Urology - Guidelines for Management of Nephrostomy Tubes

Background

The percutaneous nephrostomy tube has been inserted to allow urine to drain from an obstructed kidney. The tubes are designed to be able to stay in place for a period of 3 to 6 months. If the obstruction has not resolved in that time, you will be seen at the hospital for a change of tube.

The type of nephrostomy tube used has a locking system to hold it in place in the pelvis of the kidney. At the bottom end of the tube there is an attachment that has “open” and “lock on it. This refers to the locking mechanism holding the tube in place and is not a valve to control the flow of urine.

The locking system means that the tube should not move out of the kidney. However, the tube should be checked for signs of movement each time the bag is changed.

If you notice that there is no drainage of urine from the tube and that there has not been an increase in the amount of urine passed urethrally then the nephrostomy tube may need flushing.

If the nephrostomy is prone to blocking on a regular basis then it may be appropriate to flush the tube prophylactically twice a week.

Advice following the insertion of nephrostomy tube

After the insertion of your nephrostomy tube a bag will be placed over the top of the tube to collect urine. We advise that this is connected to a catheter bag which can be attached to your leg. This will prevent the nephrostomy tube sitting in urine and help prevent infection.

It is important you wash and dry your hands before and after emptying the urine bag, this will help reduce infection.

The drainage bag will need emptying 4 to 5 times a day or when the bag is ½- 1/3 full. A larger drainage bag (night bag) may be attached overnight and this should be changed daily.

The nephrostomy bag should always be kept below hip height to aid drainage.

You may bath and shower with the nephrostomy tube in place.

Try to drink plenty of fluids, try to aim for 6 to 8 glasses per day.

Problems at home

If you get any of the following problems once you are at home please seek advice from your GP or community Nurses:

• If your nephrostomy stops draining
• If your nephrostomy falls out
• If your urine becomes offensive smelling or discoloured
• If you experience worsening pain from your nephrostomy site

Changing your nephrostomy bag

If the changing of the bag is carried out by a nurse it is important that Aseptic Non Touch Technique (ANTT) is used.

1. Equipment needed: dressing pack; new bag cut to accomodate the tap off the nephrostomy tube and warm water.
2. Gently peel used bag off the skin, taking care not to pull the tube.
3. Protect the end of the tube/tap with sterile guaze or sterile towel.
4. Clean skin gently with warm water and gauze.
5. Dry skin well as new bag will not stick to wet skin.
6. Peel the backing paper off the new bag to expose adhesive.
7. Carefully insert the tube into the urostomy bag and position the tap so it is easily accessible to the patient. (Optimum position is with the end of the bag coming around the side of the patient towards their front).
8. Press down gently to make sure there are no creases in the adhesive.
9. Check the tap is in the 'closed' position or, if required, the bag can be attached to a leg bag or a night drainage system.
10. Wrap all rubbish up well and throw in the dustbin.

The bag needs emptying when 1/3 or 1/2 full – four to five times per day.
 
The District Nurse or the patient can change the bag twice weekly.

The GP/District Nurse will provide a prescription for the equipment which is dispensed by a local chemist or delivery company if in the hospital please contact the Urology ward.

Order more bags when you are down to half a box.

Seek medical advice immediately if:

• The tube stops draining
• The tube becomes dislodged
• The patients urine smells offensive or is blood stained
   

Fig 1. Nephrostomy tube

Fig 2. Close up of 'open' and 'lock'

Flushing the Tube – to be carried out by a nurse

Equipment:

• Sterile dressing pack (including sterile gloves)
• 10ml syringe
• 5-10mls sterile normal saline
• Sanicloth CHG 2% IPA 70% impregnated wipe
• Clean urostomy (nephrostomy) bag
   

Action: Check the tube and bag to make sure that there are no kinks that may be causing mechanical obstruction to the drainage of urine

Rationale: If there is a physical obstruction that can be easily resolved, the flush will not be necessary; or 

Action: Check the end of the tube to see if it has got a luer lock cap on it

Rationale: Occasionally tubes have been occluded by the use of a luer lock cap

Action: Open dressings pack, prepare equipment and draw the saline into the syringe, using ANTT

Action: Remove the urostomy bag for access to the distal end of the tube

Action: Wash the hands and place sterile gloves on, wipe around the port with a Sanicloth CHG2%/IPA 70% impregnanted wipe for 15 seconds and allow to dry

Action: Gently applying even pressure, instill the saline into the nephrostomy tube

Rationale: Although gentle asiration of the tube may help to disloge the blockage, excessive force may cause bleeding

Action: Allow the saline/urine to flow out of the tube

Action: Apply a clean urostomy bag and wash hands 

If there is still no drainage of urine from the nephrostomy after 24 hours then please contact the urology on-call team on 0161 624 0420.