A nephrostomy facilitates access to the kidney to help drain the urine when a retrograde approach is impossible. Nurses must understand the appropriate care and the management of nephrostomy. There are various infection risk factors and other issues surrounding patients’ long-term management with nephrostomy due to the condition’s delicate nature. Since nephrostomy care management is an essential and critical element of nursing, the necessary evidence and guidance must be provided to ensure that nurses possess the relevant knowledge and skills regarding the condition.
A nephrostomy is the insertion of a narrow-gauge pigtail drain tube to drain urine from the renal pelvis ureter and bladder into an external drainage bag. The nephrostomy tube is inserted under local anesthesia and is mostly sedated by a radiologist. It is conducted under computerized tomography (CT), fluoroscopy or ultrasound guidance. The main purpose of conducting a nephrostomy procedure is urinary obstruction. The major common urinary obstruction indicators include loin pain, fever, rising creatinine levels, nausea and vomiting, acute renal failure, fever, obstruction nephropathy demonstrated by imaging and urosepsis. Another reason for inserting nephrostomy tubes is diverting urine due to stenosis of a urostomy, hemorrhagic cystitis, herniation of urostomy, ureteral fistula or fissure, or following an injury to the ureter. It can be used as an intervention for delivering medications, removing stones, inserting an antegrade stent, ureteral biopsy and removing foreign bodies such as broken ureteric stents.
In other cases, nephrostomies are used to conduct diagnostic testing such as ureteral perfusion tests and antegrade pyelography. They are usually temporary and removed upon the obstruction’s resolution if an internal uteretic stent can be used to bypass the obstruction or if the process has been completed. Nevertheless, there are circumstances where a nephrostomy inadvisable or impossible to bypass the obstruction, such as in retroperitoneal fibrosis or advanced cancer. In such a situation, the nephrostomy is usually semi-permanent or permanent (Doughter & Lister, 2015).
Nephrostomy Insertion Procedure
The nephrostomy tube is inserted by inserting a needle, followed by a pigtail drain following a guidewire across the external layer into the internal skin layer tissue. It then goes through the muscle layers, followed by entry into the renal pelvis through the renal parenchyma tissue (McDougal et al., 2015). A nephrostomy tube is usually affixed to a drainage bag carefully secured using sutures on the skin to drain the urine. The nephrostomy procedure can be bilateral or unilateral. Where it is unilateral, the drainage bag and the nephrostomy tube are usually on the same side as the remaining kidney drains the urine into the bladder through the ureter. A bilateral nephrostomy entails having the drainage bag with the tube on both sides with minimal urine drainage into the bladder through the ureters. In both the unilateral and bilateral cases, urine may continually drain through the ureter into the bladder.
There are two alternatives to a nephrostomy: a retrograde stent insertion and a ureteroscopy, which investigates the ureter’s patency. The ureteroscopy and the retrograde stent insertion are conducted using general anesthesia with the urologist guiding and leading the medical or surgical group on the right course of action. A retrograde stent is usually more preferable if feasible for the patient because of its low morbidity rate along with its performance, which does not need a radiologist to perform a nephrostomy. Some of the cautions and contradictions associated with the procedure include the use of anticoagulants and coagulation conditions that are likely to increase the patient’s tendency to bleed.
Principles of Management and Care of Nephrostomy Patients by Nurses
There are several risks associated with percutaneous nephrostomy, and they require diligent attendance by skilled and qualified nursing practitioners. Some of the main risks include tube misplacement, severe bleeding, a vascular injury that needs embolization or nephrectomy, severe infection, tube occlusion and damage to adjacent structures, allergic reactions and death. Other aspects of nephrostomy that nurses are expected to manage to include fluid levels, infection risk and wound care, managing the tubes and bags and overseeing individual care and community help.
Figure 1. Significant risks from nephrostomy (Koukounaras & Lyon, 2017)
|Serious bleeding||3 for every 100|
|Vascular trauma that needs embolization or nephrectomy||3 for every 100|
|Nephrostomy tubing loss||1 in every 100|
|Tubing blockage||1 for every100|
|Severe infection||1 in every 100|
|Injuring the neighboring body tissues||<1 in every 100|
|Loss of life||<1 in every100|
|Hypersensitivity to the contrasting medium||<1 in every100|
Fluid Level Management
After an initial nephrostomy tube insertion, a patient’s kidney may become obstructed. They may experience a diuretic phase often characterized by polyuria, which is a high-volume output of fluids. As a result, the vital signs and the fluid balance levels of a patient need to be closely monitored. Each of the drainage routes is monitored closely and separately while calculating the total fluid produced. The urethral, left, total and right fluid output are calculated to monitor the progress. The intravenous or oral patient intake should match the overall output as calculated. The fluid balance is adjusted appropriately after close monitoring to hinder patient decline resulting from quick fluid loss (Hsu et al., 2016; Jairath et al., 2017).
Wound Care Plus a Patient’s Infection Risk
One of the significant risks posed to patients with a nephrostomy is kidney inflammation resulting from infection caused by the foreign object’s presence puncturing the kidney. The condition is referred to as pyelonephritis. Therefore, the patients need to be monitored closely to determine whether they have an infection or the presence of sepsis. Some of the indications of an infection or sepsis include fever, chills, elevated temperature, loin pain or festering urine, or decline in one’s vital signs. Once a nurse suspects an infection, they must collect a urine sample and look for proper advice from the doctor on the correct care and management procedure. They are to avoid flushing, if possible, to avoid pyelonephritis or other infections. If flushing the nephrostomy is needed, experienced nursing practitioners are to conduct it using a non-contact aseptic technique and 5ml of 0.9% sodium chloride.
The wound requires appropriate wound-site care to prevent exit-site infection. The care of the wound entails keeping it clean and dry. The drain site cleanliness and dryness should be maintained using essential dressings to avoid accidentally tugging the tube and to securely fasten the nephrostomy tube on the patient’s skin. The dressings offer firm support to the tube. Some of the specifically recommended drain site dressings include Drain-Fix, Grain Guard and Opsite Post-Op Visible. When choosing a dressing, the health practitioner should consider the patient’s comfort since the wound is located right at the back hence may lead to irritation as they sit against a chair or while they lie down. When the recommended dressings cannot be obtained or unavailable, a simple gauze-and-tape method can be used to dress the nephrostomy. However, the tube must be firmly sutured in position.
Management of the Drainage Bags and the Nephrostomy Tubes
The patient’s drainage bags must be changed frequently, every five to seven days, by upholding proper hand hygiene while dealing with the exit and drain sites. Proper care should also be taken when emptying the drainage bag to prevent contamination and cross infection. The nephrostomy tubes must be changed regularly as recommended by the manufacturer, and in most cases, it is every three months. The drainage bags must be cleared when they are three-quarters way full, and if possible, an individual must be trained on how to empty their nephrostomy bags correctly. A caregiver or the patient must be advised and trained to use a bigger nephrostomy drainage bag at night to guarantee they have a comfortable and peaceful night. (Martin & Baker, 2019). It is important to note that various hospitals supply different nephrostomy bags rarely readily present in several local communities and may be designed poorly hence uncomfortable for the patients. One of the most pleasant body-worn nephrostomy bags available are from Manfred Sauer Nephsys, which is also on the FP10 community prescription.
Community Support and Self-Care to Nephrostomy Patients
In a situation where the patients have a long-term nephrostomy, they should be taught how to change their drainage site dressing, including their nephrostomy drainage bags, regularly as advised by their doctor. Alternatively, patient caregivers can be taught to change the drainage bags and the site dressings. If independence and self-care are impossible, the individual must be mentioned to their local nursing group available. An appropriate site dressing and changing the drainage bag requires an upright posture where the patient sits on a bed, couch or stool as their back faces the healthcare practitioner such as a nurse. The site dressing and the drainage bag removal are best performed behind the patient; hence, the healthcare provider must observe proper preparation and clear communication (“The Code: Professional standards of practice and behavior for nurses, midwives and nursing associates”, 2018). In case a patient finds it difficult to sit upright, the nurse or the caregiver can position them on their side as the back faces them.
Upon discharge from the hospital, the nephrostomy patients must be taken to the available local nursing group to facilitate necessary support and help. They are to be informed on how and when to obtain medical supplies such as drainage bags and site dressings, including a written review plan on the follow-up care. The review should contain the scheduled date for changing the nephrostomy tube and the site dressing. A nephrostomy passport is availed by some manufacturers to help the patients record and monitor crucial details concerning their drainage bags and the dressings. Other relevant information upon discharge includes providing adequate weekly dressing supplies, where to obtain future supplies such as listings of reliable dispensaries or local pharmacies and contact details to seek answers upon concerns or queries.
After Interventional Radiology
When a patient arrives at the ward after a nephrostomy procedure, the nurse should monitor and ensure that the nephrostomy is draining freely. The fluid balance should be in progress, and the urine measurements are to be taken twice or once hourly. If the urine’s overall amount produced is less than 30ml every hour, the nurse should immediately inform a member of the medical team. The nephrostomy tube has to be properly secured using a suture at the drainage exit site, and the drainage dressing has to be correctly fixed. A transparent film dressing must be placed over the exit site to provide extra security and prevent water from leaking into the dressing. The dressings are to be monitored for strike-through twice in a day while observing vital signs such as pulse, temperature, oxygen monitoring, respiration and blood pressure every thirty minutes for bi-hourly followed by an hourly checkup every two hours. The nurse should also advise the patient to have bed rest every four to six hours.
The Daily Patient Management
There are various roles of a nurse as they attend to a nephrostomy patient in the ward daily. Some functions include ensuring that the nephrostomy tube is securely attached throughout with the drainage dressing appropriately affixed. The nurse must make sure that the drainage tubing is not twisted or kinked and is patent instead. Other roles are informing a member of the medical team if the overall urine output is <30ml/hour, applying the drainage bag appropriately at the point of insertion, replacing the drainage bag and attaching a Velcro waistband beneath the kidney level to facilitate smooth drainage.
They have to clear the patient’s NephSys bag employing the clean technique while the bag is three-quarter way full and having recorded the output volume on the fluid balance chart. The patient’s pain has to be well-controlled using the prescribed analgesics such as paracetamol and tramadol or codeine (Dougherty et al., 2015). The patient has to be advised to drink fluids and consume a light diet after the procedure unless the radiology or the medical team involved advises otherwise. The nurse also has to move the patient from their bed to the chair and observe the insertion site for signs of infection such as pain, leakage, swelling and redness.
Nephrostomy Discharge Care Advice and Post-Discharge Follow-up
The nurse has to teach the patient or their carer on various nephrostomy management and care procedures. Some of the aspects include checking their leg bag, drainage bag or the night bag, managing the bags without unnecessary pulling to avoid the tubing’s twisting, carrying out dressing and drainage changes weekly. Also, the proper application of the body-worn belt, the use of the night bags, emptying leg bags when they are three-quarters full or two-thirds, how to open and close the catheter bag drainage tap while emptying the bag and recognizing the signs and symptoms associated with catheter-related infections and how to reorder their clinical supplies, and the frequency. The nurses also have to ensure that the patient can contact their community nurses and understand their follow-up care plan. The follow-up care entails arranging a local nursing team for appropriate wound assessment and nephrostomy care, changing the nephrostomies every trimester, planning for appointments plus advising the patient to contact their medical team or a general practitioner if the follow-up appointment has not been conducted.
Figure 2. Nephrostomy care nursing interventions
|Issue||Causes||Preventive measures||Care plan|
|Site infection||The presence of a foreign body puncturing the skin||Observing the patient |
for infection signs and symptoms such as pain, elevated temperature, purulent discharge, itching and exit-site erythema.
Sending a swab of the site for culture, microscopy and a sensitivity test.
Seeking the correct medical advice and treating a patient accordingly.
|Maintaining correct hand hygiene. |
Performing the required exit-site care.
Changing the dressing and observing the site weekly.
|Pyelonephritis||The presence of a foreign body in the patient’s renal pelvis.||Monitoring the patient for signs and symptoms of infections, for example, purulent urine output, burning or stinging sensation when passing urine, raised inflammatory markers, loin or groin pain and elevated temperature.||Following the nephrostomy care advice given by the medical team. |
Changing the nephrostomy tubing and the drainage bags every week.
Maintaining the no-touch aseptic procedure.
|Falling out of the nephrostomy tube||Loose retention suture |
Failure in the drain locking mechanism
Falling off of the drain-fixation dressing.
|Seeking medical assistance urgently because the nephrostomy tube has to be replaced by a physician.||Ensuring the nephrostomy tube elements are well situated. |
Checking the positioning of the lock and drain mechanism.
Ensuring the retention sutures are intact and not broken or missing.
Applying the drain-fixation dressing correctly and securely.
|Nephrostomy tube stops draining.||Absence of urine output. |
Twisting or Kinked tube
|Checking the vital signs of the patients and seeking medical help promptly. |
Ensuring the patient is well-hydrated.
Straightening the tube and making sure it is not blocked.
Flushing a tube blocked with debris using 5ml, 0.9% normal saline using the aseptic method.
|Monitoring the patient’s vital signs and urine output. |
Addressing any concerns to the medical team instantly. Securing the drain and the nephrostomy tube carefully to prevent twisting.
|Increased nephrostomy output.||Diuresis due to a previous kidney obstruction.||Monitoring the fluid-balance strictly. |
Weighing the patient daily.
Cannulating the patient for intravenous cannulation.
|Checking the vital signs frequently and seeking medical help when the need arises. |
Monitoring the patient fluid-balance strictly.
Seeking medical help to match the patient fluid input and output.
Weighing the patient daily
Provisional Recommendations in the Management and Care of Nephrostomy Patients
The patients’ management and care are intensive to prevent problems such as falling out of the nephrostomy tubes, increased output, site infection, pyelonephritis, blockage, or twisting of the tubing (Szvalb et al., 2019). The nurses, patients, and their caregivers have to adhere to a high standard of practice in maintaining proper hygiene, caring for the exit site properly, changing the drainage dressing within the required timeframe, and following the medical’s advice team. An aseptic technique should be maintained. The tube elements have to be placed correctly with a carefully secured drainage bag and a nephrostomy tube. The retention suture has to be firmly secured to support the tube to prevent it from falling out, and the lock mechanism has to be fastened correctly in the lock or the drain position.
The patient’s output and their vital signs have also to be monitored regularly so that infection can be treated accordingly and on time. Once infection signs and symptoms such as pain, elevated temperature, and purulent discharge, among others, have been observed, medical assistance has to be sought promptly. There has to be clear communication between the patient, their carers, the nurses and the medical team to ensure that they receive the best care. For example, the nurses teach the patients and the cares upon discharge and facilitate medical intervention in case of an infection. If the nephrostomy is unavailable or unobtainable, the radiologist can advise the patient on the available alternatives. Each group has its role to play in offering the patient comfortable nephrostomy care and management.
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