|Year : 2017 | Volume
| Issue : 1 | Page : 54-65
Surgical management of thyroid gland disorders: Nursing care
Irene George1, Nirmala M Emmanuel2, Premila Lee3, Esther G Asirvatham1, Beaula R Jayasingh4, Nicole Johnson5
1 Staff Nurse, CMC, Vellore, India
2 Professor College of Nursine, CMC, Vellore, India
3 Professor, College of Nursing, CMC, Vellore, India
4 StaffNurse, CMC, Vellore, India
5 Tutor, College of Nursing, CMC, Vellore, India
|Date of Web Publication||9-Jun-2020|
Source of Support: None, Conflict of Interest: None
Thyroid gland dysfunction is present in a large number of the people. It is commonly seen in women and is sometimes associated with other endocrine problems. Dysfunction of the thyroid gland causes deranged metabolic functions of the body leading to altered energy levels in performing the daily tasks. Thyroid disorders should be identified at the earliest to prevent complications and to improve the physiological functions of the body. Majority of the disorders are associated with increase or decrease in the serum level of thyroid hormones. Enlargement of thyroid gland leads to respiratory distress, voice change, and dysphagia. It also causes body image disturbances in young patients. Though medications control the growth of the gland, surgery becomes an option to reduce the clinical effects of an enlarged gland. As thyroid is a highly vascular organ, precautions need to be taken before and after surgery to prevent hemorrhage. Nursing care involves preparation of the patient for surgery and meticulous postoperative care to prevent complications associated with the injury to parathyroid gland and laryngeal nerve. Early identification of complications will enable prompt management and improved quality of life of the patient. This article focuses on the various thyroid disorders, the clinical manifestations, assessment and diagnostic tests, the surgical management and the nursing care. The nursing care of patient undergoing thyroidectomy is discussed in detail.
Keywords: thyroid disorders, thyroid hormones, thyroidectomy, preoperative care, postoperative care
|How to cite this article:|
George I, Emmanuel NM, Lee P, Asirvatham EG, Jayasingh BR, Johnson N. Surgical management of thyroid gland disorders: Nursing care. Indian J Cont Nsg Edn 2017;18:54-65
|How to cite this URL:|
George I, Emmanuel NM, Lee P, Asirvatham EG, Jayasingh BR, Johnson N. Surgical management of thyroid gland disorders: Nursing care. Indian J Cont Nsg Edn [serial online] 2017 [cited 2022 Dec 7];18:54-65. Available from: https://www.ijcne.org/text.asp?2017/18/1/54/286312
| Introduction|| |
Thyroid disorders are increasing in incidence worldwide, and are most commonly seen among women ;han in men. An increasing risk for thyroid diseases is seen imong people living in South-East Asia, Latin America and Central Africa (Vanderpump, 2011). In India 42 million people suffer from thyroid diseases (Unnikrishnan, & Menon, 2011) and the incidence among young women is also on the rise (Velayutham, Selvan, & Unnikrishnan, 2015). An increase of 50.2% mortality is reported among patients with thyroid cancer from 1990 to 2010. In South Asia, thyroid cancer ranks 94 compared to 92 globally (Kalra, Unnikrishnan, & Sahay, 2013).
Thyroid dysfunction affects the metabolism of the individual and leads to disturbance in the normal physiological functions (Pinto & Glick, 2002). Medical management of thyroid disorders includes supplementation with hormones in case of deficiency disorders. Surgical management is an option for those with hyper secretion and enlarged gland. Total thyroidectomy is considered to be optimal procedure when surgery is indicated. Even for benign thyroid disease suigeiy seems to be an option as it has advantages of immediate and permanent cure with no recurrences (Wang, Richards, & Sosa, 2017). Nurses need to keep themselves abreast of the advances in the management of thyroid disorders, especially the surgical management and its outcome.
| Anatomy and Physiology of Thyroid Gland|| |
Thyroid gland is a butterfly shaped organ measuring 5x3 cm, weighing 30 g and is located in the lower neck, anterior to the trachea (see [Figure 1]). It is highly vascular, supplied by the inferior and superior thyroid arteries. Thyroid veins drain into the internal jugular vein. The parathyroid glands are sometimes embedded in the thyroid tissue at the posterior surface. The recurrent laryngeal nerve passes close to the glands (Hinkle & Cheever, 2014). The gland is made up of hollow sacs called follicles which secrete hormones aamelythyroxine (T4), triiodothyronine (T3), and calcitonin.
The main functions of the gland are to increase body temperature, increase lipolysis and reduce blood cholesterol, enhance the action of norepinephrine and epinephrine and accelerate body growth along with growth hormone and insulin (Thyroid Disorders, 2016). Hence, it has an influence on every major organ by affecting the cellular metabolism. Calcitonin helps in maintaining the calcium level in the blood by reducing reabsorption of calcium from bones and renal tubules during hypercalcemia.
The secretion of thyroid hormones is regulated by thyroid stimulating hormone (TSH) (Waugh & Grant, 2014). Thyroid releasing hormone (TRH) synthesized in hypothalamus is carried through portal circulation to the hypophysis which interacts with the TRH receptors in the front lobe of hypophysis. TSH is secreted by the hypophysis and transported by blood to stimulate the thyroid gland to produce thyroid hormones (Bursuk, 2017) (see [Figure 2]). Iodine plays a major role in the formation of the thyroid hormones. Iodine in the form of iodide decreases the response of the thyroid gland to TSH. Hence iodide initiates the negative feedback mechanism and inhibits the production oí TSH by the pituitary (Topliss, 2005).
| Common Disorders of Thyroid Gland|| |
The common thyroid disorders are goiter, hyperthyroidism, hypothyroidism, myxedema coma, thyroiditis, and thyroid cancer which are discussed below (Collins, 2008; de Wit&Kumagai, 2013; Williams & Hopper, 2015; Lewis, Dirksen, & Heitkemper, 2014).
- Goitre: It is the enlargement of thyroid gland. Goitre may occur due to deficiency of iodine and may or may not be associated with changes in serum level of thyroid hormone
- Hyperthyroidism: Hyperthyroidism is the result of excessive thyroid hormone secretion. There is a failure in the normal feedback control over thyroid hormone secretion. This leads to hypermetabolism. Increase in the levels of thyroid hormone (T3 and T4) is seen in Grave’s disease, toxic goiter, and toxic adenoma. If it is due to the dysfunction of the thyroid gland it is referred to as primary hyperthyroidism and if the increase is due to dysfunction of the pituitary or hypothalamus it is termed as secondary hyperthyroidism. Thyroid storm or thyroid crisis occurs when hyperthyroidism is untreated or poorly controlled or when the patient is severely stressed. This state is a life threatening condition as the symptoms will be more severe.
- Hypothyroidism: It is the decrease in the serum level of thyroid hormones. It is generally caused by inflammation, iodine deficiency, decreased TSH and atrophy of thyroid gland. Hypothyroidism leads to decreased metabolic rate. This lowered metabolism stimulates the hypothalamus and the pituitary gland to secrete TSH, as compensation. The increase in serum TSH causes the thyroid to overwork leading to enlargement of the gland, a condition known as goiter.
- Myxedema coma: A life threatening condition caused by abrupt withdrawal of thyroid therapy, acute illness, anesthesia, use of sedatives or narcotics, surgery or hypothermia. Though rare, it is a serious complication of untreated or inadequately treated hypothyroidism and should be considered as a medical emergency.
- Thyroiditis: Inflammation of the thyroid gland. An acute form of thyroiditis is due to infectionandsub-acute manifestations are due to upper respiratory viral infections. Chronicthyroiditis, however is due to autoimmune disorder, which is also referred to as Hashimoto’s thyroiditis.
- Thyroid cancer: There are four distinct types of thyroid cancer: papillary, follicular, medullary and anaplastic. Papillary carcinomas constitute 70-80% of all the thyroid cancers. It is slow growing and penetrates the lymphnodes. Follicular carcinoma accounts for 15% and commonly seen among older patients. It rarely spreads to lymphnodes. About 10% are medullary carcinoma and it occurs as part of a familial endocrine disorder and multiple endocrine neoplasia. Anaplastic carcinoma is a rapid growing, extremely aggressive tumour that directly invade near bv structures to cause respiratory distress. The prognosis is poor and accounts for 2% of all thyroid cancers.
| Clinical Manifestations of Thyroid Disorders|| |
Clinical manifestations of the various disorders are presented in [Table 1] (Lewis, Dirksen, & Heitkemper, 2014).
| Assessment and Diagnosis of Thyroid Disorders|| |
Assessment of thyroid functions includes a thorough history and physical assessment. History collection should focus on knowing the predisposing factors such as age, gender, changes in weight, place of residence (higher altitude), nutritional pattern, and family history of any thyroid disorders. Physical assessment includes inspection of patient’s behavior, hand movements, pulses, facial changes especially eye movement and enlargement, and neck examination for any masses. The thyroid gland and lymph nodes are palpated to feel for abnormality and displacement of the trachea. Percussion may reveal retrosternal dullness indicating a large thyroid mass. Increased vascularity of the gland may be elicited by auscultation which indicates Grave’s disease (Ignatavicius & Workman, 2016; Lewis et al., 2014). The steps in the clinical examination of the thyroid gland are listed in[Box 1] (Smith, 1990).
Serum levels of thyroid hormones are studied to appreciate the abnormal functions of the thyroid gland (see [Table 2]). Any deviation from the normal range of values indicate dysfunction of the thyroid or the pituitary or hypothalamus gland (Lewis et al., 2014; Stang, 2016).
Imaging studies such as radioactive iodine uptake, :omputerized tomography, magnetic resonance imaging, and thyroid ultrasound are done to study the extensiveness of the disease. Inflammatory disorders are differentiated from malignant changes through fine needle aspiration cytology or biopsy of the thyroid tissues.
| Management of Thyroid Disorders|| |
Disorders which manifest with hypothyroidism are treated with iodine supplement or thyroid hormone supplements. Levothyroxine Sodium in the form of tablets is given as a supplement. In case of increased levels of serum thyroid hormones, Thionamide is given to establish euthyroid state. Iodine preparations are used to reduce the size of the gland in order to avoid risk of hemorrhage during surgery as the gland is highly vascularized (Ignatavicius& Workman, 2016). Enlargement of thyroid gland associated with clinical symptoms like hoarseness, respiratory difficulty and dysphagia and cancer of the gland are managed with surgery, rhe following surgical procedures may be performed to treat thyroid disorders (see [Figure 2]).
- Thyroid lobectomy: Partial thyroid lobectomy is removal of some lobes of the gland and thyroid lobectomy with isthmectomy is the removal of thyroid lobes and isthmus, commonly done in case of benign tumours and small and non-aggressive cancers.
- Subtotal thyroidectomy: Removal of one side of the gland and isthmus and majority of the other lobe. Performed in case of small non-aggressive thyroid cancers and goiters.
- Total thyroidectomy: Removal of the entire gland, commonly done for all types of cancer.
| Nursing Management of Patient Undergoing Thyroidectomy|| |
Nursing management of a patient undergoing thyroidectomy is discussed using a case report and nursing process approach.
36 year old Mr. N presented with complaints of neck swelling for the past 3 months which gradually increased in size. He had no complaints of pain. He had already been diagnosed to have hypothyroidism and was being treated with oral Eltroxin for past 3 years. At the present admission he gave a history of weight gain, excessive sleep, and lethargy. A nodule was identified in thyroid gland which measured 1.5 cm X 1 cm along with a palapable submental lymphnode. Fine needle aspiration cytology was suggestive of thyroid gland hyperplasia. Hence, a biopsy was done which revealed focal fibrous thickening of the capsule. He was diagnosed to have papillary carcinoma of right lobe of thyroid gland and underwent total thyroidectomy.
During the preoperative period, anxiety regarding surgical procedure and outcome becomes the main concern for patients admitted for surgery. Patient need to be reassured and adequate explanation about the tests, surgical procedure, outcomes and the management need to be provided to ensure smooth postoperative period. In, patients with hypothyroidism, thyroid supplements should be continued before and after surgery. For patients with hyperthyroidism, tachycardia, hypertension, and dysrhythmias should be controlled before surgery. Sleeping pulse rate is monitored to identify arrhythmias. Breathing exercises are taught to the patient and encouraged for relaxation. Supporting the neck while coughing and during other movements of the neck is encouraged to prevent stress over the incision site in the postoperative period. The needs and problems in Mr. N were anxiety, body image disturbance, knowledge deficit, risk for infection, and risk for injury.
1. Nursing Diagnosis: Anxiety related to impending surgery
Expected Outcome: Anxiety is reduced as evidenced by verbalization and stable vital signs
- Assessed the level of anxiety to understand the patients coping status
- Explanation was given about starvation, surgery, recovery room, pre-operative and post-operative exercises, pain management, ambulation, diet modifications, presence of wounds and drains. This helps to relieve the anxiety and cope up postoperatively
- Encouraged deep breathing exercises and relaxation techniques like music therapy to ease the patient
- Administered anti-anxiety drug - Tab. Lorazepam lmg and anti-ulcer drug - Cap. Omeprazole 20mg to relieve the anxiety and to suppress gastric symptoms respectively
Evaluation: Anxiety was reduced as evidenced by his verbalization and vital signs were within the normal range (BP: 120/90mm Hg and PR: 76/mt).
2. Nursing Diagnosis: Body image disturbance related to swelling in the neck region.
Expected Outcome: Expresses good self-esteem and copes with the presence of swelling at the neck region and scar during the postoperative period
- Assessed his feelings regarding his image due to the presence of swelling
- Encouraged him to see other patients with similar surgery and scar
- Suggested ways to hide the scar by using high collared shirts
- Encouraged use of lotion and mild massage over the scar site once the wound heals
Evaluation: He did not verbalize negative thoughts regarding the swelling and the scar.
3. Nursing Diagnosis: Knowledge deficit regarding the disease process and surgical outcome secondary to lack of information and understanding related to ignorance
Expected Outcome: Learning needs are met as evidenced by verbalisation of understanding and complying with the instructions given
- Assessed the level of knowledge to determine the learning needs of the patient
- Encouraged the patient to clarifydoubts. This helps patients to be better prepared for surgery
- Used audio -visual aids while teaching. This helps in better understanding
- Explained about the surgery, anaesthesia, starvation, pain management, pre-operative and post-operative exercises, ambulation, diet modifications and complications. This gives the patient a clear picture about the post- operative period
Evaluation: Learning needs were met as evidenced by verbalization of understanding and following instructions.
4. Nursing Diagnosis: Risk for infection related to impending surgical procedure
Expected Outcome: Infection is prevented as evidenced by stable vital signs
- Assessed the level of skin integrity as skin breakdown is a source of infection
- Monitored vital signs every eight hours to identify any deviation from the baseline data
- Encouraged personal hygiene to prevent colonization of microbes in the proposed incision site
- Followed aseptic technique while doing procedures to prevent normal flora from entering into systemic circulation
- Encouraged health personnel to use handrubs before and after touching the patient to prevent cross contamination
Evaluation: Infection was prevented as evidenced by stable vital signs (Temperature-98.5F, BP-120/70 mm Hg, PR-76/ mt)
5. Nursing Diagnosis: Risk for injury related to restlessness secondary to effect of premedication
Expected Outcome: Injury is prevented as evidenced by absence of falls
- Assessed the level of anxiety to prevent restlessness
- Administered pre-medications (Tab. Lorazepam lmg) after transferring the patient to the stretcher to prevent falls
- Encouraged the patient to empty the bladder before getting on to the trolley to be comfortable
- Secured the patient on trolley as per institutional policy
Evaluation: Injury was prevented as evidenced by safe transfer of patient to operating theatre.
Postoperative care begins in the operating room where the patient is monitored for stability before shifting to the wards. Monitoring for complications becomes the primary focus of postoperative care. The main needs of the patient are airway, breathing, circulation, pain management, nutrition, and electrolyte imbalance. Lifelong treatment of Levothyroxine replacement is required in patients with total thyroidectomy, at a dose of 100 -200 μg per day, depending on weight and sex, and serum TSH is followed up to adjust the dose of Levothyroxine. Routine 2 week oral Calcium and Vitamin D supplementation (Caltrate D containing 1.5g Calcium Carbonate and Vitamin D3 125 IU in each tablet) without laboratory assessment is administered to all patients who have total thyroidectomy, and this method is a safe and cost-effective for preventing symptomatic hypocalcaemia. Patients take 3g of Calcium three times daily for the first week and 1.5g three times daily for the second week. If symptoms of hypocalcaemia remain, additional doses of 2g of Calcium Gluconate are intravenously injected. Hypo- parathyroidismis considered permanent if a Calcium supplement is required after 6 months. In patients with hoarseness, an additional indirect laryngoscopy is scheduled at 1, 3, and 6 months after surgery or until the vocal cord function has recovered. After 6 months, if there is no improvement in the voice, the patient is diagnosed to have permanent recurrent laryngeal nerve palsy.
Suture site is monitored for bleeding and infection. Sofřamycin ointment is applied three times a day over the suture site to prevent infection. Hematoma is prevented by insertion of vario drain at the surgical site. The amount, colour, and consistency of drain are noted everyday. The wound drain site care is given to prevent infection and the drain is removed when drainage is less than 50 ml per day.
Specific nursing care issues in Mr. N were ineffective breathing pattern, fluid volume deficit, risk for hyperthermia, deficient knowledge, and risk for complications
1. Nursing Diagnosis: Ineffective breathing pattern related to depressed ventilation.
Expected Outcome: Normal breathing pattern is maintained as evidenced by verbalization and Sp02 within normal limits.
- Monitored the respiratory rate, depth, and rhythm to identify respiratory distress
- Encouraged deep breathing and coughing exercises to prevent atelectasis and to promote adequate ventilation
- Maintained patent airway by positioning the patient with head end elevation at 30° during the immediate postoperative period to enhance airflow.
- Ensured adequate pain relief to aid the patient in taking deep breaths
- Monitored the vital signs every four hours to identify any deviation from the baseline data.
- Administered oxygen 5L/mt for 6 hours during the immediate post-operative period to prevent tissue hypoxia
Evaluation: Normal breathing pattern was maintained as evidenced by verbalization of absence of discomfort while breathing, RR 20/mt, and Sp02 - 98% in room air.
2. Nursing Diagnosis: Fluid volume deficit related to blood loss secondary to surgery.
Expected Outcome: Fluid volume is maintained as evidenced by adequate urine output and capillary refilling within 3 seconds
- Assessed the fluid status to know the baseline data
- Administered IV fluids to prevent hypovolemia after surgery. Intravenous Normal Saline 500ml was administered over 4 hours and then was discontinued.
- Encouraged him to take oral fluids whenever needed to improve the hydration
- Monitored strict intake and output chart to identify any variations from the baseline. His intake was 2700ml/day and output was 1900 ml/day
Evaluation: Fluid volume status was maintained as evidenced by normal skin turgor, PR-76/mt and BP- 120/70 mmHg.
3. Nursing Diagnosis: Risk for hypothermia related to surgery.
Expected Outcome: Normal body temperature is maintained as evidenced by stable temperature
- Provided extra blanket to minimize the heat loss
- Avoided and discouraged use of external heat source to reduce peripheral vasodilatation and vascular collapse.
- Monitored patients body temperature to prevent from hypothermia
Evaluation: Normal body temperature was maintained as evidenced by temperature measuring between 98 and 99° F.
4. Nursing Diagnosis: Deficient knowledge regarding therapeutic regimen for lifelong thyroid replacement therapy related to lack of understanding
Expected Outcome: Learning need is met as evidenced by verbalization of understanding and compliance to treatment regimen
- Described the desired effects of medications to patient to create awareness
- Assisted the patient to develop checklist to ensure self administration of thyroid supplements
- Described the side effects of the medications to create the awareness
Evaluation: Learning needs were met as evidenced by verbalization of understanding.
5. Nursing Diagnosis: Risk for complications related to surgery
Expected Outcome: Complications are prevented as evidenced by stable vital signs
- Monitored the vital signs every four hours to identify any deviation from the baseline .HR-76/mt and temperature is 98.7 FHematomaformation
- Assessed for any redness or swelling in the operated site to identify early symptoms of hematoma Laryngeal nerve damage
- Assessed for hoarseness of voice.This is the initial sign of laryngeal nerve injury
- Encouraged the patients to say ‘eeeeeeee’ to identify any vocal changes
- Assessed for Chvostek and Trousseau sign (see [Figure 3] & [Figure 4]). The patients manifested positive Chvosteks sign on the second postoperative day and serum Calcium was 7.6 mg/dl.Inj Calcium Gluconate 10% 10 ml was given intravenously over 10 minutes.
|Figure 3: Types of thyroidectomy (Source: Harvard Health Publications, 2017)|
Click here to view
|Figure 4: Positive Trousseau sign (Source: Chvostek’s and Trousseau’s sign, 2017)|
Click here to view
Taught him head and neck exercises and encouraged to do them regularly to prevent neck contractures and to improve circulation (see [Figure 5])
|Figure 5: Head and neck exercises (Source: Edgar Cayce’s Association, 2016)|
Click here to view
Evaluation: Complications were identified, managed and prevented as evidenced by stable vital signs.
| Conclusion|| |
Thyroidectomy is becoming a common procedure for majority of the disorders of thyroid in order to prevent recurrence of tumours and to prevent the clinical symptoms such as respiratory distress and dysphagia. At times it is also done for cosmetic purposes, to improve the body image. Caring for a patient undergoing thyroidectomy is a challenge to a nurse, as it involves continuous monitoring and early identification of complications.
Conflicts of Interest: The authors have declared no conflicts ofinterest.
| Continuing Education Series No: 32 Surgical Management Of Thyroid Gland Disorders: Nursing Care|| |
After reading the preceding article and taking this test, you should be able to:
- AList the common disorders of thyroid gland
- Enumerate the clinical manifestations of disorders of thyroid gland
- Discuss the management of disorders of thyroid gland
- Explain the nursing interventions for patients undergoing thyroidectomy
- Suppression of TSH due to increase in serum thyroxine level is known as
- Positive feedback mechanism
- Negative feedback mechanism
- A life threatening condition caused by the abrupt withdrawal of thyroid hormone therapy is
- Myxedema coma
- Grave’s disease
- A nurse assigned to Mr. X with hyperthyroidism will know that he will have
- Decreased appetite
- Weight gain
- Patient’s basal body temperature will be increased in
- Myxedema Coma
- The function of the thyroid gland can be evaluated by
- Physical examination
- CT scan
- Radioactive iodine uptake scan
- Removal of one side of the thyroid gland along with isthmus is known as thyroidectomy
- A nurse monitors for the following sign in a thyroidectomy patient to identify hypocalcemia
- The mineral essential in the functioning of thyroid gland is
- A nurse while performing a preoperative assessment on a patient posted for total thyroidectomy, would consider as priority need
- Lack ofinformation
- Lack of family support
- Checking for carpopedal spasm in post thyroidectomy patients is also referred to as the following sign
- While monitoring a patient during immediate post- operative period following thyroidectomy, the nurse identifies respiratory compromise, rapid weak thready pulse, and swelling at the operated site. This is due to
- Laryngeal nerve damage
- Hematoma formation
- Thyroid crisis
- The commonly arising carcinoma of the thyroid gland is
- The major psychological issue among young patients undergoing thyroidectomy is
- Body image disturbance
- TSH is secreted by the
- A patient who underwent thyroidectomy is found to have hypocalcemia. While administering Inj. Calcium gluconate intravenously, the nurse would monitor for
- Increased respiratory rate
- Muscle twitching
- Increased heart rate
- The following are the functions of thyroid gland except
- Increase body temperature
- Reduce blood cholesterol
- Enhance the action of norepinephrine and epinephrine
- Improve immunity
- The effectiveness of surgical management for carcinoma thyroid is confirmed by checking the serum level of
- Serum thyroglobulin
- Thyroid hormone binding ratio
A patient complains of spasm of the muscles following thyroidectomy. This is a manifestation due to injury to the
- Laryngeal nerve
- Parathyroid gland
- Sternocleidomastoid muscle
Laryngeal nerve damage can be identified by
- Hoarseness of voice
- Persistent cough
Mrs. A on treatment for hypothyroidism, presents with unconsciousness, hypothermia, hypotension, and respiratory depression. The nurse would expect the patient’s thyroxine level to be
- Slightly elevated
- Extremely elevated
- Slightly decreased
- Extremely decreased
| CE Test No : 32|| |
| Surgical Management Of Thyroid Gland Disorders: Nursing Care|| |
Select the best answer and shade the circle against the suitable alphabet in the answer form provided.
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| References|| |
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Ignatavičius, D. D., & Workman, M. L. (2016). Medical- surgical nursing: Patient-centered collaborative care
(8th ed.). St. Louis, Missouri: Elsevier.
Kalra, S., Unnikrishnan, A. G., & Sahay, R. (2013).The global burden of thyroid disease. Thyroid Research and Practice, 10(3)
Lewis, S. L., Dirksen, S. R, & Heitkemper, M. M. (2014). Medical-surgical nursing: Assessment and management of clinical problems
. St. Louis, Missouri: Elsevier, Mosby.
Pinto, Α., & Glick, M. (2002). Management of patients with thyroid diseases: Oral health considerations. Journal of American Dental Association, 133(
Smith, T. J. (1990). Neck and thyroid examination. In Η. K. Walker., W. D. Hall, & J. W. Hurse (Eds). Clinical methods: The history, physical, and laboratory examinations
(3rd ed.). Boston: Butterworth Publisher.
Unnikrishnan, A. G., & Menon, U. (2011). Thyroid disorders in India: An epidemiological perspective. Indian Journal of Endocrinology and Metabolism, 15(
6), 781-784. doi: 10.4103/2230-8210.167546
Velayutham, K., Selvan, S. S. Α., & Unnikrishnan, Α. G. (2015).Prevalence of thyroid dysfunction among young females in a South Indian population. Indian Journal of Endocrinology and Metabolism, 19(
Waugh, Α., & Grant, A. (2014). Ross and Wilson’s anatomy and physiology in health and illness
(12th ed.). Canada: Elsevier.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]