had surgical intervention. Nevertheless, after the surgery, she was placed on post-
operative antibiotics (ciprofloxacin and metronidazole) which serve as prophylaxis as well as
analgesics to relief discomfort.

Prognosis/complications
Patient’s prognosis was good. This is related to the fact that she sought medical intervention
early. Likewise, she did not develop any complication. This is in contrast with the complications
of goitre mentioned in literature review.

IMPLICATION FOR NURSING

The fact that this patient presented with goitre shows that there may still be many outside
there with the condition. Hence, Nurses should embark on surveillance particularly during Nurses
Week to identify people with goitre and help them receive treatment.

CONCLUSION
The patient, a 30 year old lady, was admitted into the Female Surgical Ward on 17th March,
2014, with a clinical diagnosis of Left Thyroid Enlargement (Goitre). She had sub-total
thyroidectomy surgery. She was given adequate nursing, as well as medical care during the period
of hospitalization. Her condition was satisfactory with the treatment regimen and was discharged on
25th March, 2014. Home visit was done on 30/3/2014 and follow-up visit on 8/4/2014.

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RECOMMENDATIONS
To Individuals
 Individuals in the community are hereby encouraged to use iodised cooking salt and
consume iodine-rich diets and products so as to prevent iodine deficiency which could lead
to goitre.
 People in the community should seek medical advice on any abnormal change in their body
physiology such as swelling in the neck, bulging of the eyes, difficulty in swallowing, etc
early to enhance proper and prompt management, thereby reducing the chance of chronicity
and complications.

To Health Care Workers

 Health care workers, particularly Nurses should engage in health education on the use of
iodised salts and encourage the populace on routine medical check-ups.
 Primary Health Care Workers should health educate mothers on the use of iodised salts.
 Disease surveillance should be carried out periodically to identify people that are still living
with goitre and ensure proper treatment.

To the Government and other Health Agencies

 Advocating government policies that will enforce the production, importation and use of
iodised salt in Nigeria.
 National Agency for Food and Drug Control (NAFDAC) and other government agencies
regulating foods should enforce the fortification or supplementation of foods with iodine.
 Government, through the Federal Ministry of Health should reduce the cost of treatment for
goitre, and if possible make it free, this will encourage people living with the disease to
come for treatment.
 The WHO and UN should set a target for the eradication of goitre just as in other diseases
like poliomyelitis.

REFERENCE
Brickley L.S (2007), Bate’s Guide to Physical Examination and History Taking (9th edition),
Philadelphia, Lippincott Williams and Wilkins publishers.
Healthline Networks (2014), “Goitre”. Available online at www.m.healthline.com/symptom/goitre.
Medscape (2013) “Differential Diagnosis and Complications of Goitre”. Retrieved from
http://emedicine.com/article/120497-overview.
Morton P.G and Fontaine D.K (2009), Critical Care Nursing; A wholistic Approach. Philadelphia,
Lippincott Williams and Wilkins publishers.
Neto I. (2013), “Multinodular Goitre” Available online at www.thyroidmanager.org/chapter/multi...
NHS Choices (2012), “Goitre”, Retrieved from
www.nhs.uk/conditions/goitre/pages/introduction.GSPX.
North American Nursing Diagnosis Association (2012 – 2014), Nursing Diagnosis.
Punch Newspaper (2012), “Incidence of Goitre”, Available at
www.punch.ng.com/home/health.

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Smeltzer C., Bare G., Hinkle L., and Cheever H., (2012), Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing (12th edition), USA, Lippincott Williams and Wilkins publishers.
Thyriod Manager.org (2010), “Multinodular Goitre”. Available at
www.thyroidmanager.org/chapter/multi...
United Nations Children Fund (UNICEF) (2014), Universal Salt Iodization in Nigeria; Process,
Successes and Lessons. www.unicef.org/nigeria/nh_publications_... Assessed on
12/08/2014.
Usha R.N (2009), Textbook of Medical-Surgical Nursing (1st edition), New Delhi, India, JAYPEE
Brother Medical publisher Ltd.
Waugh A. and Grant A. (2010), Ross and Wilson Anatomy and Physiology in Health and Illness
(11th edition), Edinburgh, Churchill Livingstone Elsevier.
Wisse .B. (2013), “Health Guide: Goiter – Simple; Symptoms, Diagnosis, Treatment” Retrieved
from http://www.nytimes.com/health/guides/disease/goiter/overview.html
World Health Organization (2010), World Health Organization Journal on Goitre. Available at
www.patient.co.uk/health/goitre/html.

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