27. CCA Study Notes: Urinary Elimination, Urine Observation, and Toileting Assistance

The Big Picture

Urination means emptying urine from the bladder. People differ in how often they urinate, and many things affect how much urine the body produces.

When helping a client with toileting, pay attention to safety, privacy, comfort, and the client’s normal habits. Follow the client’s care plan and observe urine for changes that need reporting.

Clients may need help getting to the bathroom or may use equipment such as a raised toilet seat, bedpan, urinal, or commode.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

Normal Urination and Urinary Output

urinary output is the amount of urine a person excretes.

The care plan determines whether urinary output needs measurement and recording. Directions might require measurement:

• every hour
• at the end of each shift
• at the end of each day
• not at all

A healthy adult excretes about 1 500 mL of urine each day.

Several factors affect urine production:

• age
• disease
• the amount and kinds of fluid taken in
• dietary salt
• medications

Coffee, tea, alcohol, and some medications increase urine production.

A high-salt diet causes the body to retain water. When the body retains more water, it produces less urine.

dehydration means the amount of water in body tissues decreases because fluid output exceeds fluid intake. Causes include:

• low fluid intake
• vomiting
• diarrhea
• bleeding
• excessive sweating
• increased urine production

Urination, Micturition, and Voiding

urination means emptying urine from the bladder. The terms micturition and voiding mean the same thing.

Urination frequency varies from person to person. Factors include:

• fluid intake
• personal habits
• access to toilet facilities
• activity
• work
• illness

People often void:

• after getting up
• before meals
• at bedtime

Some people void every 2 to 3 hours. Others void less often.

Needing to void during the night disturbs sleep for many people.

Key fact: Many clients in facilities experience urinary incontinence, but incontinence is not a normal part of aging.

Helping Maintain Normal Elimination

Always follow the client’s care plan when helping with urinary elimination.

Clients might need:

• help getting to the bathroom
• a raised toilet seat because of mobility or hip challenges
• a bedpan
• a urinal
• a commode

When supporting normal elimination:

• Practise medical asepsis and follow Standard Practices.
• Give fluids as directed in the care plan.
• Learn the client’s normal voiding routine and habits. Check the care plan and speak with the supervisor.
• Help the client reach the bathroom when requested, or provide the required commode, bedpan, or urinal.
• Respond promptly because the need to void might be urgent.
• Help the client use a normal voiding position when possible. Women sit or squat, and most men stand.
• Warm a bedpan or urinal under warm water for comfort.
• Keep the client covered for warmth and privacy.
• Close curtains, room doors, bathroom doors, drapes, or window shades for privacy.
• Leave the room when the client is safe alone.
• Stay nearby when the client is weak or unsteady.
• Keep toilet tissue and the call bell ⓘ within reach in facilities.
• Give the client enough time. Do not rush.
• Do not leave a client lying on a bedpan for a long time. Extended pressure might cause skin irritation or pressure sores.
• Support relaxation. Some people prefer to read during elimination.
• For difficulty starting urination, wrapping a warm blanket around the client is one approach described for promoting relaxation.
• Give perineal care as needed.
• Help the client perform proper hand hygiene after voiding.
• Offer the bathroom, bedpan, urinal, or commode at regular times when a client feels too embarrassed or weak to ask.

Some clients feel embarrassed when other people are nearby while they urinate. Running sink water, flushing the toilet, or sounds from a television or radio help mask urination sounds.

What Normal Urine Looks Like

Observe urine for:

• colour
• clarity
• odour
• amount
• particles

Normal urine is usually:

• pale yellow, straw-coloured, or amber
• clear
• free of particles
• faint in odour

Foods, Medications, and Urine Changes

Some normal colour changes come from food.

Red food dyes, beets, blackberries, and rhubarb make urine appear red.

Carrots and sweet potatoes produce a bright yellow colour.

Certain medications also change urine colour.

Asparagus changes the odour of urine.

Dark urine is listed as a possible sign of dehydration.

Abnormal Urine and Reporting

Report: Tell the supervisor when urine looks or smells abnormal.

Do not discard abnormal urine before the supervisor has had a chance to observe it.

Instead:

1. Cover the urine with a labelled paper towel.
2. Keep it in the client’s bathroom or the soiled utility room.
3. Wait until the supervisor observes it or gives permission to dispose of it.

Also report client complaints of:

• urgency
• burning during urination
• dysuria, which means painful or difficult urination

Dysuria is usually caused by a urinary tract infection (UTI).

Common Urinary Elimination Difficulties

Dysuria

dysuria means painful or difficult urination.

Listed causes include:

• urinary tract infection
• trauma
• urinary tract obstruction

Hematuria

hematuria means blood in the urine.

Listed causes include:

• kidney disease
• urinary tract infection
• trauma

Nocturia

nocturia means frequent urination at night.

Listed causes include:

• increased blood flow to the kidneys while lying down, leading to increased urine production
• excessive fluid intake
• kidney disease
• disease of the prostate
• heart failure

Oliguria

oliguria means a scant amount of urine, usually less than 500 mL in 24 hours.

Listed causes include:

• inadequate fluid intake
• shock
• burns
• kidney disease
• heart failure

Polyuria

polyuria means producing abnormally large amounts of urine.

Listed causes include:

• medications
• excessive fluid intake
• diabetes
• hormone imbalance

Urinary Frequency

urinary frequency means needing to urinate at frequent intervals.

Listed causes include:

• excessive fluid intake
• bladder infections
• pressure on the bladder
• medications

Overflow Incontinence

overflow incontinence means urine leaks when the bladder becomes too full.

Listed causes include:

• weak bladder muscles that result in incomplete bladder emptying
• blockage or obstruction
• neurological conditions, including diabetic neuropathy, multiple sclerosis, and spinal cord injuries

Urinary Incontinence

urinary incontinence means an inability to control the passage of urine from the bladder.

Listed causes include:

• trauma
• disease
• urinary tract infections
• reproductive or urinary tract surgery
• aging
• fecal impaction
• constipation
• not reaching the bathroom in time

Aging appears among the listed possible causes, but urinary incontinence itself is not considered a normal part of aging.

Urinary Urgency

urinary urgency means needing to void immediately.

Listed causes include:

• urinary tract infection
• fear of incontinence
• a full bladder
• stress

Urinary Tract Infections

A urinary tract infection, or UTI, can occur when bacteria enter the urinary tract through the urethra ⓘ.

Bladder Infection

A bladder infection is called cystitis.

It occurs more often in women than men. The distance from the urethral opening to the anus is shorter in women. The distance from the urethral opening to the bladder is also shorter.

Urethral Infection

An infection of the urethra is called urethritis.

Bacteria from the gastrointestinal system and anus might spread to the urethra, usually through sexual practices. People of all genders experience urethral infections.

UTIs in Older Persons

In older people, UTIs can be caused by inadequate emptying of the bladder. This may happen because of urinary tract blockages, neurological causes such as stroke, or certain medications.

A urinary drainage catheter can also introduce harmful bacteria into the bladder.

Ways to Help Prevent UTIs

For all people, listed prevention measures include:

1. Maintain proper hydration. Water keeps urine diluted. Cranberry or blueberry juice is also listed.
2. Empty the bladder regularly.
3. Provide good perineal care after voiding, especially after a bowel movement.
4. Follow agency or facility instructions for catheter care.
5. Avoid unnecessary urinary catheterizations.

For clients with female genitalia:

6. Wipe from front to back.
7. Urinate soon after vaginal intercourse to help clear bacteria that may have entered the urethra.
8. Avoid douches, sprays, and powders that can alter the normal flora in the vaginal area.
9. Avoid bubble baths, bath oils, and other perfumed products that can irritate the urethra.
10. Wear breathable fabrics and loose-fitting clothing that keep the vaginal area dry.

Standard Practices During Elimination Care

Hand Hygiene and Gloves

Perform hand hygiene before and after wearing gloves.

Wear gloves whenever contact with urine, feces, secretions, or mucous membranes poses a risk. Examples include:

• assisting clients with diarrhea or urinary or fecal incontinence
• handling or cleaning bedpans, urinals, commodes, toilets, or bathroom floors
• handling soiled clothing or linens
• changing incontinence products
• measuring output
• collecting specimens

Change gloves between procedures on the same client because the gloves may be contaminated.

For example, change gloves after perineal care before cleaning an indwelling catheter.

Remove contaminated gloves before touching a clean surface. Remove soiled gloves before raising bed rails.

Handling Soiled Materials

Never place soiled incontinence briefs on the floor.

When you must remain with the client:

1. Place the soiled briefs at the foot of the bed.
2. Maintain the client’s safety and privacy.
3. Discard the briefs in the proper container.
4. Put the lid on the container for odour control.

Wear a protective apron or gown when blood, body fluids, secretions, or excretions might splash or spray you. Emptying bedpans or commodes is one example.

Carrying and Cleaning Equipment

Cover bedpans and tightly cap urinals before carrying them.

Dispose of body wastes immediately and carefully to avoid splashing.

If a splash occurs, clean the area immediately.

Clean and disinfect:

• bedpans
• urinals
• commodes

Do this immediately after use.

Place soiled disposable materials in leak-proof plastic bags. Seal them tightly. Immediately discard the bags according to employer policy.

Put soiled linen and clothing in the correct laundry hamper. Follow employer policy for laundering them as soon as possible.

In a client’s home, wash soiled linen separately from other laundry.

When supporting a client receiving cytotoxic chemotherapy medications, follow the required guidelines for handling linens and surfaces.

Bedpans

Who Uses a Bedpan

Bedpans serve clients who cannot get out of bed.

Clients with female genitalia use a bedpan for:

• urination
• bowel movements

Clients with male genitalia use a bedpan for bowel movements rather than urination.

Bedpans come in materials such as:

• plastic
• stainless steel
• biodegradable cardboard

Stainless steel bedpans often feel cold. Warm one under warm running water before use, then dry it with a paper towel.

A waterproof or incontinence pad placed beneath the bedpan helps protect the bed and linens.

Avoid: Do not dust the bedpan rim with powder to prevent sticking. This practice is no longer used because the powder might cause breathing difficulties.

Fracture Pans

A fracture pan, also called a slipper pan, has a thinner rim and measures about 1 cm deep at one end.

Place the smaller end under the client’s buttocks.

Fracture pans serve clients:

• in casts
• in traction
• with limited back movement
• with fragile bones or painful joints
• after a hip fracture

Follow medical asepsis and Standard Practices when handling a bedpan and its contents.

Clean the bedpan thoroughly after every use and follow employer policy.

Giving a Bedpan

Before the Procedure

1. Identify the client according to employer policy.
2. Explain the procedure.
3. Provide privacy.
4. Perform proper hand hygiene and put on gloves.
5. Gather the bedpan, bedpan cover or paper towels, toilet tissue, and extra gloves.
6. Arrange the equipment on a chair or bed. Keep heavily contaminated items off the overbed table because food is served there.

During the Procedure

7. Warm and dry the bedpan if needed.
8. Lower the bed rail nearest you if it is raised.
9. Place the client on the back with the bed as flat as possible. Pillows might support the head and shoulders.
10. Move the top linens and gown out of the way while keeping the lower body covered.
11. Ask the client to bend the knees and raise the buttocks by pushing the feet against the mattress.
12. Place your hand beneath the lower back and help raise the buttocks.
13. Slide the bedpan under the client.
14. If the client cannot help with placement:
    1. Turn the client onto the side away from you.
    2. Place the bedpan firmly against the buttocks.
    3. Push the bedpan down and toward the client.
    4. Hold the bedpan securely while turning the client onto the back.
    5. Make sure the bedpan sits centred beneath the client.
15. Cover the client.
16. Raise the head of the bed until the client reaches a sitting position. If the bed does not adjust, help the client sit with pillows for support.
17. Make sure the urethra and anus sit directly over the bedpan opening.
18. Raise the bed rail if it is used.
19. Put toilet tissue and the call bell within reach in facilities.
20. Ask the client to call when finished or when help is needed.
21. Perform proper hand hygiene.
22. Leave the room and close the door.
23. Return when the client calls. Knock before entering.
24. Perform proper hand hygiene and put on gloves.
25. Raise the bed to a comfortable working height. Lower the bed rail if used and lower the head of the bed. If pillows supported the client, remove them and place the client on the back.
26. Ask the client to raise the buttocks and remove the bedpan. If the client cannot raise the buttocks, hold the bedpan securely and turn the client onto the side facing away from you.
27. Clean the genital area when the client cannot do it independently. Wipe from front, at the urethra, toward the back, at the anus. Use fresh toilet tissue for every wipe. Provide perineal care.
28. Cover the bedpan and take it to the bathroom. Before leaving the bedside, lower the bed and raise the bed rail if used.
29. Observe the colour, amount, and character of the urine or stool.
30. Empty the bedpan into the toilet. Rinse it with cold water and clean it with disinfectant.
31. Remove the soiled gloves and perform proper hand hygiene.
32. Put the bedpan and lid away.
33. Help the client perform proper hand hygiene.

After the Procedure

34. Provide for safety and comfort.
35. Put the call bell within reach in facilities.
36. Follow the care plan for bed rail use.
37. Remove the privacy measures.
38. Follow employer policy for soiled linen.
39. Perform proper hand hygiene.

Report and record your actions, observations, and basic assessments according to employer policy. This information keeps the health care team informed and serves legal purposes.

Steps involving the call bell or bed rails do not apply in every community setting.

Urinals

Using and Storing a Urinal

Clients with male genitalia use urinals for voiding by placing the penis inside the urinal.

Some plastic urinals include:

• a cap
• a hook-style handle
• a one-way spout that helps prevent spills

Hang the urinal somewhere sturdy and within the client’s reach, such as:

• a bed rail
• the back of a chair

Never place a urinal on:

• an overbed table
• a bedside table
• a stand used as a work surface, eating surface, or place for the client’s belongings

Follow employer policy for urinal placement.

Position for Using a Urinal

Standing is the best listed position for bladder emptying.

A client using a urinal might:

• stand
• sit on the side of the bed
• lie in bed

Some clients need one or two people for support while standing. When a client cannot stand independently, the support worker might need to position and hold the urinal.

After Urination

When the urinal has a cap, remind the client to close it after voiding to prevent spills.

Remind the client to:

• hang the used urinal on a bed rail or chair back
• call when the urinal needs emptying

Follow medical asepsis and Standard Practices when handling the urinal or its contents.

A filled urinal spills easily and creates a safety hazard. Keeping a filled urinal nearby might also embarrass the client.

Empty filled urinals promptly. Rinse and clean them thoroughly after every use to control odours and reduce the buildup and spread of microbes.

Providing a Urinal to a Client With Male Genitalia

Before the Procedure

1. Provide privacy.
2. Decide whether the client will stand, sit, or remain in bed. The client needs a position that allows safe urination.
3. Explain the procedure.
4. Perform proper hand hygiene and put on gloves.

During the Procedure

5. When the client remains in bed, give the urinal to the client and remind them to tilt the bottom downward to prevent spills.
6. When the client will stand:
   1. Help the client sit on the side of the bed.
   2. Help the client put on nonskid footwear.
   3. Help the client stand and give support when unsteady.
   4. Give the client the urinal.
7. Position the urinal when needed. Position the penis inside the urinal when the client cannot do so.
8. Provide privacy.
9. Place the call bell within reach in facilities.
10. Ask the client to call when finished or when help is needed.
11. Remove gloves and perform proper hand hygiene.
12. Leave the room and close the door.
13. Return when the client calls. Knock before entering.
14. Perform proper hand hygiene and put on gloves.
15. Close the urinal cap when present and take the urinal to the bathroom.
16. Observe the colour, amount, and character of the urine.
17. Empty the urine into the toilet. Rinse the urinal with cold water and clean it with disinfectant.
18. Return the urinal to its proper location.
19. Remove gloves, perform proper hand hygiene, and put on clean gloves.
20. Help the client wash their hands.
21. Remove the gloves and perform proper hand hygiene.

After the Procedure

22. Provide for safety and comfort.
23. Put the call bell within reach in facilities.
24. Follow the care plan for bed rail use.
25. Remove privacy measures.
26. Follow employer policy for soiled linen.
27. Perform proper hand hygiene.

Report and record your actions, observations, and basic assessments according to employer policy.

Steps involving call bells or bed rails do not apply in every community setting.

Commodes

What a Commode Is

A commode is a portable chair or wheelchair with an opening for a bedpan or container.

It gives the client a normal position for elimination.

Some commodes have wheels for movement. Clients who cannot walk to the bathroom often use them.

The arms and back give the client support and help prevent falls.

Clean the bedpan or container after every use and follow Standard Practices.

When no specimen is required, a small amount of water placed in the commode container or bedpan makes cleaning easier.

Commode Safety

Safety: Client safety comes first when helping a person onto a commode, off a commode, or while the person uses it.

Some clients face a fall risk and must not stay unattended.

Safety: You must ensure that the commode wheels are locked and that the commode is positioned correctly over the toilet.

Make sure the client’s buttocks do not rub against the toilet while you position the commode over it.

Clients who need extra support but still walk to the bathroom receive both privacy and safety from a properly positioned commode.

A commode also serves some clients who do not sit unsupported on a toilet. In this situation, the commode sits over the toilet without its bedpan or container, as long as the client’s functional ability and the available space support that setup.

In some situations, the client first sits on the commode chair. The chair then moves into the bathroom and over the toilet.

Never:

• tie a client to a commode
• restrain a client to a commode
• place a client who cannot sit up independently on a commode

Commodes tip easily.

Number to remember: The longest a client should remain on a commode chair is 20 to 30 minutes.

Helping a Client to the Commode

Before the Procedure

1. Explain the procedure.
2. Provide privacy.
3. Perform proper hand hygiene and put on gloves.
4. Gather the commode, toilet tissue, a cover or bath blanket when available, several pairs of gloves, and a transfer belt ⓘ when the care plan indicates one.

During the Procedure

5. Move the commode beside the bed. Remove the cushion and lift the container lid.
6. Help the client sit on the side of the bed.
7. Help the client put on a robe and nonskid footwear.
8. Assist the client onto the commode when needed. Use a transfer belt when indicated.
9. Cover the client with a cover or bath blanket when available.
10. Put the call bell and toilet tissue within reach in facilities.
11. Ask the client to call when finished or when help is needed. Stay with the client when necessary while providing as much privacy as possible.
12. Remove gloves and perform proper hand hygiene.
13. Leave the room and close the door when the client is safe alone.
14. Return when the client calls. Knock before entering.
15. Perform proper hand hygiene and put on gloves.
16. Help clean the genital area as needed. Remove gloves and perform proper hand hygiene.
17. Help the client back to bed. Remove the robe and footwear. Follow the care plan for bed rail use.
18. Put on clean gloves. Remove and cover the commode container. Clean the commode.
19. Take the container to the bathroom.
20. Observe the urine for colour, amount, and character.
21. Empty the container into the toilet. Clean and disinfect it.
22. Return the container to the commode. Put the commode and other supplies in their proper places.
23. Remove soiled gloves, perform proper hand hygiene, and put on clean gloves.
24. Help the client wash their hands.
25. Remove gloves and perform proper hand hygiene.

After the Procedure

26. Provide for safety and comfort.
27. Put the call bell within reach in facilities.
28. Follow the care plan for bed rail use.
29. Remove privacy measures.
30. Follow employer policy for soiled linen.
31. Perform proper hand hygiene.

Report and record your actions, observations, and basic assessments according to employer policy.

Steps involving call bells or bed rails do not apply in every community setting.

Protecting Dignity, Privacy, and Independence

During bedpan, urinal, and commode assistance, promote:

• dignity
• independence
• individualized care
• client preferences
• privacy
• safety

Keep the client covered when possible. Give privacy when the person is safe alone.

Do not rush elimination. Keep needed items within reach and respond when the client asks for help.

Common Mix-Ups

Wrong Idea	Better Idea
Urinary incontinence is a normal part of aging.	urinary incontinence is not a normal part of aging.