Nephrostomy (Guidelines)

Care of nephrostomy: medical and nursing care on ward. Immediate post-nephrostomy insertion

Following return from theatre, the patient may need additional antibiotics if pyrexial. Confusion hypotension and rigors would indicate more aggressive investigation with blood cultures, treatment with fluid replacement, antibiotics and possibly inotrope support.

• Pain:
  Pain is not usually a major problem postoperatively, but further analgesia may be necessary.
• Drainage:
  Several litres of urine can be produced by a kidney following relief of obstruction. Ensure that the drainage bag is secure and emptied frequently.
• Haematuria:
  Light blood staining is usual. Heavier and persistent blood loss (more blood than urine) is a cause for concern and serial haemoglobins may be needed to assess the quantity and seriousness of blood loss.
• Hypotension:
  Possible causes include sepsis and / or blood loss either into urine or around the kidney. Look for evidence of bleeding into the urine and around the kidney. Ultrasound or CT angiography may be required.

Documentation:
The patient should return to the ward with a nephrostomy passport having been instigated when the nephrostomy was inserted. If not, one should be started and should follow the patient through the lifetime of a nephrostomy being required in order to chart the care of the nephrostomy.

Problems in the days following nephrostomy insertion may include:
NB. For more information, go to: 'problems and troubleshooting' section.

A dry drainage bag, urine production ceases: 

• Catheter occluded by blood or debris: try flushing the catheter. Clean the hub with a Clinell wipe and inject 5mls sterile saline gently and allow to drain freely.
  Repeat once but do not inject more than 10mls in total. If the nephrostomy fails to drain following flushing, this may be due to: 
• Displacement or kinking of the catheter: check the dressings to ensure the catheter is secure. Flushing / Irrigation of saline as above may result in saline bypassing the catheter if it is partially displaced. Flushing / Irrigation is difficult if compression has caused kinking of the catheter. Failure to drain from the catheter suggests displacement. Antegrade pyelogram is required to confirm placement.
• Failure to drain may also be due to hypotension or other prerenal cause for decreased urine production.

Leakage of urine:

• This may be due to catheter blockage or displacement. Flushing the catheter may be helpful. If the catheter is draining but bypassing is persistent, changing to a stoma bag may help to keep the patient dry. Antegrade pyelography may be required to confirm other causes such as catheter kinking (see section on escalation plan). 
• Sometimes leakage is due to a split catheter hub where the catheter is attached to the bag. Changing to a stoma bag or a change of catheter is required (Atayi et al. 2024). 
• Ensure the sleeve covering the Copes loop thread is correctly located to prevent leakage
  from the thread side-hole (pigtail catheters).

 Care of nephrostomy: Community schedule

• A home visit should be scheduled on the first day post discharge with the community nurse team. 
• Treat the nephrostomy site as a wound.
  See Highland Wound Formulary for further information.
• Drainage bags: should be changed weekly, or if using ostomy bag and flange, these should be changed twice weekly.
• Dressings: should be changed at least once weekly however, should be changed as indicated by wound condition if soiled, wet, worn, peeling.
  
  • If there is evidence of infection, frequency should be increased.
  • If infection suspected, swab and treat accordingly.
• There are several fixation devices available however NHS Highland interventional radiologist advises to use Drain guards for pigtail Nephrostomies due to experience with their efficacy in use.
  • These should be changed every seven days, however, can be left intact for up to twelve days if the site is clean and dry.
  • It may need to be changed more frequently if the patients’ skin condition is moist or there is excess exudate.
  • See: Drain guard information
• Fortnightly deflation and re-inflation of the Foley balloon with the specified volume of water should be performed to prevent catheter falling out. See section on 'problems and troubleshooting' for further information.
• Skin care around site of entry.

Dressing and bag changes

Dressings should be changed using ANTT^® by an appropriately trained individual as indicated by the nephrostomy wound condition. For simple leakage, the carer could be taught how to do this however, a trained nurse should always monitor and change the dressings if more complex or any concerns regarding the wound.

Change the dressings at least daily if there is bleeding, offensive smell or discharge, or the dressings are soiled or wet. Continued discharge, leakage or bleeding is unusual and should prompt investigation for infection or other cause. Please also refer to Highland Wound Formulary for guidance on wound care. Dressings and stabilization devices are available on Formulary and PECOS ordering system.

Changing the dressing

Remove the old dressings using a non-touch technique by peeling off and cutting carefully avoiding damage to the catheter. Peel the adhesive off the catheter and clean with Clinell 2% chlorhexidine in 70% alcohol wipe to remove adhesive if necessary. A drain guard is the preferred securement for pigtail nephrostomies as they have been found to reduce the risk of these catheters falling out.

Two types of dressings can be used:

• Keyhole swabs:
  Cut swabs are placed around the catheter and secured with surgical dressing tape such as Primafix. The Primafix should secure the catheter to the skin so that traction on the catheter does not cause displacement. A stabilization device e.g. Clinifix, should be used to secure the catheter tube.
• Clear plastic film dressing:
  A clear film dressing can be used instead of swabs / Primafix if the entry site is dry which is the preferred dressing for use in the community and is easier for the patient to keep dry during showering. A stabilization device (e.g.Clinifix) for extra security should also be used. The emphasis is on securing the catheter to prevent traction causing displacement.

Changing stoma or adhesive flange bags

Patients with ostomy or adhesive flange bags should have the bag and flange changed twice weekly. The adhesiveness and durability of pouches / flanges may vary. Wearing appliance too long or changing too frequently may damage skin integrity. The flange aperture may need to be enlarged and the anti-reflux inner bag split by inserting a sterile gloved finger into the bag to accommodate a Foley catheter hub.

Nephrostomy site infection / discharge

Evidence of infection may manifest as purulent discharge, palpable swelling below the skin, local skin discoloration, friable granulation tissue or systemic illness (Lister et al. 2020). Swab the site, change the dressings daily and bags twice weekly and consider antibiotic therapy. It may be helpful to change the catheter during a course of antibiotics and medical advice should be sought to ensure treated appropriately.

Drainage bag and securing of nephrostomy:

Patients with pigtail catheters will have a drainage bag attached to the catheter by a length of tubing using a Luer lock connection. Foley catheters will usually have a standard catheter leg bag attached, and as with urethral and Suprapubic catheters, different sizes of bags are available on formulary. The larger bags may be helpful to avoid the need for a night bag however should be emptied frequently to reduce the risk of dislodging the nephrostomy catheter due to the bag being too full and heavy.

The catheter tubing should be secured with a stabilisation device. Velcro straps supplied with the catheter drainage bags can be used for securing to the patient’s leg. Some patients prefer to tuck the nephrostomy bag into a pocket or underwear; however, it should be emphasized it must be secure. Manfred Sauer NephSys waist belt systems are preferred securement system for use in both single and bilateral nephrostomy placement.

• Manfred Sauer Nephrostomy drainage system (NephSys) is listed in the Community Formulary and available via prescription. Information about the product and how to fit it is available via the nephrostomy passport which has the product order codes available. There is also the option of setting the patient up for a free home delivery service for Manfred Sauer products which are the only prescribable products currently available in community. More information and up to date contact details are available on the Manfred Sauer website.
• Patients who are confused or less able to look after the catheter may be better suited to having the catheter inserted into a nephrostomy stoma bag to ensure it is secure. The flange aperture can be enlarged with scissors to accommodate a Foley catheter hub.
• It is recommended that Luer and Foley type drainage bags should be changed weekly, and stoma bags should be changed twice weekly.

Dressing or nephrostomy bag and flange change procedure

Equipment: 

• Dressings or bag and flange as appropriate
• Non-Sterile gloves x 1
• Sterile gloves x 2
• Dressing pack
• Chloraprep skin applicator x 1 (2% chlorhexidine gluconate and 70% alcohol )
• Apron

Fortnightly balloon checks

The Foley balloon needs to be checked fortnightly to ensure the correct volume of fluid remains in the balloon and is replaced if reduced through diffusion to reduce the risk of the nephrostomy tube migrating or falling out.

Equipment:

• Sterile water up to 10 ml (patient specific)
• 1 x Clinell (2% chlorhexidine in 70% isopropyl alcohol wipe)
• 2 x 10mL sterile syringes
• Sterile gloves
• Dressing pack
• Apron

• A nephrostomy passport should be initiated with up-to-date information regarding the insertion date, amount of water in the balloon of Foley catheter and if possible plan for next exchange. The inserting radiologist’s report in the case notes and on SCI Store will specify the volume of water in the Foley catheter balloon in each kidney. The ward nurses MUST pass this information on to the patient and community care team. This allows checking of appropriate volume in balloon throughout Foley duration and for replacement upon routine Foley change.
• The patient or their carer must be trained how to look after the catheter before discharge from the ward. This should include hand-washing and non-touch technique for the weekly change of bag if appropriate. This should be documented in the nephrostomy passport.
• Enough supplies for one week must be sent home with the patient. For Foley nephrostomy, this must include a size 16CH and size 12CH standard catheters so that they are available for immediate use in the event of the Foley nephrostomy falling out. Community teams only have patient specific supplies available after ordering when discharge information is given to them. There may be a delay in receiving supplies if community team not advised of discharge in timely manner.
• The discharge IDL must include nephrostomy insertion information and the need for ongoing care to inform the GP and community nursing team.
• The Community nurse team must be contacted and informed of the patient’s name, date of discharge and must include instructions for fortnightly checks for re-inflation of the Foley balloon fluid and the specified volume. They must also be notified of this Nephrostomy Care Document.
• The IDL and discharge letter should identify the need for ongoing care with respect to the nephrostomy. This should include recommendations for planned nephrostomy removal/exchange or follow up. Routine pigtail nephrostomy exchanges will be co-ordinated through interventional radiology and routine Foley exchanges may be undertaken by interventional radiology or community nursing team supported by interventional radiology. Routine Foley changes should be co-ordinated when interventional radiology service is available if their service input is required.
• The nephrostomy history should follow the patient from insertion through hospital stay and to the patient’s home. This will ensure smooth transition of care. All nephrostomy details should be communicated on the patient’s discharge IDL.
  • The NHS Highland nephrostomy patient information leaflet should be completed ane given to the patient, with points of contact for help identified and plan for when next exchange should take place.
  • The Manfred Sauer nephrostomy passport
  • And the care and management of your nephrostomy system booklets are recommended for use.

Discharge Checklist:

For all patients discharged from Raigmore the following information MUST be included on the IDL nursing summary to ensure smooth transition of care: 

• Date of Insertion:
• Type of Nephrostomy:
  
  • Temporary Pigtail Nephrostomy
  • Long Term Foley Catheter
• The future plan for the nephrostomy:
  
  • Is it to be changed, if so when and where
  • Is it to be removed, if so when and where
• For Foley catheter please ensure size of catheter and volume of water in balloon is documented and a replacement catheter and a size 12 catheter is provided for community team
• Document skin integrity to site and dressing requirement
• Specific schedule of care documented
  
  • A home visit to be arranged for first day post discharge
  • Drainage bags changed weekly or if using nephrostomy stoma bag and flanges twice weekly
  • Skin care around nephrostomy site
  • Dressings to be changed as indicated by wound, at least weekly but more frequently if soiled, wet, worn or evidence of infection
  • Drain guard dressings used with pigtail nephrostomy can remain in situ for up to 7 to 12 days, depending on skin integrity/exudate this may need to be changed more frequently
  • For long term Foley nephrostomy fortnightly deflation and re-inflation of the balloon with the specified volume of water is required

Please ensure supplies of dressings, drainage bags, balloon check equipment & catheters if applicable, are sent home with patient.

ALL PATIENTS TO GO HOME WITH PATIENT INFORMATION LEAFLET

Discharge supplies: 

Supply enough for one week for each nephrostomy:
(Choice will depend on dressings and product in use when discharged)

• Tegaderm or Nephrostomy bag and flange.
• 1 X Drain Guard (Revolution Dressing on community formulary) for pigtail catheter.
• 1 X Stabilization Device for catheter tubing (e.g. Clinifix / NephSys belt system).
• 1 x Clinell (2% chlorhexidine in 70% isopropyl alcohol wipe).
• Size 16CH and Size 12CH standard Foley Catheter (if discharged with Foley catheter).
• Spare individualised Drainage Bag i.e. short tube bag / long tube bag or / Manfred Sauer flexi tube bag/ 500mL bags / 750mL bags, etc.
• Individualised securing strap i.e. leg straps / waist belt Manfred Sauer retention device used with Manfred Sauer product specific drainage bags for pigtail Nephrostomies. 

• For inpatient / ward-based training support please contact your Clinical Educator.
• Practice development may offer annual update training sessions.
• Manfred Sauer have dedicated nurse team who offer training and support for nurses, families and careers but this is not available in our area of NHS Highland. They may offer online / email / phone advice support for use of their products.

A nephrostomy is a tube inserted percutaneously. The catheter passes through skin, subcutaneous fat, muscle and the renal cortex and the tip lies in the collecting system usually within the renal pelvis. Its function is to allow the drainage of urine if there is an obstruction to the normal urinary pathway. Foley nephrostomy changes should take place every 12 weeks or as clinically indicated.

After balloon deflation the catheter is withdrawn under Surgical-ANTT aseptic conditions and a fresh 16FG catheter inserted after lubricating with Lignocaine gel. Care is taken to advance to the same depth as the old catheter, using a gentle screwing action is usually successful, before inflating the balloon with the specified volume of water.

When planning nephrostomy change:

• Please contact the interventional radiographers (Raigmore Hospital extension:5649) before planning a change and confirm there is a radiologist on duty the same day or the day after the change.
• Confirm the specified volume of water to be replaced in the Foley retaining balloon.

Exclusion criteria for changing the nephrostomy tube:

•  Pyrexia: contact GP for advice.
•  First change after new insertion: this should be carried out with interventional radiologist.
•  Non-availability of size 16CH Foley catheter: plan change once catheter is available.
•  Non-availability of hospital backup: always confirm interventional radiologist is on duty when planning   nephrostomy changes so you have hospital back up if required.

Equipment

• Sterile catheter pack / consider dressing pack with sterile disposable measure enclosed.
• Apron.
• Non-sterile gloves.
• Sterile gloves x 2.
• Chloraprep skin applicator x 1 (2% chlorhexidine in 70% isopropyl alcohol).
• 5 to 10mL syringe for removal of water from balloon.
• 5 to 10mL syringe prepared with pre-checked volume of sterile water.
• 6mL sterile anaesthetic lubricating jelly (e.g. Instillagel) approximately 4mL of tube only for lubrication.
• Size 16 standard length Foley catheter plus size 12 in case of difficulty inserting size 16.
• Closed system sterile drainage bag.
• Occlusive dressing or nephrostomy bag and flange if tract insertion site is leaking.

Procedure

Problems with elective changes:

• Bleeding: minor bleeding is expected especially if infected.
• Unable to remove catheter: arrange hospital exchange of catheter.
• Unable to advance new catheter to correct depth: try size 12 catheter. If unsuccessful arrange hospital reinsertion. If successful, arrange with hospital exchange of catheter and upsizing to size 16.
• No urine drains immediately: it may take a few hours after the change of catheter for the renal pelvis to fill with urine. If no drainage after 2 hours arrange admission.
• Evidence of systemic sepsis e.g. pyrexia, rigors: arrange urgent admission for hospital review.
  • For reinsertion or change of size of catheter contact interventional radiologist or urologist on call in Raigmore Hospital.
  • The consultant urologists are on call Mon to Fri, 8 to 5pm and Sat and Sun 8 to 12pm.
  • If you need to call the hospital out with these times, go through the surgical registrar on call. 
  • If admission required, see section on escalation plan and contact numbers.

Foley catheter fallen out:

• If a nurse trained in Foley nephrostomy tube exchange is available, an attempt should be made to replace the catheter. After cleaning the skin with 70% isopropyl alcohol 2% chlorhexidine clinell skin wipe follow procedure for Foley nephrostomy catheter insertion. If successful in re-inserting the catheter the balloon should be inflated cautiously with the patient specific specified volume of water.
• If a 16FG catheter will not advance, try a size 12. If unsuccessful, hospital attendance or admission is required for fluoroscopically guided re-insertion or repuncture (see section on escalation plan and contact numbers). If successful, arrange for upsizing through interventional radiologist, radiology or urologist on call.
• If there is associated pain, deflate the balloon and arrange for admission (see section on escalation plan and contact numbers).

Unable to re-inflate Foley catheter balloon:

• After change of catheter or during the fortnightly balloon deflation and re-inflation procedure it may be difficult or painful to re-inflate the balloon to the correct volume.
• The most likely explanation is that the catheter has moved position, and the balloon now lies in the ureter, in a small calyx or in the track through the tissues. If the catheter is pushed too far into the track the tip can pass into the ureter or into the upper pole calyx or be kinked. The inflated balloon shuts off the drain holes in the tip from the urine filled renal pelvis. Deflation of the balloon and / or withdrawal of the catheter a fraction may produce urine and the balloon can then be re-inflated.
• If it remains difficult or painful to try to re-inflate the balloon, stop. Secure the un-inflated catheter to the skin with dressings.
• Contact the interventional radiologist on call via hospital switchboard to arrange an early contrast study (see section on escalation and contact numbers).
• As long as the patient is aseptic and the catheter is still draining this contrast study does not need to be done on an urgent basis. However, ensure the catheter is secure. If not draining, urgent admission will be required.

Catheter fails to drain urine:

There are three common reasons for a dry catheter bag: 

• Catheter extrusion
  Traction on the bag, loss of water from the balloon or an inadequate dressing will allow the Foley catheter to extrude and lose position in the kidney. This can occur gradually over weeks or acutely if the bag is pulled inadvertently. It may be possible to reinsert the catheter into the track but usually a trip to Radiology is necessary.
• Catheter pushed in too far
  See section section on unable to re-inflate Foley catheter balloon above for instruction.
• Occlusion due to sediment, debris, concretion
  Aggregation of chalky material may be visible in the catheter lumen and there may be chalky debris in the urine. Flushing / irrigating with no more than 10 mls of sterile saline may help to clear the blockage.

Trouble shooting

When planning elective Foley nephrostomy change, confirm in the morning of the planned change.
That the Interventional radiologist is available so that in the event of difficulties requiring their input, they can fit it into their workload that day.

If interventional radiology is not available when you are planning the elective change, it may be necessary to arrange at a later date when this service is available.

SUPPORT CONTACT NUMBERS:

Raigmore Hospital based: Contact Interventional Radiology via hospital switchboard 01463 704000.

• If no interventional radiologist available contact the interventional radiographers in Angio theatre on Raigmore extension 5649 who will be able to schedule reinsertion, advice on when interventional radiologist or Specialist trained radiographer is available or advice on who to contact.
• If urgent admission is required in the absence of Interventional radiologist, contact the on-call Urology Consultant through Raigmore Hospital switchboard 01463 704000 during working hours. Out with these timings, discuss with on-call surgical receiving team via hospital switchboard if urologist unavailable.

Urology Specialist Nurses:

Can be contacted Ffr additional support and advice:

• By telephone via hospital switchboard or direct dial 01463 705724 / 705428 /888271.
• Alternatively Email: nhsh.urologynurses@nhs.scot (please note this is a shared email monitored regularly around clinical commitments and may take several working days before reviewed). 

No matters requiring urgent attention should be emailed to this address. For anything urgent please consult directly with clinical staff on duty.

For NHS Highland inpatient / ward-based training and support please contact your ward Clinical Educator.

• NHS Highland: Nephrostomy Patient information leaflet
• My Nephrostomy Passport 
• Care and management of your nephrostomy booklets. These are available as a free resource and can be downloaded and printed from from Manfred Sauer website.
• Nexus Nephrostomy UK: What is a Nephrostomy - Nephrostomy UK

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