Managing the Client with

Thyroid Cancer

MODULE DESCRIPTION
This module contains the necessary information regarding thyroid cancer. Also
contained in the module are the treatment modalities used in treating leukemia as well as their
complications and the nursing interventions the nurse should implement if encountered with
these problems.
LEARNING OUTCOME
At the end of this module, the student will have a clear understanding on thyroid
cancer as well as the treatment modalities. More importantly, the student will have the
competency of dealing with the thyroid cancer client.

PRE-TEST
1. A type of thyroid cancer that starts in childhood or early adult life and usually remains
localized; the most common and the least aggressive type of thyroid cancer.
a. Papillary adenocarcinoma
b. Follicular adenocarcinoma
c. Medullary thyroid cancer
d. Anaplastic thyroid cancer
2. All of the following are risk factors for developing thyroid cancer except:
a. Male sex
b. Heredity
c. Exposure to high levels of ionizing radiation
d. Female sex
3. All of the following are contraindications for a client to undergo radioactive iodine
imaging except:
a. Allergy to iodine-containing substances
b. Pregnancy
c. Lactation
d. History of angina pectoris
4. All, but one are indications for the use radioactive iodine-131 therapy:
a. Iodine-sensitive thyroid cancer
b. Metastatic iodine-dependent thyroid cancer
c. Iodine-independent thyroid cancer
d. Localized iodine-sensitive thyroid cancer
5. Which of the following is a priority assessment for the immediate thyroidectomy
patient?
a. A blood pressure ranging from 90/67 to 108/71 in the last 2 hours.
b. Frequent swallowing observed.
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 c. A blood in the surgical dressing that remained unchanged in diameter in the
entire shift.
d. A pain rating scale of 7/10 3 hours post-op.

MODULE CONTENT
THYROID CANCER
 Less prevalent than other forms of cancer.
 Accounts 90% of all endocrine malignancies.
 Types of thyroid cancer:
TYPE OF THYROID INCIDENCE CHARACTERISTICS
CANCER (70%)
Papillary adenocarcinoma 70  Most common and least aggressive
 Asymptomatic nodule in a normal
gland
 Starts in childhood or early adult life,
remains localized
 Metastasizes along the lymphatics if
untreated.
 More aggressive in elderly
Follicular adenocarcinoma 15  Appears after 40 years of age.
 Encapsulated; feels elastic or rubbery
on palpation
 Spreads through the bloodstream to
bone, liver and lung
 Prognosis is not as favorable as for
papillary adenocarcinoma
Medullary 5  Appears after 50 years of age
 Occurs as part of multiple
endocrine neoplasia (MEN)
 Hormone-producing tumor causing
endocrine dysfunction symptoms
 Metastasizes by lymphatics and
bloodstream
 Moderate survival rate
Anaplastic 5  50% of anaplastic thyroid cancer
occurs in patients older than 60 years
of age.
 Hard, irregular mass that grows
quickly and spreads by direct invasion
of adjacent tissues
 Maybe painful and tender
Thyroid lymphoma 5  Appears after the age of 40
 May have history of goiter, hoarseness,
DOB, pain and pressure
 Good prognosis
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CLINICAL MANIFESTATIONS:
 Typically do not have any signs and symptoms.
 As the tumor grows, the patient may experience:
o A lump or nodule in the neck
o Vocal changes, such as increasing hoarseness
o Dysphagia or odynophagia
o Neck and throat pain
o Swollen lymph nodes in the neck

RISKS FACTORS:
1. Female sex
2. Exposure to high-levels of radiation
3. Heredity

ASSESSMENT AND DIAGNOSTICS:

1. Physical examination
a. Palpation of the nodule assessing for consistency, nodularity and mobility of
the tumor/s.
b. Assess any involvement or enlargement of adjacent lymph nodes.
2. Imaging techniques:
a. Ultrasound of the thyroid
i. A non-invasive, non-radiologic imaging technique that uses high-
frequency sound waves to create a 2-dimensional image of the thyroid.
ii. The image will reveal the nodularity and gross morphology of the
thyroid mass, which may help establish the possibility of malignancy.
b. CT scan and MRI scan
c. Thyroid scan and uptake
i. A thyroid scan is a nuclear medicine examination that uses gamma
rays from radioactive iodine to determine any dysfunction of the
thyroid.
ii. A type of thyroid scan known as the whole body thyroid scan helps
detect any growth of thyroid cells anywhere else in the body.
iii. Nursing care:
1. The radiologist will explain the procedure to the client, its
benefits and risks and preparation as well as the limitations of
the imaging technique.
2. A consent should be obtained prior to procedure.
3. Pre-procedural:
a. Check for the signed consent.
b. Assess for the patient’s renal function. Additional tests
such as thyroid function test may be done

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 c. Check if the female client of reproductive age is not
pregnant. Obtain a thorough OB history. Do a
pregnancy test.
d. Obtain a thorough history such as the allergies, intake of
medications, recent procedures that use iodine-based
contrast dye, lactation, intake of any medicines or
supplements with natural iodine.
e. Tell the patient to have a living arrangement prior to
and after the procedure, where he/she will be isolated,
as he will be radioactive for about a week after the
procedure.
f. The patient will be on NPO several hours prior to the
test.
g. If the tracer is to administered PO, a pill or capsule
containing the radioactive tracer will be given 24 hours
prior to the day of the scan.
h. If an IV tracer will be used, an IV access may be
established prior to the scan and the tracer will be given
30 minutes before the scheduled test.
4. During the procedure:
a. The patient will be asked to don a hospital gown. No
jewelries or any metal objects near or attached to the
body.
b. The patient will be asked to sit or lie still in a table in
front of a probe.
c. The radiologist or the technician will take images of the
thyroid or the entire body in different angles.
5. After the procedure:
a. The patient will be asked to drink enough water to flush
out the radioactive tracer
b. Educate the client to flush his/her urine twice.
c. Tell the client to isolate depending on the half-life of the
radioactive tracer used. Radioactive iodine-131 has a
half-life of about 8 days.

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An example of a thyroid scan. The red arrow indicates an increase in the uptake of the I-131,
indicating metastatic thyroid cell growth in the region of the pelvis. The very dark spot in the
leg is a urine bag. (https://www.snmmi.org/AboutSNMMI/Content.aspx?
ItemNumber=1785#:~:text=To%20detect%20thyroid%20cells%20located,and%20Hurthle
%20cell%20thyroid%20cancers.)
3. Thyroid function test
a. Determines the level of thyroid hormones
4. Needle biopsy
a. The definitive diagnostic exam for thyroid cancer
MANAGEMENT
SURGICAL MANAGEMENT
Thyroidectomy
 The surgical removal of the thyroid.
 Usually done as subtotal (partial) or total thyroidectomy
 Done when the metastatic growth is isolated in the thyroid or as a palliative treatment
when the thyroid mass is already impeding the airway and the esophagus of the client.
 Pre-procedural:
o Cardiopulmonary clearance, to determine the client’s physiologic status to
predict his/her risk of developing intra-operative and post-operative
complications.
o Thyroid function test
 Determines if the client’s cancer is hormone-producing or not.
o Anti-thyroid medications:
 Potassium iodide supplementation
 Usually in the form of pills or elixir (SSKI or Lugol’s solution)
 Used to decrease the vascularity of the thyroid, to reduce
massive bleeding during surgery.

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  PTU or methimazole
o To decrease the production of thyroid hormones, if the
tumor is hormone-producing.
 Types of thyroidectomy:
o Total or complete
 The entire thyroid gland is excised, which may include the parathyroid
gland
o Partial or subtotal thyroidectomy
 The part of the thyroid where the mass is located is excised, sparing the
part with no mass or growth.
NURSING CARE POST-THYROIDECTOMY
TOTAL THYROIDECTOMY SUBTOTAL THYROIDECTOMY

Complication:
 Tetany
o Commonly seen complication
of total thyroidectomy, but can
also be seen with subtotal
o Caused by the complete
removal of the parathyroid
gland
o Assessment:
 Chvostek and
Trouseau’s signs
 Low serum calcium
 Assess the airway
o Nursing care:
 Monitor for signs of
tetany.
 Monitor calcium levels
 Administer calcium
gluconate, as prescribed
 Bedside:
 Tracheostomy
set
 Ca gluconate
 Hypothyroidism
o Due to the complete removal
of the thyroid gland
o Assessment:
 Monitor signs and
symptoms related to
hypothyroidism such
as:
 ↓ VS
 Lethargy
Complication:
 Thyroid storm
o A sudden surge of thyroid
hormones that may lead to a
hypermetabolic state and
overburden the heart and lungs.
o Commonly seen in subtotals,
due to mechanical
manipulation of the thyroid
gland or overstimulation of the
negative feedback loop (due to
sudden drop of thyroid
hormones), thus causing the
remaining thyroid gland to
overproduce thyroid hormones.
o Assessment:
 ↑ VS
 Tachyarrhythmias
 Hyperpyrexia
 Hyper-irritability
 Hyperventilation
 Increased serum thyroid
hormones (TSH, T3
and T4)
o Untreated thyroid storm may
cause cardiovascular collapse
and cardiac arrest.
o Management:
 Monitor vital signs
 Assess post-operative
thyroid hormone levels
 Administer potassium
iodide PO or NGT stat
 High-dose PTU, PO or
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  Cold intolerance per NGT
o Nursing care:  Methimazole, if client
 Administer thyroid is suffering from any
replacement drugs such liver disease.
as levothyroxine, as  Esmolol IV or
prescribed. propranolol to decrease
the tachyarrhythmia
 Diltiazem PO or IV
stat, if beta-blocker is
contraindicated.
 High-dose
corticosteroids
(prevents the
conversion of T4 to T3)
 Heparin IV stat, if with
atrial fibrillation
 Cholestyramine 4g PO
or NGT, prevents the
enterohepatic
absorption of
metabolized thyroid
hormones.
 Anti-pyretics and
cooling blankets to
control fever.
 Hypocalcemia
o Caused by the inadvertent
removal of the parathyroid
gland.
o Nursing care:
 Assess signs and
symptoms of
hypocalcemia
 Ca gluconate IV
Hemorrhage and airway obstruction
 The thyroid gland is a highly-vascular organ and hemorrhage is inevitable.
 Assessment:
o Soaked wound dressing.
o Check any pooling of blood under the neck of the client.
o Frequent swallowing and gagging/choking
o Decreasing BP, increasing PR, RR
 Unattended post-thyroidectomy hemorrhage, can cause airway obstruction (clotting of
blood in the airway) and aspiration.
 Management:
o STAT intubation/tracheostmoy
o High-dose tranexamic acid IV stat
o Coordinate with the OR team for STAT transport of the patient to the OR

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RADIOTHERAPY FOR THYROID CANCER
 Radiation therapy for thyroid cancer is usually done as therapeutic or palliative. The
goal of palliative radiotherapy is to shrink the tumor to a manageable size to decrease
airway and esophageal obstruction, when the cancer is beyond treatment.
o Teletherapy
 Uses a high-energy beam that targets the thyroid gland, destroying all
actively dividing cancer cells.
 Used when the thyroid cancer cells do not take-up iodine (iodine-
resistant metastatic cells)
 Targeted external beam therapy, uses a fine-guiding sensor that focuses
the energy beam to the exact location of the tumor growth, taking into
account that a client cannot stay still perfectly as well as the pulsations
of the nearby innominate artery, involuntary swallowing and breathing.
 The neck and the nearby structures may also be irradiated if there is
suspicion of metastasis in the adjacent structures and lymph nodes.
NURSING CARE
Skin changes similar to sunburn  Meticulous skin care
 Do not put any ointment on the
burned area
 Keep the skin dry, to reduce the risk
of infection
Xerostomia  Give the client sugarless lozenge or
(maybe temporary) chew xylitol-based or
carboxymethylcellulose-based gum
 Avoid using alcohol-based
mouthwash
 Gargle using warm saline solution
 Humidify the room environment
 May give saliva-stimulating
medications like pilocarpine or
cevimeline (Evoxac) as prescribed.
Dysphagia/odynophagia  Soft, bland diet
(may be temporary)  Small frequent feeding
 Tube feeding
o Maybe temporarily placed to
assist in feeding difficulties
and address nutritional and
hydration problems.
 Pain medications, as indicated
Easy fatigability  Provide adequate rest periods
 Cohort nursing activities, if possible
 Provide high-calorie food

o Radioactive Iodine-131 (RAI)

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 Usually used for iodine-sensitive thyroid cancer cells, usually follicular
thyroid cancer and papillary thyroid cancer, only.
 A radioactive pill or syrup containing iodine-131 is taken by the client.
 Most of the RAI-131 will be absorbed by the thyroid cells. Thus the
radiation is mostly delivered to the thyroid.
 The radiation produced by the iodine damages the cell’s DNA, thereby
disabling them to divide any further.
 RAI-131 therapy may be used alone, to treat thyroid cancer or in
combination of other treatment such as chemotherapy.
 May also be used in situation of metastasis of thyroid cancer, as the
RAI-131 is usually absorbed systemically.
 Also used as a palliative treatment to reduce the size of the tumor.
 Cannot be used for iodine-independent or resistant form of thyroid
cancer.
 Pre-procedure preparation:
o You will be given recombinant TSH for 2 days. This is
to stimulate the thyroid cells to take-up RAI.
o Avoid iodine-rich foods or supplements for at least 2
weeks prior to therapy.
 During therapy
o NPO prior to and hours after taking the radioactive
pills/syrup.
o Isolation room.
o The nuclear medicine staff will check the level of
radioactivity of the client and all things that came into
contact with the client using a Geiger counter.
o The client is encouraged to increase oral fluid intake to
flush out the radioactive iodine.
o The client’s sweat, urine and feces may be radioactive.
Flush toilet twice or more.
o Limit stay within the patient’s room and keep a distance
to no less than 3-4 feet from the client if doing any
nursing care.
o Visitors may be allowed, however, they are reminded to
avoid going near the patient, touching any
implements/articles that may come into contact with
patient and should not stay for too long inside the
patient’s room. Pregnant women or those who suspect
themselves to be pregnant should not enter the patient’s
room.
 After therapy
o The nuclear medicine staff or the doctor will check the
patient’s radioactivity level every day.
o The client maybe given or may resume taking thyroid
hormone drugs such as levothyroxine.

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o The patient should:
 Avoid long and close contact with people.
 Avoid crowded places or enclosed spaces.
 Should sleep in a separate bed or room for a
couple of days after discharge.
 Avoid sexual contact or use condom.
 It is also recommended that:

 women use reliable contraception for at

least 6 months
 men use reliable contraception for at
least 4 months
 This is because the eggs and sperm
produced after treatment may be
damaged by the radiation. This could
cause abnormalities in a child conceived
soon after the treatment. Research
suggests that if the patient wait for the
advised period of time, he/she doesn’t
have an increased risk of abnormalities
with future pregnancies or children.
 Refrain from traveling especially via air. Should
air travel is unavoidable, secure a certification
from the doctor that the client underwent RAI
therapy, as the patient may set-off security
alarms from the radiation they emit.
o Adverse effects of RAI therapy
 Short-term effects:
 Sialadenitis
o Encourage fluid intake while in
therapy
o Provide sugarless lozenge to
stimulate salivation
o Anti-inflammatory drugs
 Xerostomia and taste changes
o Provide sugarless lozenge
o May give artificial saliva
o Salivation and tastes returns to
normal after 4-8 weeks.
 Swollen/tender neck
o May give pain relievers
 Nausea
o The physician may give
antiemetics
 Possible long-term effects:

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 Infertility
o In women, radioactive iodine
treatment should not affect the
ability to have children, even if
there is a need to have repeated
treatments. Some women may
have irregular periods after
treatment.
o Men who need to have repeated
treatment with radioactive iodine
may have lower sperm counts
and lower testosterone levels.
This usually gets better with time.
Rarely, it means that he may be
unable to father a child (be
infertile). The doctor may
advise sperm banking before the
start treatment.
o After this treatment, doctors
usually recommend that women
wait for at least 6 months and
men for at least 4 months before
trying to conceive a baby. The
research suggests that if they wait
for the advised period of time,
there is no increased risk of
abnormalities with future
pregnancies or children.
 Chronic saliadenitis
o May give artificial saliva
 Dry or watery eyes
o Radioactive iodine treatment can
affect the lacrimal glands. These
are glands in the eyes which
make tears. The treatment can
affect the production of tears.
Some people may develop dry
eyes and rarely, some people get
watery eyes.
o For dry eyes: the physician may
give sterile NSS drops as needed
or artificial tears.
 Low blood cell counts
o Rarely a long-term effect of RAI.
o Monitor cell counts as frequently
as prescribed.

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 o Provide rest periods.
o Avoid going to crowded places.
o Practice hand hygiene
o Institute bleeding precautions
 Radiation fibrosis
o A lung problem that may occur
with repeated RAI therapy.
o The lung tissues losses elasticity,
thus making breathing more
difficulty.
o A rare effect of RAI.
o Monitor lung function as often as
needed.
 Secondary cancers
o As with all conventional can
treatment, there is a possibility
that the client may develop
another cancer throughout his/her
life-time which may be
associated with radiation therapy
o Patient is monitored as prescribed
or advised by the oncologist to
assess any risks or chance of
secondary cancers.
o Prior to treatment, the client
should already be educated about
this risk.

POST-TEST
1. A nurse is caring a client who underwent subtotal thyroidectomy 8 hours ago due to
stage 2C medullary adenocarcinoma of the thyroid gland. He noted on the progress
note, that no changed in the amount of blood is seen on the dressing. However, the
senior nurse, came and noted some harsh air entry and stridor on the client’s lung field
upon auscultation. Which of the following action/s the nurse failed to do in order to
assess appropriately the presence of covert bleeding in the surgical site?
a. Monitor the VS especially the blood pressure of the client.
b. Look for any polling in the back of the neck of the client.
c. Observe any frequent swallowing episodes.
d. Remove the dressing temporarily and look for any bleeding on the suture line.
2. A client who underwent RAI therapy 2 days ago have been cleared by the nuclear
medicine specialist as “negligible radioactivity”. Which of the following statement, if
made by the client would require the nurse further intervention?
a. “I can stay on our room, together with my husband.”

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 b. “I should avoid going to the market for a couple of weeks.”
c. “If I need to travel abroad, I have to secure certification from my oncologist
that I underwent RAI therapy.”
d. “I should flush the toilet twice after urinating or defecating.”
3. A client underwent subtotal thyroidectomy due to thyroid cancer 3 hours ago. The
nurse noted intermittent sinus tachycardia that lasts 15 to 30 seconds in the ECG
telemetry. Understanding that the client had underwent a subtotal thyroidectomy,
which of the following drugs would be prudent for the nurse to put on standby?
a. Potassium iodide PO
b. Tranexamic acid IV
c. Esmolol IV
d. Methylprednisolone IV
4. A male client is newly diagnosed with follicular thyroid adenocarcinoma and was
advised to undergo RAI therapy. He was concerned about his fertility. Which of the
following statements should the nurse make in order to allay the fear of the client?
a. “Studies show that RAI can decrease the sperm count and testosterone levels,
but this will improve overtime.”
b. “The radioactive iodine do not have an effect on your fertility as it selectively
attacks thyroid cells, not sperm cells.”
c. “It will not have any effect on your fertility, but you will have to use an
effective and reliable contraception for a year to avoid having a child with
possible birth defect.”
d. “Your fertility is the least of our concern here. Your thyroid cancer is.”
5. The client who has stage 4 thyroid cancer is scheduled for total thyroidectomy 2 days
from now. You are about to start giving her Lugol’s solution. The client asked you
why the doctor wants her to take this drug. Which of the following is the best
response of the nurse?
a. “This drug will slowly decrease the level of your thyroid hormones so that you
have a slim chance of developing post-thyroidectomy complications like
thyroid storm.”
b. “Lugol’s solution is usually given prior to a thyroidectomy to stain the thyroid
tissues in order that the doctor can distinguish the tissues that has to be
removed.”
c. “The doctor ordered this drug to sterilize your gut prior to surgery.”
d. “This is usually given to decrease the vascularity of the thyroid in order to
reduce blood loss during surgery.”
6. You are precepting a group of student nurses from a local university in their tour-of-
duty in the oncology floor of the hospital. One of the patients in the floor was
admitted for stage IIB anaplastic carcinoma of the thyroid. He underwent several
rounds of external radiotherapy. The client has been experiencing dysphagia. The
student nurse was assigned to the client. As you are observing, which of the following
action/s of the student nurse should you intervene?
a. The student let the client take a sip of water from a calibrated cup.
b. The student nurse let the client eat a teaspoon of applesauce.
c. The student let the client take small amount of vegetable broth.

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 d. The student let the client eat a piece of whole wheat cracker.
7. You are caring for a client who underwent complete thyroidectomy 6 hours ago.
While taking the client’s vital sign, he complained of tingling sensation in his peri-
oral area. Which of the following complications of thyroidectomy, complete, should
the nurse suspect?
a. Hemorrhage
b. Hypocalcemia
c. Hypothyroidism
d. Thyroid storm
8. A female client is about to undergo whole body thyroid scan. Which of the following
assessment should the nurse include to rule out any possibility of pregnancy?
a. The day of the last menstrual period
b. The regularity of menstrual period
c. The menarche
d. The first day of the last menstrual period
9. A client came to the clinic due to a palpated mass, about the size of a pea in his neck.
The doctor requested an ultrasound of the thyroid. Which of the following should the
nurse include in the teaching plan prior to UTZ of the thyroid?
a. Maintain an NPO 6-8 hours prior to the procedure.
b. Avoid applying anything to the neck.
c. Refrain from swallowing while the doctor scan the neck
d. No special preparation is needed for this kind of test.
10. The client is about to undergo a whole body scan. Which of the following should the
nurse include in the teaching plan prior to the scan?
a. Eat a full meal the morning prior to the scan
b. Empty the bladder complete prior to entering the scanning room.
c. Avoid intake of any food or drink that contains iodine.
d. The client should eat at least 100 milligrams of any food or beverage with
iodine.

CRITICAL THINKING ACTIVITY

A 25 year old male client was diagnosed with stage IIIA follicular adenocarcinoma of the
thyroid. Histopathology report suggests that the cancer cell is dependent of iodine and is
hormone-secreting. Whole body scan report reported suspicious metastatic growth in the
lungs and the stomach. He was advised to undergo a round of RAI-131 therapy,
chemotherapy and suggested to undergo total thyroidectomy.
1. Make a teaching plan on that the nurse should include in the pre-operative and post-
operative period for total thyroidectomy.

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 2. Make a teaching plan of the things the nurse should teach regarding a client
undergoing chemotherapy.
3. Make a teaching plan prior to, during and after RAI-131 therapy.
Format of the teaching plan.
Health Education Rationale of the Possible or Actual Possible Nursing
action/s Complication/s if not Diagnosis/es
done or implemented corresponding to the
complication/s that
may arise

REFERENCES:

Hurst Review Services, Inc. (2019) NCLEX-RN® Review student manual: a clinical
judgment approach. Massachusetts

Hogan, M. (2008) Comprehensive review for NCLEX-RN. Upper Saddle River, New
Jersey: Pearson Education.

Smeltzer, S., Bare, G., Hinkle, J., Cheever, K. (2008). Brunner and Suddarth’s textbook
of medical-surgical nursing (11th ed.) n.a.

https://cancer.dartmouth.edu/radiation-oncology/stereotactic-radiosurgery
https://www.cancerresearchuk.org/about-cancer/thyroid-cancer/treatment/radiotherapy/
radioactive-iodine-treatment/during-radioactive-iodine-treatment

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