Nephrostomy Tube Care

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Definition

A percutaneous nephrostomy tube (PNT) is a urinary diversion system comprised of a collection bag, a nephrostomy tube at an exit site (usually in the skin over the flank area), and a nephrostomy tube that enters and ends in the renal pelvis of the kidney. This allows for direct drainage of urine from the kidney when normal urinary flow is impeded. The PNT is most often used for a urinary obstruction such as a calculus.

Purpose

The purpose of PNT care is to prevent complications when a PNT is in use.
Precautions

Aspiration of fluid from the nephrostomy tube is prohibited as such action will damage the renal pelvis. Gravity drainage is used to collect specimens, and the nurse should never use force when irrigating the tube. A tube should never be irrigated with more than 5 ml of solution, since the capacity of the renal pelvis is between 4 and 8 ml. The nurse must avoid dislodging the tube while removing the dressing.
Preparation

The nurse should wash hands prior to beginning the procedure, then assemble all of the following equipment:

* disposable underpad
* clean gloves
* measuring tape
* sterile gloves
* sterile cotton tip applicators (4)
* sterile 0.9% NaCl or povidone-iodine solution or sponges
* sterile 4×4 pad or transparent dressing
* sterile 2×2 pads
* tape
* pouch belt

Description

The nurse should provide privacy for the patient in preparation for the procedure. He or she should position the patient on the side opposite the tube site with the nephrostomy site up. This provides better viewing of the tube and allows an easier dressing change.

The nurse should put on clean gloves and place a disposable underpad beneath to the patient to absorb any drainage. To minimize tension at the site and to prevent dislodging, the nephrostomy tube should be anchored with a small piece of tape. The collection bag must be emptied. The old dressing can be removed by carefully loosening the edges, and then moving to the center of dressing. Care should be taken to avoid dislodging the tube while removing the dressing. A sterile cotton-tip applicator placed on the catheter will help stabilize the catheter while removing the dressing. The site is then assessed for signs of infection, any moisture, or other drainage. The PNT is then measured from exit site to tip. If the PNT length is longer than the measurement at time of insertion, the catheter may have migrated out, and the physician should be notified at that point. The nurse should remove the soiled gloves at this time and replace with sterile ones. The exit site should be cleansed with the agent of choice (0.9% saline or povidone-iodine solution), using sterile 2×2 pads. Each pad can only be used once. Cleansing should start at the exit site and work outward in a circular motion; this action should be repeated twice. If there is any crusted matter at the site, this must be loosened and removed by using a cotton-tip applicator moistened with 0.9% saline. Then, sterile dressing should be applied. After removing the old tape, the tube must be secured with new tape to the skin below the dressing, approximately 2.5 inches (6.5 cm) from the exit site. The patient will need to be assisted in the application of the pouch belt. Anchoring the PNT with tape reduces trauma and minimizes the possibility of dislodging or kinking the tubing; adding the belt further secures the PNT. The nurse may remove gloves at this point and wash hands. The patient's dressing needs to be dated and initialed, and will need to be changed daily, or more often if necessary.
Aftercare

The used equipment needs to be disposed of properly. Upon completion of the procedure, the nurse should again wash hands. Then the nurse will need to document observations and the techniques used, including the assessment of the site, the external catheter length, the type of dressing applied, and the devices used to secure the PNT.
Complications

There is an increased risk of infection because the PNT provides a direct pathway to the kidney. There is also a risk for dislodging the PNT during this procedure.
Patient education

The patient may shower 48 hours post-insertion. The patient should be given all of the following instructions:

* Cover the dressing and exit site with a waterproof covering before showering.
* Empty the collection bag prior to showering.

* Securely tape the PNT at the exit site and use a belt for the collection bag in the shower to prevent tube migration.
* Generally, after 14 days, if there are no complications, the site may be left uncovered when showering.

The patient should notify the doctor if any problems arise such as:

* signs of infection at the exit site of the PNT, including warmth, redness, swelling, tenderness, and discharge
* drainage from the PNT
* decreased urine output
* inability to flush the PNT
* presence of any bleeding, clots, stones, sediment, and odor
* incontinence or inadequate bladder emptying
* inadequate pain control, nausea, or vomiting
* fever
* accidental dislodgement of the PNT, or suspected migration of the PNT

Results

The site should not display any signs of infection. PNT measurement should be consistent with the baseline value. Abnormal findings are signs of infection, suspected migration, or a dislodged PNT. In the collection bag, any bleeding, clots, stones, sediment, and odor are all abnormal findings.
Health care team roles

Registered nurses (RNs) and licensed practical nurses (LPNs) may perform this procedure. After returning home, the patient may simply cleanse the insertion site with soap and water, and change the dressing daily. In an inpatient setting, an aseptic technique must be maintained.

Nurses are responsible for:

* dressing changes
* proper disposal of equipment
* documentation of the procedure
* patient education