11.1 Normal Elimination and Toileting Assistance

Why Elimination Care Matters on the INACE

Assisting with elimination (urination and defecation) is among the most frequent tasks a Certified Nursing Assistant (CNA) performs, and it appears on the Illinois Nurse Assistant Competency Examination (INACE) both in the 85-question written test and in the hands-on skills evaluation. The INACE is administered by Southern Illinois University Carbondale (SIUC) on behalf of the Illinois Department of Public Health (IDPH); you must pass both the written and manual-skills components within 24 months of finishing your IDPH-approved Basic Nurse Assistant Training Program to be listed on the Illinois Health Care Worker Registry.

Good toileting care protects three things the exam emphasizes repeatedly: dignity, independence, and skin integrity. Urine and stool are acidic and contain bacteria; even 15-30 minutes of skin contact can begin breakdown and lead to a pressure injury or a urinary tract infection (UTI). Knowing what "normal" looks like is what lets you recognize and report the abnormal.

Normal Voiding (Urination)

The single most testable threshold: report urine output under 30 mL per hour to the nurse, because that signals dehydration or possible kidney problems. An adult who has not voided in 8 hours may have urinary retention and needs nurse assessment.

Abnormal Urine — Report to the Nurse

Normal Bowel Elimination

A normal pattern ranges from 3 stools per day to 3 per week — frequency varies widely between people, so the resident's own baseline matters more than a fixed number. Normal stool is brown, soft, and formed. Use the watchwords below; the bolded items are the ones examiners most often pair with "report immediately."

• Black, tarry stool (melena) — upper gastrointestinal (GI) bleeding; report at once.
• Bright red blood — lower GI bleeding or hemorrhoids.
• White/clay-colored — liver or gallbladder problem.
• Watery diarrhea — infection (including Clostridioides difficile), medication.
• No bowel movement in 3+ days — risk of constipation or fecal impaction.

Worked Scenario: The Reluctant Resident

Mrs. Alvarez, age 84, rings her call light asking for the bedpan. By the time you arrive 12 minutes later she has had an incontinent episode and is embarrassed. The exam-correct sequence: respond to call lights promptly (urgency plus delay equals accidents and falls), provide perineal care wiping front to back, change linens, and report the pattern. Slow call-light response is a documented driver of both incontinence and fall injuries, so on the INACE "answer call lights promptly" is almost always a correct option.

Toileting Assistance Procedures

Bathroom / commode: assist with the proper mobility aid, give privacy (door closed, stay within hearing), keep toilet paper within reach, assist with front-to-back hygiene and handwashing, then observe contents before flushing.

Bedpan: apply gloves; warm the pan under running water; raise the head of the bed about 30 degrees if not contraindicated for a natural sitting position; for a fracture pan, the flat low end goes under the buttocks; remove gently, provide perineal care, and measure output if the resident is on intake and output (I&O).

Urinal (male): position between the legs or hand it to the resident, give privacy, then empty, measure, and clean.

Promoting Regular Elimination

Measuring Intake and Output (I&O)

Many residents are placed on I&O monitoring, and the INACE expects accurate measurement in milliliters (mL), not ounces. Memorize the conversion 1 ounce = 30 mL, so a 240 mL cup of water equals 8 ounces and a 120 mL juice box equals 4 ounces. Record voided urine, emesis, and liquid stool as output; record water, juice, milk, soup, gelatin, and ice cream as intake. Always measure urine in a graduate at eye level on a flat surface, never by guessing from the toilet or bedpan.

Incontinence Care and Skin Protection

When a resident is incontinent, change wet or soiled briefs and linens promptly, cleanse gently front to back, pat dry, and apply a barrier cream only if it is part of the care plan. Leaving skin wet leads to incontinence-associated dermatitis and pressure injuries. Use a scheduled toileting plan (offering the toilet every 2 hours, for example) to reduce episodes, and never scold or rush a resident — embarrassment lowers cooperation and dignity.

Common traps: do not withhold fluids to control incontinence (it concentrates urine and worsens UTI risk); never assume iron or beets explain dark stool without nurse assessment; always measure output at eye level in a graduate if the resident is on I&O; and report rather than dispose of unusual contents before the nurse can assess them.