Toileting & Elimination
Key Takeaways
- A standard bedpan is placed with the wider rounded end toward the resident's head; a fracture pan is flatter and placed with the shallow flat end toward the head.
- Functional incontinence is the type a nurse aide most directly controls: answer call lights promptly, offer scheduled toileting, and keep the path clear and lit.
- Never scold, shame, or hurry a resident over an incontinence episode; change them promptly and matter-of-factly and record it without editorial.
- Small liquid stool leaking after several days without a bowel movement suggests fecal impaction and is reported immediately.
- In Rhode Island an enema and a colostomy irrigation may be performed only under direct supervision, and digital removal of an impaction is never a nursing assistant duty.
Toileting & Elimination
Elimination of body wastes is a fundamental human physiological need. Assisting residents with urinary and fecal elimination requires the Certified Nursing Assistant (CNA) to maintain bodily hygiene, preserve resident dignity, meticulously measure fluid balance, and prevent infection. Because changes in elimination patterns often signal acute medical complications (such as urinary tract infections, renal failure, bowel obstruction, or internal bleeding), the CNA must understand normal standards and report abnormal findings immediately.
Normal Characteristics & Observations
| Parameter | Normal Findings | Abnormal Findings (Report Immediately) |
|---|---|---|
| Urine Volume | 1,200 mL – 1,500 mL per 24 hours (approx. 30 mL/hour minimum) | Less than 30 mL/hour (oliguria), total absence (anuria), or excessive output (polyuria) |
| Urine Color & Clarity | Clear, pale yellow to deep amber; transparent | Dark amber (dehydration), cloudy/turbid (infection), pink/red (hematuria), tea-colored (liver breakdown) |
| Urine Odor | Faint, characteristic aromatic odor | Foul, pungent, or ammoniacal odor (infection); sweet/fruity odor (diabetic ketoacidosis) |
| Stool (Feces) | Soft, formed, brown, shaped like rectum | Hard/pellet-like (constipation), liquid (diarrhea), black/tarry (melena/upper GI bleed), bright red blood (hematochezia), clay-colored (biliary obstruction) |
Elimination Equipment & Positioning Protocols
1. Standard Bedpan vs. Fracture Bedpan
Bedpans are utilized for bedbound residents who cannot ambulate to the bathroom or bedside commode.
-
Standard Bedpan:
- Design: Made of heavy plastic, shaped like a contoured toilet seat with a deep bowl.
- Placement: Positioned with the wider, rounded rim toward the resident's head and the narrower, tapered end toward the resident's feet.
- Procedure: Have resident flex knees and press down on heels to raise hips (or roll resident onto side, press pan against buttocks, and roll back onto pan).
- Positioning: Elevate head of bed to semi-Fowler's or Fowler's position (30°–60°) to mimic natural sitting elimination gravity.
-
Fracture Bedpan:
- Design: Lower profile, flatter wedge shape with a shallow bowl and a handle at the flat end.
- Indications: Used for residents with hip fractures, total hip replacements, spinal cord injuries, lower extremity casts, or severe arthritic immobility who cannot raise hips.
- Placement: Positioned with the shallow, flat end toward the resident's head and the handle facing the foot of the bed.
Bedpan Placement Comparison:
STANDARD BEDPAN: [Wider Rounded End --> Head] | [Narrow Tapered End --> Feet]
FRACTURE BEDPAN: [Flat Shallow End --> Head] | [Handle End --> Feet]
2. Urinal & Bedside Commode Assistance
- Urinals: Used primarily for male elimination. Can be used in bed or seated position. Ensure handle is secure, cap is snapped closed immediately after use to prevent spills, and intake/output is measured before emptying.
- Bedside Commode: A portable chair with a toilet seat and removable bucket underneath. Ideal for residents who can get out of bed but cannot walk to the bathroom. Always lock commode wheels, ensure grab arms are stable, and use a gait belt during transfers.
Incontinence Care
Incontinence is the involuntary loss of urine or stool. It is common, it is not a normal part of aging, and it is never treated as the resident's fault.
Immediate care after an episode
- Respond promptly and without comment. Do not sigh, do not mention it to anyone who does not need to know, and do not let the resident overhear a complaint about the work.
- Provide privacy and gather supplies before you start so the resident is not left exposed while you search for a washcloth.
- Put on gloves and provide perineal care front to back, using a clean area of the washcloth for each stroke.
- Pat the skin dry rather than rubbing, and apply a moisture barrier if the care plan directs it.
- Change all soiled linen and clothing, checking that the bottom sheet is dry and wrinkle-free.
- Inspect the skin while you are there — moisture-associated damage and pressure injuries live in exactly this area.
- Record the episode so the nurse can adjust the toileting schedule, and report any new incontinence, redness, breakdown, odor, or the resident's report of burning.
Types of incontinence
| Type | What triggers it |
|---|---|
| Stress | Coughing, sneezing, laughing, lifting |
| Urge | A sudden overwhelming need with too little warning to reach the toilet |
| Overflow | Frequent small dribbles from a bladder that never empties |
| Functional | The bladder works, but mobility, dexterity, vision, or cognition prevents reaching or using the toilet in time |
| Mixed | More than one of the above together |
Functional incontinence is the type nurse aides most directly influence: an answered call light, an accessible bathroom, adequate lighting, easy clothing, and a scheduled offer of toileting can resolve it entirely.
Observing and Reporting Elimination
| Report | Because it may indicate |
|---|---|
| Cloudy, dark, or foul-smelling urine | Urinary tract infection or dehydration |
| Blood in urine (hematuria) or blood in stool | Infection, injury, or bleeding requiring evaluation |
| Burning, pain, or urgency on urination (dysuria) | Urinary tract infection |
| Output under 30 mL/hour, or no urine at all | Retention, dehydration, or kidney failure |
| No bowel movement in three days | Constipation progressing toward impaction |
| Small liquid stool leaking around a hard mass | A classic sign of fecal impaction — report immediately, do not treat |
| Black, tarry stool | Upper gastrointestinal bleeding |
| White, clay-colored stool | Biliary problem |
| Diarrhea | Infection, medication effect, or C. difficile — report and use Contact Precautions if directed |
| Abdominal distention, hardness, or pain | Obstruction, retention, or impaction |
⚠️ Scope reminders for elimination care in Rhode Island. An enema and a colostomy irrigation may be performed only under direct supervision. Digital removal of an impaction is never a nursing assistant duty. Assisting with a commode, toilet, bedpan or urinal, emptying a catheter bag, assisting with an ostomy appliance, and assisting with bowel and bladder retraining are all routine duties (216-RICR-40-05-22.12.1).
Which bedpan is specifically designed for a resident who has a total hip replacement or spinal injury?
A resident who has not had a bowel movement in four days begins passing small amounts of liquid stool. What does this most likely indicate?
A resident who can walk with a walker is repeatedly incontinent because she cannot reach the bathroom in time and her call light often goes unanswered for several minutes. What type of incontinence is this, and what is the nurse aide's most effective response?