Question

A client with hydronephrosis has undergone an emergency nephrostomy. When caring for a client with a nephrostomy tube, the nurse should give priority to: A. Irrigating the tube every 4 hours B. Obtaining hourly output for 24 hours C. Clamping the tube for 15 minutes every two hours D. Reporting any red-tinged drainage from the tube

Short answer

The priority nursing action for a client with a nephrostomy tube is to report any red-tinged drainage from the tube. This is because red-tinged drainage may indicate a complication, such as bleeding within the renal collecting system or injury to the kidney. Prompt recognition and reporting of this sign can help healthcare professionals act quickly to address the issue and minimize the risk of further complications or damage to the patient's kidney.

Step-by-step solution

Understand Nephrostomy and Hydronephrosis

Nephrostomy is a surgical procedure where an opening is created between the kidney's collecting system and the skin to allow urine to be drained externally through a nephrostomy tube. This procedure is usually performed for patients with hydronephrosis, a condition where the kidney becomes swollen due to the accumulation of urine, which can be caused by obstructed urine flow.

Evaluate Option A

Irrigating the tube every 4 hours might be an important care action to maintain the patency of the nephrostomy tube and ensure proper drainage of urine. However, it may not necessarily be the highest priority in this situation, as there might be other actions that contribute more significantly to patient safety and health status like monitoring the output or red-tinged drainage.

Evaluate Option B

Obtaining hourly output for 24 hours is crucial in nephrostomy care, as it helps in monitoring the patient’s kidney function and assessing whether the nephrostomy tube is draining urine effectively. This action is important for identifying potential complications, such as urinary retention, renal failure, or infection. Regular monitoring will also assist in evaluating the success of the nephrostomy procedure. However, it may still not be the highest priority when compared to others, as we need to examine all options before selecting our answer.

Evaluate Option C

Clamping the tube for 15 minutes every two hours does not seem like a proper nursing care action in this situation, as doing so could cause a build-up of urine and increase the risk of infection or complications. The primary purpose of the nephrostomy tube is to provide continuous drainage from the kidney, so clamping the tube may not be consistent with that goal.

Evaluate Option D

Reporting any red-tinged drainage from the tube can be a crucial action for the nurse to take, as it may indicate a complication, such as bleeding within the renal collecting system or injury to the kidney. Prompt recognition and reporting of this sign can help healthcare professionals act quickly to address the issue and minimize the risk of further complications or damage to the patient's kidney.

Choose the Highest Priority Action

Based on our evaluation, option D (Reporting any red-tinged drainage from the tube) should be given the highest priority, as it presents the most significant potential risk to patient health and safety. While other actions like monitoring hourly output and irrigating the tube are important, they may not require the same level of urgency as addressing potential complications or damage signaled by red-tinged drainage. Therefore, the correct answer is D.

Key concepts

Hydronephrosis

Hydronephrosis is a medical condition characterized by the swelling of one or both kidneys. This happens when urine fails to drain from the kidney to the bladder, leading to urine build-up. Several factors can cause this blockage, such as kidney stones, tumors, or strictures in the urinary tract. When untreated, the pressure from the accumulated urine can damage the kidneys.
Nephrostomy is often recommended for hydronephrosis patients. This surgical procedure involves inserting a nephrostomy tube to drain urine externally, bypassing the obstruction. The aim is to relieve pressure from the kidneys to prevent further damage and restore kidney function. Understanding hydronephrosis and the role of nephrostomy is crucial for effective patient care.

Nursing Priorities

In nephrostomy care, setting nursing priorities is essential for effective patient management. Nurses need to identify urgent and critical tasks to ensure quality care and patient safety.
Among these tasks, monitoring the nephrostomy output is crucial. Consistent hourly monitoring helps evaluate kidney function and detect any changes early.

• Monitoring vital signs to assess overall health.
• Providing regular and effective irrigation to maintain tube patency.
• Educating patients and families on nephrostomy care, ensuring they understand how to manage and report any issues.

These elements of nursing priorities play a significant role in preventing complications and promoting recovery.

Patient Safety

Patient safety in nephrostomy care revolves around preventing infections and ensuring the nephrostomy tube is functioning correctly. Nurses should vigilantly watch for any signs of complications, such as red-tinged drainage, which could indicate bleeding or infection.
Educating the patient about infection prevention, such as proper hygiene practices, is critical. This education can include handwashing techniques and the importance of keeping the nephrostomy area clean and dry. Moreover, nurses should educate about recognizing infection symptoms, like fever or increased pain.

• Ensure the nephrostomy bag is properly secured to prevent accidental dislodgment.
• Regularly check the skin around the site for signs of irritation or infection.

By focusing on these safety measures, nurses can significantly reduce the risk of complications.

Urinary Drainage Monitoring

Urinary drainage monitoring is vital in nephrostomy care for assessing kidney health and ensuring the nephrostomy tube's functionality. This monitoring involves tracking the volume and appearance of the urine output, as deviations from the norm can signal issues.

• Observe for any changes in urine color, especially red-tinged which needs immediate attention.
• Measure and record urine output hourly to assess kidney function.
• Ensure that tubing is free of kinks and obstructions for optimal drainage.

Caution is needed to quickly identify potential problems, such as decreased output or changes in urine appearance, which could indicate complications like blockages or infections. By carefully monitoring urinary output, healthcare providers can act swiftly to rectify issues, ensuring successful outcomes for patients with nephrostomy tubes.