Multinodular Goiter Case Study

The College of Maasin
Nisi Dominus Frustra

Tunga-tunga, Maasin City, So. Leyte, Philippines
A CASE STUDY ON MULTINODULAR

NONTOXIC GOITER
Presented by:
Caberte, Rhiela Mae G.
Dacup, Jobeth L.
Submitted to:
Mrs. Roselle Joy Balaquit, RN, MAN
I. Introduction:
The thyroid is a gland that secretes hormones into the bloodstream, and it is
part of the endocrine system. The thyroid is a butterfly-shaped organ (or gland)
that sits directly under the Adam's apple on the front of the neck (larynx). Thyroid
hormones are produced and released by the thyroid gland, which is made up of
two lobes joined by an isthmus. Thyroid hormones regulate body temperature,
digestion, and heart function, among other things.
A thyroid nodule is a mass of thyroid cells that grows abnormally in the thyroid
gland. Thyroid nodules can be caused by a tumor, a fluid-filled cyst, inflammation
(thyroiditis), or a simple expansion of normal thyroid tissue (either benign or
cancerous). There are different types of thyroid nodules; Colloid Nodules, Thyroid
cysts, Inflammatory Nodules, Multinodular Goiter, Hyperfunctioning Thyroid
Nodules, and Thyroid Cancer. Many patients with thyroid nodules have no
symptoms and are discovered by coincidence during a regular physical exam or
an imaging check for unrelated reasons to have a mass in their thyroid gland. A
small percentage of patients may notice a growing lump in the front of their neck.
Some of the common signs and symptoms of a thyroid nodule includes hoarseness
or voice change, pain in the neck and goiter (enlargement of the thyroid gland)
The prevalence of a disease is determined by the screening method used and

the population studied. Nodule incidence rises with age and is higher in women,
those with iodine shortage, and people who have been exposed to radiation.
According to several studies, the prevalence is 2-6 percent by palpation, 19-35
percent by ultrasound, and 8-65 percent by autopsy.
General Objectives:
After 2-3 hours of case presentation, the BSN 3 Group 2 students will gain knowledge
and enhance their skill and be able to apply these learnings to formulate an appropriate
nursing management for a patient with thyroid cyst.
Specific Objectives:
On the completion of this case presentation, the nursing students will be able to:
• Define Thyroid Cyst

• Discuss the cause, signs and symptoms, and possible complications of Thyroid
Cyst
• Analyze the laboratory and diagnostic test and procedure
• Track the pathophysiology of Thyroid Cyst
• Make appropriate basic and actual drug study for Thyroid Cyst
• Make and implement appropriate nursing diagnoses and nursing interventions
NURSING HEALTH HISTORY

I. Biographic Data:
a. Name: C.O
b. Age: 48
c. Gender: Female
d. Case Number: 34025
e. Address: Canturing, Maasin City, Southern Leyte
f. Birthday: August 18, 1974
g. Nationality: Filipino
h. Religion: Inglesia ni Cristo
i. Civil Status: Married
j. Name of Father: L.L.M
k. Name of Mother: R.A.N
l. Attending Physician: Dr. Juntilla
m. Date of Admission: June 07, 2022
n. Diagnosis: Multinodular Nontoxic Goiter
II. Chief Complaint/s

• Enlargement of thyroid gland
III. History of Present Illness

One day prior to admission, the client states that she noticed progressive
growth of her thyroid gland which is the main reason why she wanted it
removed. She reported that she has only experienced difficulty swallowing
with no pain.
IV. Past Health History
The patient stated that the enlargement of her thyroid became noticeable
around the age of 47. She also stated that she has not experienced any
bothering symptoms of the enlargement of her thyroid. She also noted that she
has history of hypertension and hyperglycemia. She takes her maintenance
medication to control her blood pressure and hyperglycemia. She also noted
that has undergone previous surgery, cesarean delivery and
hemorrhoidectomy.
V. Family Health History

Male HTN- Hypertension
Female DM- Diabetes Mellitus
Deceased
Patient
PATERNAL MATERNAL
Grand Father
Grand Mother Grand Father Grand Mother
DM
HTN
Aunt Mother
Uncle Uncle Father Aunt Uncle
DM DM
PATIENT
DM & HTN
Patient has a family history of DM on her paternal side and HTN on her
maternal side. Therefore, DM and HTN are hereditary.
GORDON’S FUNCTIONAL HEALTH PATTERN
Health Perception Pattern
Before Hospitalization: The patient stated that she views her health as one of her top
priorities, in which she does her best to maintain her health. She stated that she tries to
eat healthy in order to make sure to maintain a healthy blood pressure and blood sugar.
She stated she tries her best to maintain good habits to help her optimize her overall
health.
During Hospitalization: The patient stated that her health is still one of her top priorities.
She reports that being hospitalized encourages her even more to maintain healthy habits
to help her have a fast recovery after her surgery. She stated that she still tries her best
to have a healthy eating, activity, and sleeping pattern.
Nutritional Metabolic Pattern
Before Hospitalization: The patient stated that she eats 3 meals and 1 snack a day. She
stated that she usually eats breakfast at 7-8am, lunch at 12-1pm, and dinner at 7-8pm,
Her usual meal consists of 1 cup of rice every meal, and usually pairs it with eggs,
vegetables, and meat. She usually eats bread as her snack. She also stated that she
drinks a lot of water in a day, she estimated that she drinks 8-9 glasses of water per day.
During Hospitalization: The patient stated that her appetite hasn’t changed during her
stay in the hospital, she still eats 3 meals a day on time and snacks. She reported that
she still drinks lots of water around 8 glasses per day.
Elimination Pattern
Before Hospitalization: The patient estimated that she voids 4-5 times a day, she
reported that her urine is pale yellow and stated that she has no difficulty urinating. The
patient also stated that she only defecates only once a day, usually in the morning. She
stated that sometimes she experiences difficulty in defecating.
During Hospitalization: The patient stated that nothing changed during her stay in the
hospital, she stated that she still urinates 4-5 times a day, and stated no difficulty in
urinating. She also reported that she still defecates once daily in the morning.
Activity-Rest Pattern
Before Hospitalization: The patient stated that she doesn’t follow any workout/exercise
routine. She reports that she does household chores such as sweeping and cleaning, and
she considers it as her “exercise”. She stated that she goes for a walk in the morning,
when she has free time.
During Hospitalization: The patient stated that she has decreased physical activity
during her time in the hospital. She reported that she’s usually just in bed, using her phone
and only gets up when she has to go to the bathroom.
Sleep-Rest Pattern
During Hospitalization: The patient report that she usually sleeps very late at night. She
reported that she usually sleeps around 10-11pm, and wakes up around 5-6am. She also
stated that she hasn’t experienced any sleep difficulties and disturbances.
During Hospitalizaion: The patient stated that she has difficulty sleeping. She stated
that she usually sleeps around 11-12pm/am. She reported that she began experiencing
sleep disturbances due to hot room temperature, she stated that she wakes up around 2-
3am, and she reported that she sometimes has difficulty going back to sleep.
Cognitive Perceptual Pattern
Before Hospitalization: The patient stated that she is always alert, aware and conscious
especially towards her surroundings. She stated that she is aware of her current condition
and follows instruction to maintain her health. She also likes spending her free time
looking up or reading information regarding health.
During Hospitalization: The patient stated that she is still conscious and alert, aware,
and conscious of her surroundings. She is aware about her current condition and about
the surgery she will undergo. She reported that she has been following the instructions
given by her doctor to have a safe recovery.
Role Relationship Pattern
Before Hospitalization: The patient stated that she is a wife and a mother. She has a
husband and one daughter. She states that she feels loved and connected with her family.
She reports role satisfaction as a mother and wife.
During Hospitalization: The patient stated that she is satisfied with the love, care, and
support that she has received from her family, especially during this time of her life. She
reported that she slightly feels a decreased in role satisfaction because she stated that
she should be the one taking care of them, not the opposite.
Sexual-Reproductive
Before Hospitalization: The patient stated that she is not sexually active for quite a
while. She reported that she and her husband doesn’t have enough energy to engage in
sexual activities. She also stated that she feels too old to engage in such activities.
During Hospitalization: The patient stated that she is still not sexually active, especially
now that she is confined in the hospital. She reports having no time or energy to perform
sexual activities with her husband. She also stated that due to her current condition, she
is not in the mood to do so.
Coping Stress Pattern
Before Hospitalization: The patient stated that she has many coping mechanisms
during times of stress. She reports that when she is stressed, she usually watches K-
dramas and listens to K-pop music. She also stated that sometimes during stressful
moments she likes to eat lots of snacks.
During Hospitalization: The patient stated that she is more stressed now because of
her upcoming surgery. She stated that she constantly watches K-dramas and also plays
K-pop music inside her room, because it helps her calm down. It also stated that she likes
eating snacks while watching movies to relieve stress.
Value-Belief Pattern
Before Hospitalization: The patient stated that she is a protestant (Inglesia Ni Cristo).
She reported that she goes to church every Thursday and Sunday with her family. She
also stated that she prays at night before going to sleep. She strongly believes in God
and she is certain that He will be there for her throughout her life.
During Hospitalization: The patient stated that she still prays every night before going
to sleep. She stated that she strongly puts her faith in God and she believes that God will
help her during the surgery and the recovery period. She stated that she is hopeful that
she will have a successful operation and a fast recovery.
PHYSICAL ASSESSMENT
SYSTEM NORMAL FINDINGS ACTUAL FINDINGS
Vital signs: BP = 90/60 to 120/60; BP= 110/70

T = 36.5-37.5 °C; T= 36.1ᴼc
P = 60-100/min; P= 75bpm
RR = 12-20/min; RR=16cpm
General: Well-developed. Well nourished, The pt was seen wearing t-

appearing stated age. Alert, shirt and jogging pants
oriented to time, place, person, • Well-developed
and situation. Recent and remote • Well-nourished
memory intact. Good insight and • Appears stated age
cognitive function. No aphasia, (48 years old)
dysarthia or hoarseness. Gait and • Recent memory
station normal. Rhomberg intact
negative. Appears to be her • Good insight
stated chronological age. Posture • No hoarseness
is erect and comfortable for age. • Gait and station is
Gait is rhythmic and coordinated, normal
with arms swinging at side.
• Appears to be her
Answers questions with
stated chronological
appropriate answers and in an
age (48)
appropriate manner.
• Posture is erect and
comfortable for age
• Answers questions
with appropriate
answer and in an
appropriate manner
Integumentary Skin is smooth, without lesions, • Skin is smooth,
skin surfaces vary from moist to without lesions
dry depending on the area • Skin is warm at
assessed. Skin is normally warm temperature
at temperature. Rebounds and • Rebound <5 secs (1
does not remain indented when sec)
pressure is released. Mucous • Mucous membranes
membranes should be pink and pink
moist. Both nipples and areolas
come in different sizes and colors,
from light pink to brownish.
HEENT Head is generally round, with • Head is round w/o

prominences in the frontal and prominences on the
occipital area. No tenderness frontal and occipital
upon palpation. Face is area.
symmetrical. Eyes are non- • No tenderness upon
protruding and equal palpebral palpation
fissure. Neck has no palpable • Face is symmetrical
cervical chain lymph nodes. No • Eyes non-protruding
thyroid enlargement. There should and equal palpebral
be no nodularity, lesions, pain fissure
upon palpation and tenderness • Nonpalpable cervical
chain lymph nodes
• Thyroid
enlargement
• Nodularity noted
• No lesions, pain upon
palpation and
tenderness
Respiratory No tenderness or pain is palpated • No tenderness or

over the lung area. No pain is noted on
adventitious sounds such as palpated area
crackles or wheezes are • No adventitious
auscultated. Voice transmissions sounds
is soft, muffled and indistinct.
Cardiovascular No blowing or swishing or other • No blowing or

sounds are heard. No murmurs swishing are heard
are heard. No extra heart sounds. • No murmurs are
Rate should be 60-100bpm with heard
regular rhythm. A regularly • No extra heart
irregular rhythm, such as sinus sounds
arrythmia when the HR increases • PR: 75bpm with
with inspiration and decreases regular rhythm
with expiration, may be normal in
young adults.
Breasts A generalized increase in • No nodularity and
nodularity and tenderness may be tenderness
a normal finding associated with • No masses palpated
the menstrual or hormonal • No rash/infection
medications. Breast should be at • No discharge
normal temperature. No masses
should be palpated. No rash or
infection should be noted. A milky

discharge is usually normal only
during pregnancy and lactation.
However, some women may
normally have a clear discharge.
Gastrointestinal Abdomen is flat, rounded, or • Abd is rounded
scaphoid. Linea nigra may be • Scar present (CS)
normal only during pregnancy. • No N/V
Nausea may reflect gastric • No masses upon
dysfunction, may also occur at palpation
particular times, such as early in • No enlargement
the day with some pregnant
clients. Certain smells and food
intolerances may trigger nausea
and vomiting. Abdomen should
have no masses upon palpation,
no enlargement.
Genitourinary Pubic hair is distributed in an • Voids 7 times per day

inverted triangular pattern and • Light yellow urine
there are no signs of infestation. • No difficulty/pain
There should be no enlargement upon urination
or swelling of lymph nodes. Labia
majora are equal in size and free
of lesions, swelling, and
excoriation. Bartholin’s glands are
usually soft, non-tender and
drainage free. The surface of the
cervix is normally smooth, pink,
and even. In pregnant clients, the
cervix appears blue (Chadwick
sign). The fundus is normally
round, firm, and smooth.
Softening of the womb (Hegar’s
sign) may be present in pregnant
clients.
Musculoskeletal Extremities should be nontender, • Extremities no
without nodules. Client tolerates tenderness without
test without extreme pain. No nodules
swelling or deformities or nodules • No pain noted
are noted on ankles and other • No deformities or
joint. No crepius sound upon nodules
• No swelling present
moving. Client has full ROM

against resistance.
Deep tendon reflexes
1+ may or may not be normal
2+ a brisk response, normal
3+ very risk response, may or may
not be normal
4+ a tap elicits a repeating reflex,
always abnormal
DEVELOPMENTAL TASKS/DEVELOPMENT
THEORY ACTUAL
Erickson’s Psychoanalytical Theory - Patient is at the age of 48 and is
Stage 7: Generativity vs Stagnation (40-65) already married and has one
- Patient strives to create or nurture daughter.
things that will outlast them such as - Patient states that she cares and
parenting children or fostering nurture for her family, especially her
positive changes that benefit other daughter.
- Patient contributes to society and - Patient works as a Medical
does things to promote future Technologist on a public hospital
generations
Piaget’s Cognitive Development - Patient is able to do mathematical
Formal Operational Stage (11 and up) calculations, think creatively, use
- Patient at this stage gain the ability to abstract reasoning, and able to
think in an abstract manner by imagine the outcome of particular
manipulating ideas in their head, actions.
without any dependence on concrete
manipulation
Freud’s Psychosexual Developmental - The patient is married and has one

Theory daughter.
The Genital Stage (11 to death) - She is not sexually active since she
- The individual develops strong sexual could not find suitable time for her
interest to opposite sex. and her husband to make love and
- Focus solely on individual needs, she thinks they are too old to engage
interest in the opposite sex. in such intimate activity.
- Individual is now well balanced, warm - She considers herself to be lucky in
and caring. having a loving and caring husband.
Kohlberg’s Moral Development Theory - The patient is able to step back and
Post conventional assess each situation as a whole.
- Capable of abstract thought, they - Patient is able to reflect on what is

become capable of internalizing. good and just.
- Standards of conduct. This is termed
post conventional development and is
mature form of moral reasoning.
JAMES FOWLERS STAGE OF FAITH - The patient stated that her faith in
DEVELOPMENT THEORY God didn’t waver at all, it still
Theory remained the same.
Stage 6 “Universalizing” faith (Later - She stated that she is firm believer in
Adulthood) her religion and she gets her energy
- The person at this stage is not from God.
hemmed in by differences in religious
or spiritual beliefs among people in
the world, but regards all beings as
worthy of compassion and deep
understanding
DEFINATION OF TERMS
1. Nontoxic multinodular goiter (MNG) is a disease of the thyroid gland
characterized by the presence of thyroid nodules (dominant focal structural
lesions) without biochemical abnormalities of the thyroid gland.
(Singh, O. N., Placzkiewicz, J. E., Jarzab B. (2019) Goiter, Nontoxic
Multinodular, Multinodular Goiter, Mcmaster Textbook of Internal Medicine.
Retrieved from: https://empendium.com/mcmtextbook-
sae/chapter/B78.II.9.4.?rfmcm
2. Goitre is a general term for an enlarged thyroid gland. Multinodular goitre is
where the enlarged thyroid appears with a number of separate lumps (nodules)
in the gland.
(British Tyroid Foundation (2018), Multinodular Goitre, You and your
Hormones, Retrieved from: https://www.yourhormones.info/endocrine-
conditions/multinodular-goitre/
3. Nontoxic goiter is thyroid gland enlargement with no disturbance in the thyroid
function. It is not due to inflammation or neoplasia. Abnormalities of iodine
supplies or metabolism always lead to nontoxic goiter.
(Alkabban FM, Patel BC. Nontoxic Goiter. [Updated 2021 Nov 2]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK482274/)
ETIOLOGY
PREDISPOSING RATIONALE ACTUAL
FACTORS
• AGE • With advancing age, the
prevalence of clinically
relevant thyroid nodules
increases, whereas the
risk that such nodules are
malignant decreases.
• FAMILY OR • Having parents or siblings

PERSONAL who have had thyroid
HISTORY nodules or thyroid or other
endocrine cancers
increases your chance of
developing nodules.
• GENDER • It is a fact that women are

more prone to malfunction
of the thyroid than
men. Women experience
a high flux of hormones
during pregnancy and
again at menopause.
• GEOGRAPHIC • Endemic goiters occur

within groups of people
living in geographical
areas with iodine-
depleted soil, usually
regions away from the sea
coast.
PRECIPITATING RATIONALE ACTUAL

FACTORS
• When thyroid cells absorb too
• RADIATION much radioactive iodine, it can
EXPOSURE cause thyroid cancer to
develop several years after
the exposure.
• REGULAR • Goitrogens are substances

INTAKE OF that disrupt the production of
SUBSANCES thyroid hormones.
(GOITROGENS) This triggers the pituitary to
release thyroid-stimulating
hormone (TSH), which then
promotes the growth of thyroid
tissue, eventually leading to
goiter.
• DIET • The body needs iodine to
produce thyroid hormone. If
you do not have enough iodine
in your diet, the thyroid gets
larger to try and capture all the
iodine it can, so it can make
the right amount of thyroid
hormone
ANATOMY AND PHYSIOLOGY
The thyroid gland is an endocrine organ found

on the neck, it is responsible for regulating the
body’s metabolic rate via hormones it produces.
In this article, we will be looking at its anatomy,
its cellular structure, its endocrine physiology
and its clinical relevance.
Anatomy
The thyroid gland is a ductless alveolar

gland found in the anterior neck, just below the laryngeal prominence (Adam’s apple). It
is roughly butterfly-shaped, with two lobes wrapping around the trachea and connected
in the middle by an isthmus. The thyroid gland is not usually palpable.
It is supplied by superior and inferior thyroid arteries, drained via superior, middle and
inferior thyroid veins and has a rich lymphatic system.
Physiology
The thyroid gland is an endocrine organ found on the neck, it is responsible for regulating
the body’s metabolic rate via hormones it produces. In this article, we will be looking at
its anatomy, its cellular structure, its endocrine physiology and its clinical relevance.
- Basal Metabolic Rate

- Gluconeogenesis
- Glycogenolysis
- Protein synthesis
- Lipogenesis
- Thermogenesis
SYMTOMATOLOGY
SYMPTOMS RATIONALE ACTUAL
• When the thyroid gland becomes
• TROUBLE
significantly enlarged, the goiter can
SWALLOWING begin to compress the esophagus (and
OR BREATHING other nearby structures, such as the
trachea), leading to dysphagia, as well as
breathing difficulties in some cases.
• PAIN AND • When a goiter becomes large enough, it

PRESSURE IN may appear as a swelling in the neck. A
THE NECK goiter is usually painless but may cause
pressure-related symptoms.
• COUGHING • As the nodules get larger, they can irritate

your throat and lead to a long-lasting
cough.
• CHANGES IN • Hoarseness can be caused by pressure

VOICE from a goiter on structures in the neck,
including the windpipe and the nerves
that control the voice.
• Enlargement of the thyroid can expand
• LUMP ON NECK
the gland well beyond its typical size and
cause a noticeable bulge in the neck.
This can be caused by single or multiple
nodules (lumps) in the thyroid or by an
autoimmune process.
PATHOPHYSIOLOGY: MULTINODULAR NONTOXIC GOITER
PREDISPOSING FACTORS PRECIPITATING

7 FACTORS
Age
Radiation Exposure
Family/Personal History
Lack of Iodine in Diet
Gender (Female Hormones)
Regular intake of
Geographic
substance (Goitrogens)
Geographic Diet Regular

intake of
Female Age Family/ Radiation substance
Personal Lack of Lack of (Goitrogens)
Exposure
History access to Iodine
Puberty and Decreased Iodine Intake
Pregnancy thyroid Increased
Absorption of
function Mutation of Thiocyanate
radioactive
Genes:
iodine
Estrogen Sodium
Iodide IODINE LEVEL Competitive
Symporter, Leads to inhibition of Iodine
Thyroid Thyroid transport and
Peroxidase, Abnormalities organification
Dual
Oxidase 2
DECREASED/SUPPRESSION
PRODUCTION THYROID
HORMONES
DECREASED T4 AND T3 IN
THE BODY
INCREASED DEMANDS OF
THYROID HORMONE
TRIGGERS NEGATIVE
FEEDBACK LOOP
STIMULATES PITUITARY TO
RELEASE TSH
INCREASED LEVEL TSH
THYROID FOLLICULAR
CELLS ARE STIMULATED
INRCREASE CELLULARITY
AND FOLLICULAR
HYPERPLASIA
INCREASED
NECK
CIRCUMFERENCE THYROID ENLARGEMENT
(GOITER)
CONTINUOUS REPITITION
OF NEGATIVE FEEDBACK
LOOP
RECURRENT EPISODES OF LEGEND

HYPERPLASIA AND
INVOLUNTION DISEASE
PROCESS
DYSPNEA PAIN IRREGULAR ENLARGEMENT

OF THYROID S/SX
DYSPHAGIA CHANGE OF (MULTINODULAR GOITER)
VOICE
DIAGNOSIS
COMPRESSION OF INCREASED
ESOPHAGUS AND/OR VASCULARITY COMPLICATIONS
TRACHEA
RISK HEMORRHAGE WORST

TRACHEOMALACIA ASPHYXIATION
PROGNOSIS
DEATH
PATHOPHYSIOLOGY DISCUSSION: MULTINODULAR NONTOXIC GOITER
Enlargement of the thyroid gland or also known as Goiter can be triggered by a variety of
factors. Predisposing factors, which are factors that increases the risk of a person to
develop Goiter includes; Age, Family/Personal History, Gender, and Geographic. The
thyroid gland during aging undergoes important functional changes, therefore the
prevalence of thyroid disorders increases with age. Goiter is also more common among
females; this is due to the female hormones; estrogen and progesterone. When females
undergo physiological changes such as puberty and pregnancy, it will result to a
fluctuation of hormones, more particularly, estrogen. Estrogen plays a role in stimulating
the growth of the thyroid gland, when there is excess estrogen, it can predispose a person
in developing goiter. Another factor that can make a person more susceptible to the
disease are those who have family/personal history of any thyroid problems, this includes,
mutation of Sodium Iodide Symporter, which is responsible for the active transport of
iodide in the thyroid gland; Thyroid Peroxidase, assist the binding of iodine to a protein
called thyroglobulin; and Dual Oxidase 2, responsible for iodine organification. All in
which, these substances are essential in the production of the thyroid hormones. Mutation
of these substances will then inhibit the production of thyroid hormones. The last
predisposing factor is the Geographic, people who reside in areas with little access to
iodine containing products/foods are more susceptible to thyroid enlargement due to lack
of iodine in their diet.
The precipitating factors of this disease, includes; Radiation Exposure, Lack of Iodine in
Diet, Regular intake of substance (Goitrogens). Studies have shown that people who
have increased exposure to radiation have an increased risk of developing goiter, this is
because the thyroid gland is not able to distinguish between normal iodine and radioactive
iodine, absorption of radioactive iodine in the thyroid gland causes thyroid abnormalities.
Diet also plays a role in the enlargement of thyroid, people who lack iodine in their diet
are more prone in developing goiter. Regular intake of Goitrogens which interferes with
the normal function of the thyroid gland, since these substances contain Thiocyanate,
which competes with the absorption of iodine, resulting to blocking iodine uptake in the
thyroid gland.
All the mentioned factors lead to an overall decrease/suppression of the production of the
thyroid hormones. Low production of these hormones will result to low levels of T4 and
T3 in the body. Low levels of T4 and T3 triggers the negative loop feedback, therefore
stimulating the pituitary gland to secrete another hormone called the Thyroid Stimulating
Hormone (TSH). The negative loop feedback results in the increased levels of TSH. High
levels of TSH stimulates the follicular cells in the thyroid gland, once stimulated it will
trigger an increase in cellularity therefore causing follicular hyperplasia, therefore causing
the enlargement of the thyroid gland (Goiter). The enlargement of the thyroid gland is
evident with an increase in the neck diameter.
When left untreated, this will then result to continuous repetition of the negative feedback
therefore, causing recurrent episodes of hyperplasia and involution of the thyroid gland.
Due this continuous process, it will result to an irregular enlargement of the thyroid gland
causing multiple nodules to develop (Multinodular Nontoxic Goiter).
Complications of multinodular nontoxic goiter includes the compression of the esophagus

and/or trachea, it is manifested by dysphagia, dyspnea, changes in voice, and pain. When
the pressure continues to increases, life threatening complications such as
tracheomalacia (collapse trachea) and asphyxiation (deprivation of oxygen) blocking the
airway. Another complication is the increased intra-nodular vascularity. Development of
abnormal thyroid vascular anatomy combined with immature angiogenesis and fragility of
the nodule, can increase the risk of hemorrhage. When untreated complications of this
disease occur, it can lead to death.
Patient’s Name: C.O Age: 48 years old Marital Status: Married
Diagnosis: Multinodular Nontoxic Goiter
RT-PCR
Laboratory Indication Reference value Actual Findings Nursing

/Diagnostic test consideration
Reverse It's a test to detect Normal: Result: Pre:
Transcription genetic material from • Non-reactive SARS-COV2 1. Explain the
Polymerase Chain a specific organism, (Causative agent of procedure to
Reaction (RT-PCR) such as a virus. The Covid-19) viral RNA the client
test detects the not detected 2. Ask consent
presence of a virus if 3. Confirm
you have the virus at client’s
the time of the test. identity
The test could also Intra:
detect fragments of 1. Ask client to
the virus even after tilt health
you are no longer backward
infected. 2. Swab desired
area
Post:
1. Provide
comfort and
further
instructions
HEMATOLOGY

Hematology Hematological tests Normal: Result: Pre:
can help diagnose • 11-13.5 • Protime: 11.6 1. Explain the
anemia, infection, seconds secs procedure to
hemophilia, blood- • INR: 0.96 the client
clotting disorders, • % Activity 2. Ask consent
and leukemia. 90% 3. Confirm
client’s
identity
Intra:
1. Clean the
puncture site
2. Use
tourniquets
3. Withdraw
Blood
Post:
1. Apply light
pressure on
puncture site
with cotton
ball.
2. Monitor
puncture site
for unusual
bleeding
CLINICAL CHEMISTRY REPORT

Clinical Chemistry Clinical chemistry Normal: Result: Pre:
Report refers to the • Sodium: 135- • Sodium:137.5 4. Explain the
biochemical analysis 145 mEq/L mEq/L procedure to
of body fluids. It uses • Potassium: • Potassium: the client
chemical reactions to 3.6-5.2 3.35L mmol/L 5. Ask consent
determine the levels mmol/L • Calcium 6. Confirm
of various chemical • Calcium: 2.15- (ionized): 1.08 client’s
compounds in bodily 2.55 mmol/L mmol/L identity
fluids. Intra:
4. Clean the
puncture site
5. Use
tourniquets
6. Withdraw
Blood
Post:
3. Apply light
pressure on
puncture site
with cotton
ball.
4. Monitor
puncture site
for unusual
bleeding
THYROID FUNCTION TEST

Thyroid Function Thyroid function tests Normal: Result: Pre:
Test are used to check • TSH: 0.35- • TSH: 1.724 1. Explain the
for a number of 4.50 mIU/mL • FT4: 16.56 procedure to
thyroid problems. • FT4: 9-23 the client
The tests measure pmol/L 2. Ask consent
the amount of 3. Confirm
different hormones client’s
including thyroid identity
stimulating hormone Intra:
(TSH), thyroxine 1. Clean the
(T4), and puncture site
triiodothyronine (T3). 2. Use
Other tests on the tourniquets
thyroid include 3. Withdraw
various antibodies Blood
related to thyroid Post:
tissue.
1. Apply light
pressure on
puncture site
with cotton
ball.
2. Monitor
puncture site
for unusual
bleeding
ELECTROCARDIOGRAPHIC REPORT

Electrocardiographic It is a simple test that Normal: Result: Pre:
Report can be used to check • Normal sinus • Sinus Rhythm 1. Explain the
your heart's rhythm rhythm within Normal procedure to
and electrical activity. Limits the client
Sensors attached to 2 No special
the skin are used to preparation is
detect the electrical needed
signals produced by 3. Instruct client
your heart each time to empty the
it beats. bladder
Intra:
1. Apply a
conductive get
on the chest
area
2. Position the
patient on his
supine on bed
Post:
1. Remove the
conductive gel
from the
patient’s skin
2. Inform the
patient that
the study will
be interpreted
by the
physician
3. Instruct
patient to
resume
regular diet
and activities.
HEMATOLOGY

Hematology Hematological tests Normal: Result: Pre:
can help diagnose • White Blood • White Blood 7. Explain the
anemia, infection, Cells: 4.5-11.0 Cells: 9.2 x procedure to
hemophilia, blood- x 10^9/L 16^9/L the client
clotting disorders, • Hematocrit: • Hematocrit: 8. Ask consent
and leukemia. 35.5-44.9 35 9. Confirm
• Platelet • Platelet client’s
Count: 150- Count: 220 x identity
400 x 10^9/L 10^3/uL Intra:
Differential Count Differential Count 7. Clean the
• Neutrophil: • Neutrophil: puncture site
40-60% 65% 8. Use
• Lymphocyte: • Lymphocyte: tourniquets
20-40% 30% 9. Withdraw
• Monocyte: 2- • Monocyte: 2% Blood
8% Post:
• Eosinophil: 0- • Eosinophil: 5. Apply light

6% 3% pressure on
• Bleeding TOTAL: 100 puncture site
Time: 1-9mins • Bleeding with cotton
• Clotting Time: Time: 2’45” ball.
4-10mins min 6. Monitor
• Clotting Time: puncture site
3’55” min for unusual
• Blood Type: O bleeding
positive
BLOOD CHEMISTRY

Blood Chemistry Blood chemistry Normal: Result: Pre:
tests measure • Glucose: • Glucose: 90.06 1. Explain the
certain chemicals in <99mg/dL mg/dL procedure to
your blood. Results • Cholesterol:<200 • Cholesterole:189. the client
of these tests give mg/dL 79 mg/dL 2. Ask consent
your health care • Triglycerides: • Triglycerides: 3. Confirm
provider important <150 mg/dL 138.64 mg/dL client’s
information about • Cholesterol • Cholesterol identity
your general health, direct: <100 direct: 49.49 Intra:
how well your organs mg/dL mg/dL 1. Clean the
(such as the liver and • LDL: 50-100 • LDL: 112.6 puncture site
kidneys) are working, mg/dL mg/dL 2. Use
and whether you • Creatinine: 0.7- • Creatinine: 0.74 tourniquets
may be experiencing 1.3 mg/dL mg/dL 3. Withdraw
side effects from HIV • Urea VV 6-24 • Urea VV 21.77 Blood
drugs. Abnormal mg/d: mg/dL Post:
results can point to a
problem that needs • Uric Acid: 3.5- • Uric Acid: 7.78 1 Apply light
to be addressed. 7.2 mg/dL mg/dL pressure on
• ALT: 4-36 u/L • ALT: 15.77 u/L puncture site
• AST: 8-48 u/L • AST: 5.44 u/L with cotton
ball.
2 Monitor
puncture site
for unusual
bleeding
SEROLOGY

Serology: HbsAg A protein on the Normal: Result: Pre:
surface of hepatitis B • Negative/ • Nonreactive 1. Explain the
virus; it can be Nonreactive procedure to
detected in high the client
levels in serum 2. Ask consent
during acute or 3. Confirm
chronic hepatitis B client’s
virus infection. The identity
presence of HBsAg Intra:
indicates that the 1. Clean the
person is infectious. puncture site
2. Use
tourniquets
3. Withdraw
Blood
Post:
1. Apply light
pressure on
puncture site
with cotton
ball.
2. Monitor
puncture site
for unusual
bleeding
RADIOGRAPHIC RESULT

Chest X-ray PA A chest X-ray is an Normal: Result: Pre:
view imaging test that • Lungs are clear • Lungs are 1. Explain the
uses X-rays to look • Normal cardio- clear procedure to
at the structures and mediastinal outline • Cardio- the client
organs in the chest. • Trachea at midline mediastinal 2. Ask consent
It can help the • The hemidiaphragms silhouette 3. Confirm
healthcare provider are domed structures appears client’s
see how well the that should be well normal in size identity
lungs and heart are defined and visible to and 4. Remove any
working. the midline on a orientation metallic
frontal view.’ • Tracheal air objects
• Unremarkable column 5. Ensure
osseous and soft appears patient is not
tissue midline pregnant

• Dome-shaped 6. Assess
diaphragmatic patient to hold
breath
leaflets and 7. Provide

intact sula appropriate
• Captured clothing
osseous and Intra:
soft-tissues 1. Instruct
are patient to stay
unremarkable still and hold
breath
Post:
1. Assist patient
in changing
clothes
2. Provide
comfort
ULTRASOUND

Ultrasound Diagnostic Normal: Result: Pre:
ultrasound, also • A normal • R thyroid lobe 1. Explain the
called sonography or thyroid gland 2.2 x 2.3 x 2.5 procedure to
diagnostic medical is cm (LWH), the client
sonography, is an approximately volume is 8.0 2. Ask consent
imaging method that 4-4.8 x 1.8 x cc 3. Confirm
uses sound waves to 0.8 to 1.6 cm • L 2.2 x 1.2 x client’s
produce images of in size, with a 1.3 c, (LWH) identity
structures within your mean volume is 2.0 4. Remove any
body. The images sonographic cc jewelries
can provide valuable volume of 7 to • Major vessels 5. Assist client to
information for 10 mL and are intact. The change into
diagnosing and weight of 10 visualized gown
directing treatment to 20 grams submandibular Intra:
for a variety of glands are not 1. Apply gel into
diseases and usual the area being
conditions. examined
• No enlarged Post:
cervical lymph 1. Remove gel
nodes are from client
seen 2. Provide
comfort
FINE NEEDLE ASPIRATION BIOPSY

Fine needle Doctors use an Normal: Result: Pre:
aspiration biopsy FNA to check an • • Benign 1. Explain the
abnormal area or • Gross: Mass procedure to
lump for cancer or is doughy, the client
other diseases. It 2cm in 2. Ask consent
may be done when diameter at R 3. Confirm
the doctor can feel or side anterior client’s
touch a lump (it is neck identity
palpable). It may also • Microscopic 4. Remove any
be done if imaging Description: jewelries
tests show an The smear 5. Assist client to
abnormal growth or show few change into
area.. isolated gown
thyrocytes w/ Intra:
fine chromatin 2. Sterilize the
and abundant area before
foamy procedure
histocytes or 3. Assist
scanty colloid physician
background during
procedure
4. Monitor
patient for any
unusuality
Post:
1. Monitor client
for bleeding
2. Monitor for
side effects of
anesthesia
3. Provide post-
op care
Name: C.O Age: 48 Gender: Female Marital Status: Married
DRUG STUDIES
DRUG NAME MODE OF ACTION INDICATIONS CONTRAINDICATI SIDE NURSING

ONS EFFECTS/ADVERSE INTERVENIONS
EFFECTS (specify)
Generic Name: Inhibits hydrogen Symptomatic - Hypersensiti SIDE EFFECTS: Baseline
omeprazole potassium GERD without vity to GI: Diarrhea, Assessment
Brand Name: adenosine esophageal lesions omeprazole, Abdominal Pain, Verify
Prilosec triphosphate (H+/K+ other proton Nausea, Vomiting, medication order
Prilosec OTC pump), an enzyme pump Constipation and prepare
on the surface of inhibitors CNS: Headache, medication.
Therapeutic gastric parietal - Concomitant Dizziness Compare
Class: Proton cells. use with RESPI: Upper medication to
Pump Inhibitor products respiratory infection, the medication
containing Cough order. Bring
Pharmacological rilpivirine MUSCULO: Asthena, medication to
Class: - May Back pain the patient and
Benzimidazole increase risk complete
Actual Dose, of fractures, ADVERSE necessary

Timing and gastrointesti EFFECTS: assessment
Route: IVTT: nal GI: Pancreatitis,
40mg, STAT infections, Hepatotoxicity NURSING
hepatic GU: Interstitial INTERVENTION
impairement nephritis /EVALUATION
, pts Asian Identify the
decent patient.
a. Ask the
patient
his/her
name
b. Ask the
staff
member
to identify
the
patient
c. Check the
name on
the
identificati
on
bracelet if
available
d. State the
purpose
of the
medicatio
n to the
patient
e. Administe
r
medicatio
n through
IV
POST-
PROCEDURE:
• Record
medicatio
n
administr
ation.
• Monitor
patient for
signs and
symptom
s of acute
interstitial
nephritis

EFFECTS (specify)
Generic Name: Essential for - Treatment - Hypersensiti SIDE EFFECTS Baseline
Calcium function, integrity of of vity to GI: Chalky taste, Mild assessment
gluconate nervous, muscular, hypocalcemi calcium constipation, Fecal Assess B/P,
Brand Name: skeletal systems. a formulation. Impaction, Nausea EKG and
Plays an important All and Vomiting cardiac rhythm,
Therapeutic role in normal preparations MUSCULO: Muscle renal function,
Class: cardiac/renal : Calcium- pain, Unusual fatigue serum
Antacid, function, respiration, based renal RESPI: Slow magnesium,
Antihypocalcemic blood coagulation, calculi, respirations phosphate,
, cell membrane and hypercalce calcium, ionized
Antihyperkalemic, capillary mia, ADVERSE EFFECTS calcium.
Antihypermagnes permeability. ventricular ENDO:
emic, Assists in regulating fibrillation. Hypercalcemia Intervention/ev
Antihyperphosph release/storage of aluation
atemic hormones/neurotran Monitor serum
Pharmacological smitters. BMP, calcium,
Class: Neutralizes/reduces ionized calcium,
Electrolyte gastric acid magnesium,

replenisher (increases pH). phosphate; B/P,
cardiac rhythm,
Actual Dose, renal function.
Timing and Monitor for signs
Route: of
PO: 1g TID hypercalcemia.
Patient/family
teaching
• Do not take
within 1–2 hrs of
other oral
medications,
fiber-containing
foods.
• Avoid
excessive use of
alcohol,
tobacco,
caffeine.

EFFECTS (specify)
Generic Name: Binds to bacterial Treatment of History of SIDE EFFECTS Baseline
cefuroxime cell membranes, susceptible hypersensitivity/an GI: Oral candidiasis, assessment
Brand Name: inhibits cell wall infections due to aphylactic reaction Nausea, Mild Obtain CBC,
Ceftin synthesis. group B to cefuroxime, diarrhea, Mild renal function
Zinacef streptococci, cephalosporins. abdominal cramping tests. Question
Therapeutic pneumococci, REPRO: Vaginal for history of
Class: staphylococci, H. candidiasis allergies,
Antibiotic influenzae, E. coli, SKIN: Rash, Pruritus, particularly
Pharmacological Enterobacter, Urticaria cephalosporins,
Class: Klebsiella penicillins.
Second- ADVERSE EFFECT
generation GI: Antibiotic- Intervention/ev
cephalosporin associated coltis aluation
Actual Dose, GU: Nephrotoxicity Assess oral
Timing and IMMUNE: cavity for white
Route: Prophylaxis patches on
mucous
PO: 500mg TID membranes,

for 7 days tongue (thrush).
Monitor daily
pattern of bowel
activity, stool
consistency.
Mild GI effects
may be tolerable
(increasing
severity may
indicate onset of
antibiotic-
associated
colitis). Monitor
I&O, renal
function tests for
nephrotoxicity.
Be alert for
superinfection:
fever, vomiting,
diarrhea,
anal/genital
pruritus, oral
mucosal
changes
(ulceration, pain,
erythema).
Patient/family
teaching
• Doses should
be evenly
spaced.
• Continue
antibiotic
therapy for full
length of
treatment.
• May cause GI
upset (may take
with food, milk).

EFFECTS (specify)
Generic Name: Inhibits - Acute - Hypersensiti SIDE EFFECTS Baseline
celecoxib cyclooxygenase-2, postoperativ vity to GI: Diarrhea, assessment
Brand Name: the enzyme e pain celecoxib, Dyspepsia, Assess onset,
responsible for sulfonamide Abdominal pain, type, location,
Therapeutic prostaglandin s Flatulence, Nausea duration of
Class: synthesis. - Active GI CNS: Headache, pain/inflammatio
Anti-inflammatory bleeding Dizziness, Insomnia n. Inspect
Pharmacological - Asthma RESPI: Upper appearance of
Class: NSAID, - Urticaria or respiratory tract affected joints
COX-2 selective allergic infection for immobility,
reactions to SKIN: Rash deformity, skin
Actual Dose, aspirin MUSCULO: condition.
Timing and - Treatment Peripheral edema, Assess for
Route: of Back pain allergy to sulfa,
PO: 200mg B.I.D perioperativ aspirin, or
e pain in ADVERSE EFFECT NSAIDs
coronary CVS: MI, CVA
artery GI: GI bleeding (contraindicated)

bypass graft .
surgery.
Intervention/ev
aluation
Assess for
therapeutic
response: pain
relief; decreased
stiffness,
swelling;
increased joint
mobility;
reduced joint
tenderness;
improved grip
strength.
Observe for
bleeding,
bruising, weight
gain.
Patient/family
teaching
• If GI upset
occurs, take with
food.
• Avoid aspirin,
alcohol
(increases risk
of GI bleeding). •
Immediately
report chest
pain, jaw pain,
sweating,
confusion,
difficulty
speaking, one-
sided weakness

EFFECTS (specify)
Generic Name: Converts to T3 , - Treatment - Hypersensitivity SIDE EFFECTS Baseline
levothyroxine then binds to thyroid of to levothyroxine GI: GI intolerance assessment
Brand Name: receptor proteins hypothyroidi - Acute MI, SKIN: Rash, Urticaria Obtain baseline
Levoxyl exerting metabolic sm, pituitary untreated TSH, T3 , T4 ,
Synthroid effects through DNA thyroid- subclinical or overt ADVERSE EFFECTS weight, vital
Tirosint and protein stimulating thyrotoxicosis, ENDO: signs.
Unithroid synthesis. hormone uncorrected Hyperthyroidism Signs/symptoms
Therapeutic (TSH) adrenal CVS: Cardiac of diabetes,
Class: suppression insufficiency. arrhythmias diabetes
Thyroid Hormone . SKELETAL: insipidus,
(T4) Decrease bone adrenal
Pharmacological density insufficiency,
Class: hypopituitarism
Synthetic isomer may become
of thyroxine intensified.
Treat with
adrenocortical
Actual Dose, steroids before

Timing and thyroid therapy
Route: in coexisting
PO: 100–125 hypothyroidism
mcg/day and
hypoadrenalism.
Intervention/ev
aluation
Monitor pulse for
rate, rhythm
(report pulse
greater than 100
or marked
increase).
Observe for
tremors, anxiety.
Assess appetite,
sleep pattern.
Patient/ family
teaching
• Do not
discontinue drug
therapy;
replacement for
hypothyroidism
is lifelong.
• Follow-up
office visits,
thyroid function
tests are
essential.
• Take
medication at
the same time
each day,
preferably in the
morning.
• Monitor pulse
for rate, rhythm;
report irregular
rhythm or pulse
rate over 100
beats/min.
• Promptly report
chest pain,
weight loss,
anxiety, tremors,
insomnia
SURGICAL MANAGEMENT
Thyroidectomy
Thyroidectomy is the surgical removal

of all or part of the thyroid gland. The
thyroid is a butterfly-shaped gland
located at the base of the neck. It
produces hormones that control every
aspect of metabolism, from the heart
rate to how quickly calories burn.
Thyroidectomy is used to treat thyroid
disorders, such as cancer,
noncancerous enlargement of the
thyroid (goiter) and overactive thyroid
(hyperthyroidism).
The two types of thyroidectomy

include:
1. Total thyroidectomy: The gland is removed completely. Usually done in

the case of malignancy. Thyroid replacement therapy is necessary for life.
2. Subtotal thyroidectomy: Up to five-sixths of the gland is removed when
antithyroid drugs do not correct hyperthyroidism or RAI therapy is
contraindicated.
NURSING MANAGEMENT:
PREOPERATIVE
1. Explain the procedure to the patient

2. Obtain inform consent from patient
3. Instruct client on NPO diet after midnight
4. Perform preoperative checklist (Check nails, jewelries, hair accessories)

5. Assist client into hospital gown
6. Assess for allergies
7. Assist in administration of anesthesia
INTRAOPERATIVE
1. Ensure proper room temperature, humidity and lighting in OR

2. Ensure equipments are ready and are safely functioning
3. Monitor aseptic technique
4. Monitor the patient throughout the operative procedure to ensure the patient’s
safety and well being
POSTOPERATIVE
1. Transfer patient to recovery room

2. Monitor and record vital signs q15 mins
3. Monitor recovery from surgery and anesthesia
4. Monitor for return of bowel movement
5. Closely monitor for bleeding
6. Place client in a Semi-fowler’s position
7. Monitor airway
8. Provide comfort
Name: C.O Age: 48 Gender: Female Marital Status: Married

NURSING CARE PLANS
CUES/DATA NURSING NSG GOAL AND NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTION
SUBJECTIVE Anxiety related to After 8 hours of 1. Introduced self 1. Promotes After 8 hours of
DATA: threat to current nursing and established cooperation and nursing
“Kulbaam lagi ko status secondary interventions, the rapport enhances nurse- interventions, the
client will; patient goal was met as
kay hadlok baja to surgical
- Be able to evidenced by:
lagi operahan.” As experience and relationship
report
verbalized by the the outcome of decreased - Client was
surgery as fear and 2. Identify the able to report
patient
evidenced by anxiety client’s perception 2. Understanding decreased
verbalization of reduced to of the threat pts point of view fear and
OBJECTIVE DATA: manageable presented by the promotes a more anxiety
anxiety
- Verbalization level situation accurate plan of reduced to
of anxiety SCIENTIFIC - Acknowledge care manageable
- Decreased fear and level
BASIS: identify ways
in 3. Monitor vital - Patient
Patients to deal with
productivity signs 3. To identify acknowledges
undergoing
- Expressed physical fear and
surgery worries
responses identify ways
concern about fear of
associated with to deal with:
regarding death, fear of
both medical and Music therapy
changes, complication, and
fear of emotional
fear of con-
unexpected conditions
Sequences
- Verbalizes result, causing
schedule anxiety before 4. Assess the 4. Promotes a

surgery for surgery. (Bedaso level of anxiety more accurate
tomorrow & Ayalew, 2019) plan of care
(June 8,
2022) 5. Be available to 5. Promotes
client for listening expression of
and talking feelings and helps
client look at
realities of the
illness or
treatment
6. Acknowledge 6. Validates reality

anxiety and fear of feelings
7. Provide comfort 7. To reduce

measures (calm stimuli that
environment heightens client’s
anxiety
8. Identify actions 8. Promotes client

and activities the to manage anxiety
client has on his/her own
previously used to
cope with anxiety
9. Assist in 9. To eliminate
developing skills negative self-talk
(Substituting
positive thought)
10. Review 10. This helps

strategies such as prepare client for
use of dealing with
visualization to anxiety
practice
anticipated event

SUBJECTIVE Impaired comfort After 8 hours of 1. Assess factors 1. Obtaining a After 8 hours of
DATA: related to nursing that may cause baseline of the nursing
interventions, the patient’s concerns interventions, the
“Di naman sija postoperative pain discomfort and
client will obtain a baseline provide a starting goal was met as
kaajo sakit, as evidenced by
evidenced by
uncomfortable ra verbalization of point for
- Verbalize
kay murag naay discomfort pain scale healthcare staff to - Client
<3 treat discomfort verbalizes
hukaw ahung
tutunlan” as SCIENTIFIC - Demonstrate pain scale <2
BASIS: coping 2. Assess the 2. Pain may be - Client
verbalized by the mechanism patient’s pain considered a form demonstrates
patient Pain is one of the
causes of when in level. of discomfort that coping
distress should addressed. mechanism
discomfort.
OBJECTIVE - Verbalize It establishes what (listening to
Discomfort can be feeling of music) when
DATA: physical or level is acceptable
improved in distress
- Verbalizes mild psychological and for the patient and
comfort - Verbalize
pain site is characterized a goal level of pain
feeling of
- PS: 3/10 by an unpleasant control
improved
- Guarding feeling resulting in comfort
behavior on a natural response 3. Assess the 3. This
surgical site noted of avoidance or patient’s coping assessment helps
reduction of the strategies to cope healthcare staff
- Minimal
source. with discomfort utilized desired
movements noted coping mechanism
- Verbalizes feeling (Ashkenazy,
2019) for discomfort
of tiredness and
exhaustion
4. Assess for 4. Language

communication barriers, sensory
barriers. impairment, and
other factors can
hold the patient
back from
expressing
feelings and
concerns
5. Make 5. Environmental
environmental changes to the
changes to patient’s
improve patient’s preference might
comfort give him or her a
feeling of control
and increase
comfort
6. Provided 6. This helps shift

relaxation the focus away
techniques that from the currently
may decrease experienced pain,
discomfort anxiety, and
tension and
instead focus on
more pleasant
experiences
7. Reposition the 7. Changes in

patient frequently, patient position
elevate HOB help relieve
pressure and may
help with pain
management,
elevated HOB
enhances patient’s
breathing
8. Offer heat or 8. Heating

cold application as blankets and ice
non- packs can be used
pharmacological as additional tools
pain treatment to treat pain or
option elevate comfort
level
9. Explain 9. Letting the

procedures and patient know what
routine patient to expect may take
care to client and away feelings of
SO anxiety and
promote comfort
10. Suggest 10. Some illnesses

appropriate may need further
referrals if evaluation by more
necessary to specialized
increase comfort providers and staff

SUBJECTIVE Risk for Ineffective After 8 hours of 1. Monitor 1. Respirations After 8 hours of
DATA: Airway Clearance nursing respiratory rate, may remain nursing
interventions, the interventions, the
“Murag kumaw pa related to tracheal depth, and work of somewhat rapid,
client will: breathing but the goal was met:
i-ginhawa kay obstruction
murag naay secondary to development of
- Maintain a - Patient
something sa thyroidectomy as patent respiratory distress maintained
evidenced by airway with is indicative of a patent
ahung tutunlan
verbalization of aspiration tracheal airway with
unya guot pod sija
feelings of prevented compression from aspiration
sa dressig.” As - Verbalizes edema prevented
restrictions in
verbalized by the breathing reduced - Patient
patient. feeling of 2. Assess for 2. Indicators of verbalizes
restriction in dyspnea and tracheal reduced
SCIENTIFIC breathing
OBJECTIVE BASIS: cyanosis obstruction and feeling of
DATA: Common cause of laryngeal spasm, restriction in
- Postoperative dyspnea include requiring prompt breathing
phase: compression due evaluation and
thyroidectomy to formation of a intervention
- Surgical incision hematoma,
at neck noted tracheal collapse, 3. Caution patient 3. Reduces the
laryngeal edema to avoid bending likelihood of
- Dry and intact
and bilateral neck tension on the
dressing at neck surgical wound.
noted recurrent laryngeal
nerve injury. (Wu,
- Verbalizes 4. Assist with 4. Maintain clear
et al., 2019)
feelings of repositioning, airway and
restrictions in ventilation
breathing deep breathing

exercises
5. Check dressing 5. If bleeding

frequently occurs, the anterior
especially the dressing may
posterior portion appear dry
because blood
pools dependently
6. Investigate 6. May indicate

reports of difficulty edema or
swallowing, sequestered
drooling of oral bleeding in tissues
secretions. surrounding the
operative side.
7. Position the 7. Upright position

patient upright if limits abdominal
tolerated. contents from
Regularly check pushing upward
the patient’s and inhibiting lung
position to prevent expansion. This
sliding down in position promotes
bed better lung
expansion and
improved air
exchange.
8. Encourage 8. Fluid help

patient to increase minimize mucosal
fluid intake drying and
maximize ciliary
action to move
secretions
9. Consider the 9. This facilitates

need of liquefaction of
humidifiers in secretions and
home care setting enhances comfort
10. Create 10. Prevent fatigue

planned rest and help conserve
periods with energy.
patient and
promote energy
conservation
methods.

SUBJECTIVE Risk for bleeding After 8 hours of 1. Determine the 1. Early After 8 hours of
DATA: related to prior nursing patient’s health identification of nursing
“Gahapon sa alas thyroidectomy as history for signs possible risks for
patient will: that can be bleeding provides goal was met as
3 man ko gi evidenced by
evidenced by
operahan” as presence of associated with a a foundation for
- Take
verbalized by the surgical incision at measure to risk for bleeding implementing - Patient
neck prevent appropriate takes
patient
bleeding and preventive measure to
SCIENTIFIC able to measures prevent
OBJECTIVE recognize bleeding by
BASIS:
DATA: signs of 2. Monitor 2. Hypotension following
Patients
- Postoperative bleeding that patient’s vital and tachycardia post
undergoing
phase: needs to be signs, especially are initial operative
surgical reported care
thyroidectomy procedures can BP and HR compensatory
- Patient does instructions
- Surgical incision bleed for a variety mechanisms
not and able to
at neck noted of reasons. The experience usually noted with recognize
- Dry and intact incision made by excessive bleeding. signs of
dressing at neck the surgeon bleeding bleeding
noted causes injury to 3. Evaluate the 3. It inhibits the that needs
the blood vessel patient’s use of synthesis of to be
therefore causing any medications vitamin K in the reported
bleeding after that can affect liver, reducing - Patient does
surgery. (Curnow, hemostasis clotting factors not
et al., 2016) experience
4. Review 4. These excessive
laboratory results laboratory tests bleeding as
provide important evidenced
for coagulation information about by minimal

status the patient’s blood seen
coagulation status on dressing
and bleeding
potential
5. Monitor surgical 5. Early detection

site/dressing for of bleeding
active bleeding promotes
immediate nursing
intervention
6. Advise patient 6. Dark greenish to

to regularly check black stool as well
stool color and as tarry
consistency consistency could
indicate bleeding in
the upper
gastrointestinal
area.
7. Educate the 7. Information

patient at risk about
about precautionary
precautionary measures lessens
measures to the risk for
prevent tissue bleeding.
trauma or
disruption of the
normal clotting
mechanisms
8. Educate the 8. Early evaluation

patient and SO and treatment of
about signs of bleeding by a
bleeding that need health care
to be reported provider reduce
the risk for
complications from
blood loss
9. Measure and 9. Determines

record total intake extent of fluid loss,
and output need for
replacement, or
progress of
replacement
therapy
10. Change 10. Promote

dressing when hygiene and
needed using provides
aseptic technique opportunity to
assess surgical
site

SUBJECTIVE Readiness for After 8 hours of 1. Ascertain 1. Belief in the After 8 hours of
DATA: enhanced health nursing client’s belief ability to nursing
“Unsa man ahung management about health and accomplish
client will be able her ability to desired action is goal was met as
dapat buhaton inig related to
to; evidenced by
uli namo, doc?” as postoperative care maintain health predictive of
verbalized by the as evidenced by - Assume performance - Patient assume
patient. expression of responsibility for responsibility for
desire to enhance management 2. Determine 2. Provides management
health regimen client’s current baseline data regimen
OBJECTIVE DATA: health status and about pt’s
management
- Expresses - Demonstrate perception of knowledge about - Patient
desire to SCIENTIFIC proactive possible threats to health demonstrate
enhance management by health proactive
BASIS: anticipating and
health Involving patients management by
planning for
management in shared decision- eventualities of 3. Verify the 3. This provides an anticipating and
- Client making (SDM) and condition of client’s level of opportunity to planning for
follows providing sufficient potential knowledge and ensure accuracy eventualities of
prescribed preoperative and complication understanding of and completeness condition of
regimens postoperative therapeutic of knowledge base potential
information can regimen for future learning complication
- Manages
illness, improve their
recovery and 4. Determine 4. The manner in
symptoms, source(s) client which people
or risk satisfaction.
(Jaensson et. al, uses when access and use
factors seeking health healthcare
2019)
information information
5. Identify steps 5. Understanding

necessary to the process
reach desired enhances
health goals commitment and
the likelihood of
achieving the
goals
6. Accept the 6. This promotes a

client’s evaluation sense of self-
of own strengths esteem and
and limitation confidence to
while working continue efforts
together to
improve abilities
7. Acknowledge 7. This provides

individual’s efforts positive
and capabilities to reinforcement
reinforce encouraging
movement toward continued progress
attainment of toward desired
desired outcome goals
8. Promote 8. Knowing that he

client/caregiver or she can make
choices and own choices
involvement in promotes
planning for and commitment to
implementing program
added tasks and

responsibilities
9. To assist in the
9. Encourage the management of
use of relaxation stress and
skills promote general
health and well-
being
10. Assist in 10. This promotes

implementing proactive problem
strategies for solving
monitoring
progress and
responses to the
therapeutic
regimen
JOURNAL READING
Title: Thyroid Cancer: High Risk for Thyroid Cancer in Patient with Multinodular
Goiter
Author: Farahiti, J. (2019)
Background: Thyroid cancer is common and the incidence is increasing rapidly,
especially in women. Thyroid cancer presents as a thyroid nodule. There has been
controversy in the literature about the risk of thyroid cancer in patients with multiple
thyroid nodules (multinodular goiter) as well as with Graves’ disease and toxic
nodular goiters which are the most common causes of hyperthyroidism. Initially,
studies suggested that patients with Graves’ disease, multinodular goiter and toxic
nodular goiter carried a lower risk of thyroid cancer than patients with only a single
thyroid nodule. However, recent studies suggested a higher risk of cancer in these
patients (10-20%). This study looked at how frequently thyroid cancer was found
in patients undergoing thyroid surgery because of Graves’ disease, multinodular
goiter and toxic nodular goiter.
Implications of the Study: This study suggests that the risk of thyroid cancer in
patients with multiple nodules is high as nearly one in five patients with multiple
nodules had thyroid cancer. However, this does represent a selected population
as all of these patients went to surgery, so the results cannot be applied to all
patients with multiple nodules. Despite this, it is clear that the risk of thyroid cancer
in patients with multiple nodules is not less than those with single nodules. Further,
this study confirms that patients with Graves’ disease to have a lower risk of thyroid
cancer. Finally, this study does suggest that total thyroidectomy by an experienced
surgeon should be more considered in patients with multiple nodules, especially in
males and younger patients.
Summary: This study reviewed studies from 3 centers in the United States. A total
of 1523 patients underwent thyroid surgery between 2000 and 2011. All patients
with cancer or indeterminate fine needle aspiration biopsy findings before the
operation were excluded from this analysis. The risk of thyroid cancer was
calculated and analysis was performed to identify the risk factors for thyroid
cancer. The total risk of cancer was 16% in the studies and was similar in all 3
centers. The average cancer size was 1.1 cm and 39% of cancers were larger than
1 cm. Younger age, male sex and presence of nodules were associated with higher
risk of thyroid cancer. The highest risk of cancer was found in toxic nodular goiter
(18%) and the lowest risk in Graves’ disease (6%).

Multinodular Goiter Case Study

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Multinodular Goiter Case Study

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The College of Maasin

Nisi Dominus Frustra

A CASE STUDY ON MULTINODULAR

The prevalence of a disease is determined by the screening method used and

• Define Thyroid Cyst

NURSING HEALTH HISTORY

II. Chief Complaint/s

III. History of Present Illness

IV. Past Health History

V. Family Health History

Female DM- Diabetes Mellitus

GORDON’S FUNCTIONAL HEALTH PATTERN

Health Perception Pattern

Nutritional Metabolic Pattern

Cognitive Perceptual Pattern

Role Relationship Pattern

Coping Stress Pattern

Vital signs: BP = 90/60 to 120/60; BP= 110/70

General: Well-developed. Well nourished, The pt was seen wearing t-

HEENT Head is generally round, with • Head is round w/o

Respiratory No tenderness or pain is palpated • No tenderness or

Cardiovascular No blowing or swishing or other • No blowing or

infection should be noted. A milky

Genitourinary Pubic hair is distributed in an • Voids 7 times per day

moving. Client has full ROM

Freud’s Psychosexual Developmental - The patient is married and has one

- Capable of abstract thought, they - Patient is able to reflect on what is

• FAMILY OR • Having parents or siblings

• GENDER • It is a fact that women are

• GEOGRAPHIC • Endemic goiters occur

PRECIPITATING RATIONALE ACTUAL

• REGULAR • Goitrogens are substances

ANATOMY AND PHYSIOLOGY

The thyroid gland is an endocrine organ found

The thyroid gland is a ductless alveolar

- Basal Metabolic Rate

• PAIN AND • When a goiter becomes large enough, it

• COUGHING • As the nodules get larger, they can irritate

• CHANGES IN • Hoarseness can be caused by pressure

PATHOPHYSIOLOGY: MULTINODULAR NONTOXIC GOITER

PREDISPOSING FACTORS PRECIPITATING

Geographic Diet Regular

INCREASED LEVEL TSH

RECURRENT EPISODES OF LEGEND

DYSPNEA PAIN IRREGULAR ENLARGEMENT

RISK HEMORRHAGE WORST

PATHOPHYSIOLOGY DISCUSSION: MULTINODULAR NONTOXIC GOITER

Complications of multinodular nontoxic goiter includes the compression of the esophagus

Patient’s Name: C.O Age: 48 years old Marital Status: Married

Diagnosis: Multinodular Nontoxic Goiter

Laboratory Indication Reference value Actual Findings Nursing

Laboratory Indication Reference value Actual Findings Nursing

CLINICAL CHEMISTRY REPORT

Laboratory Indication Reference value Actual Findings Nursing

THYROID FUNCTION TEST

Laboratory Indication Reference value Actual Findings Nursing

Laboratory Indication Reference value Actual Findings Nursing

Laboratory Indication Reference value Actual Findings Nursing

• Lymphocyte: • Lymphocyte: tourniquets

20-40% 30% 9. Withdraw

• Monocyte: 2- • Monocyte: 2% Blood

• Eosinophil: 0- • Eosinophil: 5. Apply light

Laboratory Indication Reference value Actual Findings Nursing