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The Effect of Nursing Guidelines on Minimizing Incidence of Complications for Patients with Percutaneous Nephrostomy Tube

Sahra Zaki Azer*, Sahar Ali Abd-El Mohsen, Samia Youssef Sayed

Medical - Surgical Nursing Department, Faculty of Nursing, Assiut University, Egypt

Abstract: The aim of the study was to identify the effect of nursing guidelines on minimizing the incidence of complications for patients undergoing percutaneous nephrostomy. Research design: A quasi-experimental study design has been used. Setting: The study was carried out, in urologic surgery department and outpatient clinic of urology and . Subjects and methods: Sample: sixty adult patients undergoing PCN were included, having the following criteria; the age between 18 – 65 years, both male and female, and were divided randomly in to study and control groups. The study group (thirty patients) received the nursing guidelines, while the control group (thirty patients) received routine hospital care. Tools: three tools were utilized: Structure interviewing questionnaire, nursing guidelines, and patient evaluation sheet. Results: more than two-thirds of patients in the study group (66.7 %) were male, 86.7% were married, 33.3 % were from (fifty to sixty-five). All patients in both control and study groups don’t complain about urinary tract obstruction. Conclusion: application of the nursing guidelines had its positive impact on the outcomes of patients who underwent percutaneous nephrostomy tube placement. Recommendation: A printed copy of the nursing guidelines is to be distributed among patients with percutaneous nephrostomy tube. A workshop for nurses working in urology operating room is to be organized for enriching nurses with recent guidelines related to percutaneous nephrostomy tube.

Keywords: guidelines, complications, percutaneous nephrostomy

Citation: Sahra Zaki Azer, Sahar Ali Abd-El Mohsen, Samia Youssef Sayed, The Effect of Nursing Guidelines on Minimizing Incidence of Complications for Patients with Percutaneous Nephrostomy Tube. American Journal of Nursing Research, 6 (5). 327-334. January 2018. doi:10.12691/ajnr-6-5-15

1. Introduction

A nephrostomy is a surgical opening created between the kidney and the skin which allows for direct drainage of urine from the higher part of the urinary system when the normal flow is impeded [1].

Percutaneous nephrostomy is an image-guided placement of a catheter into the renal accumulating system. Nephrostomy tubes are inserted within the operating room or radiology department to provide permanent or transient urinary drainage following a procedure or to alleviate ureteric obstruction. Irrigation of a nephrostomy tube is indicated if there is absence of urine in the drainage system, blood in the urine or if flank pain occurs [2].

There are two forms of nephrostomy drainage tubes; Pigtail: The retaining mechanism is a coil that's retained within the renal pelvis (placed in Radiology). There are two forms of pigtail catheters available on the market – Cook Mac-loc and the Boston medical. The only difference is the method of unlocking the catheter for removal. The second type is the Wide Bore e.g. Malecot or Foley catheter (placed in the operating room) [3].

Indications for insertions of nephrostomy tube; to remove renal calculi, relieve an obstructed system and to maintain or improve renal function following ureteric obstruction, and to obtain access to the renal pelvis for radiological procedures e.g. insertion of an antegrade stent [4].

Patient preparation before the procedure; the patient must be assessed for current physical status and presence of comorbidities which can have an effect on the incidence of complications following the procedure. Prophylactic antibiotics had been extensively used in preparing patients for percutaneous nephrostomy [5]. Nothing per mouth six hours prior to the procedure, advice the patient stop anticoagulants and other medication, administer analgesia as prescribed, non-insulin dependent diabetic patients need to have blood glucose levels (BSL) checked according facility protocol from fasting time, insulin-dependent diabetic patients need to have insulin dextrose infusion and hourly BSL checked, and all investigations ought to be received pre-procedure and outcomes to be reviewed by doctor [8].

Post-procedure nursing care; administer analgesia as prescribed, an affected person need to be on bed rest for four hours, linked to a sterile closed drainage machine and drainage bag should be maintained always below kidney level. Post-procedure vital signs must be monitored half hourly for two hours, hourly for the next two hours then four hourly for twenty-four hours. Measure urine output hourly for four hours, then four hourly for twenty-four hours then progress to eight hourly until stable and if total urine output is less than thirty mL/hr. notify physician. Monitor urine for color and presence of sediment [6].

The nurse must be observing the presence of blood in the urine once after nephrostomy insertion is normal but it should decrease within forty-eight hours. Notify physician if urine flow consistently stays heavily bloodstained. Strict intake and output chart should be maintained. The nurse ought to assess urea, electrolytes & creatinine (UEC’s) until results are stabilized. Nephrostomy tube dressing site must be evaluated every hour for four hours, four hourly for twenty-four hours, then once per shift for bleeding and signs of infection (pain, leakage, redness, swelling, bleeding), report any abnormalities to a health practitioner. Inspect nephrostomy tube to make certain it's far secure and no kinking has occurred, encourage the patient to drink as a minimum two liters of fluid daily unless contraindicated, and observe for leakage at connection sites. All urine specimens must be collected from nephrostomy tube by gravity and do not use aspiration [7].

Irrigation of the nephrostomy tube is required if there is the absence of urine if urine remains heavily bloodstained if affected person has a chronic flank ache or suspected blockage. Do not flush more than ten mL of sterile water. Observe for continuous urine flow and signs of infection. Notify a doctor immediately if the tube cannot be irrigated or if it is dislodged or fallen out [8].

Patient discharge instructions; provide individualized education to the patient; educate patient/carer to perform tube care under the supervision of a registered nurse before discharge. Provide affected person with extra three drainage bags and three drain fix dressings prior to discharge. Normal leg bags are used. The pigtail tubes have an adapter extension that fit normal leg bags. If the tube is to be permanent make a booking in the radiology department for routine change every six to eight weeks. Refer patient to appropriate services for access to equipment before discharge [9].

Complications may be minor or major; minor complications are defined as complications occurring in relation to the procedure that is of no consequence and can be managed conservatively, [10]. These patients may still require overnight hospitalization for observation [11].

Post-procedure bleeding varies in severity and might range from simple temporary hematuria to intense hemorrhage requiring transfusion or intervention. Minor bleeding complications encompass temporary hematuria. Catheter-associated complications which include kinking, obstruction or dislodgement can also often be encountered and can require in additional intervention in fourteen percent of cases [12]. Small leaks and tears stopped spontaneously with adequate urinary drainage. Other minor complications encompass pain and fever, pneumonia and atelectasis [13].

Major complications are identified as complications that require treatment, prolonged hospitalization of more than forty-eight hours. Hemorrhage requiring transfusion, this may appear in prolonged hematuria, hemodynamic instability in line with renal hematomas. Hemorrhage may be associated with vascular injury all through the procedure. Injured vessels can be ligated to arrest the bleeding, or as a closing resort, partial or general nephrostomy may additionally have to be finished [14].

Significant infection and sepsis following percutaneous nephrostomy are an essential and properly- an identified problem, requiring an escalation in medical institution care and longer use of antibiotics, with or without shock, persistent fever with chills and symptoms of hemodynamic instability are worrisome signs and need to be diagnosed and handled as a consequence [15]. Septic shock is a serious complication and has been reported to be a contributing issue towards patients' mortality in some published case series [6]. The use of prophylactic antibiotics is therefore recommended in high risk patients [5].

Pleural complications which encompass pneumo-, hydro-, or hemothorax and empyema are uncommon however were diagnosed to arise from percutaneous nephrostomy, with a stated rate of 0.1-0.3% [7,10]. To prevent leakage of fluid into the pleural hollow space along the pleural tract throughout the procedure; pleural drainage with chest tube insertion may be essential [16].

Bowel transgression is some other uncommon however doubtlessly extreme complication of percutaneous nephrostomy and is said to occur in 0.2-0.3% of cases [17,23]. Many risk elements have been diagnosed that may contribute to increased risks. Patients with a markedly dilated collecting system, colonic obstruction, and patients with scarce perirenal fat are more likely to have a more posteriorly located colon. This increases the chance of colonic transgression while coming near the kidney [18].

2. Aim of the Study

The aim of this study is to identify the effect of nursing guidelines on minimizing the incidence of complications for patients undergoing percutaneous nephrostomy.

3. Research Hypothesis

Patients who will receive the nursing guidelines will have a fewer complications following PCN insertion than these patients who will receive routine hospital care.

4. Patients and Method

4.1. Research Design

The quasi-experimental study design will be utilized.

4.2. Setting

The study was conducted, in urologic surgery department and outpatient clinic of urology and nephrology at .

4.3. Sample

Sixty adult patients undergoing percutaneous nephrostomy (PCN) were included, having the following criteria; the age between eighteen to sixty-five years, randomly classified into study and control group. The study group (thirty patients) received the nursing guidelines, while the control group (thirty patients) received the routine hospital care.

4.4. Tools

Three tools were used for data collection in this study:

Tool 1: Structure interviewing questionnaire:

It was designed by the researchers based on literature review and it includes three parts:

Part I: Sociodemographic data about the patients (age, sex, marital status, family size, educational level …ect).

Part II: Patient-related risk factors encompass; advanced age, diabetes, bladder disorder, indwelling urinary catheter, bacteriuria and calculi, obesity, scoliosis, hepatomegaly, extremely mobile kidneys, chronic lung sicknesses and poor respiratory reserve which include emphysema. Length of the procedure and severity of urinary tract obstruction.

Tool 2: Nursing guidelines:

It has been designed in simple Arabic language by the researchers according to clinical experiences, the related literature review and opinion of the medical and nursing expertise to identify the effect of nursing guidelines on minimizing the incidence of complications for patients undergoing percutaneous nephrostomy. It encompasses: knowledge about definition & indications of PCN, patient preparation before the procedure, post-procedure nursing care and irrigation of the nephrostomy tube, patient discharge instructions and post-procedure complications

Tool (III): Patient evaluation sheet: to assess complications and patients 'outcomes during hospitalization and after two weeks, then four weeks after discharge.

4.5. Data Collection: Procedure

The study was carried out in three phases:

1. The preparatory phase:

Preparation of tools for data collection and teaching protocol was done during this phase. It has been reviewed by a panel of medical-surgical nursing and medical professionals. To facilitate the implementation of the nursing guidelines, researcher prepared the teaching places, teaching aids and media (pictures, handouts, and video). This has been followed by arranging for the nursing guidelines schedule based on the contents of guidelines, number of patients and time availability

Methods:

• Official approval and administration permission have been obtained from the head of urologic surgery department to gather the necessary data, the purpose of the study and the nursing guidelines were explained to them to obtain their cooperation.

• Oral permission for voluntary participation has been obtained from patients and the nature and purpose of the study were explained.

• The tools were tested by five expertise from the field of staff urologic surgery and nursing for content validity and reliability.

• The researcher was interviewed the patients to collect the necessary data for this study and provide the nursing guidelines for each patient in the study group.

Ethical consideration:

Research proposal becomes accepted by Ethical Committee within the College of Nursing. There is no hazard for study subject during application of the research. The study was complying with ethical principles in clinical research. Formal consent acquired from patients or guidance who are willing to participate in the study, after explaining the aim of the study. Study subject has the right to refuse to participate and or withdraw from the study with no rational any time and privacy have been taken into consideration for the collection of data.

A pilot study: A pilot study on (10%) six patients was carried out during July 2017 so as to check the clarity and applicability of the tools. According to this pilot study, the required modifications have been made. Those patients who were involved in the pilot study weren't included in the study.

• Data collection covered a period of six months starting from August 2017 till the end of January 2018.

2. Implementation phase:

After admission: Each patient was interviewed individually, formal consent was obtained, and each patient was asked to answer interview questionnaire sheet. Initial assessment of personal characteristics, general medical data, and urologic assessment was done and recorded.

Nursing guidelines sessions:

The nursing guidelines had been implemented for the study group in term of sessions during two days preoperatively. The teaching nursing guidelines sessions aimed to elaborate to identify the effect of nursing guidelines on minimizing the incidence of complications for patients undergoing percutaneous nephrostomy. The nursing guidelines were developed by the researchers based on the review of relevant literature and available resources. There were a total of three sessions were conducted for each patient, each session ranged from (twenty to thirty) minutes except for the session of discharge instructions, which took fifty minutes. Each session usually started by a summary of what had been taught during the previous session and the objectives of the new session. After every session, there has been five mins for discussion and gave feedback. Reinforcement of nursing guidelines was performed according to patient's needs to ensure their understanding. Every affected person within the study group obtains a copy of the nursing guidelines booklet. The researcher used pictures for illustration, diagram, and video to educate the patient.

• The first session: Was started during first twenty-four hours post admission preoperatively after patient’s hemodynamic stability, it contains three parts:

Part I: Information about the definition & indications of PCN.

Part II: Information about patient preparation before procedure.

Part III: post-procedure nursing care; teach patients how perform daily activities with PCN, change the urinary bag, and caring at the site of PCN.

The second session: started after twenty-four hours postoperatively; teach the patient about daily activities to control infection such as hand washing, keep skin clean and dry, drinking two liter of water, empting the bag when filling, keep the dressing dry, change the bag frequently every week, put the large bag during night, must be sure the tube is patent, and irrigation of the nephrostomy tube. At the end of this session, the patient was able to perform hand washing, change the bag, put the dressing on the site of tube and irrigation of the nephrostomy tube.

The third session: Patient discharge instructions, and post-procedure complications

• The importance of putting the urinary bag on the low level of the patient

• Pain: when the patient feel discomfort must take analgesics, if the pain is sever must returne to the doctor.

• Sleep with on the other side of PCN site.

• The patient takes normal diet.

• Showering: continuing to take showers daily at home is encouraged. Shower with the warm water and keep the dressing dry.

• Physical activity and exercises: encourage walking and avoid heavy exercises.

• Avoid doing anything that requires heavy lifting, pushing or straining.

• Return to work, if light work.

• Medication instruction related to the type of drugs, action, time, side effects, and precaution.

• Information about post-procedure complications: the patient must be returned to the doctor if the following occur; infection, the tube outside from the site and the tube, not patent.

• Inform the patient about follow up visit schedule.

3. Evaluation phase:

The last phase of proposed nursing guidelines is the evaluation phase. In which the patients were evaluated for the development of complications two times (after two and four weeks) by the researcher after nursing guidelines implementation.

5. Results

Table 1: Distributions of the studied groups according to personal characteristics: the data reveals that more than two thirds of patients in the study group (66.7 %) were male, (86.7%) were married, (33.3 %) their age were ranged from (50 < 65years), 36.7 % of them were able to read and write, and 46.7 % were not working. 46.7% of them have a standard level of weight. While 60.0 % of patients in the control group were male, 70.0 % were married, 46.7 % of them their age were ranged from (50 < 65 years), 46.7 % were able to read & write, and 36.7% were working in other types of jobs than those listed. The majority of control group patients were having a standard level of weight. With no statistically obvious distinction among both groups regarding personal characteristics and hospital stay. There was a statistically significant difference between the study and control groups regarding duration of the procedure with (P-value = 0.023*).

Table 1. Distributions of the studied groups according to personal characteristics (n= 60):

Table 2. Distribution of the studied groups according to general medical data (n=60):

Table 3. Distributions of the sample according to urologic assessment for study and control group (n= 60).

Table 2: Distribution of the studied groups according to general medical data: this table shows that about 16.6 % of the study group has type 2diabetes, with a mean duration of 6.33±3.21 years and 6.7 % have obesity. While in the control group 83.4% have type 2 diabetes, the mean duration of the disease was 7.57±5.69 years and 10.0 % have obesity. All of the patients in both groups haven’t any other disease.

Table 3: Distributions of the sample according to urologic assessment for study and control group: the data mentioned that all study group 100 % have an indwelling urinary catheter, 3.3 % have bladder dysfunction, and 46.7% have renal calculi. While in the control group about 93.3 % have an indwelling urinary catheter, 6.7 % have bladder dysfunction, 6.7 have bacteriuria and 50 % have renal calculi. All of the patients in both groups do not have urinary tract obstruction.

Table 4: Comparison between the studied groups as regard minor complications during hospitalization, after 2 & 4 weeks, this table illustrated that there has been statistically obvious distinction among study and control groups as regard transient hematuria, pain, and fever during hospitalization, two weeks and four weeks after implementing the nursing guidelines.

Table 5: Comparison between the studied groups as regard major complications during hospitalization, after 2 weeks, & after 4 weeks, this table shows that there has been a statistically surprising distinction among study and control groups as regard wound infection during three visits after implementing nursing guidelines.

Table 4. Comparison between the studied group as regard minor complications during hospitalization, after 2 weeks & after 4 weeks (post - implementing nursing guidelines) (n=60):

Table 5. Comparison between the studied group as regard major complications during hospitalization, after 2 weeks, & after 4 weeks (post - implementing nursing guidelines) (n=60)

6. Discussion

The data of the prevailing study clarify that in the control group sufferers; more than two thirds of patients in the study group were male, the majority of them were married, concerning age; one third of them were from (fifty to sixty-five years), a little more than third of them were able to read and write, and nearly half of them were unemployed and were having a standard level of weight. While more than half of patients in the study group were male, the majority of them were married, regarding age; nearly half of them were from (fifty to sixty-five years), and were able to read & write and the majority of those patients were having a standard level of weight. With no statistically obvious distinction between both groups regarding personal characteristics and hospital stay. There was a statistically significant distinction between the study and control groups regarding duration of the procedure with (P-value = 0.023*).

In the same line with the previous study result [19] found that the majority of the sample in their study were male (54.2 %), mean age was 51.9 years, Mean BMI (kg/m²) was 28.7 and 32.1 in both groups, while [20] disagrees with this study result regarding age when they found that the mean age of the studied sample in their study was 67.4 years.

Regarding the distribution of the studied groups according to general medical data; five patients in the study group were having type 2diabetes, the mean duration of which was 6.33±3.21 years and two patients were obese. While in the control group about fifth of patients were having diabetes, the majority of them were having type 2 and only one case had type 1diabetes, the mean duration of the disease was 7.57±5.69 years and three cases were obese. All patients in both groups were free from any other disease, with no statistically significant difference between both groups regarding medical data.

This study finding comes in agreement with [19] in their study which revealed that there has been no statistically significant distinction between both studied groups regarding diabetes mellitus (17.9%) in group 1 and (17.1%) in group 2.

Regarding urologic assessment of both groups; the present study results illustrated that all study group patients have an indwelling urinary catheter, one case had bladder dysfunction, and nearly half of them were having renal calculi. While in the control group the majority of patients have an indwelling urinary catheter, two cases have bladder dysfunction, and bacteriuria and half of them have renal calculi. All of the patients in both groups were not having urinary tract obstruction, with no statistically significant distinction between both groups regarding all items of urologic assessment.

[20] agree to some extent with the previous study result in that mild urinary tract infections developed in six (1.2%) patients.

Regarding development of minor complications during hospitalization in both the study and control group patients it was observed that; after two and four weeks, there was a statistically significant difference between both groups as regard transient hematuria, pain, and fever post implementing the nursing guidelines.

[20] Conducted a study from January 1996 to August 2005, on a total of 650 PNT insertions in 530 patients (356 men and 174 women). Of the five hundred and thirty patients, 10 (1.8%) experienced hemorrhage with an obvious reduction in hemoglobin level (mean 2.1 g/dL, variety 1.4 to 3.2) requiring blood transfusion (mean 400 mL, range 250 to 750). Also, they reported that the occurrence of minor complications within the one month of follow-up.

Supports our study result that there was an improvement among the study group patients than those of the control group regarding the incidence of bleeding are [21] who reported that bleeding complications can be minimized by appropriate pre-procedural preparation. Also regarding tube-related complications, along with catheter dislodgement, blockage, leaking, and kinking and cutting of the catheter they found that those complications occurred in seventeen (3.5%) of four hundred and eighty patients. Finally, 16 (3.3%) of four hundred and eighty patients were referred for PNT reinsertion within one month of the initial procedure.

There has been a statistically big difference among the study and control groups as regard wound infection post implementation of the nursing guidelines.

It is crucial to affirm that drainage bag is open and draining care should be taken to avoid over-distension of the renal collecting system at some stage in the technique, as this will bring about bacterial reflux into the per papillary plexus, all of these are nursing implications which were suggested by [5] as measures to control prevalence of complications among patients undergoing percutaneous nephrostomy.

It is important for the nurse to be aware of possible complications that can occur during percutaneous nephrostomy use and to continually assess laboratory studies, vital signs, and key images during the procedure to facilitate patient safety and provide an optimal patient experience [22].

7. Conclusion

From the present study results, it can be concluded that application of the nursing guidelines had its positive impact on the outcomes of patients who underwent percutaneous nephrostomy tube placement.

8. Recommendations

- Replication of the present study on a larger probability sample for generalization of results.

- A printed copy of the nursing guidelines is to be distributed among patients with percutaneous nephrostomy tube.

- A workshop for nurses working in urology operating room is to be organized for enriching nurses with recent guidelines related to percutaneous nephrostomy tube.

References

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