Xavier University Ateneo de Cagayan

College of Nursing
S.Y. 2016 2017

A Concept Map of Nodular Goiter

Submitted to:
Maam Jesusa Gabule, RN MAN
Clinical Instructor

Submitted by:

Castro, Shaira Marie G.

Paderanga, Ma. Elyza Allene N.

BSN 3 NB
September 16, 2016

A. DISEASE CONDITION
The thyroid gland is an important organ of the endocrine system. It is located at the
front of the neck just above where your collarbones meet. The gland makes the
hormones that control the way every cell in the body uses energy. This process is
called metabolism.
(Brunner & Suddarths) Some thyroid glands are nodular because of areas of
hyperplasia (overgrowth). no symptoms may arise as a result of this condition, but
not uncommonly these nodules slowly increase in size with some descending into
the thorax, where they cause local pressure symptoms. Some nodules become
malignant, and some are associated with a hyperthyroid state. Therefore, the patient
with many thyroid nodules may eventually require surgery.
Nodular goiter can refer to:

1. Nontoxic nodular goiter - is an enlarged thyroid without hyperthyroidism. It is

often present for years before toxic nodular goiter occurs. Simple nontoxic goiter,
which may be diffuse or nodular, is noncancerous hypertrophy of the thyroid
without hyperthyroidism, hypothyroidism, or inflammation. Except in severe iodine
deficiency, thyroid function is normal and patients are asymptomatic except for an
obviously enlarged, nontender thyroid.
2. Toxic nodular goitre - (or Plummer syndrome) is a condition that can occur when
a hyper-functioning nodule develops within a longstanding goiter. This results in
hyperthyroidism, without the ophthalmologic effects seen in Grave's disease.
These toxic multi or uni-nodular goiters are most common in women over the age
of 60.
3. Toxic multinodular goitre

B. PREDISPOSING/PRECIPITATING FACTORS
PREDISPOSING FACTORS
Sex
The female-to-male ratio is 4:1. In the Wickham study, 26% of women had a goiter,
compared to 7% of men. Thyroid nodules are less frequent in men than in women,
but when found, they are more likely to be malignant.
Age
The frequency of goiters decreases with advancing age. The decrease in frequency
differs from the incidence of thyroid nodules, which increases with advancing age.
Familial Goiter
Genetic marker (TG, MNG-I)
Geographic Areas
PRECIPITATING FACTORS
Iodine deficiency is the most common cause of goiter. 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. So, a goiter can be a sign the thyroid is not able to
make enough thyroid hormone. The use of iodized salt in the United States
prevents a lack of iodine in the diet.

 Overgrowth of normal thyroid tissue. Why this occurs isn't clear, but such a
growth which is sometimes referred to as a thyroid adenoma is
noncancerous and isn't considered serious unless it causes bothersome
symptoms

from

its

size.

Some

thyroid

adenomas

(autonomous

or

hyperfunctioning thyroid nodules) produce thyroid hormones outside of your

pituitary gland's normal regulatory influence, leading to an overproduction of
thyroid hormones (hyperthyroidism).
Thyroid cyst. Fluid-filled cavities (cysts) in the thyroid most commonly result from
degenerating thyroid adenomas. Often, solid components are mixed with fluid in
thyroid cysts. Cysts are usually benign, but they occasionally contain malignant
solid components.
Chronic inflammation of the thyroid (thyroiditis).Hashimoto's disease, a thyroid
disorder, can cause thyroid inflammation resulting in nodular enlargement. This
often is associated with reduced thyroid gland activity (hypothyroidism).
Multinodular goiter. "Goiter" is a term used to describe any enlargement of the
thyroid gland, which can be caused by iodine deficiency or a thyroid disorder. A
multinodular goiter contains multiple distinct nodules within the goiter, but its
cause is less clear.
Thyroid cancer. Although the chances that a nodule is malignant are small,
you're at higher risk if you have a family history of thyroid or other endocrine
cancers, are younger than 30 or older than 60, are a man, or have a history of
radiation exposure, particularly to the head and neck. A nodule that is large and
hard or causes pain or discomfort is more worrisome in terms of malignancy.

C. CLINICAL MANIFESTATIONS
Thyrotoxic symptoms - Most patients with toxic nodular goiter (TNG) present with
symptoms typical of hyperthyroidism, including heat intolerance, palpitations,tremor,
weight loss, hunger, and frequent bowel movements. Anorexia and constipation may
occur, in contrast to frequent bowel movements often reported by younger patients.
Dyspnea

or

palpitations

may

be

common

occurrence.

Cardiovascular

complications occur commonly in elderly patients, and a history of atrial fibrillation,

congestive heart failure, or angina may be present. Obstructive symptoms - A

significantly enlarged goiter can cause symptoms related to mechanical obstruction.

A large substernal goiter may cause dysphagia, dyspnea, or frank stridor. Rarely, this
goiter results in a surgical emergency. Involvement of the recurrent or superior
laryngeal nerve may result in complaints of hoarseness or voice change.
Common:

heat intolerance
muscle weakness/wasting
hyperactivity
fatigue
tremor
Palpitations
Insomnia
Anxiety
Increased bowel movement
irritability
weight loss
osteoporosis
increased appetite
non-painful goitre (swelling of the thyroid gland)
tachycardia (high heart rate - above 100 beats per minute at rest in adults)

D. DIAGNOSTIC STUDIES (relevance to the condition)

The health care provider will do a physical exam. This involves feeling your neck as
you swallow. Swelling in the area of the thyroid may be felt.
If you have a very large goiter, you may have pressure on your neck veins. As a
result, when the provider asks you to raise your arms above your head, you may feel
dizzy.
Blood tests may be ordered to measure thyroid function:
Free thyroxine (T4)
Thyroid stimulating hormone (TSH)
Tests to look for abnormal and possibly cancerous areas in the thyroid gland
include:
Thyroid scan and uptake
Ultrasound of the thyroid
If nodules are found on an ultrasound, a biopsy may be needed to check for
thyroid cancer.

E. MEDICAL AND SURGICAL MANAGEMENT

MEDICAL MANAGEMENT
Toxic multinodular goiter can be treated with antithyroid medications such
as propylthiouracil or methimazole or radioactive iodine.
Another treatment option is injection of ethanol into the nodules

SURGICAL MANAGEMENT
Thyroid nodules that are found to be suspicious for malignancy must be removed
along with the remainder of the thyroid gland to prevent the spread of thyroid cancer.
BENEFITS AND RISKS OF SURGERY
Thyroid surgery can remove one-half (thyroid lobectomy or hemi-thyroidectomy)
or all of the thyroid gland (total thyroidectomy) to establish with certainty whether a
goiter or nodule is cancer or not. Surgery to remove an enlarged thyroid can relieve
compression of nearby structures and improve symptoms in patients with related
difficulty swallowing, cough, or shortness of breath. Thyroid surgery can also cure
certain forms of thyroid gland overactivity associated with goiter or nodules.
Thyroid surgery almost always requires hospitalization and anesthesia. The incision
causes pain for a day or two after surgery, and it leaves a scar, which is usually
relatively inapparent after a year. As with any operation, bleeding and infection can
complicate thyroid surgery.
Behind the thyroid gland, there are two sets of important structures that can be
accidentally injured during the course of a thyroid operation. The recurrent laryngeal
nerves run along side the windpipe on their way to the voicebox (larynx), where they
control the muscles that move the vocal cords.

If one of these nerves is cut,

smashed, or has its blood supply cut off, then a person will suffer some degree of
voice loss.
This vocal cord paralysis can lead to a range of voice changes, ranging from losing a
high octave or two while singing to the inability to shout to a severely disabling

whisper of a voice. If both recurrent laryngeal nerves are injured, then a person may
have difficulty breathing and require that a hole be created connecting the windpipe
with the front of the neck (tracheostomy).
Four parathyroid glands are also located behind the thyroid: two on each side. If the
parathyroids are accidentally removed or injured, then the patient's blood calcium
levels drops-resulting in tingling, numbness, and muscle cramps. Rarely, a severely
low calcium level can lead to throat spasm or a seizure.

Fortunately, these

complications are unusual in the hands of an experienced thyroid surgeon; mild

injuries often resolve spontaneously over days or weeks after surgery; and there are
treatments that can improve matters.
F. NURSING DIAGNOSIS & INTERVENTION
Nursing diagnosis in patients with goiter especially post-surgery can be formulated
as follows:
1. Risk for Ineffective Airway Clearance related to obstruction of the trachea,
swelling, bleeding and laryngeal spasm,
characterized by:
Subjective data: pain swallowing, painful wound.
Objective data: breathing fast and deep, there are secretions / mucus.
2. Impaired Verbal Communication related to vocal cord injury / damage to the
larynx, tissue edema, pain, discomfort,
characterized by:
Subjective data: swelling of the throat tissues, pain in the wound, the patient does
not feel comfortable, pain swallowing.
3. Risk for Injury / tetany related to the surgery, stimulation of the central nervous
system,
characterized by:
Subjective data: rapid breathing (tachypnea), wound pain.
Objective data: increased body temperature, tachycardia, cyanosis, convulsions,
numbness, and infection of the surgical wound.

4. Acute Pain related to the surgery of the tissue / muscle and postoperative edema,
characterized by:
Subjective data: ask, ask for information, statements misconceptions.
Objective data: do not follow the instructions / complications that can be prevented.
Nursing Priorities
1. Reduce metabolic demands and support cardiovascular function.
2. Provide psychological support.
3. Prevent complications.
4. Provide information about disease process/prognosis and therapy needs.
Discharge Goals
1. Homeostasis achieved.
2. Patient effectively dealing with current situation.
3. Complications prevented/minimized.
4. Disease process/prognosis and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
G. BIBLIOGRAPHY:

Holzheimer R. G., M.D., Ph.D. (2014) Benign nodular thyroid disease. Retrieved on
September 19, 2016 at http://www.ncbi.nlm.nih.gov/books/NBK6893/reneholzheimer.de/ Medical Faculty, Martin Luther University, Halle-Wittenberg, Germany
Davis, A.B., MD (2013) Toxic Nodular Goiter Clinical Presentation retrieved on
September 19, 2016 at http://emedicine.medscape.com/article/120497-clinical#b4
http://emedicine.medscape.com/article/120034-overview#a6
https://medlineplus.gov/ency/article/000317.htm
http://www.nanda-books.com/2012/10/nursing-care-plan-for-goiter-assessment.html
http://endocrine.surgery.ucsf.edu/conditions--procedures/goiter.aspx