Thyroid cancer is the most common endocrine cancer, and the number of new cases in the United States is increasing annually by 3% per 100,000. Most thyroid nodules or tumors develop from thyroid follicular cells; 95% of these nodules and tumors are benign. The remaining 5% of thyroid nodules or tumors are cancerous, and there are several forms of thyroid cancer. Papillary carcinoma is the most common form of primary thyroid cancer. It is also the slowest-growing thyroid cancer and is usually multifocal and bilateral in distribution. Papillary carcinoma metastasizes slowly into the cervical lymph nodes and the nodes of the mediastinum and lungs. Follicular cancer is the next most common form. It is more likely to recur than other forms; it generally metastasizes to the regional lymph nodes and is spread by the blood to distant areas such as the bones, liver, and lungs. More than 90% of patients treated for either papillary or follicular carcinoma will live for 15 years or longer after their diagnosis.
Anaplastic carcinoma of the thyroid is a less common form of thyroid cancer and is resistant to both surgical resection and radiation; the 5-year survival rate is between 3% and 17%. Anaplastic cells metastasize quickly, invade the trachea and surrounding tissues, and compress vital structures. Medullary cancer is even less common (3% to 4% of thyroid cancers); it originates in the parafollicular cells of the thyroid. Metastasis occurs to the bones, liver, and kidneys if the disease is not treated. In addition to metastases, other life-threatening complications include compression of surrounding structures (particularly in the neck), thus leading to difficulty swallowing and breathing. Surgery can cure medullary thyroid cancer; 86% have 5-year survival rate, and 65% survive 10 years or more.
The American Cancer Society estimated that in the year 2005 roughly 25,690 new cases of thyroid cancer would be diagnosed in the United States. An estimated 860 women and 630 men were expected to die of thyroid cancer during the year 2005.
While most individuals with thyroid cancer have no apparent risk factors, the following factors may be involved: family history of goiter, family history of thyroid disease, female gender, and Asian race. People who have been exposed to radiation therapy to the neck are particularly susceptible to thyroid cancer, including those exposed to low-dose radiation as children and others exposed to high-dose radiation for malignancies. About 25% of individuals who had radiation in the 1950s to shrink an enlarged thymus gland, tonsils, or adenoids develop thyroid nodules; approximately 25% of those with nodules actually develop thyroid cancer (6% of those exposed to neck radiation in the first place). Other causes of thyroid cancer include prolonged secretion of thyroid-stimulating hormone (TSH) because of radiation, heredity, or chronic goiter.
Nursing care plan assessment and physical examination
Most patients present with an asymptomatic neck mass. They may also have complaints of neck discomfort, hoarseness, dysphagia (difficulty swallowing), feeling as if they are “breathing through a straw,” and rapid nodule growth. Elicit a family history because some forms of thyroid cancer are inherited. If the thyroid has been completely destroyed by cancer cells, the patient may report a history of sensitivity to cold, weight gain, and apathy from hypothyroidism. If the thyroid has become overstimulated, the patient may describe signs of hyperthyroidism: sensitivity to heat, nervousness, weight loss, and hyperactivity. Changes in thyroid function may also lead to gastrointestinal changes such as diarrhea and anorexia.
Observe the patient’s neck, noting any mass or enlargement. Patients with anaplastic thyroid cancer may have a rapidly growing tumor that distorts the neck and surrounding structures. Palpate the thyroid gland for size, shape, configuration, consistency, tenderness, and presence of any nodules. Describe the number of nodules present and whether the nodule is smooth or irregular, soft or hard, or fixed to underlying tissue. Note the presence of enlarged cervical lymph nodes, which occur in 25% of patients with the disease. Auscultation may reveal bruits if the thyroid enlargement results from an increase in TSH, which increases thyroid circulation and vascularity.
Assess the patient’s ability to cope with the sudden illness and the diagnosis of cancer. Determine what a diagnosis of cancer means to the patient. Consider the type of cancer (and the speed of cancer growth) when assessing the patient’s and family’s response to the disease.
Nursing care plan primary nursing Ineffective airway clearance related to swelling and obstruction.
Nursing care plan intervention and treatment plan
Most physicians prescribe surgical treatment of thyroid cancer, with the definitive treatment depending on the size of the nodule. Surgical interventions range from a thyroid lobectomy for cancers smaller than 1 cm that show no signs of metastasis to a total thyroidectomy and, possibly, a modified neck dissection if lymph nodes need to be removed. To prevent complications after the thyroidectomy, careful monitoring for airway obstruction and stridor is essential. A tracheostomy tray should be kept near the patient at all times during the immediate recovery period. In addition, monitor for signs of thyrotoxicosis (tachycardia, diaphoresis, increased blood pressure, anxiety) and hypocalcemia (tingling of the fingers and toes, carpopedal spasms, and convulsions). The surgical dressing and incision also need to be assessed for excessive drainage or bleeding during the postoperative period. If the patient complains that the dressing feels tight, the surgeon needs to be alerted immediately.
Generally, after surgery is completed, the patient is started on synthetic levothyroxine therapy to suppress TSH levels and establish a euthyroid (normal) state. Most patients do not have chemotherapy or radiotherapy because these modalities are usually ineffective with rapidly growing thyroid cancers. Chemotherapy is usually reserved as an adjuvant measure to halt the spread of metastasis; however, paclitaxel (Taxol) is currently being investigated as a treatment for anaplastic thyroid cancer.
Radioactive iodine (131I) may be used to destroy any remaining thyroid tissue not removed by surgery and to treat affected lymph nodes. For radioiodine therapy to be most effective, patients need to have high serum TSH levels; thus, an intentional hypothyroid condition is induced by stopping thyroid medications for 1 to 2 weeks. This temporary condition causes the pituitary gland to release more TSH.
The most important nursing interventions focus on teaching and prevention of complications. When you prepare patients before surgery, discuss not only the procedure and aftercare but also the methods for postoperative communication such as a magic slate or a point board. Explain that the patient will be able to speak only rarely, will need to rest the voice for several days, and should expect to be hoarse. Answer all questions before surgery. After the procedure, monitor the patient’s ability to speak with each measurement of vital signs. Assess the patient’s voice tone and quality, and compare it with the preoperative voice.
Maintain the bed in a high-Fowler position to decrease edema and swelling of the neck. To avoid pressure on the suture line, encourage the patient to avoid neck flexion and extension. Support the head and neck with pillows or sandbags; if the patient needs to be transferred from stretcher to bed, support the head and neck in good body alignment.
Before discharge, make sure that the patient has a follow-up appointment for a postdischarge assessment. Make sure that the patient has the financial resources to obtain all needed medications; some patients require thyroid supplements for the rest of their lives. Refer the patient or family to the American Cancer Society for additional information.
Nursing care plan discharge and home health care guidelines
To maintain a euthyroid state, teach the patient and family the 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.
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