Post Total Thyroidectomy care. Was I right in doing this?

  1. I Swear to you I remember my nursing isnstructor stressing the importance of checking for blood pooling on the posterior side of the neck b/c sometimes that's how some of them bleed out. I can still hear her say, "don't just look at the front of the neck, look at the back!"

    I was in the middle of doing this here at my agency job (1st day here at this facility), when one of the staff nurses walked and and screamed at me and told me that I'm being ridiculous, and how I am going to couse this Pt to go into edema b/c her neck wasn't in the "neutral" postion as I was assesssing her neck from the back.

    I stood firm, and so did she. Now she wants to have a meeting with the manager tomorrow, with me. Please tell me I was right. Oh please let me be right.

    Also, when is it ok to remove the dressing to take a peek? We disagreed on that one, too.
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  2. 19 Comments

  3. by   Kansas_RN
    Okay....my questions is what else was going on with the patient. I mean I had my thyroid out and the next day I was sent home. Up in my room the same day as surgery. Was there an imobilizer on? Precautions written on the chart? Was the patient given these precautions? Did hemove his neck more than you did during your exam?
    I've just never heard of this without some sort of other worries regarding the patient.

    Just my two cents. Without more info I would say that you didn't do anything wrong.
  4. by   Town & Country
    I swear, I remember that from nursing school, too!
  5. by   fotografe
    Quote from SunStreak
    I swear, I remember that from nursing school, too!
    In my first semester, and yes, we were told to check the underside of surgical patients. Gravity pulls blood down, so bleeding may be most evident on the UNDERSIDE of the patient as it pools in response to gravity. Eventually you would see all this blood, but if you wanted to see it sooner rather than later, you look underneath.
  6. by   scrmblr
    You look! But you keep the head in a neutral position...kinda tricky.
  7. by   maolin
    Quote from raindrop
    Also, when is it ok to remove the dressing to take a peek? We disagreed on that one, too.
    Typically the surgeon removes the first bandage.
  8. by   Daytonite
    I have had a subtotal and a total thyroidectomy, so I can tell you about them from the patient's perspective as well. You are absolutely correct to check for blood at the back of the neck. It is because if there is any bleeding it is likely to go to gravity, the lowest position it can. Even if it's just drainage within the dressing, you want to get a good assessment of how much is actually draining. I had two small penrose drains at either side of my incisions and as I recall one of them was really putting out sanguinous drainage for a day or two. Also, remember that the neck is a very vascular area and your instructor was right to advise you to look for excessive bleeding.

    As for neutral position, I can tell you right now that the only way I could move my head and neck around at all was to hold it in a neutral position because it hurt so bad. If you had been moving the patient and she was screaming in pain, then you would have been wrong to do that. However, I, the patient, was told from the moment I came out of my anesthesia to put both hands on either side of my head to support it and my neck whenever I moved. I wouldn't have been able to move around without doing that and having terrible pain. This is not like an abdominal surgery where the patient has trouble getting up and moving around. A patient is perfectly able to get up and walk around after a throidectomy (effects of anesthesia and narcotics aside).

    Any edema a patient experiences post-op thyroidectomy is going to primarily be from the surgeon tinkering around in the operative area. Getting more edema from too much head and neck movement is something I never heard of. If that's true, why do they have post-op patients start moving around as soon as possible after surgery? My understanding has always been that it is the trauma of the tissue manipulation by the surgeon during the surgery that causes any edema. If I'm wrong, someone please correct me. Also, a tracheostomy tray was kept at my bedside for several days as an emergency precaution. It's been a long time since I've worked on a general surgery floor, so maybe they don't do that for everyone anymore. However, swelling that causes an obstruction of the windpipe is a very real complication of this surgery.

    Now, I don't know that it's such a good idea to be taking a peek under the surgeon's original dressing placed in the OR. The surgeons themselves do like to take it off to see just how much drainage there has been since they saw the wound last in the OR. Mine was quite bulky and very nearly like a neck collar they apply after phsical traumas. It was removed the day after surgery by my surgeon and replaced with an ABD pad (because of the drainage I was having). Guess my surgeon expected a lot of drainage, I would say. After the OR dressing is removed, the patient's dressing is fair game for the nursing staff. I recall mine being changed frequently near the penrose drains.
  9. by   Daytonite
    here are some links for you to check out on throidectomies. i cannot find any reference to post-op movement contributing to post-op edema.

    http://www.sohnnurse.com/thyroidectomy.html - this is a continuing education article for "nursing interventions for potential complications after thyroidectomy"

    http://faculty.ntcc.edu/kethridge/th...20ethridge.htm - please note under the post-operative nursing interventions that they clearly say to check for wetness behind the patient's neck!

    http://www.ehendrick.org/healthy/index.htm - click on "surgeries", then click on the link for thyroidectomy
  10. by   Daytonite
    So, did this meeting with the staff RN, you and the nurse manager ever take place? If so, details please.
  11. by   sharann
    Check behind the neck this way. Wear a pair of gloves and slide your fingers on both sides under the neck, not even having to move the neck if you are worried about that, and you will quickly know if there is bleeding.
    That's it. You can also hold the neck with one hand and quickly check behind the neck to make sure. A tiny movement is not going to cause a problem that doesn;t already exist.
  12. by   Bipley
    Quote from raindrop
    I Swear to you I remember my nursing isnstructor stressing the importance of checking for blood pooling on the posterior side of the neck b/c sometimes that's how some of them bleed out. I can still hear her say, "don't just look at the front of the neck, look at the back!"

    I was in the middle of doing this here at my agency job (1st day here at this facility), when one of the staff nurses walked and and screamed at me and told me that I'm being ridiculous, and how I am going to couse this Pt to go into edema b/c her neck wasn't in the "neutral" postion as I was assesssing her neck from the back.

    I stood firm, and so did she. Now she wants to have a meeting with the manager tomorrow, with me. Please tell me I was right. Oh please let me be right.

    Also, when is it ok to remove the dressing to take a peek? We disagreed on that one, too.
    A dear friend of mine is a long term RN and she too, ignored your assessment. Her vocal cord nerves were cut during surgery because of edema and she now has a trach.

    She admits she ignored her "little voice" and now she will die sooner than she should have.

    Hold your ground, you are correct~
  13. by   UM Review RN
    As far as the "underside assessment"--how about tucking a couple of ab pads under the patient's neck and to "assess" you just change them or pull them out periodically to assess for drainage?

    I've only had one thyroidectomy patient. Orders were to keep HOB up, so the drainage (if there was any) would've come down the sides of the neck.

    We did not have a trach tray at the bedside, but I think to be safe, I will put one there the next time I have a patient with a thyroidectomy; it just makes sense.

    Can someone please tell me more about why hoarseness can indicate a problem? Could that be an indication that the vocal cord was nicked? How about if they're actually cut, what do you do then, and how can you tell?

    I thought most patients came out of surgery a little hoarse, but that's not the same as laryngeal stridor that indicates a closing airway, is it?

    The patient I had was somewhat hoarse and had a huge dressing over her site that contained no visible drains. The surgeon removed the dressing the next day to reveal a very well-approximated incision, without drainage, but with generalized neck edema.

    My patient was ambulatory also. I just "adjusted the pillow" for her a few times while she was sleeping to make sure there was nothing on it.

    She went home the next day.
    Last edit by UM Review RN on Dec 18, '05
  14. by   raindrop
    No meeting afterall. I went in, ready for this meeting, ready for her to look like an AZZ, but it never happened. I'm speculating that she complained to someone, and that someone told her I was right.

    For the record, no I was not being rough with the Pt, she was in no danger.

    For those of you that are telling me that next time I should just use a glove or gauze to assess, I don't understand how that will tell me anything without looking for myself. It's my understanding that the whole point of "looking" is b/c the blood pools under the skin, but it doesn't seep out.

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