1.4 Elimination Assistance & Catheter Care
Key Takeaways
- A standard bedpan is positioned with the wide curved end under the buttocks, whereas a fracture bedpan has a low, tapered wedge design (narrow end under the lower back/buttocks) specifically indicated for residents with hip fractures, joint replacements, or spinal immobility.
- Indwelling Foley catheter care requires cleaning the tubing at least 4 inches (10 cm) downward away from the urethral meatus, using a fresh surface of the washcloth for every cleansing stroke while stabilizing the tubing.
- Catheter drainage bags must ALWAYS be maintained below the level of the bladder at all times, off the floor, and secured to the stationary bed frame—never to movable bed side rails.
- Urine output must be measured at eye level on a flat, level surface using a calibrated graduated cylinder, recording the exact volume in milliliters (mL/cc).
- Bladder and bowel retraining programs promote continence through scheduled toileting intervals, fluid management, meticulous intake/output tracking, and consistent positive reinforcement.
Elimination Assistance & Catheter Care
Assisting residents with elimination is a core nursing assistant responsibility that requires clinical precision, strict infection control, and profound sensitivity to resident privacy, modesty, and emotional dignity. Elimination needs must be answered promptly; delays cause physical discomfort, urinary/fecal incontinence, moisture-associated skin damage, and dangerous unassisted fall attempts.
1. Elimination Equipment & Clinical Selection
Selecting the appropriate elimination device depends on the resident's physical mobility, cognitive status, and medical-surgical restrictions.
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| ELIMINATION DEVICE MATRIX |
| |
| [STANDARD BEDPAN] ---> Deep, contoured bowl with wide flat rim. |
| Placed with WIDE rim under buttocks, narrow to feet.|
| For residents who can lift hips (bridge). |
| |
| [FRACTURE BEDPAN] ---> Shallow, flat wedge design with low profile. |
| Narrow, flatter end slides under lower back/buttocks.|
| Indicated for HIP FRACTURES, THA, SPINAL INJURY. |
| |
| [URINAL] ---> Handheld plastic container with handle for males. |
| Used in bed, seated, or standing position. |
| |
| [BEDSIDE COMMODE] ---> Portable chair with toilet seat and bucket. |
| For residents who can stand/pivot but cannot walk |
| the full distance to the bathroom. |
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Clinical Comparison of Elimination Equipment
| Equipment Type | Target Resident Population | Proper Positioning & Technique |
|---|---|---|
| Standard Bedpan | Bedbound residents who possess sufficient lower-body strength to raise their hips (bridging). | Position the wide, curved seat rim under the resident's buttocks; the narrower, tapered end points toward the resident's feet. |
| Fracture Bedpan | Residents with hip fractures, total hip replacement (THA), spinal fusion, leg casts, or severe arthritis who cannot lift their hips. | The flatter, low-profile wedge end slides smoothly under the buttocks/lower back with minimal hip flexion or movement; the handle/deeper end points toward the feet. |
| Male Urinal | Male residents requiring bladder elimination while in bed or seated at the bedside. | Position the penis fully inside the opening. If the resident is capable, allow them to hold and position the urinal independently. Keep handle upright. |
| Bedside Commode (BSC) | Residents with limited endurance or mobility who can bear weight and transfer safely. | Position commode parallel or at a 45-degree angle to the bed on the strong side. Lock commode wheels (if present) and ensure non-skid footwear. |
Procedural Protocol for Bedpan Placement:
- Warm the Pan: If using a metal bedpan, run warm water over the underside to take off the chill, and dry thoroughly.
- Apply Powder (Optional): Lightly dust the rim with talc-free powder or barrier spray if appropriate to prevent the pan from sticking to fragile skin.
- Positioning the Resident:
- Option A (Bridging): If the resident can assist, ask them to bend their knees and press their heels into the mattress to lift their hips. Slide the bedpan underneath.
- Option B (Logroll / Side-Turn): If the resident is weak or dependent, turn the resident onto their side facing away from you. Place the bedpan firmly against their buttocks, and gently roll the resident back onto the pan.
- Elevate Head of Bed: Once the bedpan is positioned, raise the head of the bed to Fowler's position (45–60 degrees) unless contraindicated. Sitting upright places the abdominal muscles in a natural anatomical position and utilizes gravity to facilitate bladder and bowel emptying.
- Privacy & Safety: Place toilet paper and the call signal within immediate reach. Step outside the room to provide privacy if the resident is safe to be left alone.
2. Indwelling Foley Catheter Care & CAUTI Prevention
An indwelling urinary (Foley) catheter is a flexible tube inserted through the urethra into the bladder, held in place by a small balloon inflated with sterile water. Catheter-Associated Urinary Tract Infections (CAUTIs) are among the most common and dangerous healthcare-associated infections. Nursing assistants play a pivotal role in preventing bacterial colonization along the catheter lumen.
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| FOLEY CATHETER CLEANSING TECHNIQUE |
| |
| [1. EXPOSE & DRAPE] ---> Expose ONLY perineal area to maintain dignity. |
| [2. STABILIZE TUBE] ---> Hold catheter at URETHRAL MEATUS with one hand. |
| Prevents painful tension/pulling on balloon. |
| [3. CLEANSE DOWNWARD]---> Wash at least 4 INCHES (10 cm) DOWN the tube |
| AWAY from the meatus in ONE smooth stroke. |
| [4. FRESH SURFACE] ---> Use a DIFFERENT clean area of the washcloth |
| for EVERY single stroke. |
| [5. RINSE & DRY] ---> Rinse downward away from meatus; pat dry. |
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Step-by-Step Catheter Hygiene Protocol (clinical standard, not a scored ND task):
North Dakota's skill-task list contains no stand-alone catheter care task. What it does contain is "Donn an Isolation Gown and Gloves, then Empty a Urinary Drainage Bag, Measure and Record the Output, Doff the Gown and Gloves with Hand Washing" — one of the three mandatory first tasks. Learn the hygiene protocol below for the knowledge exam and daily practice; learn the drainage-bag steps for the skill test.
- Perform hand hygiene and don clean gloves.
- Expose only the resident's perineum, keeping the rest of the body covered with a bath blanket.
- Perform standard perineal hygiene (front-to-back for females; meatus outward for males).
- Stabilize the Catheter: Grasp the catheter tubing near the urinary meatus with your non-dominant gloved hand. This prevents accidental pulling, tugging, or dislodging of the internal retention balloon, which causes excruciating urethral trauma and severe hemorrhage.
- Cleanse Downward: Using a washcloth with warm water and mild soap, wipe at least 4 inches (10 cm) downward along the tubing away from the body in one smooth motion. Never wipe back toward the meatus.
- Change Washcloth Surface: Rotate the washcloth to expose a new, clean surface for every subsequent stroke. Clean the tubing thoroughly on all sides.
- Rinse & Dry: Rinse the catheter tubing using the same downward motion away from the meatus with a clean, damp cloth. Pat dry gently.
3. Catheter Drainage System & Tubing Management
Maintaining continuous gravity drainage and preventing retrograde flow of stagnant, bacteria-laden urine are absolute clinical imperatives.
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| CATHETER SYSTEM PLACEMENT RULES |
| |
| 1. ALWAYS BELOW BLADDER LEVEL ---> Prevents reflux/backflow of urine |
| 2. ATTACH TO BED FRAME ONLY ---> NEVER attach to movable side rails |
| 3. KEEP OFF THE FLOOR ---> Prevents floor microbial contamination|
| 4. ROUTE OVER TOP OF THIGH ---> Avoids pressure injury & kinks/loops |
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Clinical Rationale for Placement Rules:
- Below the Bladder: Urine in the drainage bag and tubing is heavily colonized with bacteria. If the drainage bag is elevated above the level of the bladder (e.g., during ambulation or transfers), urine flows backward (refluxes) into the sterile bladder cavity, causing rapid, severe CAUTI and potential urosepsis.
- Bed Frame Attachment: The drainage bag must be hooked to the non-movable bed frame. Never attach the bag to the movable side rails. If a side rail is raised or lowered while the bag is attached, the sudden tension will violently yank the catheter, tearing the urethra and bladder neck.
- Floor Clearance: The drainage bag and outlet port must never touch the floor, where dangerous multidrug-resistant pathogens (e.g., VRE, MRSA, C. difficile) reside.
- Tubing Alignment: Ensure the drainage tubing passes over the top of the resident's leg rather than underneath it. Placing tubing beneath the thigh traps the tube, causes painful localized pressure injuries, and occludes the gravity drainage pathway.
4. Emptying & Measuring Urine Output
Measuring urinary output accurately is essential for monitoring renal function, fluid balance, and hemodynamic status.
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| URINE OUTPUT MEASUREMENT STEPS |
| |
| 1. BARRIER ON FLOOR ---> Place paper towel barrier beneath drainage bag.|
| 2. POSITION GRADUATE ---> Place calibrated graduate on paper barrier. |
| 3. OPEN DRAIN SPOUT ---> Open clamp without touching spout to container.|
| 4. DRAIN COMPLETELY ---> Empty all urine into graduated cylinder. |
| 5. DISINFECT & CLOSE ---> Wipe spout with alcohol pad; close and store. |
| 6. EYE-LEVEL READING ---> Place graduate on FLAT surface; read at EYE LEVEL|
| 7. RECORD IN ML (CC) ---> Document exact volume, color, clarity, & odor. |
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Eye-Level Measurement Technique:
To read the volume accurately, place the graduated cylinder on a flat, stable surface (protected by a paper towel barrier) in the bathroom. Bend down or kneel so your eyes are directly level with the top meniscus of the fluid line. Never hold the graduate up in the air to read it, as tilting produces significant measurement errors.
Clinical Observations of Urine to Report Immediately:
- Oliguria / Anuria: Output less than 30 mL/hour or no urine output over 2 to 4 hours.
- Hematuria: Bright red, pink, or tea-colored urine indicating internal bleeding.
- Cloudiness / Turbidity: Cloudy urine with heavy white sediment, mucus threads, or foul, pungent odor indicating urinary tract infection.
5. Bladder & Bowel Retraining Programs
Incontinence is not a normal or inevitable consequence of aging. Bladder and bowel retraining programs are structured restorative nursing interventions designed to help residents re-establish voluntary control over elimination.
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| BLADDER RETRAINING PROTOCOL ELEMENTS |
| |
| [SCHEDULED TOILETING] ---> Offer toilet/commode every 2 hours: |
| upon waking, after meals, and before bed. |
| |
| [FLUID MANAGEMENT] ---> Encourage adequate hydration during daytime |
| (1500–2000 mL/day); limit fluids right at bed. |
| |
| [ACCURATE TRACKING] ---> Meticulously log all voids, bowel movements, |
| and involuntary incontinent episodes. |
| |
| [POSITIVE SUPPORT] ---> Provide praise for success; NEVER shame or |
| scold the resident for accidental leakage. |
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The CNA's Role in Continence Retraining:
- Strict Schedule Adherence: Consistency is paramount. Take the resident to the bathroom or assist onto the commode precisely at scheduled times (e.g., every 2 hours throughout the day).
- Normal Toileting Posture: Ensure the resident is sitting fully upright with feet supported flat on the floor to promote pelvic floor relaxation and complete bladder emptying.
- Running Water & Relaxation: Turn on bathroom sink water or place the resident's hands in warm water to stimulate sensory voiding reflexes.
- Emotional Dignity: Treat incontinent episodes matter-of-factly without frustration, scolding, or annoyance. Maintaining a supportive, calm demeanor preserves resident dignity and fosters active participation in retraining.
A resident who recently underwent a total right hip replacement requires assistance with elimination in bed. Which type of bedpan should the CNA use, and how should it be positioned?
When performing indwelling Foley catheter care on a resident, which cleansing technique complies with infection control standards?
Where should a nursing assistant secure the drainage bag of an indwelling Foley catheter when positioning a resident in bed?
A CNA has emptied 450 mL of urine from a resident's Foley catheter drainage bag into a graduated cylinder. What is the correct method to measure and record the urine output?