Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed. Another member of staff may be needed to reassure the patient during the procedure.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [178], C).
2. 2.Show
   Check the patient's medical notes to confirm which nephrostomy tube is to be removed. Once confirmed, establish the number and site(s) of sutures (both internal and external).
   To ensure only documented drains are removed. To ensure all non‐absorbable sutures are removed prior to attempting removal of the drain. E
3. 3.Show
   Offer the patient analgesia as prescribed.
   To promote the patient's comfort (NMC [178], C).
4. 4.Show
   If the patient has a ureteric stent in situ, removal of the nephrostomy should be done under X‐ray or ultrasound guidance.
   To ensure that the ureteric stent does not become misplaced during removal. E

Procedure

1. 5.Show
   Perform all steps of the procedure (below) using aseptic technique. Clean the drain site using 0.9% sodium chloride.
   To reduce the risk of infection (Loveday et al. [135], R).
2. 6.Show
   If the drain is sutured in place, hold the knot of the suture with metal forceps and gently lift upwards.
   To facilitate removal. E

   Plastic forceps tend to slip against nylon sutures. To allow space for the scissors or stitch cutter to be placed underneath. E
3. 7.Show
   Cut the shortest end of the suture as close to the skin as possible and remove the suture.
   To minimize cross‐infection by allowing the suture to be liberated from the drain without drawing the exposed part through tissue (Pudner [201], E).
4. 8.Show
   Disconnect the drainage bag from the stopcock. Using the ‘key’ or alternative items that fit in the slot of the stopcock, rotate the stopcock counter‐clockwise exactly 180° to the ‘unlocked’ position. Note: the retention stopcock is turned 180° to the locked position after insertion; this must be unlocked prior to removal; you must rotate the stopcock counter‐clockwise 180° to unlock it.
   To unlock and release the pigtail. This straightens the tip of the nephrostomy tube, allowing for removal of the drain. Always follow the manufacturer's guidelines. E
5. 9.Show
   Warn the patient of the pulling sensation they will experience and reassure them throughout.
   To promote comfort and co‐operation. Another member of staff may be needed to reassure the patient during the procedure. E
6. 10.Show
   Loosening up of the drain should be done if possible, especially for a drain that has been in for some time. This can be done by gently rotating the drain to loosen it from the embedded tissue.
   To minimize pain and reduce trauma. E

   Drains that have been left in for an extended period will sometimes be more difficult to remove due to tissue growing around the tubing (Walker [242], E).
7. 11.Show
   With one gloved hand, place a finger on each side of the drain exit site, exerting gentle pressure to stabilize the skin around the drain. Using the other gloved hand, take a firm grasp of the drain as close to the skin as possible and gently pull to start removing it. Steady, gentle traction should be used to remove the drain rather than sudden, jerky movements. If there is resistance, ensure that the other gloved hand is still exerting gentle pressure around the drain exit site.
   Using a firm grasp for the shortest possible length of time minimizes patient discomfort. This is especially important for supple drains such as those made from silicone or rubber, which can stretch for some distance, then suddenly break free, causing undue pain to the patient (Walker [242], E).
8. 12.Show
   Once removed, the drain should be inspected to ensure that it is intact. The end of the drain should be clean cut and not jagged.
   This clean appearance ensures that the whole drain has been removed. E

   If you have any doubt that the drain is intact, the surgeons should be contacted to inspect the drain before disposal. In rare cases an X‐ray may be used to confirm complete removal (Cox and Friess [54], R).
9. 13.Show
   Cover the drain site with a sterile dressing and tape securely.
   To prevent infection entering the drain site. E
10. 14.Show
    If the site is inflamed or there is a request for the tip to be sent to microbiology, cut it off cleanly, using sterile scissors, and send it in a sterile pot. Also send a wound swab of the exit site.
    To recognize and treat suspected infection (Fraise and Bradley [81], E; Walker [242], E).

Post‐procedure

1. 15.Show
   Dispose of the used drainage system in a clinical waste bag.
   To ensure correct and safe disposal of contaminated waste (DEFRA [63], C).
2. 16.Show
   Observe the drain site for signs of haematoma, urinoma or infection.
   To identify any complications early. E
3. 17.Show
   Record information in relevant documents; this should include:

   • date and time of procedure
   • procedure(s) performed
   • any problems or concerns during the procedure
   • any swabs or samples taken during the procedure (e.g. exit site swab or urine sample)
   • any referrals made following the procedure.
   To provide a point of reference or comparison in the event of later queries (NMC [178], C).