8ª AULA FUNDAMENTOS BÁSICOS DA PRÁTICA ASSISTENCIAL

Main ideas, concepts, and lessons conveyed

Academic integrity (opening message)

• The course emphasizes integrity as a foundational value for the academic community.
• Learning activities (tasks, assessments) are framed as opportunities to build:
  • knowledge and skills
  • a professional foundation grounded in truth, ethics, and honesty
• Actions explicitly described as incompatible with integrity include:
  • cheating
  • misuse of answers
  • sharing or selling questions, tests, and other institutional materials
• Consequences mentioned:
  • academic and administrative sanctions per university regulations
  • potential civil and criminal liability for dissemination/commercialization/misuse (depending on circumstances and law)
• Message to students: integrity begins with everyday choices and continues into professional life.

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Course context and transition to the technical lesson

• This is the 8th class and described as the second-to-last class of the course module.
• The instructors review prior topics already covered:
  • basic assistance and effective communication
  • humanity/human contact
  • leveling of care
  • wound care and dressings
  • catheterization (today’s focus begins)
  • medication administration (recently covered)
• Preview: the last class will focus on legislative and ethical issues, including exam-style legislative questions tied to ethical nursing regulations.

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Main technical topic: Catheterization fundamentals (nasogastric tube + urinary catheter)

Scope and approach for today

• While acknowledging other invasive probe types, the lesson narrows to:
  • nasogastric tube placement (and related purposes)
  • indwelling urinary catheterization (and related principles)

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Regulatory biosafety/PPE emphasis (before demonstrations)

• The lesson highlights regulatory standard 6 (Ministry of Labor and Employment) stating:
  • employers must provide personal protective equipment (PPE) to workers
  • healthcare workers are a high-risk category due to biological exposure
• PPE and safety logic:
  • PPE acts as a barrier in the chain of transmission
  • when PPE is unfeasible or insufficient, responsible bodies must be notified
• PPE examples listed:
  • lab coats
  • gloves (including sterile gloves for certain sterile procedures)
  • masks
  • goggles
  • face shields
  • closed-toe shoes
• Risks referenced:
  • blood, bacteria, viruses, fungi
  • contamination through instruments/equipment between patients
  • prevention of transmission of viruses such as HIV and hepatitis B

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Nasogastric tube: indications, contraindications, purpose, and complications

Indications (when it’s used)

• Purpose: deliver food to the gastric region when oral feeding isn’t possible.
• Also used for:
  • gastric lavage after ingestion of toxic substances
  • radiologic procedures (injecting contrast via tube)
  • preventing/treating gastric distension
  • critical care monitoring/assessment of gastric dysfunction
  • infusing diets and medications enterally
• Indirect monitoring concept:
  • assessing gastric residue helps infer gastric emptying and intolerance risk
  • if residue is high, it may signal risk such as aspiration intolerance
• In paralytic ileus or obstruction contexts:
  • tube helps relieve accumulated contents by reducing distension

Contraindications / stopping rules (as taught)

• During insertion, if the patient:
  • begins coughing or vomiting, the team should not simply continue automatically
  • has twisting/active emesis of gastric material
• Lesson’s practical decision:
  • stop the procedure, stabilize patient condition, and retry appropriately later
  • justification: continuing could increase severe complication risk (e.g., aspiration-related issues)

Key anatomical/clinical concept: dysphagia and posture/airway safety

• Dysphagia (difficulty swallowing) may arise from obstructive or neurological causes—often discussed with elderly patients.
• Bed restraint is treated as ethically sensitive:
  • restraint can increase ethical pitfalls
  • legal protection is referenced for situations where restraint may be necessary, with caution and appropriate rationale
  • reason restraint may be considered: patients may pull out the catheter when hands are free

Common nasogastric tube type mentioned: Levini/Levine probe

• Described as:
  • named after the doctor who designed/performed it
  • shorter, single internal channel
  • primarily used for aspiration and related uses (including gastric lavage and sometimes diffusion)
• Gauge/size range given:
  • 14 to 18 FR
• Meaning of FR:
  • correlates with millimeter diameter (higher FR = larger caliber)

Choosing tube size (lesson’s logic)

• Higher caliber (larger FR):
  • more effective for aspirating thicker/denser contents
  • better for gastric lavage efficiency
  • more discomfort
  • more risk of mucosal/pharyngeal injury
• Smaller caliber:
  • more comfortable
  • less efficient for aspirating loose debris
  • used when appropriate for feeding rather than lavage/aspiration tasks

Duration and complications

• Tube should remain only until definitive care is established.
• Prolonged contact can cause progressive pressure/chemical irritation.
• Complications listed:
  • irritation of nasal, tracheal, pharyngeal, and laryngeal mucosa
  • gastroesophageal reflux
  • volume deficiency/dehydration
  • lung/oral infections
  • necrosis of the nasal ala
  • occlusion (another complication noted)
• Why nasal injury can happen in ICU:
  • failure to evaluate and maintain/clean and correctly position/secure the device over time can lead to pressure injury and infection susceptibility

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Nasogastric tube placement steps and verification methods (detailed methodology)

Pre-measurement and marking (taught)

• Mark length using an anatomical estimation route:
  • from tip of nose to earlobe
  • then from earlobe to the xiphoid process (upper abdominal reference)
• Mnemonic-like concept repeated:
  • “nose → earlobe → xiphoid/appendix” (as stated in subtitles)
• Rationale:
  • accounts for individual anatomy and approximates pathway from nasal cavity/pharynx to stomach with a safety margin

Procedure overview

• Patient positioning:
  • keep patient as upright as possible; maintain good neck control
• Choose nostril:
  • based on resistance/which side is unobstructed
• Insertion:
  • insert initial probe part into nostril
  • if resistance occurs, flex cervical spine more and ask patient to swallow
  • swallowing helps passage and reduces risk of entering airways
• Secure:
  • mark external position
  • apply tape to prevent migration/dislodgement
• Monitor patient for distress:
  • if discomfort beyond expected occurs or breathing is interrupted, stop and reassess vitals

Placement confirmation (verification methods)

1. Auscultatory test (described as a limiting method)
   • after insertion to the marked point, use a 20 ml syringe
   • inject ~20 ml of air
   • place stethoscope in the epigastric region (below xiphoid)
   • listen for a murmuring/bubbling sound indicating correct stomach placement
   • warning: potential false positives if sounds transmit similarly from other sites
2. Aspiration test
   • aspirate via syringe
   • if gastric contents return:
     • color described as greenish/yellowish
     • acidic pH implied (as described)
   • presence of gastric content supports correct placement
3. Radiological confirmation (gold standard)
   • X-ray used, especially for high-risk/special populations
   • radiology is presented as the definitive confirmation method

Fixation technique (taught)

• Standard fixation:
  • commonly secure around the nose area to improve comfort and prevent kinking
• If nasal fixation is limited (e.g., fissure/necrosis):
  • use alternative fixation possibilities as allowed by circumstances

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Urinary catheterization: indications, timing concepts, and physiology

Distinction emphasized: relief catheter vs indwelling catheter

• Relief/temporary catheterization:
  • removed immediately after emptying bladder
• Indwelling catheter:
  • remains connected to a drainage system
  • uses an inflatable balloon at the tip for internal fixation inside bladder
  • “delay” refers to longer dwell time, not immediate removal

Indications (clinical reasoning)

• Physiologic/clinical triggers discussed include:
  • low urine output warning threshold
  • inability to urinate due to postoperative or medical constraints
  • prostate issues/obstruction risks
  • urinary tract infection suspicion requires caution with catheter duration

Urine output thresholds and related terminology (taught)

• Low output:
  • < 25 ml/h (described as ~600 ml/24h) considered unsatisfactory/minimally concerning
• Terminology mentioned:
  • Oliguria: diuresis/elimination < 400 ml (as taught)
  • Polyuria: urine output > 2.5 L / 2500 ml
  • Dysuria: painful urination
  • Incontinence mentioned as involuntary urine elimination (often referenced with elderly)

Non-pharmacological measures before insertion

• Rationale: catheter causes discomfort and may increase infection risk if not inserted with sterile technique.
• Examples of attempts before catheter insertion:
  • warm compress to skin
  • encouragement techniques to stimulate urination
  • neurophysiology example: turning on faucets/water sounds can induce the urge via subconscious/cortex-related pathways

Procedure authority/qualification (taught)

• The lesson states invasive procedures should be performed by qualified professionals:
  • nursing professional with nursing training
• Urinary catheterization also referenced as restricted to qualified roles

Timing/duration correction mentioned

• Nasogastric replacement timeframe (not fully consistent in subtitles) was debated briefly.
• Urinary catheter dwell time correction presented:
  • 3 to 7 days noted as the correction for the next slides (indwelling catheter usage window referenced during discussion).

Balloon and insertion route concepts

• Balloon role:
  • helps fixation and retention inside bladder
• Route choice:
  • mention of urethral route vs suprapubic access when urethral passage isn’t possible/contraindicated
• Nasogastric side selection:
  • based on which nostril is unobstructed

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Indwelling urinary catheter: ethical and patient-respect considerations

• Consent and gender preference were emphasized:
  • if a patient (woman) prefers a female professional, this should be respected
  • insertion should be done with consent/authorization rather than coercion or circumvention

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Practical video reference (Professor Luís Gustavo)

• The lesson includes a demonstration video (nasogastric insertion focus then bladder catheter details).
• Demonstration emphasized:
  • measure and mark length
  • lubricate probe (simulator gel)
  • insert with patient upright and neck control
  • ask patient to swallow when resistance occurs
  • test placement with 20 ml syringe air insufflation + stethoscope
  • alternative aspiration confirmation
  • then dressing change steps were also shown (taping/securement and cosmetic/comfort organization)

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Post-lesson application: exam question review (infection prevention in catheterized patients)

• They pose a FUNDATEC/Fundatec-style multiple-choice question about preventing/handling healthcare-associated infections.
• Scenario:
  • 86-year-old with indwelling urinary catheter for 8 days due to urinary retention
  • findings: fever, cloudy urine, suprapubic pain → suspected catheter-associated UTI
• Options reviewed (and clarified):
  • A: routine daily catheter changes reduce infection → rejected
  • B: collection system should remain open to prevent microorganism accumulation → rejected
  • C: collection bag should remain above bladder → rejected
  • D: hand hygiene before and after handling urinary system is essential → accepted as correct
• Additional clarification:
  • collection bag should remain below bladder level to prevent backflow and infection.

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Speakers / sources featured (identified from subtitles)

Named speakers (appearing in the lesson)

• Professor Renata
• Professor Aldo
• Professor Luís Gustavo (appears via demonstration video for nasogastric insertion)
• Professor Renata Silvia (correction/mention within chat/turn-taking)
• Débora (student comment/praise referenced)
• Patrícia (student comment referenced)
• Jeisa (student comment referenced)
• Natário (thanks/interaction)
• Simone (student/facilitator comments referenced multiple times)
• Silvia (teacher/student role referenced; participates in timing correction discussion)
• Antônia Querane, Fernanda, Patrícia, Gesiane (students recognized for correct answers)

Institutional/regulatory sources mentioned

• University regulations (for academic/integrity sanctions)
• Ministry of Labor and Employment (regulatory standard number six on PPE/biosafety obligations)
• COFEN (mentioned in context of Brazilian nursing training requirements)
• Federal Nursing Council (COFEN) / nursing ethical regulations
• FUNDEC / FUNDATEC / Municipality of Carlos Barbosa (source context for the exam question as stated in subtitles)