5.3 Elimination, Urinary Catheter Care & Bowel Management

5.3 Elimination, Urinary Catheter Care & Bowel Management

Assisting residents with urinary and bowel elimination is a core responsibility of the Nursing Assistant (CNA). Maintaining clean elimination equipment, performing safe indwelling catheter care, monitoring drainage systems, and observing bowel characteristics are essential for resident comfort, skin integrity, and infection prevention.

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Bedpan Selection & Positioning Techniques

Residents who are bedbound or unable to ambulate to the bathroom rely on bedpans or urinals for elimination. Providing prompt assistance protects skin from moisture damage and preserves dignity.

Types of Bedpans

Correct Positioning & Application

• Standard Bedpan: Position with the wider, contoured seat end toward the resident's lower back/buttocks and the narrow end pointing toward the feet.
• Fracture Pan: Position with the flatter, shallow end under the buttocks and the handle/container end pointing toward the feet. This allows the pan to slide under the buttocks with minimal hip elevation.

Bedpan Placement for Hip Replacement/Fracture:
[Select Fracture Pan] ➔ [Keep Spine/Hips Aligned] ➔ [Slide Flat End Under Buttocks] ➔ [Raise Head of Bed to Comfortable Sitting Position]

Safety and Ergonomics

• Never force a resident onto a bedpan. For residents who cannot raise their hips, logroll the resident onto their side, place the bedpan against their buttocks, and roll them back onto the pan.
• Unless contraindicated, raise the head of the bed to a semi-Fowler's or Fowler's position once the bedpan is in place to mimic natural gravity-assisted elimination.
• Leave the call light and toilet paper within reach. Cover the bedpan after removal and observe contents before measuring/discarding.

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Indwelling Urinary Catheter Hygiene

An indwelling urinary catheter (Foley catheter) is a flexible tube inserted through the urethra into the bladder to drain urine continuously into a drainage bag. Because the catheter creates a direct pathway for pathogens into the urinary tract, meticulous hygiene is required.

Catheter Cleaning Protocol

Perineal care for a resident with a catheter must be performed at least daily, after bowel incontinence, and whenever soiled.

1. Preparation: Wash hands, don clean gloves, explain the procedure, and drape the resident for privacy.
2. Anchoring the Tubing: With one gloved hand, hold the catheter tubing firmly at the urinary meatus (where the catheter enters the body). This prevents accidental pulling or traction on the bladder sphincter.
3. Cleansing Stroke: With the other hand, take a soapy washcloth folded into quarters and clean down the catheter tubing away from the meatus for at least 4 inches (10 cm).
4. Infection Control: Move in one direction only (away from the body). Use a fresh, clean area of the washcloth for every stroke to avoid dragging rectal or fecal bacteria back toward the urethral opening.
5. Rinsing & Drying: Rinse the catheter tubing away from the meatus using a fresh washcloth and pat dry gently.

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Catheter Drainage System Safety & Maintenance

Proper maintenance of the catheter drainage system is critical to prevent Catheter-Associated Urinary Tract Infections (CAUTIs), which represent one of the most common healthcare-associated infections.

Critical Drainage Bag Positioning Rules

• Below Bladder Level: The drainage bag MUST remain suspended below the level of the resident's bladder at all times (whether the resident is in bed, sitting in a wheelchair, or ambulating).
• Gravity Flow: Urine must drain freely by gravity. Keeping the bag below the bladder prevents urine in the tubing from backflowing (refluxing) into the bladder. Backflow carries colonizing bacteria directly into the sterile urinary bladder.
• Attachment Site: Attach the drainage bag to the non-movable bed frame or beneath the wheelchair seat. NEVER attach the drainage bag to a movable side rail, as raising the rail lifts the bag above bladder level.
• Floor Clearance: Never allow the drainage bag or emptying spigot to touch the floor, which contaminates the system with floor pathogens.

Catheter System Checklist:
✓ Drainage bag below bladder level
✓ Bag attached to bed frame (never side rail)
✓ Tubing secured to inner thigh
✓ Tubing free of kinks, loops, or compression
✓ Bag off the floor

Tubing Safety & Output Measurement

• Securing Tubing: Secure the catheter tubing to the resident's inner thigh (or upper thigh) using a catheter strap or tape. This prevents pulling on the urethra during movement.
• Kink Inspection: Check the tubing frequently to ensure it is free of kinks, twists, or loops, and is not compressed under the resident's legs or bed rails.
• Emptying & Measuring: Empty the drainage bag at the end of each shift or when full. Use a clean, calibrated graduate container. Do not let the drain spout touch the container. Record the exact output in milliliters (mL/cc).

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Bowel Elimination & Stool Observation

Monitoring bowel movements allows the CNA to identify gastrointestinal complications early.

Normal vs. Abnormal Stool Characteristics

• Normal Stool: Brown, soft, formed, and passed comfortably every 1 to 3 days.
• Abnormal Observations:
  • Color Changes: Clay-colored or pale (liver/gallbladder dysfunction), black/tarry (melena, indicating upper GI bleeding), bright red (lower GI bleeding/hemorrhoids), or green/yellow (rapid transit/infection).
  • Consistency Changes: Hard, dry, marble-like lumps (constipation) or liquid/watery (diarrhea).

Constipation, Diarrhea & Fecal Impaction

🚨 Clinical Priority — Fecal Impaction Sign: If a resident has not had a solid bowel movement for several days but suddenly passes small amounts of liquid stool or stool seepage, suspect a fecal impaction. This is an urgent finding that must be reported to the charge nurse immediately. CNAs do NOT digitally remove impactions.

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Elimination & Catheter Care Quick-Reference Guide