8.3 Elimination Care, Catheters & Output Monitoring
Key Takeaways
- Normal adult urinary output averages approximately 1,500 mL per 24 hours with a mandatory physiological minimum of 30 mL per hour; normal urine is clear, pale yellow to amber, with a mild aromatic odor.
- Abnormal urinary findings requiring immediate nurse reporting include hematuria (blood in urine), cloudiness/pyuria (infection/pus), foul pungent odor, dysuria (painful urination), oliguria (<30 mL/hr), and anuria (<100 mL/day).
- Bowel elimination is evaluated using the Bristol Stool Form Scale: Type 1–2 indicate severe/mild constipation, Type 3–4 represent normal smooth formed stool, and Type 6–7 denote diarrhea.
- Fecal impaction is a severe rectal blockage characterized by continuous oozing of liquid brown stool around the obstruction; nursing assistants must report this immediately and never attempt digital disimpaction without nurse oversight.
- Indwelling Foley catheter safety rules require keeping the drainage bag below bladder level at all times, securing the catheter to the thigh, ensuring kink-free tubing over the leg, emptying with a graduated cylinder without touching the drain spout, and washing catheter tubing at least 4 inches downward away from the urinary meatus.
Elimination Care, Catheters & Output Monitoring
Elimination of metabolic wastes via the urinary and gastrointestinal systems is a vital physiological process essential for maintaining fluid, electrolyte, and acid-base balance. Age-related changes in the genitourinary and digestive systems—including decreased bladder capacity, weakened pelvic floor musculature, prostatic hypertrophy in males, diminished rectal sensation, and reduced colonic transit speed—predispose geriatric residents to urinary retention, incontinence, chronic constipation, and fecal impaction.
The Certified Nursing Assistant (CNA) is responsible for assisting residents with toileting, bedpan, and commode use; monitoring and documenting stool and urine characteristics; maintaining indwelling catheter systems; and preventing Catheter-Associated Urinary Tract Infections (CAUTIs).
1. Urinary Elimination Physiology & Clinical Characteristics
A healthy adult produces and voids approximately 1,200 to 1,500 mL of urine daily, with an average of 200 to 400 mL per void. The kidneys must produce a minimum of 30 mL of urine per hour to adequately filter metabolic toxins (urea, creatinine, uric acid) and maintain renal perfusion.
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| URINARY CHARACTERISTICS SPECTRUM |
| |
| [NORMAL URINE] ---> Clear, straw to deep amber, faint aromatic odor |
| [HEMATURIA] ---> Pink, bright red, or dark brown (tea-colored) |
| [PYURIA / TURBIDITY] ---> Cloudy, murky, containing mucus/pus/sediment |
| [FOUL ODOR] ---> Pungent, ammonia-like, fishy (suggests UTI) |
| [OLIGURIA] ---> <30 mL/hr or <400 mL/24 hr (renal failure/shock)|
| [ANURIA] ---> <100 mL/24 hr (complete renal shutdown) |
| [POLYURIA] ---> >2,500 mL/24 hr (diabetes mellitus/diuretics) |
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Clinical Terms & Abnormal Urinary Findings
| Urinary Parameter | Normal Clinical Standard | Abnormal Finding / Term | Pathological Causes & CNA Reporting Action |
|---|---|---|---|
| Color | Pale yellow (straw) to deep amber, depending on hydration level. | Hematuria (pink, frank red, rust, or tea-colored urine). | Indicates bleeding in kidneys, ureters, bladder, or urethra; trauma from catheter traction; UTI; or renal calculi. Report immediately. |
| Clarity / Turbidity | Clear, transparent, without visible particulate matter. | Cloudy / Turbid / Pyuria (murky appearance with floating sediment, pus, or mucus shreds). | Indicates active infection (UTI), bacteria, white blood cells, or high mineral crystallization. Report immediately. |
| Odor | Mild, faint, aromatic odor. | Foul / Ammoniacal / Pungent / Sweet | Strong foul or ammonia odor indicates bacterial colonization (UTI). Sweet, fruity odor indicates diabetic ketoacidosis (DKA). |
| Volume / Output | ~1,500 mL/24 hr (minimum ≥30 mL/hour). | Oliguria (<30 mL/hr or <400 mL/24 hr); Anuria (<100 mL/24 hr); Polyuria (>2,500 mL/24 hr). | Oliguria/anuria indicates acute kidney injury, severe dehydration, or urinary obstruction. Polyuria indicates uncontrolled diabetes or diuretics. |
| Sensation | Painless, effortless micturition. | Dysuria (burning, sharp pain, stinging, or difficulty during urination). | Classic hallmark of cystitis (bladder infection), urethritis, or mechanical trauma. Report immediately. |
| Pattern / Control | Voluntary micturition every 3 to 4 hours while awake. | Urinary Retention (inability to empty bladder; palpable suprapubic distention); Incontinence (involuntary leakage). | Retention causes bladder rupture or hydronephrosis; incontinence causes perineal skin breakdown (IAD: Incontinence-Associated Dermatitis). |
2. Bowel Elimination & The Bristol Stool Form Scale
Normal bowel elimination varies among individuals, ranging from one bowel movement per day to one every 2 to 3 days. Normal feces are soft, formed, cylindrical/tubular in shape, brown in color (due to stercobilin and urobilin from bile breakdown), and passed without excessive straining.
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| THE BRISTOL STOOL FORM SCALE (BSFS) |
| |
| [TYPE 1] Separate hard lumps, like nuts (hard to pass) --> Severe Constip|
| [TYPE 2] Sausage-shaped, but lumpy --> Mild Constip |
| [TYPE 3] Like a sausage with cracks on the surface --> NORMAL |
| [TYPE 4] Like a sausage or snake, smooth and soft --> OPTIMAL NORMAL|
| [TYPE 5] Soft blobs with clear-cut edges (easy pass) --> Lacking Fiber |
| [TYPE 6] Fluffy pieces with ragged edges, mushy stool --> Mild Diarrhea |
| [TYPE 7] Watery, no solid pieces, entirely liquid --> Severe Diarrh |
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Abnormal Stool Characteristics:
- Melena (Black Tarry Stool): Dark, black, sticky, foul-smelling stool caused by digested blood from upper gastrointestinal bleeding (stomach ulcer, esophageal varices). Report immediately.
- Hematochezia (Bright Red Blood in Stool): Fresh red blood coating or mixed in feces, indicating lower gastrointestinal bleeding (diverticulitis, colon polyps, hemorrhoids, anal fissures).
- Clay-Colored / Acholic Stool: Pale, white, or putty-colored stool resulting from a lack of bile pigments caused by biliary tract obstruction (gallstones, liver disease, pancreatic cancer).
- Mucus, Pus, or Parasites: Presence of slimy mucus or visible worms in feces.
3. Constipation, Fecal Impaction & Enema Administration
Constipation Risk Factors & Prevention
Constipation is defined as the infrequent, difficult passage of hard, dry stools. Risk factors include immobility, low-fiber diets, inadequate fluid intake, opioid pain medications, iron supplements, and suppressing the defecation urge. Nursing assistants promote regular bowel function by encouraging physical ambulation, offering high-fiber foods (prunes, bran, vegetables), ensuring adequate hydration, and positioning residents upright on the toilet or commode with feet supported.
Fecal Impaction: Recognition & Clinical Management
[!CRITICAL] The Hallmark Sign of Fecal Impaction: When a hardened, immovable mass of feces becomes wedged in the rectum, solid stool cannot pass. However, liquid stool from the upper colon seeps around the impaction mass and continuously leaks from the anus. Continuous oozing or seepage of liquid brown stool in a resident who has not had a normal formed bowel movement for several days is the classic hallmark of fecal impaction (frequently mistaken for simple diarrhea).
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| FECAL IMPACTION PATHOLOGY |
| |
| [Descending Colon / Sigmoid] |
| | |
| v |
| [HARD, IMMOBILE FECAL MASS WEDGED IN RECTUM] |
| | |
| +-----------------------+-----------------------+ |
| | | |
| v v |
| [Solid Stool Blocked] [Liquid Stool Seeps Around Mass]|
| | | |
| v v |
| [No Formed Bowel Movement] [Continuous Liquid Brown Oozing]|
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- Accompanying Symptoms: Rectal tenesmus (constant feeling of needing to defecate), abdominal distention, cramping, nausea, vomiting, and rectal fullness.
- CNA Action: Immediately notify the licensed nurse. Nursing assistants must NEVER attempt digital rectal disimpaction (manual removal) unless specifically trained, certified, and authorized by state law and facility policy, as digital stimulation can stimulate the vagus nerve, causing sudden severe bradycardia (slow heart rate) and syncope.
[!WARNING] Digital Disimpaction Prohibition & Vagal Response: CNAs must never attempt manual or digital rectal disimpaction. Digital manipulation of the rectum can stimulate the vagus nerve (Cranial Nerve X), triggering severe reflex bradycardia (sudden slowing of heart rate), acute hypotension, cardiac dysrhythmias, or syncope (fainting). Digital disimpaction is an invasive skilled procedure performed exclusively by licensed nurses or physicians.
Enema Administration Principles
An enema is the instillation of a fluid solution into the rectum and sigmoid colon to stimulate peristalsis and promote defecation.
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| ENEMA ADMINISTRATION PROTOCOL CHECKLIST |
| |
| [1. Position Resident in LEFT SIMS' Position (Left Lateral Semi-Prone)] |
| | |
| v |
| [2. Prepare Warm Solution (100°F–105°F / 38°C–40.5°C; NEVER COLD/HOT)] |
| | |
| v |
| [3. Lubricate Tip 2–4 Inches & Expel Air from Enema Tubing] |
| | |
| v |
| [4. Gently Insert Tip 2–4 Inches Toward Umbilicus on Exhalation] |
| | |
| v |
| [5. Hang Solution Bag 12–18 Inches Above Anus; Instill Slowly Over 10 Min] |
| | |
| v |
| [6. If Cramping Occurs: Lower Bag / Clamp Tubing; Stop if Pain/Bleeding] |
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- Positioning: Always position the resident in the Left Sims' (left lateral semi-prone) position. Because the sigmoid colon curves downward along the left side of the abdomen, this position allows gravity to facilitate natural fluid flow into the colon.
- Temperature: Ensure the solution is lukewarm (100°F to 105°F). Cold solution induces severe abdominal cramping; hot solution scalds fragile rectal mucosa.
- Height: Hold or hang the enema container no higher than 12 to 18 inches above the anus. Raising the bag too high creates excessive hydrostatic pressure, causing rapid fluid entry, painful spasms, and premature expulsion.
- Insertion: Lubricate the distal 2 to 4 inches of the nozzle; insert gently 2 to 4 inches into the adult rectum angled toward the umbilicus while the resident exhales. If resistance, sharp pain, or rectal bleeding occurs, stop immediately, withdraw the tube, and summon the nurse.
4. Indwelling Foley Catheter Care & CAUTI Prevention
An indwelling urinary catheter (Foley catheter) is a flexible tube inserted through the urethra into the bladder to continuously drain urine into an external collection bag. Catheterization carries high risks of Catheter-Associated Urinary Tract Infections (CAUTIs), urethral trauma, and bladder spasms.
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| FOLEY CATHETER SAFETY & DRAINAGE RULES |
| |
| [URINARY BLADDER] |
| | |
| v |
| [Catheter Tubing Secured to Thigh with StatLock / Leg Strap] |
| | |
| v |
| [Tubing Routed OVER the Leg - Free of Kinks, Twists, or Dependent Loops] |
| | |
| v |
| [DRAINAGE BAG ALWAYS MAINTAINED BELOW BLADDER LEVEL AT ALL TIMES] |
| | |
| +---> Hang on Stationary Bed Frame (NEVER Side Rails) |
| +---> NEVER Allow Bag or Spout to Touch the Floor |
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The 6 Essential Foley Catheter Care Rules for CNAs:
1. Drainage Bag Below Bladder Level at All Times
- The urinary drainage bag must always be positioned below the level of the resident's bladder—whether the resident is in bed, sitting in a wheelchair, ambulating, or during transfers.
- Rationale: Urine drains via gravity. If the collection bag is raised above bladder level, contaminated urine flows backward (retrograde reflux) from the tubing into the sterile bladder, rapidly causing acute cystitis and pyelonephritis (CAUTI).
2. Hang on Stationary Bed Frame — NEVER on Bed Side Rails or the Floor
- Attach the drainage bag hanger strictly to the non-movable, stationary bed frame.
- Rationale: Attaching the bag to a movable side rail can raise the bag above bladder level when the rail is elevated, or pull/yank the catheter balloon against the bladder neck when the rail is lowered. Never place the drainage bag on the floor, which causes massive microbial contamination.
3. Tubing Routed Over the Thigh without Kinks or Dependent Loops
- Route the drainage tubing over the top of the resident's leg. Ensure there are no dependent loops (coils of tubing hanging below the bag level), kinks, or twists.
- Rationale: Routing tubing under the resident's thigh or buttocks creates pressure occlusion from body weight, halting urine flow and causing skin pressure injuries.
4. Secure Catheter with a Stabilization Device
- Ensure the catheter is anchored securely to the resident's upper anterior thigh (or lower abdomen in males) using a commercial adhesive anchor (StatLock) or elastic leg strap.
- Rationale: Securing prevents mechanical traction, accidental dislodgement, and severe urethral tearing.
5. Meticulous Catheter Hygiene Procedure
- Perform catheter care during routine morning pericare, daily, and immediately following any episode of fecal incontinence.
- Don clean gloves. Perform complete perineal hygiene first.
- With your non-dominant hand, firmly grasp and anchor the catheter tubing directly at the urinary meatus (to prevent pulling on the anchoring balloon inside the bladder).
- Using a clean, soapy, warm washcloth, cleanse the catheter tubing at least 4 inches (10 cm) DOWNWARD AWAY from the urinary meatus in a single unidirectional stroke.
- Rotate the washcloth to a fresh, clean surface, rinse the tubing downward away from the body, and pat dry.
- Rationale: Wiping downward away from the meatus prevents pulling bacteria from the tubing into the urinary tract.
6. Emptying the Catheter Drainage Bag
- Don gloves. Place a clean paper towel barrier on the floor directly beneath the drainage bag.
- Place a calibrated graduated cylinder on the paper towel beneath the drainage spout.
- Open the drain clamp without allowing the spout to touch the sides of the graduated cylinder, paper towel, or floor.
- Allow urine to drain completely. Clean the drain spout with an alcohol swab, close and re-clamp the port, and return it to its protective sleeve.
- Place the graduated cylinder on a flat surface, read the volume at eye level, record the output on the I&O sheet, discard urine in the toilet, rinse and disinfect the container, remove gloves, and wash hands thoroughly.
A Certified Nursing Assistant is caring for a resident with an indwelling Foley catheter who is being transferred from the bed to a wheelchair for an afternoon activity. Which safety action is mandatory during transfer and transport?
An elderly resident with chronic immobility has not had a formed bowel movement in four days. The nursing assistant observes that the resident's brief is repeatedly saturated with a continuous seepage of liquid brown stool, and the resident complains of abdominal cramping and rectal fullness. What condition should the CNA suspect?
When performing routine indwelling Foley catheter care during morning hygiene, which technique is required to prevent Catheter-Associated Urinary Tract Infections (CAUTIs) and urethral injury?