Quality of life, pain and anxiety in patients with nephrostomy tubes

Objective: to evaluate the impact on the quality of life as well as anxiety and pain in patients with nephrostomy tubes. Method: this is a longitudinal descriptive study performed on a sample of n=150 patients. To evaluate the quality of life, the EuroQol-5D questionnaire was used; anxiety was quantified by the Beck Anxiety Inventory; to study pain, a visual analogue scale was employed. Results: statistically significant differences were found in the quality of life, with its worsening (r = 0.51; p <0.01) when evaluated at the first tube replacement. Patients presented mild to moderate anxiety before the procedure, which was reduced at the first tube replacement, although this difference was not significant (r = 0.028, p = 0.393). Finally, the degree of pain was also significantly reduced (r = 0.13, p<0.01) after six weeks. As for gender, women presented the worst values in the three variables studied (worse quality of life and greater anxiety and pain). Conclusions: nephrostomy tubes have a negative impact on the patient’s quality of life. During the time they live with these tubes, patients have mild to moderate pain and anxiety.

Introduction radioscopic control, usually in the prone position and under local anesthesia at the puncture site. The result is the placement of a pig tail tube that communicates the kidney with the exterior (3) . Due to the low incidence of complications (between 4% and 10%), it is a very appropriate technique as a urinary diversion (3) . The tube, at its distal end, is attached to a urine collecting bag that is usually attached to the patient's leg. To avoid possible obstruction of the tube by the deposition of metabolic waste, patients should go weekly to the health centers to perform drainage and control of the peri-catheter area (4)(5)(6)(7) . In addition, with almost monthly frequency, the tubes should be replaced at the radiology services.
The ease of the procedure and its low morbidity makes it an increasingly widespread and accepted technique.
The number of patients submitted to this technique is increasing exponentially. In addition, due to the various pathologies that may require the placement of the tubes, the target population varies a wide range of ages, from newborns to elderly patients. Its duration can be from a few weeks to many years, or they may even carry the tubes permanently. Therefore, patients should learn to live with tubes for a certain time (8) .
The term health is a multidimensional concept that the World Health Organization (WHO) describes as a state of complete physical, mental, and social wellbeing and not just the absence of disease or infirmity. In the definition of health, different spheres coexist, such as culture, society, economy or the dominant politics of each country or continent where the term is evaluated.
Health-related quality of life (HRQOL) is a concept that, although its definition is also multidimensional and is increasingly important as it is a way of assessing the health of a given population (9) . Moreover, it allows to detect problems and analyze the effectiveness and efficacy of health interventions. The instruments for measuring HRQOL are essential in the different stages of the nursing care process, despite the limitations they present. One of the main obstacles that can arise when administering a given questionnaire is the sociocultural context in which it will be carried out. Habits, customs, traditions or beliefs can condition certain items, as well as the way to ask about them. In order to measure HRQOL in these conditions, very robust questionnaires are required, which can be administered quickly and easily and allow reliable and valid results to be obtained.
It is important to use measuring instruments that have been validated and adapted for the population to be studied (10)(11)(12) .
HRQOL refers to a concept widely studied in several pathologies or diseases, such as pulmonary diseases (13) , chronic kidney failure (14)(15)(16)(17)(18)(19) , heart failure (20) or in patients with Crohn's disease who undergo intestinal resection surgery (21)(22) , among others. This instrument is essential because it incorporates the patient's perception as one of the obligatory and necessary parameters in the different steps that constitute the process of any health intervention. Likewise, it represents a dimension in which all health education must address. It should be present both in the assessment of needs, diagnosing problems, planning of interventions, execution of activities or tasks and, finally, in the evaluation of health outcomes. It is necessary to have valid and reliable instruments for this measurement to provide scientifically based empirical evidence for the health decision-making process.
The main objective of this study was to evaluate the impact on quality of life, as well as to analyze the level of anxiety and pain before and after the nephrostomy tubes implanting procedure.
Two hypotheses were proposed: 1) The quality of life of patients with a nephrostomy tube will be lower in the first tube replacement than before their implantation.
2) Patients will also have, then, a higher level of anxiety and pain, compared to their self-assessment before the procedure. Radiology Diagnostic service were informed about the study. As exclusion criteria, it was determined that patients who had previously had another nephrostomy tube or any other type of ostomy and/or those patients whose cognitive status would prevent them to produce reliable answers would not have participated in the study. Another exclusion criterion was removal of the tube before the first replacement or the need to remove it urgently, before the predetermined date for the first replacement (six weeks post-implantation). All patients were informed on the possibility to revoke their participation in the study at any time.
In this study, we started from the patient's situation before surgery and then compared it approximately six weeks after the tube was implanted, when the patient went to the radiology service for the first time to undergo the first tube replacement. Since all nephrostomies were performed in this service, either by the Interventional Vascular Radiology team or by the Central Radiology team, we believe that both research data collection, pre and post-procedure (first tube replacement) would have been performed in the same Radiology service to avoid biases due to different information received in other services, such as in the emergency room or in the urological hospitalization unit.
As variables, the quality of life, anxiety and pain before and after the procedure were studied, as well as the use of psychopharmaceutical drugs. In addition, other socio-demographic variables were included to assess how they influence these changes and to assess whether there are particularly vulnerable populations for whom intervention is particularly essential in order to minimize the negative impact of living with nephrostomy tubes. The following variables were analyzed: age, gender, marital status (single, married, separated, and widowed), family unit (number of people living with the patient, included him/herself), education (no studies, primary studies, high school, university studies), leisure activity (no leisure activities, leisure time less than twice a week, 2 to 5 times a week, and more than 5 times a week) and work situation (employed, medical leave, unemployed, and retired).
The instruments used to quantify these variables were: Quality of life EuroQ-5D questionnaire (the mean of each of the five dimensions was used as a measure), the Beck Anxiety Inventory (BAI) for anxiety, and the visual analogue scale to assess pain.
The European Quality of Life-5 Dimensions (EQ-5D) questionnaire is a widely accepted international instrument for assessing health-related quality of life.
In addition, it has been validated for different cultural contexts (25) , including the Spanish one, and is very useful as an instrument for measuring health status within a population (26) . It is a questionnaire designed to be administered in a variety of measurement conditions: by mail, self-administered or by interview. The EQ-5D is divided into three parts: the first part allows the respondent to define their health status in five dimensions (mobility, personal care, daily activities, pain/discomfort and anxiety/depression), each one scoring three levels of severity oscillate between score 1 (no problems), 2 (some problems) and 3 (many problems). Higher scores are related to a worse perception of quality of life. For example, the questionnaire of an individual with no mobility problems, personal care or daily activities, but with moderate pain and anxiety, would be summarized as 11122. The second part is a visual analog scale graded from 0 (worst possible health) to 100 (best possible state of health), which allows the individual to assess his/her current health status. In order for patients to assess in a more tangible and understandable way the Rev. Latino-Am. Enfermagem 2019;27:e3191.
impact of the nephrostomy tube on their quality of life and to be able to detect differences in scores that mean clinically relevant changes, we considered it appropriate to simplify the values of this scale and to employ one that ranges from 0 to 10, taking into account, on the other hand, that we also use a visual pain scale with the same numerical range, as we will explain later on, trying to avoid possible misinterpretation and confusion.
The third part of the questionnaire collects other data in the form of variables that allow the demographic characterization of the individuals evaluated (27)(28) .
Beck's anxiety test is a useful tool that evaluates the most frequent symptoms of anxiety. Moreover, since 2011, it has been adapted to the Spanish population (29) . The total score is the sum of all items, evaluating the symptoms present in the last week and in the current moment (29) . Both the EQ-5D questionnaire and the Beck Anxiety Inventory have proved to be sufficiently reliable,

Results
Of the total sample analyzed (n = 150), 68% (n = 102) were men and 32% (n = 48) women. Two patients were considered lost since they did not continue in the study due to death before the first tube replacement. The mean age of the patients was 61.67 years old, significantly  Table 1.
Analyzing quality of life in general, as shown in As it can be seen in Table 3, the patient's anxiety prior to the procedure was greater than at the first tube replacement (6 th week), both in general ( should be noted that women presented greater anxiety than men, both pre-and post-procedure.

Discussion
The results of the present study show that patients living with a nephrostomy tube have reduced quality of life both globally and stratified by gender, confirming our first hypothesis, since the relationship between the placement of a nephrostomy tube and the decrease in the quality of life was statistically significant.
It should be noted that women had lower levels of quality of life, both before and after the procedure, similar results to those reported in other studies that evaluated quality of life according to gender (30)(31) . Other sociodemographic variables, such as being single, divorced or widowed, lead to a worse perception of quality of life than married patients. Some of the reviewed studies (32)(33)  that both variables decreased in general compared to those presented before of the procedure. It is an unexpected and contradictory finding of the difference in pain outcome by analyzing it using the EuroQol-5D questionnaire, which shows no differences before and after, and the analogue visual scale of pain, which shows a clear reduction in pain when evaluated at the first tube replacement. Therefore, based on both results, the second hypothesis, that the level of anxiety and pain would increase at the first tube replacement, compared to the levels of pain and anxiety presented before implantation, was not confirmed. These result coincides with other studies (35)(36)(37)(38) . Regarding the gender difference in anxiety, other articles (39)  On the other hand, men may have higher pain thresholds than women, which could correspond to gender-related stereotypes that occur in cultures and/or societies where men repress certain emotions and actions, including pain, as endorsed by some studies (45)(46)(47)(48) .
In addition to the negative impact of anxiety and pain presented by patients during the time they carry the tube, one of the most negatively affected areas is work. It should be noted that of all people who had worked before the nephrostomy tube was implanted, a high percentage of them are on medical leave, which shows not only the degree of physical impairment, but also the enormous social and labor impact.
The main strength of this study is to address the lack of research that specifically evaluates the quality of can be a key pillar to support interventions that, if it is not possible to maintain the quality of life prior to nephrostomy, at least reduce to the maximum the impact that this procedure imposes.