Percutaneous Nephrostomy Tube Insertion: Procedure, Risks, Nursing Care, and Ethical Considerations

Introduction

Under normal physiology, urine from the kidneys flows through the ureter into the bladder passes down the urethra, and disposes of the body. If the ureter is blocked with a stone(s) or blood clot, the kidney is affected and this could develop into a condition that necessitates operating on the tube to remove the blockage. In the meantime, it is essential to relieve the blockage by inserting a tube into the kidney via the skin. The accumulated urine then passes through the tube into an exogenous collecting bag. This medical procedure is known as percutaneous nephrostomy (The Royal College of Radiologists, 2014).

The procedure of percutaneous nephrostomy tube (PNT) insertion was first explained in 1955 (Skolarikos, Alivizatos, Papatsoris et al., 2006). The purpose of PNT is to drain a blocked urinary unit. Insertio]n of the nephrostomy triggers many complications that render placement of the catheter a demanding task. The high risk of complications associated with insertion of the catheter requires that the patient be cared for adequately. This paper reflects on the care provided to patients on whom the procedure is performed taking into account the risks involved and necessary measures to avoid complications.

The expert radiologist uses X-ray imaging to guide the placement of PNT into the end of the ureter proximal to the kidney. Therefore, this procedure is done in the operating theatre at the Department of Radiology. It is used to facilitate temporary drainage or to bypass an obstruction in the lumen of the urinary tract. Failure of urine to collect in the artificial duct, pain in the flank, or traces of blood in the fluid that collects in the bag. Then, a medical officer should order a circulating nurse or scrub nurse to perform irrigation of the catheter (“Topic 10”, n.d. ).

Aetiology

Ureteral obstruction is the main indication for nephrostomy.  Hsu et al. (2016) claim that ureteral obstruction is a heterogeneous clinical entity that poses a frequent challenge to clinicians concerning determining the best method to relieve distension in the kidney and the tube. The etiology of ureteral obstruction can be cancer of the bladder or prostate glands or extrinsic from a major condition of the proximal organs such as the colon or gynecological. The therapeutic aim of nephrostomy is to drain the upper urinary system to relieve pain related to the accumulation of urine and support renal function.

According to Hsu et al. (2016), causes of benign ureteral obstruction relate to intraluminal pathology and include ureteral stenosis and obstruction of the ureteropelvic junction besides ureteral stones. In addition, obstruction from outside the lumen of the tube can occur from benign tumors, for example, retroperitoneal fibrosis, and uterine leiomyomas (Bansal et al. 2009). Definitive treatment of the primary condition is the primary treatment for benign ureteral obstruction (Tan et al. 2016).

Risks to Patient

There is increasing evidence demonstrating that many patients who undergo an invasive procedure, such as PNT placement, are prone to complications (Vincent 2004; Leape L, 1991) and Nephrostomy is not an exception. The presence of myriad opportunities for errors due to the intricacy of invasive procedures increases the risks of undesirable outcomes (“Topic 10”, n.d.). Moreover, the online article argues that problems associated with surgical site infections (SSI) are attributed to nosocomial infections.

Generally, nephrostomy insertion is a safe procedure, although some complications can arise that are typical of a medical treatment. One of the major challenges with the insertion is the inability to insert the tube satisfactorily into the kidney, necessitating an alternative method to relieve the blockage, usually surgery. In other cases, urine can leak from the kidney and collect in the abdomen necessitating a procedure to drain the accumulated urine in the abdomen. Bleeding may also occur from the punctured kidney, which may become severe and necessitate surgery or a radiological procedure to stop the bleeding (The Royal College of Radiologists, 2014). On other occasions, the kidney or the region around it may get infected, although this can be treated using antibiotics.

Despite the above-mentioned complications, PNT is usually safe and has a great probability of bettering the status of the patient. In many cases, nephrostomy insertion may substitute an operation to remove the stone or blood clot, or any other cause of the blockage. However, it is hard to anticipate the incidence of an adverse effect as they are generally minor and infrequent (The Royal College of Radiologists, 2014). However, associations of experts have attempted to provide some guidelines on the incidence of adverse events associated with PNT placement.

Based on the Society of Cardiovascular and Interventional Radiologists (SCVIR) the common complications associated with insertion of the tube are vascular damage and septic shock at 4% and 9% rates, respectively (Ramchandani et al. 2001). The SCVIR further recommended a threshold level of 4% for both complications (American College of Radiologists, 2001), the excess of which warrants a performance review to detect the shortcomings in the practice. Initially, the UK or Europe lacked a similar recommendation, although the audit sub-committee of the Royal College of Radiologists (RCR) employed a threshold of 8% for all major complications for a pilot audit conducted at the beginning of the century (Lewis & Patel, 2004).

In more serious cases, complications involve renal loss and in some instances death, although it serves as an indicator of progress of malignant ureteral obstruction (Gill, Williams, Holland, Phillips, & Conti, 2014). Besides the above complications, Monsky et al. (2013), and Shekarriz et al. (1999) argue that percutaneous nephrostomy insertion may impair a patient’s life because of irritating urinary symptoms, pain, regular changes of the tube, and poor performance status. In this light, Hsu et al. (2016) argue that there is no clear proof that nephrostomy insertion improves a patient’s quality of life.

Nursing Care

Nurses provide care to patients undergoing interventional radiology in different phases: pre-procedural, procedural, post-procedural, continuing, and post-operative.

Pre-procedure management

Nursing care before a vascular or non-vascular procedure is important. At this stage, the nurse must appraise the well-being of the patient. It involves obtaining essential information by conducting medical and social history. The nurse assesses the knowledge of the patient on nephrostomy and conducts an anxiety assessment to determine the anxiety level about the PNT insertion to establish whether the patient is ready. The nurse can relax the patient by explaining and reassuring them that the procedure is necessary and will benefit them (Royal College of Nursing [RCN] & Royal College of Radiologists [RCR], 2014). According to RCN and RCR (2014), providing patient information leaflets that have been designed by the RCR or the British Society of Interventional Radiology (BSIR) will help in educating the patient about the procedure.

The service of a nurse will be required at different stages of the procedure. The nurse may also provide support to carers and family members of the patients. He or she should communicate with the source of the patient’s referral and other staff to guarantee completion of the work. The nurse also should prepare the necessary equipment to ensure a successful nephrostomy without any complications. The nurse should communicate openly with other members of the radiology team about the psychological and physiological status of the patient. In addition, the nurse can assess the environment for risks to patients and employees alike and intervene to prevent the suspected injury. The nurse should anticipate complications of different drugs and contrast media used.

Cahill (2017) argues that pre-procedure management also involves obtaining written consent from the patient before performing the operation or changing the tube. The patient is administered the necessary medication by mouth. The nurse must confirm with the team about prescriptions and contraindications of medications including anticoagulants. The nurse performs an X-ray procedure checklist (Cahill, 2017).

The nurse performs different roles on the patient after the insertion of the catheter. She or he must administer the prescribed analgesia to manage pain. The attending nurse must ensure that she connects a sterile bag to the PNT and maintains it lower than the position of the patient’s kidney every time.  She should check the patient’s vital signs, including temperature, breathing rate, and blood pressure consistently and inform the nurse leader or the radiologist in the event of an abnormal measurement or observation. He or she should also monitor the urine and record the output, color, and blood traces in the urine. While it is okay for the urine to have traces of blood shortly after the procedure, the amount should reduce after 48 hours (Cahill, 2017). The nurse should report to the nurse leader if the trace of blood persists in the urine.

The attending nurse should advise the patient to drink at least 2 liters of water every day unless water except in contraindications. She should also observe the dressing and tubing for any leakages. She should also examine the tube regularly to confirm that it is fastened to the side of the patient’s side and that the PNT has not bent at any point (Cahill, 2017).

Procedural care

The other form of nursing care given to patients occurs when the patient is undergoing the procedure. During nephrostomy, the RNC and RCR (2014) argue that nurses are an essential aspect of the radiology team where they play scrubbing and circulating role. Specific roles of nurses during this phase involve participating in the procedure planning and managing the procedural list. They design and execute the overall care of the patient who may either be conscious or sedated. Specifically, they check the vital signs of the patient, including pulse, electrocardiogram (ECG), oxygen saturation, and blood pressure. Moreover, they not only engage in but also ensure the completion of the WHO safety checklist. During this phase, the nurse should coordinate and record the planned patient care. In addition, the nurse is charged with developing a conducive environment for the patient and staff (Royal College of Nursing & Royal College of Radiologists, 2014). The nurse should also monitor the radiological team for proper wearing of personal protective equipment, as well as practice the principles of sepsis and champion infection control. The nurse should communicate effectively with other team members.

The nurse assigned to the scrub role prepares sterile instruments and equipment and keeps them ready for the nephrostomy insertion. According to the RNC & RCR (2014) before the commencement of the actual procedure, she or he should make sure that notes are available and that the WHP radiology checklist is completed. Based on the RCR (2013) the WHO radiology checklist includes checking the procedural requirement with the radiologist, and gathering all the equipment and machines to ensure that they are up-to-date. The checklist also includes confirming that the patient has provided informed consent to the procedure by signing it. The other item in the checklist is to confirm with the patient and the radiologist the right procedure, and body area of the intervention (RCR, 2010).

Post-operative care

When the intervention radiology team has completed the procedure, the scrub nurse checks and applies wound dressing, removes the drapes and verifies that the nephrostomy tube inserted in the body is secure and that the patient has achieved homeostasis. She checks to confirm that all the equipment used is present and disposes of surgical needles and blades as per the Health and Safety Executive Guidelines (Health and Safety Executive 2013). Finally, she should clear the working surface, and dispose of other contaminated materials. She cleans the area around the wound dressing and provides a clean and dry gown and sheet for the patient to wear and use. Then the nurse should give the post-procedure nurse all health records of the patient.

The circulating nurse works alongside the scrub nurse in facilitating quality care to the patient. The nurse checks and records the readings in the ECG and blood pressure, pulse, and other vital signs.

The care the attending nurse gives to the patient who has undergone nephrostomy involves changing the dressing. The tube is secured in place with a drain-fix dressing. The dressing should be changed every week. To change the dressing, the nurse must make the patient lay on the side with the nephrostomy tube facing upwards. Then follow the procedure for removing the dressing. Next, she or he should examine the skin around the site of the entry and report any infection, irritation, over-granulation, or inflammation to the nurse leader. Then she should ensure the tube is in the right position before replacing the dressing (Cahill, 2017).

The other aspect of care involves changing the bag. The nurse in charge of the patient should change the bag every week. The nurse can adjust the strap of the bag to fit the patient’s leg or waist. In addition, she or he should not connect the bag to a night bag because the connections are incompatible.

Patient Discharge

Upon discharging the patient, the nurse should provide individualized education to the patient or carers or family members. He or she should refer to community health nursing service in the patient’s place of residence to continue the necessary care. The inpatient nurse should give the patient drain fix dressings and extra bags to take home before discharge (Cahill, 2017). The nurse should ensure that she or he books the patient for a change of the tubing which must be communicated through the discharge letter to the community nursing service center.

Professional, legal, and ethical aspects

Specially trained radiologists must perform nephrostomy insertion. These experts have special skills and training in applying X-ray technology and scanners, besides interpreting the images produced. The images guide them in performing the procedure. They have the best training in catheter insertion (The Royal College of Radiologists, 2014).

Before the patient leaves the word for the radiology department, the nurse should conduct the following checklist:

1. Is the patient diabetic?
2. Is the patient on clopidogrel or warfarin?

• ID bands in place x2 and correct

1. The consent form labelled, signed, and understood
2. Intravenous cannula insitu
3. Last took 6 hours to pre-procedure

• Clear fluids only up to 2 hours pre-procedure
• Allergies

1. Any history of asthma or lung problems
2. Any history of angina or health conditions
3. Inpatient resuscitation profile, whether for results or not

• Blood taken
• Correct notes and label charts including drug, IV fluid, fluid balance, observation chart, and diabetic chart.
• Theatre gown

1. Dentures including crowns, caps, loose teeth, or removed teeth

It is an ethical practice to get the consent of prospective patients for nephrostomy tube insertion. Before the patient is prepared and moved to the theatre for the procedure, the radiologist must ensure that the patient has accepted the procedure to be performed on him or her to avert any undesirable litigation against the facility or the radiologist. Usually, after discussing with the patient’s physician and deciding that the nephrostomy is the best procedure to cure the condition the patient has presented with, the consent of the patient must be sought.

Seeking the patient’s consent to the invasive procedure typically involves presenting a consent form and asking him or her to sign to show that he or she agrees to the decision. The form comprises an introduction, procedure, risk, alternative, and the agreement section in that order. The introduction presents the issue and the decision of the hospital to perform the medical procedure on the patient. The introduction also invites the patient to read the information on the form to understand what the procedure entails. The “procedure” section describes the process of nephrostomy to the patient detailing what it entails. The form also describes the complications that may arise due to the procedure and offers alternatives in case she or he would prefer another treatment modality. Then the form ends with an agreement relinquishing all rights to the fluids and parts of the patient’s body removed during the procedure (University of Pennsylvania Health System, 2009). Because of the risk involved with the procedure and the reduction in quality of life due to the external drainage system, some patients may refuse to take the procedure (Hsu, Ali, et al.2016), and opt for other options such as surgery.

Evaluation

            Extrinsic tubes and bags as part of routine nephrostomy have various complications including blockage, leakage, and dislodgment of the tube, nephrostomy tube changes in as high as 83 percent of patients undertaking the procedures compared to an alternative, ureteral stents (Hsi et al. 2016).  Many complications are associated with the procedure, for example, an inadvertent bowel upset that occurs when the colon orientates into a retrieval position (Hsi et al. 2016). According to Hsi (2016), adverse events related to the pleural occur in 0.1 to 0.2 percent of the patients. They include hydrothorax, hemothorax, empyema, and pneumothorax. Puncturing of the intercostal vasculature or vessels may cause bleeding causing gross hematuria. This condition is often self-limited and may require blood transfusion and occurs in 2 to 4 percent nephrostomy placement. Moreover, bleeding of the arteries may occur later after the completion of the procedure and is often secondary to arterial and arteriovenous calyceal fistulas, and pseudoaneurysms which are in turn related to damage of the renal arterial branches (Hausegger, & Portugaller, 2006).  However, a study comparing patients with gynecological malignancies who underwent nephrostomy against ureteral stenting indicated a lower incidence of severe hematuria (8 percent) a week following the procedure compared to 14 percent of gross hematuria for patients who undertook stenting (Song, Fei, Song, 2012). However, such complications were treated using a conservative method without acute intervention (Song et al. 2012). However, Song and colleagues (2012) found that the difference in the complications between the two procedures was not statistically significant.

Conclusion

Nephrostomy provides temporary or permanent relief for ureteral obstruction. However, research shows that various complications can occur due to the complexity of the procedure often related to damage of the underlying vasculature. However, the incidences of such complications are low. Nevertheless, the limitations associated with carrying the side bag for collecting urine the irritations associated with the tube, and the risk of infection reduce the quality of life of patients.

References

Agency for Clinical Intervention. (n.d. ). Nursing Management of Patients with Nephrostomy

Tubes. Retrieved from

https://www.aci.health.nsw.gov.au/__data/assets/pdf…/ACI_Nephrostomy_Jan13.pdf

Cahill, A. (2017). Nursing care of patients with percutaneous nephrostomy tubes. Retrieved from

Gill, N., Williams, K., Holland, P., Phillips, C., & Conti, F. (2014). Prognosis following percutaneous nephrostomy insertion for malignant obstructive uropathy: One center’s experience. Internal Journal of Surgery, 12 (3).

Hausegger, K.A, & Portugaller, H.R. (2006). “Percutaneous nephrostomy and antegrade ureteral stenting: technique-indications-complications.” Eur Radiol., 16, 2016-2030 [PMID: 16547709 DOI: 10.1007/s00330-005-0136-7]

Hsu, L., Ali, H., Pucheril, D., Hansen, M., Littleton, R., & Peabody, J. (2016). Use of percutaneous nephrostomy and ureteral stenting in the management of ureteral obstruction. World Nephrol, 5 (2), 172-181.

Leape L et al. 1991, “The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II”, New England Journal of Medicine, 323, 377-384.

Lewis, S., & Patel, U. (2004). Major complications after percutaneous nephrostomy – lessons from a department audit. Clinical Radiology, 59, 171-179.

Royal College of Nursing & Royal College of Radiologists. (2014). Guidelines for nursing care in interventional radiology, second edition: The roles of registered nurse and nursing support. Retrieved from https://www.rcr.ac.uk/publication/guidelines-nursing-care-interventional-radiology-second-edition

Song Y, Fei X, & Song, Y. (2012). “Percutaneous nephrostomy versus indwelling ureteral stent in the management of gynecological malignancies”, Int J Gynecol Cancer, 22, 697-702. [PMID: 22315095 DOI: 10.1097/IGC.0b013e318243b475]

The Royal College of Radiologists. (2014). Percutaneous Nephrostomy. Retrieved from http://www.uhs.nhs.uk/OurServices/Radiology-scansandimaging/PatientInformation/PercutaneousNephrostomy.aspx

University of Pennsylvania Health System. (2009). Consent for percutaneous nephrostomy and possible stricture and dilation, stent placement, tissue sampling, or stone removal. Retrieved from

Vincent C et al. 2004, “Systems approaches to surgical quality and safety: from concept to measurement”, Annals of Surgery, 239, pp. 475–482.

This paper provides a comprehensive overview of percutaneous nephrostomy tube (PNT) insertion, a medical procedure used to relieve ureteral obstruction by draining urine from the kidney. It discusses the procedure’s history, indications, potential complications, and nursing care at various stages, including pre-procedural, procedural, and post-operative phases. The paper also explores the risks to patients, ethical considerations, and the importance of proper consent. The nursing role is emphasized in ensuring patient safety, managing complications, and providing education and support for recovery. Additionally, the paper reviews the legal, professional, and ethical aspects involved in nephrostomy care.