Friday, March 11, 2011

Although Thyroid cancer occurs in all age groups Incidence increases with age. The average age at time of diagnosis is 45. There appears to be an association between external radiation to the head and neck in infancy and childhood, and subsequent development of thyroid carcinoma. (Between 1949 and 1960, radiation therapy was commonly given to shrink enlarged tonsil and adenoid tissue, to treat acne, or to reduce an enlarged thymus.) People who have goiters have an increased risk for developing thyroid cancer. The incidence among such patients is 10–15 percent. A lack of iodine in the diet may lead to thyroid cancer. Because iodine is added to salt in the United States, thyroid cancer is rarely caused by iodine deficiencies in this country. Thyroid cancer may also have a genetic basis. Some researchers have found that an alteration in the RET gene may be transmitted from a parent to a child, causing medullary thyroid cancer. If several people in a family are diagnosed with thyroid cancer, other members may wish to be tested for a mutation of the RET gene. This syndrome, when present, is also called familial medullary thyroid cancer or Multiple Endocrine Neoplasia, type 2 (MEN 2). Individuals who have MEN 2 syndrome are also at risk for developing other types of cancer. 
Types characteristics of thyroid cancers 

  • Papillary adenocarcinoma (Most common and least aggressive, Asymptomatic nodule in a normal gland, Starts in childhood or early adult life, remains localized, Metastasizes along the lymphatics if untreated, More aggressive in the elderly, Growth is slow, and spread is confined to lymph nodes that surround thyroid area, Cure rate is excellent after removal of involved areas). Papillary carcinoma accounts for half of all thyroid cancers in adults; it’s most common in young adult females and metastasizes slowly. It’s the least virulent form of thyroid cancer. Follicular carcinoma is less common but more likely to recur and metastasize to the regional nodes and through blood vessels into the bones, liver, and lungs. 
  • Follicular adenocarcinoma ( Appears after 40 years of age, Encapsulated; feels elastic or rubbery on palpation, Spreads through the bloodstream to bone, liver, and lung, Prognosis is not as favorable as for papillary adenocarcinoma, Brief encouraging response may occur with irradiation, Progression of disease is rapid; high mortality ) 
  • Medullary (Appears after 50 years of age, Occurs as part of multiple endocrine neoplasia MEN), Hormone-producing tumor causing endocrine dysfunction symptoms, Metastasizes by lymphatics and bloodstream, Moderate survival rate, inheritable type of thyroid malignancy, which can be detected early by a radioimmunoassay for calcitonin ) 
  • Anaplastic (50% of anaplastic thyroid carcinomas occur in patients older than 60 years, Hard, irregular mass that grows quickly and spreads by direct invasion to adjacent tissues, May be painful and tender, Survival for patients with anaplastic cancer is usually less than 6 months, The most aggressive and lethal solid tumor found in humans, Least common of all thyroid cancers, Usually fatal within months of diagnosis) 
  • Thyroid lymphoma (Appears after age 40 years, May have history of goiter, hoarseness, Dyspnea, pain, and pressure, Good prognosis ) 

Complications For Thyroid Cancers
Untreated thyroid carcinoma can be fatal. Hemorrhage Hematoma formation Edema of the glottis Injury to the recurrent laryngeal nerve Hypothyroidism occurs in 5% of patients in first postoperative year; increases at rate of 2% to 3% per year. Hypoparathyroidism occurs in about 4% of patients and is usually mild and transient; requires calcium supplements I.V. and orally when more severe. 

Clinical Manifestations for Thyroid Cancers 
On palpation of the thyroid, there may be a firm, irregular, fixed, painless mass or nodule. The occurrence of signs and symptoms of hyperthyroidism is rare. 

Symptoms of Thyroid Cancer 
As with many other forms of cancer, most people in the early stages of thyroid cancer have no symptoms or signs of disease. When symptoms or signs occur, they may include the following: Hoarseness A lump near the Adam’s apple of the neck Swollen lymph nodes in the neck or nearby Dysphagia (difficulty swallowing) Pain in the neck or throat Medullary carcinoma of the thyroid secretes CALCITONIN and thus can cause symptoms due to the presence of this hormone, such as flushing, nausea, and diarrhea. In addition, medullary carcinoma of the thyroid is often inherited. Family members can be screened by measuring their calcitonin levels or by looking for abnormal chromosomes, such as RET. Anaplastic carcinoma typically presents in older men as a very hard mass in the neck. It is often incurable at the time of diagnosis, as it does not concentrate iodine, and thus radioactive iodine (RAI) therapy cannot be used. It is poorly responsive, if at all, to chemotherapy and external radiation therapy. 

Nursing . Assessment
Focused Nursing Assessment for Thyroid CancerExplore patient’s feelings and concerns regarding the diagnosis, treatment, and prognosis. The first indication of disease may be a painless nodule discovered incidentally or detected during physical examination.If the tumor grows large enough to destroy the thyroid gland. Patient’s history may include sensitivity to cold and mental apathy (hypothyroidism). If the tumor triggers excess thyroid hormone production, the patient may report sensitivity to heat, restlessness, and overactivity (hyperthyroidism). The patient may also complain of diarrhea, dysphagia, anorexia, irritability, and ear pain. When speaking with the patient, you may hear hoarseness and vocal stridor. On inspection, you may detect a disfiguring thyroid mass, especially if the patient is in the later stages of anaplastic thyroid cancer. (See Anaplastic thyroid cancer.) Palpation may disclose a hard nodule in an enlarged thyroid gland or palpable lymph nodes with thyroid enlargement. By auscultation, you may discover bruits if thyroid enlargement results from an increase in TSH, which increases thyroid vascularity. 

Diagnostic Evaluation 
A thyroid scan with 99mTc will detect a cold nodule with little uptake FNA biopsy Surgical exploration ultrasound MRI CT scans Thyroid scans Radioactive Iodine uptake studies Thyroid suppression tests 

Nursing Diagnosis 
Commong Nursing Diagnosis That Could Be Found In Patient With Thyroid Cancer: Fear/Anxiety [specify level] Acute/chronic Pain Risk for ineffective Airway Clearance Impaired verbal Communication Risk for Injury, [tetany, thyroid storm] Deficient Knowledge [Learning Need] regarding Condition, prognosis, treatment, self-care, and Discharge needs Nursing Care Plan for Thyroid Cancer. 

Nursing Intervention and Rationale Nursing Care Plan for Thyroid Cancer Nursing Diagnosis Fear/Anxiety Could be related to: 

  • Situational crisis cancer Thyroid Cancer 
  • Threat to, or change in, health, socioeconomic status, role functioning, interaction patterns 
  • Threat of death 
  • Separation from family hospitalization, treatments, diagnostic procedures, diagnosis of chronic/life-threatening condition 

Nursing Outcomes Evaluation Criteria, Client Will: 

  • Fear or Anxiety Self Control: Display appropriate range of feelings and lessened fear. Appear relaxed and report anxiety is reduced to a manageable level. Demonstrate use of effective coping mechanisms and active participation in treatment regimen. 

Nursing Interventions and rationale Nursing diagnosis Fear/Anxiety: 

  • Review client’s and significant other’s (SO’s) previous experience with cancer. Determine what the doctor has told client and what conclusion client has reached. Rationale Clarifies client’s perceptions; assists in identification of fear(s) and misconceptions based on diagnosis and experience with cancer. 
  • Ascertain client/SO(s) perception of what is occurring and how this affects life. Rationale Fear is a natural reaction to frightening events and how client views the event will determine how he or she will react 
  • Encourage client to share thoughts and feelings. Rationale Provides opportunity to examine realistic fears and misconceptions about diagnosis. 
  • Provide open environment in which client feels safe to discuss feelings or to refrain from talking. Rationale Helps client feel accepted in present condition without feeling judged and promotes sense of dignity and control. 
  • Be alert to signs of denial/depression. Indicates need for specific interventions to identify and deal with problems. Rationale Client may deny problems until unable to deal with situation. Depression may accompany problems associated with fear that interfere with daily activities 
  • Maintain frequent contact with client. Talk with and touch client, as appropriate. Rationale Provides assurance that the client is not alone or rejected; conveys respect for and acceptance of the person, fostering trust. 
  • Be aware of effects of isolation on client when required by immunosuppression or radiation implant. Limit use of isolation clothing, as possible. Rationale Sensory deprivation may result when sufficient stimulation is not available and may intensify feelings of anxiety, fear, and alienation. 
  • Assist client and SO in recognizing and clarifying fears to begin developing coping strategies for dealing with these fears. Rationale Coping skills are often stressed after diagnosis and during different phases of treatment. Support and counseling are often necessary to enable individual to recognize and deal with fear and to realize that control and coping strategies are available. 
  • Provide accurate, consistent information regarding diagnosis and prognosis. Avoid arguing about client’s perceptions of situation. Rationale Can reduce anxiety and enable client to make decisions and choices based on realities. 
  • Explain the recommended treatment, its purpose, and potential side effects. Help client prepare for treatments. Rationale The goal of cancer treatment is to destroy malignant cells while minimizing damage to normal ones. Treatment may include curative, preventive, or palliative surgery as well as chemotherapy, internal or external radiation, or newer, organ-specific treatments such as whole-body hyperthermia or biotherapy. Bone marrow or peripheral progenitor cell transplant may be recommended for some types of cancer. 
  • Note ineffective coping such as poor social interactions, helplessness, giving up everyday functions, and usual sources of gratification. Rationale Identifies individual problems and provides support for client and SO in using effective coping skills. 
  • Administer anti-anxiety medications, such as lorazepam (Ativan) or alprazolam (Xanax), as indicated. Rationale May be useful for brief periods of time to help client handle feelings of anxiety related to diagnosis or situation during periods of high stress, to assist client with diagnostic procedures, such as lying still during scan, and/or to minimize nausea. 
  • Refer to additional resources for counseling and support as needed. Rationale May be useful from time to time to assist client and SO in dealing with anxiety. 

Nursing Diagnosis Acute pain/Chronic Pain Related to: 

  • Disease process compression or destruction of nerve tissue, infiltration of nerves or their vascular supply, obstruction of a nerve pathway, inflammation, metastasis to bones. Side effects of various cancer therapy agents 

Nursing Outcomes Evaluation Criteria Client Will 

  • Report maximal pain relief or control with minimal interference with activities of daily living (ADLs). 
  • Follow prescribed pharmacological regimen. 
  • Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Nursing Interventions and Rationale Nursing Diagnosis Acute/Chronic Pain 

  • Determine pain history, for example, location of pain, frequency, duration, and intensity using a rating scale (scale of 0–10), or verbal rating scale “no pain” to “excruciating pain”; and relief measures used. Believe client’s report. Rationale Information provides baseline data to evaluate need for, and effectiveness of, interventions. Pain of more than 6 months’ duration constitutes chronic pain, which may affect therapeutic choices. Recurrent episodes of acute pain can occur within chronic pain, requiring increased level of intervention. 
  • Evaluate painful effects of particular therapies, such as surgery, radiation, chemotherapy, or biotherapy. Provide information to client about what to expect. Rationale A wide range of discomforts are common such as incisional pain, burning skin, low back pain, mouth sores, or headaches, depending on the procedure or agent being used. Pain is also associated with invasive procedures to diagnose or treat cancer. 
  • Provide nonpharmacological comfort measures such as massage, repositioning, and back rub; as well as diversional activities, such as music, reading, and TV. Rationale Promotes relaxation and helps refocus attention. 
  • Place in semi-Fowler’s position and support head and neck in neutral position with sandbags or small pillows as required in immediate postoperative phase. Instruct client to use hands to support neck during movement and to avoid hyperextension of neck. Rationale Prevents hyperextension of the neck 
  • Encourage use of stress management skills and complementary therapies such as relaxation techniques, visualization, guided imagery, biofeedback, laughter, music, aromatherapy, and Therapeutic Touch. Rationale Enables client to participate actively in nondrug treatment of pain and enhances sense of control. Pain produces stress and, in conjunction with muscle tension and internal stressors, increases client’s focus on self, which in turn increases the level of pain. 
  • Provide cutaneous stimulation, such as heat and cold packs, or massage. Rationale May decrease inflammation, muscle spasms, reducing associated pain. 
  • Be aware of barriers to cancer pain management related to client, as well as the healthcare system. Rationale Clients may be reluctant to report pain for reasons such as fear that disease is worse; worry about unmanageable side effects of pain medications; belief that pain has meaning, such as “God wills it,” they should overcome it; or that pain is merited or deserved for some reason. Healthcare system problems include factors such as inadequate assessment of pain, concern about controlled substances or client addiction, inadequate reimbursement, and cost of treatment modalities. 
  • Evaluate pain relief at regular intervals. Adjust medication regimen as necessary. Inform client and SO of the expected therapeutic effects and discuss management of side effects. Rationale Goal is maximum pain control with minimum interference with ADLs. 
  • Develop individualized pain management plan with the client and physician. Provide written copy of plan to client, family and SO, and care providers. Rationale An organized plan beginning with the simplest dosage schedules and least invasive modalities improves chance for pain control. Particularly with chronic pain, client and SO must be active participant in pain management and all care providers need to be consistent. 
  • Refer to structured support group, psychiatric clinical nurse specialist, psychologist, or spiritual advisor for counseling, as indicated. Rationale May be necessary to reduce anxiety and enhance client’s coping skills, decreasing level of pain. Note: Hypnosis can heighten awareness and help to focus concentration tondecrease perception of pain. 

Nursing Diagnosis Risk for Ineffective Airway Clearance Related to 

  • Tracheal obstruction, swelling, bleeding, laryngeal spasms. 

Nursing Outcomes Evaluation Criteria Client Will 

  • Maintain patent airway, with aspiration prevented. 

Nursing Interventions and Rationale Nursing Diagnosis Risk for Ineffective Airway Clearance 

  • Monitor respiratory rate, depth, and work of breathing. Rationale Respirations may remain somewhat rapid because of hyperthyroid state, but development of respiratory distress is indicative of tracheal compression from edema or hemorrhage. 
  • Auscultate breath sounds, noting presence of rhonchi. Rationale Rhonchi may indicate airway obstruction and accumulation of copious thick secretions. 
  • Assess for Dyspnea, stridor, “crowing,” and cyanosis. Note quality of voice. Rationale Indicators of tracheal obstruction or laryngeal spasm, requiring prompt evaluation and intervention. 
  • Keep head of bed elevated 30 to 45 degrees. Caution client to avoid bending neck; support head with pillows in the immediate postoperative period. Rationale Enhances breathing and reduces likelihood of tension on surgical wound. 
  • Assist with repositioning, deep breathing exercises, and coughing, as indicated. Rationale Maintains clear airway and ventilation. Although “routine” coughing is not encouraged and may be painful, it may be necessary to clear secretions. 
  • Investigate reports of difficulty swallowing and drooling of oral secretions. Rationale May indicate edema and sequestered bleeding in tissues surrounding operative site. 
  • Keep tracheostomy tray at bedside. Rationale Compromised airway may create a life-threatening situation requiring emergency procedure. 
  • Provide steam inhalation, humidify room air. Rationale Reduces discomfort of sore throat and tissue edema and promotes expectoration of secretions. 
  • Assist with and prepare for procedures, such as: Tracheostomy Rationale although rare, tracheostomy may be necessary to obtain airway if obstructed by edema of glottis or hemorrhage. 

Nursing Diagnosis Impaired Verbal Communication Related to: 

  • Vocal cord injury, laryngeal nerve damage. Tissue edema; pain and discomfort 

Nursing Outcomes Evaluation Criteria Client Will 

  • Establish method of communication in which needs can be understood. 

Nursing Interventions and Rationale: 

  • Assess speech periodically and encourage voice rest. Rationale Hoarseness and sore throat may occur secondary to tissue edema or surgical damage to recurrent laryngeal nerve and may last several days. Permanent nerve damage can occur (rare) that causes paralysis of vocal cords and or compression of the trachea. 
  • Keep communication simple. Ask yes and no questions. Rationale Reduces demand for response; promotes voice rest. 
  • Provide alternative methods of communication as appropriate—slate board, letter and picture board. Place intravenous (IV) line to minimize interference with written communication. Rationale Facilitates expression of needs. 
  • Anticipate needs as much as possible. Visit client frequently. Rationale Reduces anxiety and client’s need to communicate. 
  • Post notice of client’s voice limitations at central station and answer call light promptly. Rationale Prevents client from straining voice to make needs known and summon assistance. 
  • Maintain quiet environment. Rationale Enhances ability to hear whispered communication and reduces necessity for client to raise and strain voice to be heard. 

Nursing Diagnosis Risk For Injury Related to: 

  • tetany, thyroid storm. Chemical imbalance, such as with hypocalcemia, increased release of thyroid hormones, excessive central nervous system (CNS). Stimulation 

Nursing Outcomes Evaluation Criteria Client Will 

  • Demonstrate absence of injury with complications minimized or controlled. 

Nursing Interventions And Rationale 

  • Monitor vital signs, noting elevated temperature, tachycardia (140 to 200 beats/minute), dysrhythmias, respiratory distress, and cyanosis—developing pulmonary edema or heart failure (HF). Rationale : Manipulation of gland during subtotal thyroidectomy may result in increased hormone release, causing thyroid storm. 
  • Evaluate reflexes periodically. Observe for neuromuscular irritability—twitching, numbness, paresthesias, positive Chvostek’s and Trousseau’s signs, and seizure activity. Rationale : Hypocalcemia with tetany (usually transient) may occur 1 to 7 days postoperatively and indicates hypoparathyroidism, which can occur because of inadvertent trauma to and partial to total removal of parathyroid gland(s) during surgery. 
  • Keep side rails raised and padded, bed in low position, and airway at bedside. Avoid use of restraints. Rationale Reduces potential for injury if seizures occur. (Refer to CP: Seizure Disorders, ND: risk for Trauma/Suffocation.) 
  • Monitor serum calcium levels. Rationale : Clients with levels less than 7.5 mg/100 mL generally require replacement therapy. 
  • Administer medications, as indicated, for example: IV calcium (gluconate or chloride) Phosphate-binding agents, Sedativesm Anticonvulsants Rationale : Corrects deficiency, which is usually temporary but may be permanent. Note: Use with caution in clients taking digoxin because calcium increases cardiac sensitivity to digoxin, potentiating risk of toxicity. Helpful in lowering elevated phosphorus levels associated with hypocalcemia. Promotes rest, reducing exogenous stimulation. Controls seizure activity associated with thyroid storm until corrective therapy is successful. 

Nursing Diagnosis Deficient Knowledge Regarding Condition, Prognosis, Treatment, Self-Care, And Discharge Needs Related to

  • Lack of exposure and recall; misinterpretation, Unfamiliarity with information resources 

Nursing Outcomes Evaluation Criteria Client Will 

  • Verbalize understanding of surgical procedure and prognosis and potential complications. 
  • Verbalize understanding of therapeutic needs.
  •  Participate in treatment regimen. 
  • Initiate necessary lifestyle changes. 

Nursing Interventions and Rationale 

  • Review surgical procedure and future expectations. Rationale Provides knowledge base from which client can make informed decisions. 
  • Discuss need for well-balanced, nutritious diet and, when appropriate, inclusion of iodized salt. Rationale Promotes healing and helps client regain and maintain appropriate weight. Use of iodized salt is often sufficient to meet iodine needs unless salt is restricted for other healthcare problems, such as with HF. 
  • Identify foods high in calcium, such as dairy products, and vitamin D, such as fortified dairy products, egg yolks, and liver. Rationale Maximizes supply and absorption of calcium if parathyroid function is impaired. 
  • Encourage progressive general exercise program. Rationale In clients with subtotal thyroidectomy, exercise can stimulate the thyroid gland and production of hormones, facilitating recovery of general well-being. 
  • Review postoperative exercises to be instituted after incision heals flexion, extension, rotation, and lateral movement of head and neck. Rationale Regular range-of-motion (ROM) exercises strengthen neck muscles and enhance circulation and healing process. 
  • Review importance of rest and relaxation, avoiding stressful situations and emotional outbursts. Rationale Effects of hyperthyroidism usually subside completely, but it takes some time for the body to recover. 
  • Instruct in incision care cleansing and dressing application. Rationale Enables client to provide competent self-care. Note: Neck incisions heal rapidly and are watertight within 24 to 36 hours. 
  • Recommend the use of loose-fitting scarves to cover scar, avoiding the use of jewelry. Rationale Covers the incision without aggravating healing or precipitating infections of suture line. 
  • Discuss possibility of change in voice. Rationale Normal surgical area swelling and vocal cord dysfunction can cause changes in pitch and quality of voice, which may be temporary or permanent. 
  • Review drug therapy and the necessity of continuing even when feeling well. Rationale If thyroid hormone replacement is needed because of surgical removal of gland, client needs to understand rationale for replacement therapy and consequences of failure to routinely take medication. 
  • Identify signs and symptoms requiring medical evaluation: fever, chills, continued and purulent wound drainage, erythema, gaps in wound edges, sudden weight loss, intolerance to heat, nausea and vomiting, diarrhea, insomnia, weight gain, fatigue, intolerance to cold, constipation, and drowsiness. Rationale Early recognition of developing complications, such as infection, hyperthyroidism, or hypothyroidism, may prevent progression to life-threatening situation. 
  • Stress necessity of continued medical follow-up. Rationale Provides opportunity for evaluating effectiveness of therapy and prevention of complications. 

Patient Teaching Thyroid Cancer Patient Teaching discharge and Home Health Guidance for Patient with Thyroid Cancer. To maintain a euthyroid state, teach family and patient sign and symptoms of hypothyroidism for early detection of problems: weakness, fatigue, cold intolerance, weight gain, facial puffiness, periorbital edema, bradycardia, and hypothermia. Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. Explain that the patient needs routine follow-up laboratory tests to check TSH and thyroxine (T4) levels. Be sure the patient knows when the first postoperative physician’s visit is scheduled. Explain any wound care and that the patient should expect to be hoarse for a week or so after the surgical procedure. 
Patient Teaching discharge and Home Health Guidance for Patient with Thyroid Cancer: 

  • Preoperatively, advise the patient to expect temporary voice loss or hoarseness for several days after surgery. Also, explain the operation and postoperative procedures and positioning. 
  • Instruct the patient on thyroid hormone replacement and follow-up blood tests. 
  • Stress the need for periodic evaluation for recurrence of malignancy. 
  • Supply additional information or suggest community resources dealing with cancer prevention and treatment. 
  • Assist patient in identifying sources of information to structured support group, psychiatric clinical nurse specialist, psychologist, or spiritual advisor for counseling, May be necessary to reduce anxiety and enhance client’s coping skills, decreasing level of pain. Note: Hypnosis can heighten awareness and help to focus concentration tondecrease perception of pain 
  • Assist patient in identifying sources of information and support available in the community Refer the patient to resource and support services, such as the social service department, home health care agencies, hospices, and the American Cancer Society 
  • Before discharge, ensure that the patient knows the date and time of his next appointment. Answer his questions about his treatment and home care. Be sure he understands the purpose of his medications, dosage, administration times, and possible adverse effects

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