Simple Goiter PRESENTED BY

(Nontoxic) BSN3G GROUP 2

DUPLAYNA, SALVE LAURICE

ESPENDE, SAMELA
ESTREMADURA, SHAUN EMMANUEL
ETCUBANAS, JANELLE
FERNANDEX, DAN FLOYD
FORTALEZA, ALYSSA NICOLE
GARCIA, JOSEFA MAYUMI
GINSON, KATHEREN NORA
GIPANAGO, SAARA GAYLE

 Objectives
1. Define what are goiters and the different types of goiters

2. Articulate the signs and symptoms of goiters

3. Enumerate the risk factors associated with goiters

4. Describe the pathophysiology of simple nontoxic goiter formation

5. Explain the nursing interventions for simple nontoxic goiters

6. Recall the pharmacological interventions and possible surgical interventions

for goiters
Brief Introduction
 The term “goiter” simply refers to the abnormal enlargement of the
thyroid gland that causes the neck to swell (Mayo Clinic, 2022)

Simple nontoxic goiter, which may be diffuse or nodular, is

noncancerous hypertrophy of the thyroid without hyperthyroidism,
hypothyroidism, or inflammation.

Specifically, iodine deficiency is the most common cause of goiter.

Most common symptoms include throat tightness, cough,

hoarseness, trouble swallowing, and in severe cases, difficulty
breathing.

According to the Philippine Thyroid Diseases' latest study in 2012, it showed that goiter has a
prevalence rate of 10.12 percent among
adults. Meanwhile, the 2013 National Nutrition Survey
showed that about 5.8 million Filipinos were afflicted with thyroid disorders such as goiters.
 Baseline Data
Name: Biboy Marquez
Address: Brgy. Pinggot, Ilog, Negros Occidental
Age: 43 years old
Sex: Male
Civil Status: Single
Date of Birth: May 4, 1979
Number of Siblings: 3
Number of Dependents: None
Religion: Roman Catholic
Highest Educational Attainment: Grade 3
Occupation: Farmer
Person next- to kin: Mother
Date of Admission: April 19, 2022, at 9 am
Attending Physician: Dr. Amy Peralta
Medical Diagnosis: Simple Goiter (Nontoxic)
Chief Complaints: Difficulty in swallowing, DOB, swelling at the
neck area, and tightening of the throat

 Health History
Patient was delivered via cesarean section since he was in a breech position and his mother had a
goiter at that time which was an indication for cesarean delivery.
As a child, he experienced the flu or common colds, pneumonia, chickenpox, and measles.
Fully vaccinated as a child and is also fully vaccinated against Covid-19.
Makes use of herbal medicines in treating his sickness.
Never been involved in a major accident.
No known allergies to seafoods and medications.
No records of previous surgeries
Diet consists mostly of poultry products, fruits and vegetables. He has no access to shellfish or fish
as they are living in the mountainous regions of Ilocos.
His mother and older brother also have a goiter.
His father was diagnosed with hypertension last 2017.
 Hx of Present Illness
Patient was admitted to CLMMRH with complaints of swelling on the neck, difficulty swallowing,
difficulty of breathing, and tightening of the throat and fever. He verbalized, “Nurse, kasakit sang akon
tutunlan kag kabudlay mag tulon, matyag ko daw kasarado sang tutunlan ko. Nabudlayan pa gid ko mag
ginhawa". His physical examination was remarkable for a patient with goiter.

One year ago, he noticed that his neck had been swelling, but he chose not to seek prompt medical
attention. He resorted to application of herbal medicines/leaves on his neck, but it did not alleviate the
swelling. 6 months ago, he decided to seek medical attention, unfortunately, he could not submit
himself for laboratory and diagnostic tests because he has no money for it.

Seven days PTA he was already alarmed by the signs and symptoms exhibited above so they tried to
contact the local emergency response team and were brought to the nearest hospital.Upon arriving at
the triage, the vital signs are as follows: T= 37.9, P= 83, R=27, BP= 130/80 mmHg, Spo2= 97%
Nursing History (Gordon's)
 HEALTH PERCEPTIONS AND HEALTH MANAGEMENT PATTERN
He eats fresh fruits and vegetables to boost his immune system since he can't

afford the vitamins sold in local pharmacies. He relies on herbal medicines that he
grows on his small farm when he gets sick. Additionally, he is a smoker and an
occasional drinker (tuba or beer).
When he had the lump on his neck, he applied kasla leaves to reduce the swelling
since he can't afford the medical bills. Lastly, he has complete vaccination and
immunization records.

NUTRITION-METABOLIC PATTERN
His diet usually consists of cabbage which is his favorite, cauliflower, broccoli, and
poultry products. He seldom consumes fish since it is not readily available in the
mountains. He can consume 2 cups of rice and he also drinks 2-3L of water everyday.
Currently, he weighs 65kg.
 ELIMINATION PATTERN

PTA, he describes his bowel elimination pattern as normal with 1-2 bowel movement per
day, describing its characteristic as formed to semi-formed, and he usually voids 6-8x a
day. Every time he has diarrhea, he finds relief in drinking the boiled leaves of Carob plant
and lemongrass. He has no discomfort or problems with his bowel and voiding patterns.
He has no perspiration problems or body odors as he practices good hygiene.

ACTIVITY AND EXERCISE PATTERN

He has an active lifestyle so he can perform his daily tasks without unnecessary fatigue.
He starts his day by waking up at 4am, cultivating his farm and feeding his chickens, and
ends the day by cooking for his mother. His daily activities serve as his exercise.
One month PTA, he started to experience weakness, hoarseness in his voice, tightening
of the throat, and frequent coughing. He tried to limit his daily activities in order to
get enough time for rest and sleep.
 COGNITION AND PERCEPTION PATTERN
He has no problems with his vision and hearing nor is using assistive devices like hearing
aids and eyeglasses. He also has no problems related to his memory, although he said
that he is not quite literate since he only finished Grade 3 in elementary school.
His mental state is good and functional. He also responds spontaneously and has good
attention span. He syllabicates words when he reads.

SLEEP AND REST PATTERN

He has adequate sleep for about 8-10 hours a day. He takes 30 minutes to 1 hour of nap
after lunch. He does not have sleep onset problems, uses sleeping aids, and does not
have nightmares or dreams that disturb his sleep or rest.
 SELF-PERCEPTION AND SELF-CONCEPT PATTERN
He stated that he does not feel good about himself and he lacks self-confidence,
especially because he has been feeling weak for the past month and due to the change of
his appearance, specifically the swelling on his neck. He is positive that he can be cured if
he has enough money.

ROLES AND RELATIONSHIP PATTERN

He is single, he neither has children nor in a relationship. He fears getting rejected due to
the change of his appearance. He recently started to isolate himself because he feels
like his neighbors are ridiculing his appearance. Currently, he lives with his father.

SEXUALITY AND REPRODUCTION PATTERN

He is not sexually active. According to him, there are no unusual changes with his
sexual activities and sex organs in general.
 COPING AND STRESS TOLERANCE PATTERN
The patient said they struggle financially so they have to work harder on the farm. He
smokes 3-4 sticks of cigarettes as a means to cope with stress, rather than taking
medicines. Additionally, he urinates quite often when he's feeling tense. He also tries to
calm himself by pulling his hands together.

VALUES AND BELIEFS PATTERN

He is a Roman Catholic and a firm believer in the existence of the Lord. Although he
seldom goes to church, he thinks that religion is an important aspect in his life. He prays
for strength and guidance to overcome his condition.
According to Lawrence Kohlberg’s Theory of Moral Development, he is in the Universal
Principles level of moral reasoning, which means he has developed his own set of moral
guidelines which may or may not fit the law such as human rights, justice, and equality.
Assesment

General Appearance

Days 1-3

The patient has a visible growth in his

neck area. No major movements on the
neck area are performed to avoid
occurence of pain.
Head, Eyes, Ears, Nose, Throat

Days 1-3

There is swelling of the neck upon

inspection and thyroid gland is
palpable.
Verbalization of pain and difficulty
when swallowing is noted; pain scale
of 8/10.
Hoarseness of voice during interview
 Gastrointestinal

Day 1 Day 2 Day 3

Patient's diet Patient has Patient is

mainly consists of normal bowel starting to
vegetables and movemnts after swallow liquid
poultry, and shifting to NGT foods, but still
seldom eats fish feeding experiences
and other discomfort
seafood rich in when
iodine swallowing
Experiences pain
when swallowing
Loss of appetite
due to difficulty
swallowing foods
Musculoskeletal
Day 1-2 Day 3

Patient was able to

Patient started to

perform ROM

regain his energy as

movements with minimal

he is able to swallow

to no difficulty except

foods little by little

for extension, flexion,

and consume enough

and rotation of the head

and neck area where

nutrients for body

pain is noted. requirements

Patient claimed to have

Patient was now able

enough energy until

to slightly rotate,

symptoms appeared;
extend, and flex head

started to experience
with minimal pain and
weakness affecting his
difficulty.
daily activities.
Diagnostic Assessments- Complete Blood Count
Results
Hematocrit 0.41 L
[Normal: 0.42 - 0.56]
White Blood Cells 15.0 H
[Normal: 4.5-11]

A CBC was conducted which showed a slightly decreased hematocrit level

of 0.41%, a value just below the normal and high percentage of white blood
cells present in the bloodstream at a value of 15.0 x 10^12/L A low Hct and
a high WBC count ar indicative of inflammation.
Diagnostic Assessments- Clinical Chemistry

Results
Glucose (RBS) 65 mg/dL
[Normal: 80 - 130]
Sodium 150 meq/L
[Normal: 135 - 145]

Results reveal a low random blood sugar (glucose) indicating excess insulin in
the bloodstream which has affected thyroid hormone production & activity as
evidence of a goiter. It is also indicative of problems in the HPA axis, the
pituitary gland & adrenal glands, which together, control the body's stress
response by adjusting the levels of stress hormones cortisol produced.
Diagnostic Assessments- Thyroid Scan

Results
Areas of autonomy with excess
thyroid hormone secretion in a large
nodular goiter. The white arrow
indicated a sternal notch marker.

Results show a large nodular goiter with excess thyroid hormones

secretions in the majority of the neck area. The location of hot/ cold
nodules and the sizes of the nodules based on the sternal notch mark
are shown.
Diagnostic Assessments - Direct Laryngoscopy
Results
a.) supraglottic edema
Direct
b.) CriticalLaryngoscopy
tracheal narrowing &
compression, obstructions,
nontoxic multinodular gioter
a.) b.)
Inflammation and swelling of the throat have occurred, making breathing
difficult due to the added weight against the windpipe, and swallowing
painful & difficult due to the swollen tissues leaving a small opening. NGT
tube was placed to allow food to be passed and provide adequate fluids and
nutrients to patient.
Diagnostic Assessments- CT Scan of the Neck
Results: Thyroid swellling more on the left with
tracheal compression and no retrosternal or
extrascapular extensions. Displacement of the
jugular vein and carotid postlaterally

Results show that the trachea is being

compressed; consistent with DOB compaint.
Thyroid gland remains in its anatomical position
depsite the pressence of the mass; no agressive
tumor behavior occuring.
Pathophysiology
Anatomy and Physiology

Thyroid Gland
Anatomy
is a ductless alveolar gland found in the anterior neck, just below the
laryngeal prominence (Adam’s apple).

A roughly butterfly-shaped organ, with two lobes wrapping around the

trachea connected in the middle by an isthmus.

It consists of two types of cells that make up thyroid tissue—follicular cells

and parafollicular cells. These two cells are responsible for producing

certain hormones that the thyroid gland then secretes into the bloodstream

Physiology
Its function is to produce, store, and secrete thyroid hormones
triiodothyronine (T3), thyroxine (T4), and calcitonin.

These hormones regulate the body's metabolic rate controlling heart,

muscle and digestive function, brain development and bone maintenance.

Its correct functioning depends on a good supply of iodine from the diet.
Nursing Care Plan

 Nursing
Diagnoses
Ineffective airway clearance r/t tracheal
obstruction due to enlarged thyroid
AEB dyspnea, cough, and hoarseness of
voice.

Acute Pain r/t swelling of throat tissues

AEB pain and difficulty swallowing, and
discomfort
Risk for aspiration related to inability to
swallow and triggering of cough reflex
after swallowing.
Assessment Cues
SUBJECTIVE CUES
“Sang ligad na tu-ig, may nagtubo na bukol sa akon li-og. Wala ko
lang man siya gin sapak sa una antes sang may gina batyag na ko na
mga sintomas parehas sang budlay nga pagginhawa, pagbanog sang
li-og, pamamaos, ubo, kag daw ka paghugot sang tutunlan. Subong
sina, sopas kag sabaw na lang gina kaon ko. ”

OBJECTIVE CUES
Mass in his neck area.
Came in with O2 at 3LPM via Significant V/S:
nasal cannula. RR - 27 cpm
The thyroid gland is palpable and
tender when touched.
 Assessment Cues
OBJECTIVE CUES
LARYNGOSCOPY
Significant Labs:
Plasma TSH level: > 4.2 mu/L A. Supraglottic
T3: 63 ng/dl
T4: 3.6 mcg/dl
edema
Na: 150 mEq/L

WBC: 15.0 x 10 ^12/L B. Critical

tracheal
narrowing and
CT SCAN (NECK) THYROID SCAN compression,
obstruction,
Thyroid swelling Hot and cold nontoxic
more on the left nodules in a multinodular
with the tracheal multinodular goiter
compression goiter.
 Nursing Diagnosis
Ineffective airway clearance r/t tracheal
obstruction due to enlarged thyroid AEB
dyspnea, cough, and hoarseness of voice.

Inability to clear
secretions or
obstructions from
the respiratory
tract to maintain
a clear airway
 After 8 hours of nursing interventions,
the patient is expected to:

Desired 1 Maintain airway patency

Outcomes
2 Demonstrate normal respiration rate
and sound

3 Verbalize understanding of cause(s) and

therapeutic management regimen

Identify potential complications and how to

4 initiate appropriate preventive actions
 Interventions & Rationale
- Assess and monitor respirations and - Indicative of respiratory distress
breath sounds, noting rate and/or accumulation of secretions

- Evaluate patient's cough/gag reflex - To determine ability to protect own

and swallowing ability airway

- Position patient in a proper sitting - To open or maintain open airway in an

position or elevate head of the bed at-rest or compromised individual

- Perform or assist the client in learning - Various therapies/modalities may be

airway clearance techniques (e.g. required to acquire and maintain
postural drainage, active cycle adequate airways, improve respiratory
breathing techniques) function, and gas exchange
 Interventions & Rationale
- Urge reduction/cessation of smoking - Smoking is known to increase production of

mucus and to paralyze cilia needed to move

secretions to clear airway and improve lung

function

- Administer medications as indicated (Thorne - To treat the underlying disease and aid in
Iodine and tyrosine dietary supplement) airway clearance

- Provide respiratory support. Oxygen - Aid in relieving the patient from dyspnea
inhalation is given as ordered at 3LPM via

nasal cannula

- Encourage/provide opportunities for rest; - This prevents/reduces fatigue

limit activities to level of respiratory tolerance
 After 8 hours of nursing interventions,
the patient was able to:
Maintain airway patency
Evaluation 1 “Maka ginhawa na ko sang maayo kumpara sang ligad nga gina
kapos ko.” GOAL MET.

Demonstrate normal respiration rate and sound

2
“Hambal sang isa ka nurse okay naman akon RR kay nanaog sa 19 cpm. Wala man

siya may nabatian na abnormal lung sounds sang gin check-up niya akon

pagginahawa” GOAL MET.

Verbalize understanding of cause(s) and

3 therapeutic management regimen

"Kinahanglan gid na sundon ko ang mga advices kag instructions sang akon nga

doktor para mag-ayo ko.” GOAL MET.

Identify potential complications and how to

4 initiate appropriate preventive actions

“Dapat kung-inug pahuway, ma tulog gid ko para indi mag lala akon nga kondisyon

kag magka-impeksyon kay may resistensya akon lawas nga ibato.” GOAL MET.
Health Teaching Plan
After 20 minutes of nurse-patient
interaction, the patient/SO will be able
to: Objectives
1. Recognize important instructions that
will facilitate proper recovery of the
patient.

2. Verbalize understanding of the

purpose and benefits of following the
given health teaching.

3. Adapt healthy practices and behaviors

towards maintaining health and
prevention of sickness.
 Medication
Paracetamol (Tylenol) Tramadol (Ulram)
C- Analgesics (Non-Opioid) & Antipyretics C- Analgesic, miscellaneous

H- It is used to treat fever and mild to moderate pain H- Used to relieve moderate to moderately severe pain

E- 500 mg, PO, PRN for pain or fever E- 50 mg, IVTT, PRN, for pain

C - Hypersensitivity reaction C - Dizziness, vertigo, nausea, constipation, headache,

drowsiness
K - Paracetamol can be taken on an empty stomach
K - Instruct the patient to be alert for excessive sedation or
- Ensure that drug is the correct brand, dosage, correct somnolence.
route, and ordered for the correct patient; administer
aseptically and document patient's response to medication - Place patient on fall precaution and observe for changes in
movement
 Medication
Levothyroxine sodium (Levo-T)
C- Thyroid hormone, Levoisomer of thyroxine
H- Used to treat an underactive thyroid and provides more
thyroid hormones normally produced by the thyroid gland
E - 300 mcg loading dose; then shift to 100 mcg OD via NGT
C - hair loss during the first few months of treatment, vomiting,
joint pain, wheezing
K - Caution patient about the risk of increased sweating
(hyperhidrosis), and advise patient about proper skin care
- Instruct patient to report other troublesome side effects
including severe or prolonged headache and GI problems
Thorne Iodine
C- Anti-thyroid, dietary supplement
H- Provides nutritional support for the thyroid gland which
helps improve metabolism
E - 1 cap OD together with meal (8 am)
C - Dizziness, vertigo, nausea, constipation, headache,
drowsiness
K - Be aware of signs and symptoms of allergic reactions
- Perform thyroid function test to determine baseline status
before beginning therapy and for any potential adverse effects
 Medication
Piperacillin + Tazobactam (Zosyn)

C- Antibiotic

H- A combination injection used to treat bacterial infections;

inflammation due to infection has reduced

E - 4.5 g IVTT as loading dose STAT, then 2.25 g q8h (8 am- 4

pm-12 am)

C - Diarrhea, headache, constipation, nausea, insomnia, rash

K - Monitor signs of allergic reactions and anaphylaxis,

including pulmonary symptoms
 No or Low- Impact Activities

Before starting an exercise program, be sure

Exercise

to talk to your healthcare provider first.

Pick one or more activities you enjoy, such as:

Walking
Hiking on easy terrain (small hills)
Bike riding
Dancing (Zumba)
Swimming

Benefits:
Supports deeper, better sleep
improves your mood
increases bone density and energy levels
 Oxygen Therapy

Supplemental oxygen can help relieve your symptoms.

Treatment

You may feel relief from shortness of breath, fatigue, and

dizziness. You may be more alert, sleep better and be in
a better mood.

Surgery

Treatment for an enlarged thyroid also includes surgery

if the disease continues to persist and obstructs the
airway and esophagus causing difficulty of breathing and
swallowing.
 Mouth and NGT Care
Hygiene

1. Wash your hands before starting the feeding.

2.Clean the patient’s mouth at least daily – use a
moist towel to clean the tongue
3. Clean the area where the NGT goes into the nose
daily. Use a cotton bud moistened with warm water.
4. Change the nose tape every other day or when it
is loose.
5. Make sure the nose tape is secure at all times. If
the feeding tube falls out, do not re-insert it by
yourself but seek medical help as soon as possible.
6. To prevent a clogged feeding tube, flush the tube
with water each time after giving a feeding or
medication.
 Outpatient
Call your doctor right away if you have any
of the following:
- Fever above 100.4°F (38°C)
- Swelling or bleeding at the incision site
- Choking
- Trouble breathing
- A sore throat that lasts longer than 7 days
- Tingling or cramps in your hands, feet, or lips
Discharge Instructions
1. Get plenty of rest.
2. Avoid heavy lifting and strenuous activity
3. Walk a few times daily.
4. Return to work when your doctor says it’s OK.
5. Take your medicine as directed.
6. Use a pillbox labeled with the days of the week.
7. Try to take your medicine with the same types and
amounts of food and liquid each day.
8. See your doctor for regular visits
9. Have routine blood tests done.
10. Tell your doctor about any signs of further
thyroid problems.
Goiter caused by iodine deficiency - can be helped with
Diet

the introduction of iodine-rich foods into the diet, such as

seafood, iodized salt dairy products and soy products.

Also important to note:

1. Limit or stop caffeine and alcohol
intake.
2. Avoid intake of goitrogenic foods
such as cabbage, radishes,
cauliflower, soybeans, peanuts,
Stop eating foods that inhibit thyroid hormone function (cabbage, and spinach.
broccoli, cauliflower, peaches, pears, plums, and strawberries).

Cruciferous vegetables such as broccoli, cauliflower, and cabbage

naturally release a compound called goitrin when they’re hydrolyzed or
broken down. Goitrin can interfere with the synthesis of thyroid
hormones.
 Afternoon snacks:
24 Hour Meal - 1 cup ice cream
- Water (2 cups)
Plan Sample:
Dinner:
Breakfast: - Steamed okra
- Eggs (any style, season lightly with - Brown rice (1 cup)
iodized salt)
- Bread/2 slices (Gardenia) - Cod (seasoned lightly with iodized salt
- Cheese (2 slices for bread spread) and pepper). Sauce may be a tiny amount
- Milk (1 cup) of soy sauce.
- Water (2 cups)
- Use virgin coconut oil to fry fish (if
Morning Snack: frying); steaming is better
- 1 Banana
- Water (2 cups) - Water (2 cups

Lunch:
- Shrimp & Crab (1pc) sauteed in butter
with red onions and garlic.
- Brown Rice (1 cup)
- Water (2 cups)
 Conclusion

In conclusion, the patient has become confident in his knowledge and

understood all the risks of his treatment from adverse effects of
medications to the risks of surgeries. The patient was very cooperative
and eager to find a way to improve his quality of life.
 Recommendations
The managements we recommended to him are as follows:

Always maintain good personal hygiene especially sufficient oral care to prevent infection, and trim
his nails to avoid injury.

Avoid wearing constricting clothing, especially around the abdomen and neck area to allow for
enough airflow and to avoid risking injury.

Engage in low-impact exercises to help improve the body’s return to a normal state of homeostasis.
 Do you have any
questions for us?
Thank
you for
listening!