4.4 Elimination, Toileting, and Catheter Care
Key Takeaways
- Perineal care is always done front to back (urethra toward rectum) using a clean section of cloth per stroke to prevent a urinary tract infection (UTI)
- For an uncircumcised male, retract the foreskin, clean the tip in a circular motion from the urethra outward, then return the foreskin to its natural position
- Keep an indwelling catheter drainage bag below the level of the bladder at all times, secured to the thigh, kink-free, and in a closed system that is never disconnected
- A healthy ostomy stoma is pink or red and moist; report a pale, gray, dark, or bleeding stoma, and empty the pouch when it is one-third to one-half full
- Manage incontinence with prompt cleaning, skin protection, and respect; support bowel/bladder retraining with a set toileting schedule and never scold the resident
Supporting Normal Elimination
Helping residents with toileting is among the most dignity-sensitive ADL skills, and the exam tests both technique and respect. Normal urine is pale yellow, clear, and mild-smelling; normal stool is soft and brown. Support normal elimination by answering call lights promptly (a full bladder cannot wait), providing privacy, encouraging fluids and fiber, promoting activity, and assisting with a regular toileting schedule. Always observe and report changes: cloudy, bloody, dark, or foul-smelling urine; very small or large amounts; hard or loose stool; black or bloody stool; pain; or any change from the resident's normal pattern.
Assisting With Toileting Devices
When a resident cannot reach the bathroom, the aide assists with the right device, always wearing gloves and providing privacy:
- Bedpan — used by residents who cannot get out of bed. A standard bedpan is placed with the wider, rounded end under the buttocks; a fracture pan (flat, low end) is used for residents who cannot lift the hips or who have hip restrictions. Raise the head of the bed slightly so the resident is in a more natural sitting position, give privacy and the call light, and remove the pan promptly.
- Urinal — a handheld container used by male residents to urinate, in bed or standing at the bedside.
- Bedside commode — a portable chair with a removable receptacle, used at the bedside for a resident who can transfer but cannot walk to the bathroom.
After each use, help the resident with hand washing, measure and record output if the resident is on intake and output, observe the urine or stool, empty and clean the device, and remove your gloves and wash your hands. Never leave a resident on a bedpan or commode for a long time — it causes skin breakdown and indignity.
Match each elimination device to the resident situation it best fits.
Match each item on the left with the correct item on the right
Perineal Care
Perineal care ("peri-care") cleans the genital and anal area; it is done during the bath, after toileting, and whenever the area is soiled. The universal rule is to clean front to back — from the urethra toward the rectum — using a clean section of the cloth for each stroke. This keeps bacteria from the rectal area away from the urinary opening and prevents a urinary tract infection (UTI). Work from clean to dirty and rinse and dry well.
- Female resident: separate the labia and clean downward from front (urethra) to back (rectum), one stroke per clean section of cloth, then clean the anal area last.
- Male resident: clean the tip of the penis using a circular motion starting at the urethral opening and moving outward. If the resident is uncircumcised, gently retract the foreskin, clean, and then return it to its natural position to prevent painful swelling and constriction. Wash the scrotum and anal area last.
Indwelling (Foley) Catheter Care
A urinary catheter is a tube that drains urine; an indwelling Foley catheter stays in the bladder and drains into a closed bag. Catheter care is a high-frequency exam topic because a few rules prevent serious infection (CAUTI — catheter-associated urinary tract infection). Memorize these:
| Rule | Why It Matters |
|---|---|
| Keep the drainage bag below the bladder at all times | Lets urine flow down and away; a raised bag lets urine flow back and cause infection |
| Secure (anchor) the tubing to the inner thigh | Prevents tugging on the catheter, which causes pain and trauma |
| Keep tubing free of kinks and loops | Kinks block flow, back up urine, and raise infection risk |
| Maintain a closed system — never disconnect | Every disconnection opens a path for bacteria |
| Never rest the bag on the floor or hang it on a movable rail | Floor contamination; a raised rail would lift the bag above the bladder |
| Clean from the meatus down the catheter (about 4 inches), one stroke away from the body | Moves germs away from the entry point |
Report cloudy, bloody, or foul-smelling urine, leaking around the catheter, no urine output, or complaints of pain. When transferring or ambulating, carry the bag below the bladder and watch the tubing.
While ambulating a resident who has an indwelling urinary catheter, where should the aide keep the drainage bag, and how should the tubing be managed?
When performing perineal care for an uncircumcised male resident, what must the aide remember to do after cleaning the tip of the penis?
Ostomy Basics
An ostomy is a surgically created opening (a stoma) on the abdomen through which stool (colostomy/ileostomy) or urine (urostomy) drains into an attached pouch (ostomy bag). A healthy stoma is pink or red and moist — report a stoma that looks pale, gray, dark/dusky, blue, or bleeds to the nurse, as these may signal poor blood flow.
The CNA's role is supportive: empty the pouch when it is one-third to one-half full to prevent leaks and odor, keep the surrounding skin clean and dry, provide privacy, and report leaks, skin irritation, or an unusual stoma color. Always treat ostomy care with sensitivity, as it can affect the resident's body image.
Constipation, Incontinence, and Retraining
Constipation (hard, infrequent stool) is common in older adults; help prevent it with fluids, fiber, and activity, and report no bowel movement for several days or signs of impaction (hard stool blockage, sometimes with leaking liquid stool around it). Incontinence is the loss of bladder or bowel control. Manage it with respect and skin protection: change wet or soiled clothing and linens promptly, provide gentle peri-care, apply a barrier cream as ordered, and never scold or shame the resident.
Bladder and bowel retraining programs help residents regain control. The aide supports the program by taking the resident to the toilet on a set schedule (often every 2 hours and after meals, when the gastrocolic reflex aids a bowel movement), encouraging fluids during the day, offering positive encouragement, and accurately recording results. Patience and a consistent routine are essential.
Example: An aide is giving peri-care to an uncircumcised male resident with an indwelling Foley catheter. The aide provides privacy and dons gloves, retracts the foreskin and cleans the tip of the penis in a circular motion from the urethra outward, then cleans the catheter from the meatus down about four inches with a clean stroke away from the body, returns the foreskin to its natural position, and ensures the drainage bag hangs on the bed frame below the level of the bladder with kink-free tubing. The aide notices the urine is cloudy and foul-smelling and reports it to the nurse as a possible infection.
Put these perineal-care steps in the correct order for a female resident.
Arrange the items in the correct order