Observation and Positioning of Patients Complications - Essay Example

Introduction The intimate relation of the thyroid gland to the airway and the abundant vascularity of the organ make complications like airway obstruction and hemorrhage, potential life-threatening complications. A close monitoring for these complications, are therefore, very important. Initial assessment As soon as the patient arrives in the post-anesthesia care unit, the nurse must assess the patients clinical condition including the cardiopulmonary and neurological status, patient comfort, condition of the surgical wound, and the metabolic state (Lockhart, n.d.) Observation and positioning of patient There is a potential risk of airway obstruction due to anesthesia, laryngeal spasm, damage to the recurrent laryngeal nerve, or due to the presence of a hematoma pressing on the trachea (Pudner & Ramsden, 2000). The patient is made to sit upright, with the neck well supported with pillows. Supporting the head and neck ensures that the patient is comfortable and no strain is put on the incisional wound (Pudner & Ramsden, 2000). This position also helps the patient to cough and expectorate. Oxygen is given at the prescribed rate (Pudner & Ramsden, 2000). The respiration is observed for rate, depth, any stridor, and whether any choking sensation, signs of cyanosis, or respiratory distress is present. Any change in these observations may indicate laryngeal paralysis or compression of trachea by hematoma, which requires prompt medical intervention (Pudner & Ramsden, 2000). The patient is encouraged to take deep breaths and to cough and expectorate any sputum several times an hour. Deep breathing helps to expand the chest fully, and the expectoration of sputum reduces the risk of chest infection (Pudner & Ramsden, 2000). Inspection of wound and drains Since there is a potential risk of hemorrhage after thyroidectomy, the nurse should observe the wound for any signs of fresh bleeding and also check the side and back of the neck where blood may collect (Pudner & Ramsden, 2000). A progressively enlarging neck mass suggest the formation of a hematoma (Lockhart, n.d.) The nurse should check the drains, including the amount and consistency of drainage, and the proper functioning status of the drains (Lockhart, n.d). However, studies (Colak et al, 2008; Suslu et al, 2006) indicate that the routine use of drains may not be necessary in uncomplicated thyroid surgery, since it is rare for serious postoperative bleeding to occur and hematomas can be treated by needle aspiration if drains have not been placed. Further, the use of drains prolongs hospital stay, increases the risk of infection, increase postoperative pain and the analgesic requirement (Suslu et al, 2006.) Fresh blood staining of the dressing and an increased drainage indicates hemorrhage. The nurse should ensure that staple removers are by the patient’s bedside, in case the staples need to be removed quickly (e.g. hematoma causing respiratory distress) (Pudner & Ramsden, 2000). Inspection of pulse, blood pressure, and observation for metabolic disturbances The pulse and blood pressure is observed every half-hourly initially. Any increase in the pulse and blood pressure indicates hemorrhage (Lockhart, n.d). If at anytime, a hematoma is suspected, the staples are removed and the wound covered with sterile dressing (Pudner & Ramsden, 2000). The nurse should also observe the patient for evidence of metabolic disturbances, such as thyroid storm and hypocalcaemia (Lockhart, n.d). Thyroid storm or thyrotoxic crisis is induced by the excessive release of thyroid hormones due to manipulation of the thyroid gland during surgery (Sharma, 2007). Signs of thyrotoxic storm in the anesthetized patient include tachycardia and hyperthermia, while in the patient who is awake, nausea, tremor, and altered mental status may be present (Sharma, 2007). Cardiac arrhythmias may also occur. If not treated, the condition can progress to coma (Sharma, 2007). Serum calcium level measurements are checked daily, due to the potential complication of hypocalcaemia. Most patients are initially asymptomatic. Symptoms and signs of hypocalcaemia include numbness or tingling around the lips, mental status changes, tetany, carpopedal spasm, laryngospasm, seizures, QT prolongation on ECG, and cardiac arrest (Sharma, 2007). Two tests, Trousseau’s and Chvostek’s are helpful (Lockhart, n.d). A positive Trousseaus sign is occurrence of carpal spasm induced by arterial occlusion of the arm with a blood pressure cuff, while a positive Chvosteks sign is facial nerve irritability/spasms elicited by tapping the nerve over the zygoma bone (Pudner & Ramsden, 2000). In symptomatic patients, calcium is replaced with intravenous calcium gluconate (Sharma, 2007). The assistance of an endocrinologist can be requested to ensure close monitoring of calcium levels and manage the sequelae of hypoparathyroidism (Sharma, 2007). Hypothyroidism can result from the removal of the thyroid gland. Symptoms include cold intolerance, fatigue, constipation, muscle cramping, and weight gain (Sharma, 2007). The measurement of thyrotropin (thyroid-stimulating hormone -TSH) levels is the most useful test for detecting or monitoring of hypothyroidism. Levothyroxine may be started (Sharma, 2007). Evaluation of voice quality and swallowing The nurse should evaluate the patients voice quality and swallowing postoperatively (Lockhart, n.d). Any loss of phonation and respiratory difficulties should be observed. If present, it indicates damage to the recurrent laryngeal nerve (Pudner & Ramsden, 2000). Postoperative visualization of the vocal cords is also important, as patients may be asymptomatic initially (Sharma, 2007). An ENT surgeon can confirm whether the cords are damaged or not. Most hoarseness is usually temporary, and the patient can be reassured of this (Pudner & Ramsden, 2000). However, a patient with bilateral paralysis of the vocal folds with airway obstruction after extubation requires emergency reintubation or tracheotomy (Sharma, 2007). The patient may have difficulty in swallowing due to a sore throat. The nurse should monitor the IV infusion and encourage the patient to drink sips of water and gradually increase it to tolerable levels. This will maintain adequate hydration (Pudner & Ramsden, 2000). Soft diet can be given if the patient is able to tolerate it. This will the maintain nutrition of the patient (Pudner & Ramsden, 2000). Postoperative pain and infection The presence of any pain is assessed with the pain assessment tool (Pudner & Ramsden, 2000). The prescribed analgesics are administered. The head and neck of patient should be well supported with pillows and the patient is encouraged to support the head with the hands when moving. These measures reduce pain, avoid any tension on the neck, and allow the neck muscles to relax (Pudner & Ramsden, 2000). Postoperative infection may manifest as superficial cellulitis or as an abscess. Signs include erythema, warmth, and tenderness of the neck skin around the incision (Sharma, 2007). Any pus from the wound or drain is sent for Gram staining and culturing to identify the organism. Broad-spectrum antibiotics may be started (Sharma, 2007). Discharge teaching Discharge teaching for the patient and the family includes providing information about the signs and symptoms of potential complications of thyroidectomy, information on how and when to contact the physician, written and verbal information regarding medications, wound care, nutrition, and follow-up visits. The nurse must ensure that the patient has understood aspects of home care (Lockhart, n.d.) Conclusion After an initial assessment, the patient has to be positioned in the proper position and oxygen is given. A close observation of the respiration for rate, depth, stridor, choking sensation, signs of cyanosis, or respiratory distress, alerts to the presence of laryngeal paralysis or compression of the trachea by a hematoma. A thorough inspection of the wound and drains is also made. An inspection of the pulse, blood pressure, and observation for metabolic disturbances like thyroid storm, hypocalcaemia, and signs of hypothyroidism is mandatory. An evaluation of the voice quality and swallowing helps to know if the recurrent laryngeal nerve is damaged. Postoperative pain and infection require treatment. Finally, adequate postoperative discharge teaching for the patient and the family provides them the required information about potential complications after a thyroidectomy. References Colak T, Akca T, Turkmenoglu O, Canbaz H, Ustunsoy B, Kanik A, Aydin S (2008). Drainage after total thyroidectomy or lobectomy for benign thyroidal disorders. J Zhejiang Univ Sci B. 9(4): 319-23. Lockhart, JS (n.d). Nursing Interventions for Potential Complications After Thyroidectomy. Retrieved April 19, from, http://www.sohnnurse.com/thyroidectomy.html Pudner, R, Ramsden, I (2000). Nursing the surgical patient. Elsevier Health Sciences Suslu N, Vural S, Oncel M, Demirca B, Gezen FC, Tuzun B, Erginel T, Dalkiliç G (2006). Is the insertion of drains after uncomplicated thyroid surgery always necessary? Surg Today. 36(3): 215-8. Sharma, PK (2007). Complications of Thyroid Surgery. Retrieved April 19, from, http://www.emedicine.com/ent/topic649.htm Read More