Urinary – Nephrostomy Catheter Care Adapted from VNAA Procedure Manual By Ambercare Education Department – Jan 2014

Purpose To maintain a patent catheter providing drainage of urine from the kidney when flow of urine through a ureter is not possible or desirable and to prevent infection

Indications: Inserted into the renal pelvis to drain urine and relieve pressure It can be inserted percutaneously using local anesthesia or via an open surgical procedure called a pyeloplasty Most common – via local anesthetic and either radiography or ultrasound for placement It is an invasive procedure – resulting in an interruption of the skin – which of course is the body’s first line of defense Generally placed as a temporary method of diversion; however, it can be placed permanently

Indications continued Complete obstruction of ureter(s) Urinary fistula (bypass) Irrigation of the renal pelvis Renal calculi (kidney stones) Kidney stones – procedure called a nephrolithotomy – a surgeon inserts a nephroscope into the kidney and uses ultrasonic lithotripsy to break up large stones (generally > 5 mm) removing large pieces via the nephroscope. The remains are excreted in the urine. A percutaneous nephrostomy tube may be placed after this procedure for continuous or intermittent irrigation to flush out stone fragments, to help dissolve the remaining renal calculi, to prevent or remove clots from the procedure, or to infuse medications that prevent infection or further breakdown of renal calculi Various types of tubes may be used, as well as differing sizes ranging from 5 Fr to 32 Fr. The small tubes are more likely to become obstructed than the larger tubes – the nephrostomy tube is generally attached to a drainage tubing system that connects to a urine collection bag Care of the tube frequently includes irrigation or flushing at prescribed intervals to prevent clogging of the tubing with debris or to prevent clots from forming in the catheter. Routine flushing is only performed if the output drops or if the output is very purulent or bloody. Flushing tubing and dressing changes should be done sterilely.

Potential Complications with long-term placement Infection Stone formation Intermittent hematuria Renal hemorrhage Accidental dislodgment

Nephrostomy Anterior/Posterior View

Things to Consider Maintaining a sterile system is of utmost importance in preventing serious consequences of kidney infection The catheter is either taped, sutured or a securement device is used to keep catheter securely in place The catheter should not be kinked or plugged to assure continuous drainage. Bending or shaping in a “C” shape will provide some give and help the tube not to be pulled out. Prevent kinking or bending of the catheter by careful dressing of the site If the positioning, manipulation of tube, or irrigation does not remove an obstruction and allow flow of urine, notify physician immediately The catheter is never clamped unless otherwise ordered by physician

Things to consider - continued Removal of a nephrostomy catheter is done by the physician; after removal a 4x4 sterile gauze dressing or other appropriate dressing is placed over the catheter insertion site and changed daily or as needed If excessive drainage occurs after removal, a small urostomy appliance can be placed over site until drainage is minimized Monitor for s/sx of infection at site and document appropriately Labeling of tubes/dressings (date/initials, etc.) must be adhered to Patient/family education is an important aspect of the plan of care – including contacting nurse for assistance if the catheter becomes dislodged, disconnected, etc.

Urinary Nephrostomy Equipment Sterile irrigation set (if needed) 10 mL sterile syringe Gauze pads (sterile 4x4s) Antimicrobial solution (wound cleanser) Drainage basin / Drainage bag / leg straps if necessary Gloves (sterile and clean) / adhesive remover pads Sterile irrigation solution (Normal Saline or as prescribed) / sterile water Chux (underpad) Transparent dressing / paper or cloth tape Sterile cotton tips

Urinary Nephrostomy Dressing Change Adhere to Standard Precautions Explain procedure to patient Place patient in comfortable position (that allows access and observation of Nephrostomy tube) – place chux under patient (cover exposed body parts with sheet) Remove old dressing (care must be taken not to pull on tube – may not be sutured in) – use adhesive remover if necessary Anchor catheter to skin with one hand while removing tape with other hand to sure catheter is not pulled out Cleanse around nephrostomy tube with sterile 4x4s and sterile water (after cleansing with wound cleaner and sterile 4x4x) pat dry with sterile 4x4 – begin at the catheter site and move outward

Urinary Nephrostomy Dressing Change Inspect catheter for kinks, check for leakage of urine or (bile if it is a biliary tube) Examine catheter exit site. Report s/sx of redness or infection to physician Place appropriate dressing over or around catheter site – secure in place – A transparent dressing may be applied to provide a waterproof barrier

Urinary – Nephrostomy Catheter Irrigation, occluded or plugged interventions (as ordered) Most tubes are connected to a stop cock system. Tunurse stop cock to the appropriate position: Off to drainage bag (closed) when instilling solution On (stop cock) to syringe to allow flow of urine into syringe or bag Use sterile technique, gently irrigate catheter with 5 mL of NS or ordered irrigation – never force irrigant Gently allow irrigant to flow back per gravity drainage. ONLY ASPIRATE WITH PHYSICIAN’S ORDER NEVER re-install USED irrigant into tube! If unable to get a retunurse of irrigant, assess catheter for kinks; if none found, notify physician Disgard any unused irrigating solution and collected irrigation solution from drainage basin in toilet. Cleanse and dry drainage basin; patient/caregiver education must ensue. Apply catheter strap and use a leg bag to prevent pulling on the catheter (if available); use continuous gravity drainage bag at night time; discard soiled supplies in appropriate containers;

Document in patients record: Color and characteristics of urine (odor, sediment) Urinary output Condition of catheter, patency of tube Any drainage or s/sx of infection around site Condition of skin under tape – noting blisters, rashes, etc. and intervention Interventions performed Patient’s response to procedure Patient education given and understanding of such Communications with physician when necessary

Video – Mosby’s Skills See URL in link below http://mns.elsevierperformancemanager.com.libproxy.cnm.edu:8080/NursingSkills/ContentPlayer/SkillContentPlayerIFrame.aspx?KeyId=10938&Id=GNMS_47&IsConnect=False&bcp=SearchOp~0~Nephrostomy~False&Section=7 Copy and paste URL into goggle chrome Mosby’s nephrostomy video (mycnm.edu)