Sample Case Pres Thyroid CA

8/3/2019 Sample Case Pres Thyroid CA

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SAMPLE CASE PRESENTATIONfor SURGICAL TECHNOLOGY

STUDENTS

SGNA



THYROIDECTOMY

PERI-OPER ATIVE C ARE OF P ATIENT WITH

THYROID C ANCER



1. PATIENT¶S RECORD

Patient¶s Hospital Data/ Personal Data

Patient¶s name: Mr . Yusuf Afandi

Age: 35y/o

Gender: M

Educational attainment: College levelOccupation: Employee



Medical History

No known history of aller gy, previous accidents or

hospitalization 9 months ago, patient developed swelling on the

neck region, painf ul to touch;

diff iculty in swallowing

2 months ago, patient decided to seek medicaltreatment due to diff iculty of breathing and

hoarseness



Family History

Father - heavy smoker, with f amily history of hypertension

Mother- deceased; died of colon cancer 9 years ago

Unknown f amily history of neur ologic and inf ectious diseases



THE CLINICAL PICTURE OF THE PATIENT WITH THYROID CA



Chief complaint/ Signs andSymptoms/Diagnosis

Chief complaint: diff iculty of swallowing, dyspnea

Signs and Symptoms: dyspneic

tachycardic

w/ enlar ged thyr oid

(upon inspection and palpation)

Diagnosis: THYROID CA



Vital signs

Date: 2/1

Time: 7 am

Date: 2/1

Time: 3pm

Date: 2/1

Time: 10 pm

RR 25/min. 27/min 28/min.

PR 110/min. 100/min. 98/min.

BP140/90 mmHg 130/90 mmHg 130/90 mmHg

TEMP. 37.7*C 37.6*C 37.4*C

WT. 130 LBS.



Thyroid Tests Reference Values

Adult Reference Ranges:

T4 = 5.6-13.7 ug/dl (mcg/dl) FT4 = 0.8-1.5 ng/dl

T3= 87-180 ng/dl

FT3 = 230-420 pg/d;

TSH = 0.4-4.5 mIU/L (mU/L)



Procedures/ Lab works

y Blood hormone studies:

y A pr ocedure in which a blood sample is checked to measure the amounts of

certain hormones released into the blood by or gans and tissues in the body. Anunusual (higher or lower than normal) amount of a substance can be a sign of disease in the or gan or tissue that makes it. The blood may be checked for abnormal levels of thyr oid-stimulating hormone (TSH). TSH is made by thepituitary gland in the brain. It stimulates the release of thyr oid hormone andcontr ols how f ast follicular thyr oid cells gr ow. The blood may also be checkedfor high levels of the hormone calcitonin.



Procedures/ Lab works

y Radioactive iodine scan (RAI scan): A pr ocedure to f ind areas in the bodywhere thyr oid cancer cells may be dividing quickly. Radioactive iodine (R AI) isused because only thyr oid cells take up iodine. A very small amount of R AI isswallowed, travels thr ough the blood, and collects in thyr oid tissue and thyr oidcancer cells anywhere in the body. Abnormal thyroid cells take up lessiodine than normal thyr oid tissue. Areas that do not absorb the iodine normally(cold spots) show up lighter in the picture made by the scan. Cold spots canbe either benign (not cancer) or malignant, so a biopsy is done to f ind out if they are cancer.



SURGICAL BIOPSY

y Sur gical biopsy: The removal of the thyr oid nodule or one lobeof the thyr oid during sur gery so the cells and tissues can be

viewed under a micr oscope by a pathologist to check for signsof cancer.



Doctor¶s Orders

Monitor neck circumf erence

Monitor RR and PR every 2 hours Start IV NSS 500ML 12 gtts / min. x 8 hours

For thyr oidectomy af ter 3 days; for consent



Medications

Brand name/

Generic

Name

Composition Indication Dosage and

forms

Side effects Nursing

responsi-

bility

Adriamycin

Generic

Name:

Doxorubicin

BrandName:

Adriamycin

Anti-

neoplastic

antibiotic.

It works by

killing cancer

cells.

Administered

per IV r oute

-leaks into

surr ounding

Tissues

-heart

pr oblems

-bone marr ow

suppression

Assess if redness, pain,or swelling at or ar ound theinjection siteoccur.



Pre ±operative Responsibilities of the Nurse/Surgical Technologists

On the ward,patient may be checked for past illnesses and mayper form special tests to be ready for the operation. Many hospitalsnow run special pre-admission clinics where you may advice thepatient for visit for an hour or two, a week or so before the operationfor these checks.

Ask patient to stop smoking

Get his weight down.

If patient has pr oblems with blood pressure, heart, or lungs, arrangefor a ref erral check that these are under contr ol.

Check the hospital's advice about taking the pill or hormonereplacement therapy (HRT).

Instruct that patient has to have a relative or f riend who can come withhim to hospital, take him home, and look af ter him for the f irst weekaf ter the operation.

Ask him to bring all his tablets and medicines with him to hospital.



ANATOMY OF THYROID



Physiology of the Thyroid

The thyr oid is a gland at the base of the thr oat near the trachea(windpipe). It is shaped like a butter f ly, with a right lobe and a

lef t lobe. The isthmus, a thin piece of tissue, connects the two lobes. A healthy thyr oid is a little lar ger than a quarter. It usuallycannot be f elt thr ough the skin. The thyr oid uses iodine, amineral found in some foods and in iodized salt, to help makeseveral hormones. Thyr oid hormones do the following:

Contr ol heart rate, body temperature, and how quickly food is

changed into ener gy (metabolism). Contr ol the amount of calcium in the blood.



DISEASE PROCESS

DEFINITION OF CANCER:

The basic disease pr ocess begins when normalcells under go change and begin to pr olif erate in

an abnormal manner.

It must be regarded as a gr oup of disease

entities with diff erent causes, manif estations,treatment and pr ognosis.



Tissue changes



Cancer Cell Division



Major dysf unction in the cell:

Cellular Proliferation- when cancer cells divide in an indiscriminate, unregulatedmanner

Loss of contact inhibition- cancer cells have no regard for cellular boundaries

Tumors (neoplasms)

1. Benign- incapsulated neoplasm that remains localized in the tissue of origin

a. exerts pressure on surr ounding or gans

b. will decrease blood supply to the normal tissue

2. Malignant- non-encapsulated neoplasm that invades surr ounding tissue.Depends on thestage of neoplasm as to whether or not metastases or spread to distant body

parts has occurred.There are three mechanisms by which the metastases

spreads:a. vascular system

b. lymphatic system

c. implantation



Four main types of thyroid cancer :

Four main types of thyr oid cancer:

Papillary thyr oid cancer: The most commontype of thyr oid cancer.

Follicular thyr oid cancer

Medullary thyr oid cancer

Anaplastic thyr oid cancer



A PHOTO OF STAGE OF THYROID CANCER



7 WARNING SIGNS OF CANCER

Cancer¶s Seven Warning Signs

1. (C) Change in bowel or bladder 2. (A) A lesion or sore that does not heal

3. (U) Unusual bleeding or dischar ge

4. (T) Thickening or lump in the breast or elsewhere

5. ( I ) Indigestion or diff iculty swallowing

6. (O) Obvious change in wart or mole

7. (N) Nagging cough or persistent hoarseness



Treatment of Cancer

DiagnosticsA. Common Cancer Diagnostic Studies1. Chest x-ray2. Computed axial tomography

3.Cytology studies

4. Radioisotope scans

B.Biopsy1. Needle

2. Incisional

3. Excisional

4. Endoscope biopsy



NEEDLE BIOPSY PHOTO



Goals of Cancer Therapy

A. Cure

-client will be disease f ree and live normalexpectancy

B. Control

- client¶s cancer is not cured but contr olled bytherapy over long periods of time

C. Palliative

- maintain as high as the quality of lif e for theclient when cure and contr ol are not possible



Modalities of Cancer Treatment

- therapy usually involves utilizing 2 or more modalitiesof cancer treatment

A. Surgery

Pr ophylactic- removal of lesions pr one to develop into cancer

Primary- removal of the entire tumor and involved surr ounding

tissue

Palliative- relieve complications of the cancer, obstruction and

pain



THYROIDECTOMY



CHEMOTHERAPY

B. Chemotherapy- overall goal of chemotherapy is to attack the cancer cell

during its most vulnerable stage

1. medications

2. nursing implications in chemotherapy

a. assess client for complications of bone marr ow depression

( increased bleeding and bruising, sore thr oat , f ever)

b. prevent exposure of patient to people withcommunicable diseases



Continuation on nursing implications in chemotherapy

Prior to therapy, establish a baseline regarding intake and output,

bowel habits, oral hygiene, psychological status and f amily

relationships.d. Inform client regarding side eff ects and nursing measures to reduce discomfort.

e. Monitor f luid intake and output; maintain adequate hydration to prevent urinary complications

f . Inform client that if alopecia occurs, it is usually transient.

g. Be aware of possible drug interactions with chemotherapeuticagents.

h. Utilize holistic appr oach with the cliet and his f amily.Consider thepossible changes in his lif estyle and pr ovide support to client andf amily.



On Extravasation

i. Take extra precaution to prevent extravasation of antineoplastic

medications. If extravasation occurs:

-stop the inf usion

-do not remove the needle

-administer antidote or agent to prevent sloughing of area

-apply cold pack for f irst 24 hours

-apply warm pack af ter the f irst 24 hours



EXTRAVASATION



Cont.

C. Radiation ( internal and external)1. The r oute of administration depends upon the specif ic characteristics of the cancer

and of the client

2. Side eff ectsa. skin reactionsb.gastr ointestinal disturbances

c. diarrhea and constipation

d. hematopoietic

3. Saf ety measures for client with an internal radiation source

a. private r oom

b. inform all people coming in contact with the client the specif ic precautionsnecessary

c. utilize badges or radiation monitors for caregivers having direct client contact

d. list on the chart ( type of radiation, time inserted, anticipated removal time,precautions)e. prevent excessive exposure ( time, distance and shield)



Cont.

Immunotherapy

1. Based on the theory that certain substances stimulate the

immune response2. Types

A. Passive- administration of an antibody, usually in theform of serum collected f r om a client who has hadspecif ic cancer and who is thought to build up antibodies

B. Active nonspecif ic

a. Bacillus Calmette ± Guerin ( BCG)

B. Inter f er on



MEDICAL MANAGEMENT SPECIFIC TO THEPATIENT

1. Chemotherapy- prior to sur gery

2. Primary sur gery



GO ALS AND NURSING INTERVENTION IN

THE C ARE OF C ANCER P ATIENTS

Maintain client at optimum psychosocial level1. Encourage verbalization

2. Assist client to understand disease pr ocess and therapeutic regime3. Include f amily in the care

4. Assist client to cope in changes of body image due to alopecia

5. Assess client¶s support systems

6. Recognize client¶s emotional outbursts and anger as part of hiscoping pr ocess

7.Encourage measures to maintain ego.- active participation in his own care and decision-maing

- active listening

- encourage personal lif estyle



NURSING CARE

Maintain nutrition1. Diet- appr opriate to age level

- increase pr otein and calories

- supplemental vitamins

-small f requent f eedings

-increase f luid intake

-between meal supplements

2. Hyperalimentation

3. Prevent or decrease complications associated with malnutrition

a. anorexiab. nausea and vomiting

c. stomatitis



NURSING CARE

Prevent and/ or decrease infectious process.

1. Caref ul assessment of temperature elevations.2. Administer antibiotics.

3. Meticulous personal hygiene.

4. Isolation f r om communicable diseases

5. Frequent assessment of inf ectious pr ocesses.



NURSING CARE

Prevent and / or decrease hematological complications.1. Evaluate for decreasing platelets or thr ombocytopenia.

2. Administer platelets and whole blood transf usions as indicated.

3. Evaluate areas of potential bleeding.

-nose bleed

- urinary tract

- stool

- mucous membranes

4. Anemia

-maintain adequate rest-maintain adequate oxygenation

-assess for pr oblems of erythr opoiesis

-evaluate respiratory and cardiac systems for mechanisms of compensation



ERYTHROPOESIS



NURSING CARE

G. Relieve pain

1. Evaluate client¶s and f amily¶s response to pain.

2. Evaluate characteristics of pain.

3. Pr omote general comfort.

4. Administer medications for pain relief .



NURSING CARE

H. Recognize complications specific to

radiation and chemotherapy.

1. Alopecia

2. Hemorrhagic pr oblems

3. Gastr ointestinal distress

4. Bone marr ow depression5.Skin reactions

6. Decreased immune response



EQUIPMENTS USED FOR SURGERY

SUCTION APP AR ATUS

ELECTROSURGIC AL UNIT WITH DISPERSIVE ELECTRODE

ROLL OR THYROID REST FOR EXTENDING THE NECK



INSTRUMENTS USED FOR SURGERY

THYROIDECTOMY SET

BIPOL AR FORCEPS WITH CORD

LIGATING APPLIERS AND CLIPS



Terris Thyroidectomy Instrument Set

Designed in conjunction with David Terris, MD, FACS



SUPPLIES USED FOR SURGERY

PREP SET

B ASIC P ACK

B ASIN SET THYROID DR APES

ELECTROSURGIC AL PENCIL

GLOVES

BL ADES #10 #15

SUTURE ACCORDING TO SURGEON PREFERENCE ¼-IN PENROSE DR AIN



PENROSE DRAIN, ELECTROSURG PENCIL,DRAPES,THYROID COLLAR



STERILIZATION METHOD USED FOR THE

INSTRUMENTS

PHYSIC AL METHOD² Steam under pressure (autoclave) isthe most dependable and economical method of sterilization.

It is the method of choice for metalware, glassware, mostrubber goods, and dry goods.

In the downward (gravity) displacement autoclave, air inthe chamber is forced downwardand out of the bottom dischar ge outlet aspressurized steam enters f r om the top of the

chamber. The temperature in the sterilizer gradually increases as the steam heats the chamber andits contents. The actual timing does not begin until thetemperature is above 245°F (118°C).



ANESTHESIA USED FOR SURGERY

General anesthesia strategies

*Combined intravenous-inhalational induction General Anesthesia: patient was kept

completely asleep thr oughout the operation.

The anesthetic was given by liquid /IV and a

gas thr ough a f ace mask or tube placed inmouth and thr oat.



PATIENT POSITION FOR SURGERY

Medical personnel had put a r olled sheet or small pillow under his

shoulders. This lif ted his chin and extended his neck so doctor can see

his thyr oid better. Arms were tucked at his sides.



RISK FACTORS DURING THE PROCEDURE

Risk Factors for Complications during theProcedure

Obesity

Smoking

Alcoholism

Poor nutrition Severe chr onic illness, such as poorly

contr olled diabetes



SURGICAL PROCEDURES

A horizontal incision is made in the f r ont of the neck. The skin ispulled away f r om the incision and held back with retractors or

stitches. Bleeding vessels are clamped and tied off . Thesur geon separates muscles, blood vessels, and nerves in theneck to access the thyr oid gland. All or part of the thyr oid glandis cut away f r om its attachment to other tissues in the neck andremoved. Bleeding is contr olled with instruments thatcompress, constrict, and cauterize the ends of blood vessels.The incision is closed and the edges of skin are stitchedtogether.

When this gland is removed to treat thyr oid cancer, lymphnodes in the area may also be removed in case the cancer hasmetastasized.







POST OPERATIVE CARE OF PATIENT

The incision was bandaged to keep the area clean and prevent

inf ection. ( A ST brief ly removed the bandage and check the

stitches shortly af ter sur gery.) Thin rubber tubes were put into the area ar ound the incision to

drain off excess f luid. They were taken out when no longer

needed.



Post op care

Pain Medicine: To ease pain af ter the operation,the doctor

prescribed medication to given by IV as a shot, and by mouth.

Anti-Nausea Medicine: This medicine calmed stomach andcontr olled vomiting.

THYROID HORMONE THERAPY

Thyroid hormone medication LEVOTHYROXINE

(Levothroid, Synthroid, others) for life.

This has two benefits:1) It supplies the missing hormone your thyroid would normally produce,

2) It suppresses the production of thyroid-stimulating hormone (TSH) in

pituitary gland.



*IMPORTANT POINT TO CONSIDER

Temporary low calcium levels can be seen af ter thyr oidectomysimply because the parathyr oid glands became bruised or

swollen af ter sur gery, thus making it diff icult for them to pr oduce normal amounts of parathyr oid hormone. Thesepatients may have a temporary low calcium that requiresminimal or no calcium replacement and in time the parathyr oidglands f unction well once again.

The treatment for low calcium af ter total thyr oidectomy is to

supplement the diet with calcium and perhaps Vitamin D untilthe situation corrects itself . There are a number of calciumsupplements in various forms such as pills, syrups, and liquidsthat per form the job quite nicely.



Ca Supplements



ROUTINE POST OP CARE

Oxygen, Deep Breathing,Coughing and Incentive

spirometer .



PATIENT TAKE HOME INSTRUCTIONS BY THE ST

³ Always take your medicine exactly as directed. If it doesn'tseem to help, let the doctor know, but keep taking it until toldother wise. If you've been prescribed antibiotics, be sure to use

them up, even if you're f eeling better. If a medicine makes youdr owsy, avoid driving or using danger ous machinery.

For pain or swelling, you may put ice in a plastic bag, cover itwith a towel, and place it over the incision for 15 to 20 minutesout of every hour as long as necessary. Do not sleep on the icepack. Treatment with ice is most eff ective when started right

af ter the operation and used for 24 to 48 hours. When you are allowed to bathe or shower, caref ully wash the

stitches with soap and water. Then put on a clean, new bandage. Change your bandage any time it gets wet or dirty.



TAKE HOME INSTRUCTIONS

Eat healthy meals f r om all 5 food gr oups: f ruits, vegetables, breads,dairy pr oducts, and meat. This will increase your ener gy level andpr omote f aster healing.

Unless instructed other wise, drink 6 to 8 lar ge glasses of liquid, suchas water, juices, and milk, each day. Limit caff einated beverages, suchas coff ee, tea, and soda.

Regular bowel movements can be diff icult af ter sur gery. Don't strain if the stool is too hard. Walking will help to stimulate the bowels. Eating foods rich in f iber, such as f ruit, bran, cereal, and beans, will also helprestore regularity. Drink plenty of liquids; prune juice may help make

the stool sof ter. Or, if your doctor appr oves, you can take an over-the-counter f iber laxative.

You'll need extra rest while you recuperate. Try to gradually increaseyour activity each day, resting whenever you f eel it's needed. Avoidany heavy lif ting until your doctor gives the OK. ³



CONDITIONS THAT MERIT NOTIFICATION OF THE DOCTOR

Numbness or tingling ar ound the lips or extremities

Twitching or spasms

Excessive and pr ogressive f atigue

Signs of inf ection, including f ever and chills

Redness, swelling, increasing pain, excessive

bleeding, or dischar ge f r om the incision site

Cough, shortness of breath, chest pain, or severe

nausea or vomiting



6 days after SURGERY



DESIRED OUTCOMES

If the thyr oid was removed to treat a thyr oid tumor,

nodule, or excessive goiter, the outcomes include:

Removal of cancer ous tissue f r om the body

Impr ovement in swallowing or air f low that may have

been compr omised by an oversized thyr oid gland



OR3 EVALUATION FOR

GROUP CASE PRESENTATION

Excellent (4)

Very Good (3)

Good (2) Poor (1)

CRITERIAS

1. Topic selection and Statement of Objectives

2. Or ganization and Clarity

3. Powerpoint Presentation and Style4. Paper presentation and Style

5. Audience Impact/Response

TOTAL POINTS: 17 -20 excellent «

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Sample Case Pres Thyroid CA