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

2. 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

3. 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

4. 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.

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

6. Nephrostomy Anterior/Posterior View

7. 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

8. 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.

9. 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

10. 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

11. 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

12. 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;

13. 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

14. Video – Mosby’s Skills See URL in link below
Copy and paste URL into goggle chrome
Mosby’s nephrostomy video (mycnm.edu)