3.4 Toileting, Bladder and Bowel
Key Takeaways
- Offer toileting on a regular schedule (typically every 2 hours) and any time the resident asks — promptness prevents incontinence and skin breakdown.
- Use a fracture pan (narrow end under the buttocks) for residents with hip surgery or limited mobility; a standard bedpan can be too deep and painful.
- Measure output in a graduated container at eye level in milliliters (mL); urinary output should normally be at least 30 mL/hour — report less than 30 mL/hour for two or more consecutive hours.
- Keep the urinary drainage bag BELOW the level of the bladder at all times to prevent backflow and infection; never lay it on the floor.
- There are five common types of urinary incontinence — stress, urge, overflow, functional, and mixed — each managed by toileting schedules, skin care, and reporting to the nurse.
Why Toileting Is High-Stakes
Falls during toileting are the #1 cause of injury falls in long-term care, and urinary tract infections (UTIs) from improper catheter and peri-care are one of the top three infection causes. The NNAAP skills test almost always includes either a bedpan placement, urinary output measurement, or catheter care station — and the written exam routinely asks about positioning, hourly output thresholds, and catheter bag height.
Toileting Equipment
| Device | When Used | Key Technique |
|---|---|---|
| Toilet | Ambulatory residents | Ensure call light is in reach; never leave a fall-risk resident alone unless safe |
| Bedside commode | Cannot walk to bathroom but can transfer | Lock wheels; place close to bed; cover with seat after use |
| Standard bedpan | Bedrest resident | Wide end goes toward the back of the buttocks, narrow end toward the knees |
| Fracture pan | Hip surgery, hip fracture, or limited hip movement | Narrow end goes under the buttocks, wide end toward the knees |
| Urinal | Male resident | Place between thighs; ensure the penis is inserted into the opening; remove promptly when finished |
Why the fracture pan matters: a standard bedpan is too deep and requires the resident to lift the hips high — painful and unsafe after hip surgery. The fracture pan has a shallow, flat end designed to slide under the buttocks with minimal hip flexion.
Output Measurement
CNAs in North Carolina facilities measure and record fluid output on the Intake and Output (I&O) record. Errors here lead to medication and treatment errors at the nursing level.
- Use a graduated container (calibrated measuring cup).
- Place it on a flat surface and read it at eye level to get an accurate volume.
- Record in milliliters (mL) — 30 mL = 1 ounce.
- Empty the container into the toilet, rinse, store properly.
- Record output for every voiding episode, not just at the end of the shift.
Critical Thresholds
- Adults normally produce at least 30 mL per hour of urine — about 720 mL (24 oz) per 24 hours as an absolute minimum, with normal volumes around 1,500 mL per day.
- Report to the nurse any urine output under 30 mL per hour for two consecutive hours — this can signal dehydration, kidney problems, or a blocked catheter.
- Also report cloudy, dark, foul-smelling, or bloody urine; very small or very large volumes; or sudden changes in pattern.
Bladder Training
Many incontinent residents can regain control with a structured plan led by the nurse and supported by the CNA.
- Offer the toilet every 2 hours during waking hours initially.
- Praise success; never scold for accidents — shame causes withdrawal and depression.
- Once the resident is dry consistently, gradually lengthen the interval to every 3 then every 4 hours.
- Encourage adequate fluids (1,500–2,000 mL/day unless restricted) — restricting fluids worsens bladder irritability.
- Offer the toilet before and after meals, before bed, and on waking.
Bowel Training
- Establish a regular time daily (often 30 minutes after breakfast — the gastrocolic reflex helps).
- Encourage fiber (fruits, vegetables, whole grains), fluids, and ambulation.
- Provide privacy and time — do not rush.
- Position upright with feet flat (use a foot stool) when possible.
Recognizing Constipation
- No bowel movement for 3 days (varies by resident baseline)
- Hard, dry, small stools
- Abdominal distension, cramping, or discomfort
- Decreased appetite, nausea
- Straining; resident reports "feeling full"
Report constipation to the nurse. CNA interventions include encouraging fluids, fiber, and ambulation — but the nurse decides on any medication or enema.
Types of Incontinence
| Type | Cause | Typical Pattern |
|---|---|---|
| Stress | Weak pelvic floor (often after childbirth, aging) | Leaks with cough, sneeze, laugh, lifting |
| Urge | Overactive bladder muscle | Sudden strong urge with little warning |
| Overflow | Bladder cannot empty fully (e.g., enlarged prostate) | Small, frequent dribbles; resident still feels full |
| Functional | Bladder works, but the resident cannot reach the toilet in time (mobility, dementia) | Accidents when staff are slow to respond |
| Mixed | Combination, usually stress + urge | Mixed patterns above |
Skin Care for Incontinent Residents
- Change briefs as soon as soiled, not on a schedule.
- Wash gently with warm water and a pH-balanced cleanser; rinse and pat dry.
- Apply barrier cream (zinc oxide, dimethicone) as ordered.
- Inspect for redness, breakdown, fungal rashes — report all findings.
- Never use baby powder unless ordered; it cakes and irritates the skin.
Catheter Care — The Most Tested Sub-Topic
Indwelling Foley catheters keep the bladder continuously drained. They are convenient but carry a high UTI risk, so technique is everything.
Daily Care Rules
- Keep the drainage bag BELOW the level of the bladder at all times — gravity drains urine away from the body; raising the bag refluxes urine back into the bladder and causes infection.
- Never lay the bag on the floor — contamination risk.
- Secure the tubing to the inner thigh (or abdomen for some male residents) with a leg strap or tape to prevent pulling on the catheter.
- Avoid kinks, loops, or pressure on the tubing — the urine must drain freely.
- Provide peri-care twice daily and after every bowel movement. Wash the catheter from the meatus outward for about 4 inches.
- Empty the bag at the end of each shift (or when 2/3 full); use a separate measuring container — never let the drainage spout touch the container.
- Encourage fluids (unless restricted) to flush the bladder.
Report Immediately
- Cloudy, bloody, or foul-smelling urine
- Decreased output (less than 30 mL/hour for 2+ hours)
- Resident reports burning, urgency, abdominal pain
- Fever, chills, confusion (UTI can present as new confusion in older adults)
- Catheter pulled, leaking, or dislodged
A CNA is positioning a fracture pan for a resident two days post-hip replacement. The narrow end of the fracture pan should be placed:
A CNA finds that a resident's Foley catheter drainage bag has been placed on the bedside table while the resident eats lunch sitting in a chair. The correct action is: