6.4 Elimination Care & Catheter Support

Elimination is a basic physiological necessity that is often associated with embarrassment, anxiety, and a loss of independence for residents in long-term care. In Oregon, Certified Nursing Assistants must provide elimination care with the utmost respect for privacy, while adhering to strict infection control and safety standards. This section covers the correct use of elimination equipment and the clinical guidelines for urinary catheter care.

Equipment for Elimination

CNAs must select and assist with the appropriate equipment based on the resident's physical capabilities and care plan:

1. Urinals: Plastic containers used primarily by male residents for urination. The CNA should assist with positioning the urinal between the resident's legs, ensuring the opening is placed correctly to prevent spills. Urinals should be emptied immediately after use, and the CNA must observe the urine for color, clarity, and volume before dumping it. Urinals must never be placed on overbed tables or bedside stands where food is served.
2. Bedpans: Used for residents who cannot get out of bed for bowel movements or urination.
   • Standard Bedpan: A metal or hard plastic pan with a wide, contoured rim. It is placed under the resident with the wider, rounded end positioned toward the front of the body.
   • Fracture Bedpan: A flatter pan with a thin rim and a handle. It is designed for residents who cannot lift their hips easily due to a hip fracture, hip replacement, cast, or severe spinal arthritis. It is slid under the buttocks from the side, with the flat, lower end positioned under the buttocks.
   • CNA Action: When a resident is on a bedpan, the CNA should raise the head of the bed to a semi-Fowler's position (unless contraindicated) to mimic a natural sitting position, which facilitates elimination. Always leave the call light in the resident's hand.
3. Bedside Commodes: Portable chairs with toilet seats and removable buckets underneath. Used for residents who can get out of bed but cannot walk to the bathroom.
   • Safety: The CNA must lock the commode wheels before transferring the resident. Ensure the resident wears non-slip footwear, and provide privacy by draping them.

Urinary Catheter Care and Infection Prevention

An indwelling urinary catheter (Foley catheter) is a tube inserted into the bladder to drain urine. Catheters carry an extremely high risk of causing Catheter-Associated Urinary Tract Infections (CAUTIs). CNAs must follow strict clinical guidelines during catheter care, which is a frequently tested skill on the Oregon TMU/Headmaster exam:

• Catheter Care Steps:
  • Wash hands and apply clean gloves.
  • Place a protective pad under the resident.
  • Perform perineal care first.
  • Oregon TMU/Headmaster testing point: Hold the catheter tubing securely near the urethra (meatus) with one hand. This prevents traction, pulling, or displacement of the catheter, which can cause severe injury to the urethral tissues.
  • Infection Control: With a clean washcloth, soap, and water, wipe away from the meatus down the catheter tubing for at least 4 inches. Wiping away from the body prevents pushing bacteria up the tube into the urinary tract.
  • Use a clean portion of the washcloth for each downward stroke. Never wipe back toward the meatus.
  • Rinse and dry the tubing, then remove gloves and wash hands.

Catheter Safety and Drainage Bag Management

To maintain gravity drainage and prevent infection, the CNA must manage the catheter system safely:

• Bag Position: The drainage bag must always be kept below the level of the bladder. If the bag is raised above the bladder (such as during transfers or repositioning), urine will flow backward (retrograde flow) into the bladder. This backflow carries bacteria from the bag into the sterile bladder, leading to a severe UTI.
• Attachment: Attach the drainage bag to the bed frame (a non-moving part of the bed). Never attach it to the bed rail, as raising or lowering the rail can pull the catheter out or raise the bag above bladder level.
• Floor Contact: The drainage bag and tubing must never touch the floor, as the floor is highly contaminated.
• Tubing Care: Ensure there are no kinks, twists, or loops in the tubing that could obstruct the flow of urine, which can cause bladder distension and pain.

Emptying and Measuring Catheter Output

Catheter bags must be emptied at least once per shift, when they become full, or as directed by the care plan. The steps to empty and measure urine are strictly evaluated:

1. Preparation: Wash hands and put on gloves. Place a paper towel on the floor, and place a clean, graduated measuring container (graduate) on top of the paper towel.
2. Draining: Open the drain clamp (spigot) on the bottom of the bag. Point the spigot into the graduate.
   • Infection Control: The spigot must never touch the sides of the graduate or the floor.
   • Allow all urine to drain completely.
3. Closing and Sanitizing: Close the drain clamp. Wipe the spigot with an alcohol prep pad before inserting it back into its protective holder. This prevents bacteria from multiplying at the tip of the drain.
4. Measuring: Place the graduate on a flat surface in the bathroom.
   • Measurement: Read the urine level at eye level to ensure accuracy. Record the output in milliliters (mL).
5. Clean-Up: Discard the urine in the toilet. Rinse the graduate, dry it, and return it to the resident's designated storage area. Remove gloves, wash hands, and document the output. Report any unusual findings (such as blood in the urine, cloudiness, sediment, or a strong odor) to the charge nurse immediately.