Renal Concepts in Critical Care

Nephrostomy Tube Care

nursebob 07/25/10

Purpose:

  • To maintain a patent, sterile urinary drainage system.
  • Background:

  • General
    1. Dressing Change
    1. Equipment:
  • Disposable underpad
    Non-sterile gloves
    Measuring tape
    Sterile gloves
    Sterile cotton tip applicators (4)
    Sterile 0.9% NaCl
    Coverlet 4x4 or transparent dressing
    Sterile 2x2’s
    Micropore tape
    Pouch belt
  • B. STEPS

  • KEY POINTS

    1. Assemble equipment
     
    • Assist patient to a side-lying position with nephrostomy site up.
     
    • Place disposable underpad next to nephrostomy site & don non-sterile gloves.
     
    • Anchor the nephrostomy tube with a small piece of tape & empty the collection bag.
    1. This minimizes tension on the tube & prevents accidental dislodging of the tube
    1. Carefully remove old dressing, first loosening edges of dressing and moving to the center of dressing.
    1. Avoid dislodging the tube. A sterile cotton-tip applicator placed on the catheter may help stabilize the catheter while the dressing is being removed.
    • Assess exit site for redness, edema, moisture, or drainage.
    1. These observations may indicate infection or PNT malfunction.
    • Measure PNT from exit site to tip.
    1. If the PNT length is longer than measured length at time of insertion, catheter may have migrated out. Notify physician.
    • Remove soiled gloves and don sterile gloves.
     
    • Cleanse exit site with 0.9% saline using cotton tip applicators. Start at the exit site and work outward in a circular motion proceeding outwards approximately 3-4 inches. Repeat X2.
    1. If there is crusted matter at exit site, carefully loosen and remove matter using a cotton-tip applicator moistened with 0.9% saline.
    • Apply sterile 4x4 coverlet dressing or 4x5 transparent dressing.
     
    • Secure the tube with new tape to the skin below the dressing, taping approximately 2 1/2 " from the exit site. (Remove old tape) Assist patient to apply pouch belt.
    1. Anchoring the PNT with tape will reduce trauma and thus, decrease risk for exit site infection, and decrease risk of dislodging or kinking tubing. Addition of belt further decreases the risk of trauma or dislodging PNT. When showering, tape and pouch belt should remain intact.
  • Remove gloves and wash hands.
  •  
  • Date and initial dressing.
  •  
  • Document assessment of site, type of dressing applied, devices used to secure the PNT, external catheter length, and patient’s tolerance of procedure.
  •  
  • II. Drainage Bag Change

    1. Equipment:
    Figure: 3-way Stopcock
  • Clean gloves
    Alcohol swabs
    Drainage Bag
    Tape measure
    Sterile scissors
    (For patients with irrigation orders)
    3 way stopcock
    Needleless cap
    Disposable underpad
  •  

    B. STEPS

    KEY POINTS

    1. Assemble supplies and open new collection bag & connecting tubing
    1. Assure that all equipment is available and the tubing is cut to the desired length prior to disconnect the old equipment.
    • Disconnect new connecting tubing from bag and cut tubing to desired length based on individual patient preference
    1. Excessive connecting tubing length may be a hazard for backflow of urine into the kidney
    1. Reconnect tubing to collection bag
     
    1. For patients requiring irrigation of PNT, consider adding at this time a 3-way stopcock and needleless cap to the proximal end of connecting tubing.
    1. Adding a 3 way stopcock with a needleless cap will assure a closed system for irrigation
    • Assist patient to a comfortable position
     
    • Place disposable underpad under nephrostomy bag.
     
    • Don non-sterile gloves.
     
    • Swab the end of the old drainage tubing attached to the nephrostomy tube using alcohol pad/swab.
     
  • Disconnect the drainage bag from the PNT .
  •  
  • Attach a clean bag with new connecting tubing.
    1. It is acceptable to reuse the drainage bag once the bag has been cleaned with a mild soap, rinsed well with water, and allowed to air dry. Dispose of bag every 2 days or more often if clots or sediment are present..
  • Secure tubing and bag unit with a Velcro belt around the waist.
  •  
  • Label the bag with the date and time of last bag and tubing change.
  • III. Irrigation of Percutaneous Nephrostomy Tube

  • A. Equipment
  • 10 cc syringe with blunt (syringe cannula)

    5 cc of preservative-free 0.9% saline for injection

    Disposable underpad

    Non-sterile gloves

    Alcohol swabs

    Male adapter cap of needleless system

  • B. STEPS

  • KEY POINTS

    1. If obstruction is suspected, check tubing first for kinks and/or dislodgment.
    1. There will be no need to irrigate if obstruction is mechanical.
    1. If 3 way stopcock is not in place go to the procedure section " Drainage bag change" and add 3-way stopcock and new connecting tubing and new collection bag.
     
    Assemble equipment and draw up 5 cc of preservative-free 0.9% saline for injection.
    1. Do not irrigate with more than 5 cc.
    1. Place underpad beneath patient.
     
  • Turn stopcock off to nephrostomy.
  •  
  • Don non-sterile gloves.
  •  
  • Clean port with alcohol swab.
  •  
  • Attach blunt needle syringe into the medial port of the 3-way stopcock.
  •  
  • Turn stopcock off to drainage bag.
  •  
  • Gently instill saline.
    1. Do not aspirate or force. If resistance is met, reposition patient and try again. If resistance continues, disconnect and notify physician.
  • Turn stopcock off to nephrostomy tube.
  •  
  • Remove syringe
  •  
  • Turn stopcock off to medial port of stopcock allowing gravity flow of urine into bag.
    1. If urinary flow does not resume within one (1) hour, troubleshoot PNT for kinks, dislodgment, or stopcock off to bag. If no cause can be found, RN must notify physician for further evaluation.
    1. Record flush volume as intake.
     

     

    IV. Obtaining Urine Specimen from Percutaneous Nephrostomy Tube

  • A. Equipment
  • Disposable sterile field

    Alcohol wipes

    Sterile gloves

    Drainage bag with connecting tubing

    Scissors

    Disposable underpad

    Non-sterile gloves

    Sterile specimen cup

    Label

  • B. STEPS

  • KEY POINTS

    1. Follow the procedure section, "Drainage bag change"
     
    • Facilitate gravity flow of urine collection into bag by ensuring bag is held below level of kidneys.
    1. Urine cannot be aspirated from the renal pelvis for collection, but must drain naturally.
    • When sufficient volume of urine has collected, open drainage bag valve, and drain urine into sterile collection cup without allowing tip of bag to touch inside of cup.
     
    • Close drainage bag valve.
     
    • Prepare and label specimen.
     
    • Document that a specimen was obtained in Clinical Record, or on an approved ICU flow sheet
     

    V. References:

    1. Guido, B. (1988). Preparing the patient for home care of the percutaneous nephrostomy tube. Journal of Enterostomal Therapy, 15: 187-190.
    2. Mayhew, P. (1988). Development and evaluation of a protocol for the percutaneous nephrostomy tubes. Journal of Enterostomal Therapy, 15: 183-186.
    3. Sage, S. (1991). Nephrostomy Dressing Change Procedure. Ostomy/Wound Management. Jan/Feb. (32) 4 p. 32-36.
    4. National Institutes of Health, Clinical Center (1993). Caring for your nephrostomy tube.
    5. Prentice, D. and Ramsay, F. (1993). Rethinking the use of proviodine. Perspectives, 17(1): 14-15.
    6. Lewis, SL, Prowant, BF, Douglas, C., and Cooper, CL (1996). Nursing practice related to peritoneal catheter exit site care and infections. ANNA Journal, 23(6): 609-617.

     

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