Elimination and Urinary Catheter Care

Assisting with Elimination

Helping residents urinate and have bowel movements is daily CNA work, and how you do it determines whether a resident keeps or loses continence, skin integrity, and self-respect. The first rule is to respond promptly when a resident signals the need to eliminate. Waiting leads to incontinence episodes, skin breakdown, and falls - a resident who cannot hold it will try to get up alone.

Equipment and Positioning

• Bedpan - for residents who cannot get out of bed. Warm a metal pan first, powder it lightly if policy allows, and position the resident in a semi-upright (semi-Fowler's) position, which is the natural posture for elimination. A fracture pan - flatter, with a shallow end - is used for residents with hip fractures, hip replacements, or spinal injuries who cannot lift onto a standard pan
• Urinal - for male residents; hand it to the resident if he can manage it, or position it for him, and hang it on the bed rail afterward, never on the overbed table where food is served
• Bedside commode - for residents who can transfer but cannot walk to the bathroom; place it close to the bed and lock its wheels
• Bathroom or toilet - stay within hearing, never lock the door, and teach residents to use the call light rather than standing up alone

Whichever device is used: provide privacy, put toilet paper and the call light within reach, stay nearby for weak residents, wear gloves, and help the resident wash their hands afterward - then wash your own. Do not leave a resident sitting on a bedpan for a long time; the hard edge damages skin and can start a pressure injury. Empty, clean, and store equipment properly, because bedpans and urinals are sources of odor and infection.

Assisting with a bedpan and measuring and recording output is a named Montana skills task, so practice the full sequence including hand washing, gloving, measuring, and recording.

Observing Urine and Stool

You are the nurse's eyes at the bedside. Every time you empty a bedpan, urinal, commode, or drainage bag, look before you flush or discard.

Also note the amount. Normal urine output is roughly 1,500 milliliters (mL) per day; adult kidneys produce about 30 to 60 mL per hour. Output below about 30 mL in an hour, or a resident who has not voided in 8 hours, is reported to the nurse. When a resident is on intake and output (I&O) monitoring, every void must be measured in a graduate and recorded in milliliters before it is discarded.

Urinary Catheter Care

An indwelling urinary catheter (Foley catheter) drains urine continuously from the bladder through tubing into a drainage bag. Because the catheter creates a direct pathway for bacteria into the bladder, catheter care is really infection prevention. The non-negotiable rules:

1. Keep the drainage bag below the level of the bladder at all times - during bed rest, transfers, and ambulation - so urine never flows backward into the bladder
2. Never let the bag or tubing touch the floor, and never hang the bag on a movable side rail (raising the rail could lift the bag above the bladder)
3. Keep tubing free of kinks and position it so the resident is not lying on it
4. Secure the catheter to the resident's thigh (or abdomen for males, per policy) so movement does not tug on the urethra
5. Keep the system closed - never disconnect the tubing from the catheter
6. Provide catheter care during daily perineal care: clean away from the urethral opening down the tubing with soap and water, one stroke, front to back

Report leaking, absence of drainage, cloudy or bloody urine, foul odor, or complaints of pain or burning - all signs of obstruction or urinary tract infection.

Emptying and Measuring a Drainage Bag

Emptying a urinary drainage bag is both a knowledge-test topic and a Montana skills task - donning a gown and gloves, emptying the urinary drainage bag, measuring and recording output, and doffing is on the published list. The measured steps: put on a gown and gloves; place a paper towel under the drain; open the clamp and drain the urine into a graduate (a calibrated measuring container) held below the bag, taking care that the drain spout touches nothing - not the graduate, not your gloves; close the clamp and wipe the spout per policy; then set the graduate on a flat surface and read it at eye level to get an accurate volume. Record the amount in milliliters on the I&O sheet, empty the graduate into the toilet, clean and store it, remove your PPE, and wash your hands.

Incontinence Care and Dignity

Urinary incontinence (involuntary urine loss) is a symptom, not a normal part of aging, and it is one of the greatest threats to an older adult's dignity. For residents who use adult briefs: check the brief at least every 2 hours, change it promptly after every episode of wetness or soiling, give full perineal care with each change, and apply barrier cream per the care plan to protect against incontinence-associated dermatitis. Never refer to a brief as a diaper, never scold or hurry the resident, and keep the resident covered during changes.

Promoting Normal Elimination

The care plan usually aims at keeping or restoring continence, and you carry it out by:

• Offering the bedpan, urinal, or toilet on a scheduled toileting routine - after meals, before sleep, and every 2 hours as ordered
• Encouraging fluids as the care plan allows and fiber-rich foods for bowel regularity
• Helping the resident into a normal, upright position with privacy and unhurried time
• Answering call lights immediately, because the urge to void passes quickly

Report any change in a resident's usual pattern - new incontinence, new constipation, or new straining - because change, not just the finding itself, is what the nurse needs to know.