Med-Surg Endocrine System, part 16: Thyroidectomy: Nursing Care

by Cathy Parkes

A thyroidectomy is a full or partial removal of the thyroid. This type of surgery is important to know about for your Med-Surg exams, because it can be the required intervention for several disorders, including hyperthyroidism, which can result from Graves’ disease. A complication stemming from this surgery is hypoparathyroidism, which we will cover in our next article.

This surgery and the related disorders are covered in our Medical-Surgical Flashcards (Endocrine system).

Nursing care

Any time you have a patient who has had a surgery on their neck (like a thyroidectomy), consider it a serious threat to their airway! Assess for any laryngeal edema (which could manifest with stridor), and intervene rapidly if you identify that.

Make sure to have easy access to a crash cart, oxygen delivery devices, and an emergency tracheostomy kit.

Patient positioning

When a patient comes back from having their thyroidectomy surgery, place them in a semi-fowler’s position. Sitting totally upright would put the patient at a 90 degree angle, but in a semi-Fowler’s position they are angled between 15 and 45 degrees.

Support their head and neck using either sandbags or pillows to keep everything in a neutral position. You don’t want the patient to hyperextend their neck by bending it too far backwards, or have their head droop down in front. Keep the patient’s head at the midline to avoid disrupting the suture line across their throat.

Bleeding

Lots of blood flows through the thyroid gland, and bleeding is a potentially life-threatening complication after a thyroidectomy. You will want to be monitoring your patient carefully for bleeding following this surgery. Check their wound dressing for blood, and check behind their neck to make sure blood is not pooling behind them

Parathyroid damage

Remember from our anatomy overview of the Endocrine system that the parathyroid glands are 4 glands that basically bedazzle the thyroid gland. The parathyroid glands’ job is to secrete parathyroid hormone (PTH), which causes increased calcium levels.

These glands are tiny, the size of a grain of rice, and are somewhat in-the-way during a thyroidectomy and sometimes they get accidentally nicked or damaged during the surgery. So if the parathyroid glands, whose job it is to indirectly increase blood calcium, get damaged and are unable to do their job, calcium will not be increased to the level it should, and this will result in hypocalcemia.

Hypocalcemia

Calcium is an important electrolyte in the body, and the normal level of calcium (Ca) in the blood is 9-10.5 mg/dL. Calcium levels under 9 mg/dL can indicate hypocalcemia. Besides hypoparathyroidism resulting from parathyroid gland damage, other causes of hypocalcemia can be diarrhea (causes electrolyte loss) and vitamin D deficiency (because vitamin D helps the body absorb calcium).

Signs and symptoms of parathyroid damage are signs and symptoms of hypocalcemia, which includes numbness, tingling around the mouth, muscle twitching, GI upset, and positive Chvostek’s and Trousseau’s signs.

Chvostek’s sign

A Chvostek’s sign is an abnormal reaction to the stimulation of the facial nerve. If you tap the patient’s cheek and their face twitches, this is a positive Chvostek’s sign and can indicate the patient has hypocalcemia. Cathy’s easy way for remembering this is that both Chvostek and cheek start with CH!

Trousseau’s sign

Trousseau’s sign is an abnormal reaction by the hand, to pressure on the arm. If you inflate a blood pressure cuff on a patient’s upper arm and it causes spasms in their hands and fingers due to ischemia, that can indicate hypocalcemia.

Treatment

If a patient does have hypocalcemia that is confirmed with a blood test, we can provide them with calcium gluconate to bring the calcium level up.

Patient teaching

After a patient undergoes a thyroidectomy, it’s important to teach them to avoid extreme neck extension or flexing, and to keep their head in a midline position. Otherwise, they risk damage to that suture line.

As part of patient teaching post-thyroidectomy, you will also need to reinforce that the patient will need to take thyroid replacement for the rest of their lives. Their thyroid gland is now gone, so it will not be producing thyroid hormones T3 and T4 anymore.

The thyroid hormone replacement medication is levothyroxine, which is given on an empty stomach with a full glass of water.

Levothyroxine is one of the essential medications you need to know for your Pharm exams and it’s covered in our Pharmacology flashcards.

Cathy’s teaching on thyroidectomy surgery is intended to help prepare you for Medical-Surgical nursing exams and critical care. The Medical-Surgical Nursing video series is intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI and NCLEX.


Full transcript

In this video, we are going to talk about nursing care of patients who require a thyroidectomy. And this could be due to thyroid cancer or hyperthyroidism, such as you would have with Graves' disease.

So after your patient comes back from the OR, from having their thyroidectomy, you want to place your patient in a semi-Fowler's position.

And then you want to support their head and neck using either sandbags or pillows to keep it in a neutral position. So we don't want them to hyper-extend their neck or have their neck go down like this. We really want to support it and keep it midline to avoid disruption of the suture line.

We're going to want to monitor for bleeding, so we're going to want to check their dressing and also check behind their neck to make sure there's no blood pooling behind their neck.

And then we also want to monitor for signs and symptoms of parathyroid damage.

During a thyroidectomy, the parathyroid gland can be damaged as well which can cause hypocalcemia. So signs and symptoms of parathyroid damage are going to be signs and symptoms of hypocalcemia.

This includes numbness and tingling around the mouth as well as muscle twitching.

You also may have a positive Chvostek sign. So the Chvostek sign is where you tap the cheek and that's how I remember this sign because Chvostek starts with C-H, and cheek also starts with C-H. So you tap their cheek and if you get twitching of the facial muscles, then that is a positive Chvostek sign and they indicate that the patient has hypocalcemia.

Also if they have a positive Trousseau's sign that is also indicative of hypocalcemia. So that's where you inflate a blood pressure cuff on their upper arm, and it causes spasms in their hand and fingers. It causes their hands and fingers to kind of go like this due to the ischemia. So if your patient is exhibiting that, then that is definitely a strong indicator that they may have sustained parathyroid gland damage.

And then if your patient does have hypocalcemia that's confirmed with a blood test, then we can provide them with calcium gluconate to help address that.

In terms of patient teaching, we want to reinforce that they need to avoid extreme neck extension or flexing, right? They want to keep their head in a midline position.

You also need to reinforce that the patient will need to take thyroid replacement for the rest of their lives, right? The thyroid gland is gone, so it is not going to be producing T3 and T4. So the patient will need to take a medication such as levothyroxine every day for the rest of their lives. And just as a reminder about that medication, we do give that on an empty stomach, about an hour before breakfast with a full glass of water.

Okay. And that is it for nursing care after a thyroidectomy. In my next video, we will cover hypoparathyroidism as well as hyperparathyroidism. Thank you so much for watching!


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