Goiter is the enlargement of the thyroid gland. It is usually a response to a thyroid hormone deficiency (primary hypothyroidism) that results in the hypersecretion of thyroid-stimulating hormone (TSH) from the anterior pituitary gland. Oversecretion leads to subsequent thyroid hypertrophy and hypervascularity. The body’s response may compensate for thyroid hormone deficiency, leaving the patient asymptomatic. Goiter may also occur in conjunction with hyperthyroidism, known as Graves’ disease. Finally, goiter may occur with the growth of thyroid tumors. Secondary hypothyroidism occurs with TSH deficiency in the pituitary gland and is not associated with goiter.
Most goiters are classified as simple (or nontoxic). They result from any enlargement of the thyroid gland that is not caused by an inflammation or a neoplasm. Simple goiters can be classified as sporadic or endemic and are not associated initially with either hyperthyroidism or hypothyroidism. Sporadic goiters occur after a person eats certain foods (peaches, strawberries, radishes, spinach, peas, cabbage, soybeans, or peanuts) or takes certain medications (iodides, lithium, propylthiouracil) that decrease thyroxine (T4). Endemic goiters, in contrast, occur because of the patient’s geographic location in areas where the soil is depleted of iodine. Endemic goiter that results from soil deficiencies is most likely to occur during autumn and winter.
Goiter becomes a problem only when the enlargement exerts pressure on other neck structures, such as the trachea, or when the enlargement is unsightly, causing the patient to become concerned.
The causes of goiter include iodine deficiency, benign or malignant tumors, and inflammation of the thyroid gland. The use of iodine food additives has greatly reduced the incidence of endemic goiter. Difficulty in determining the incidence of endemic goiter is complicated because many individuals with the condition experience no symptoms and are not diagnosed. Sporadic goiter, or goiter caused by interference with iodine metabolism, is affected by either hereditary factors or ingestion of foods or pharmacologic agents that inhibit T4 production. Goiter caused by thyroid nodules, a common condition, may also cause no symptoms. Although thyroid nodules or tumors may be either benign or malignant, more than 75% of thyroid nodules are benign.
Nursing care plan assessment and physical examination
Patients with suspected goiter most often complain of visible enlargement of the neck or difficulty in activities such as buttoning shirts with no accompanying weight gain to account for the problem. In advanced stages, they may complain of pressure on the neck or chest, difficulty in swallowing, or respiratory distress. Other symptoms may reflect either hypothyroidism or hyperthyroidism. Obtain a drug history to determine past use of iodine-containing medications (including recent contrast media or oral contraceptives), which may falsely elevate serum thyroid function tests. Similarly, a severe illness, malnutrition, or the use of aspirin, corticosteroids, or phenytoin sodium may falsely depress serum thyroid function tests.
The patient with a significantly enlarged goiter may have a visible thyroid gland on the anterior neck. Note that the gland rises with swallowing. When you palpate the gland, stand behind the patient and palpate the gland for tender areas, areas of irregularity, firmness, or any nodules. A normal lateral lobe is approximately the size of the distal phalanx (most remote bony segment) of the thumb. Remember that excessive palpation of the thyroid gland can precipitate thyroid storm (acute thyrotoxic crisis from an oversecretion of the thyroid hormones); therefore, palpate the gland gently and only when necessary. You may also hear a bruit over an enlarged thyroid gland when you auscultate over the lateral lobes. Some patients also have respiratory stridor from compression of the trachea. The patient may also have Pemberton’s sign (dizziness, flushed face, fainting when the patient’s arms are raised above the head) caused by compression from the goiter.
While most types of thyroid dysfunction can be treated noninvasively, goiter that is caused by cancer may precipitate concern. Assess the patient’s degree of anxiety about the illness and potential complications.
The goal of medical management for the patient with a simple goiter is to reduce the size of the goiter by correcting the underlying cause. If the patient has decreased iodine stores, small doses of iodide (such as Lugol’s solution) may correct the problem. If the patient is ingesting a known substance that leads to goiter, avoidance of the food or drug is necessary. Commonly, no specific cause of the goiter is found, and the patient is placed on thyroid-replacement therapy.
If the patient is elderly or has a long-standing goiter with many nodules, further testing is needed because levothyroxine may lead to thyrotoxic crisis; the patient may need radioiodine ablation therapy to destroy areas of hypersecretion. Surgical treatment is rarely indicated and is used only when symptoms of obstruction occur after a trial of medications. Patients with goiter and thyroid nodules may also need surgical exploration to determine if they have cancer.
Nursing care plan primary nursing diagnosis: Risk for ineffective airway clearance related to tracheal compression or obstruction.
Nursing care plan intervention and treatment
The first priority is to ensure an adequate airway and breathing. If you suspect that the patient’s airway is compromised, keep an intubation tray and suction equipment at the bedside at all times. Pay particular attention to any sign of airway obstruction, such as stridor or dyspnea, and check on the patient frequently. Elevate the head of the patient’s bed to high Fowler position during meals and for 30 minutes afterward to limit the risk of aspiration. If you suspect that the goiter is increasing in size, monitor the patient’s neck circumference daily.
Care of the patient with goiter also focuses on the patient’s anxiety and knowledge deficits. Whatever the cause of the goiter, the patient may be highly anxious about the medical diagnosis itself or the resulting symptoms. Make sure that patients have the information they need to understand the disease. If the goiter is unsightly, recommend that the patient choose clothing that neither restricts activity nor draws attention to the neck. If the patient’s appearance is extremely distressing, refer the patient for appropriate counseling.
If patients need surgery for goiter removal, monitor them for acute airway obstruction and for thyrotoxic crisis, which is a potential complication of the surgery and leads to tachycardia, increased blood pressure, diaphoresis, and anxiety. Check both the incision and behind the neck for postoperative bleeding; notify the physician immediately if significant bleeding occurs. Each time you monitor the vital signs, assess the patient’s vocal quality and compare it with the patient’s preoperative speaking. Maintain the neck and head in good alignment, and support them during position changes to prevent traction on the sutures and damage to the operative site.
Nursing care plan discharge and home health care guidelines
Teach the patient to avoid medications and foods that lead to endemic or sporadic goiter. Patients with endemic goiter should use iodized salt to supply at least 300 μg of iodine daily to prevent goiter. Be sure that the patient understands all medications, including the dosage, route, action, adverse effects, and the need for any laboratory monitoring of thyroid medications. Encourage the patient to take thyroid hormone supplements at the same time each day to maintain constant thyroid levels in the blood.
Have the patient immediately report to the physician any signs and symptons of thyrotoxic crisis; these include rapid heart rate and palpitations, perspiration, shakiness and tremors, difficulty breathing, and nausea and vomiting. Teach the patient to report any increased neck swelling, difficulty in swallowing, or weight loss. If the patient had surgery, teach him or her to change any dressings, to inspect the incision for redness, swelling, and discharge, and notify the physician about changes that indicate infection.