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By
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By the end of this lecture you will be able to:
Define pacemaker
Differentiate types of pacemaker
List function of pacemaker
Assist and monitor pt under going pacing
Identifying pt ’s educational needs
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Out line
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Introduction
Definition of cardiac pacing
Clinical Indication
Pacemaker design
Pacemaker function
Types of pacing
Nursing diagnosis
Nursing intervention
Pt ’ s education
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Definition of cardiac pacing
It is an electric device that delivers direct electrical stimulation to stimulate the myocardium to depolarize
,initiating a mechanical contraction.
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Clinical Indication
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1.
2.
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3.
Symptomatic bradycardia
Symptomatic heart block
2 nd degree heart block
3 rd or complete heart block
Bifasicular or transfasicular bundle branch blocks.
Prophylaxis
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Pacemaker Design
1.
2.
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Pacemaker Design
Pulse generator
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In permanent pacemaker is encapsulated in a metal can ,to protect the generator from electromagnetic interference
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Pulse generator
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Temporary pacing system generator is externally contained in a small box
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Pacemaker Design
Pulse generator
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Transcutanus external pacing system house the generator in a piece of equipment similar to portable ECG monitor.
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Pacemaker lead
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Single chamber (unipolar) pacemaker
Lead placed in atrium or ventricle
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Produce large spic on the ECG
Sensing and pacing in the chamber where the lead is located
More likely to be affected by electromechanically interference
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Single chamber (unipolar
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2.
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Dual-chamber (bipolar) pacemaker
One Lead located in the atrium and one in the ventricle
Sensing and pacing in both chambers mimicking the normal heart function
Produce in visible spic in the ECG
Less affected by electromechanical interference.
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1.
2.
3.
Pacing function
Sensing function
Capture function
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Atrial pacing: stimulation of RT atrium produce spic on ECG preceding P wave
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Ventricle pacing : stimulation of RT or LT ventricle produce a spic on ECG preceding
QRS complex .
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AVpacing: direct stimulation of RT atrium and either ventricles mimic normal heart conduction
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Sensing :
Ability of the cardiac pace maker to see intrinsic cardiac activity when it occurs.
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Demand:
 pacing stimulation delivered only if the heart rate falls below the preset limit.
Fixed:
 no ability to sense. constantly delivers the preset stimulus at preset rate.
Triggered: delivers stimuli in response to
(sensing )cardiac event.
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Capture:
Ability of the pacemaker to generate a response from the heart (contraction) after electrical stimulation.
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1.
2.
Electrical capture : indicated by P or QRS following and corresponding to a pacemaker spike.
Mechanical capture: palpable pulse corresponding to the electrical event.
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Permanent
Temporary biventricular
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1.
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Permanent pacemaker
Used to treat chronic heart condition
Surgically placed transvenuosly under local anesthesia
Pulse generator placed in a pocket subcutaneously ,can be adjusted externally
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Permanent pacemaker
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2.
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Temporary pacemaker
Placed during emergencies
Indicated for pts ’ high degree heart block or unstable bradycardia
Can be placed transvenosly, epicardially,transcutanusly or transthorasicly
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3.
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Biventricular pacemaker
Used in sever heart failure
Utilize three leads in right atrium, right ventricle and left ventricle to coordinate ventricular coordination and improve cardiac out put
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Transvenous pacing catheter
EKG machine
Pacemaker generator with battery and cable
Emergency crash cart
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Lidocaine
Defibrillator
(2) 5cc syringe with
22 and 25 gauge needles
External Pacer
Sterile gown, gloves, mask
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Left Subclavian (most reliable)
Internal jugular (lower incidence of pneumothorax)
Femoral vein
Brachial vein
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INSERTION PROCEDURE
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1. Check that patient has a patent IV, and that the defibrillator, emergency cart and appropriate medications are available. obtain consent (time permitting).
Obtain vital signs and ECG rhythm strip prior to insertion. Connect to 12 lead EKG and continuously monitor before, during and after
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INSERTION PROCEDURE
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Anesthetize the area locally.
Prepare the external temporary generator:
Portable Chest X-ray is required to confirm placement.
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Anterior/posterior:
Anterior/anterior:
Module on stand by. minimal out put
Connect pacing to external module
Increase milliamp until a pacing spike and corresponding QRS are seen.plpate pulse
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Complication
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Movement and dislocation of the lead
Injury
Bleeding and hematoma
Ventricular ectopy or VT from wall stimulation
Infection
Cardiac tamponad
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Decreased cardiac output related to potential pacemaker mal function
Risk for injury related to peumothorax
Impaired physical mobility related to restriction of movement.
Acute pain related to surgical incision or external pacing stimuli.
Disturbed body image related to pacemaker implementation.
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Nursing intervention
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Maintain adequate cardiac output
Record information after insertion pacemaker model ,mode, program setting,pt ’ s rhythm
Attach ECG for continues monitoring
Analyze rhythm strips as per protocol
Monitor vital signs
Monitor urine output
Observe for dysrhythmia
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2.
Avoid injury
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Obtain chest x-ray to check lead wire position
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Monitor for sign and symptom of hemothorax
Monitor for sign and symptom of pneumothorax
Evaluate evidence for bleeding
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Nursing intervention
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Monitor for evidence of lead migration and perforation of heart
Observe for muscle twitching and hiccups
Evaluate chest pain
Auscultate foe friction rub
Observe for signs of cardiac tamponade
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Nursing intervention
4.
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Provide electrically safe environment
Protect exposed parts of electrode leads with rubber
Wear rubber gloves when touching a temporary pacing lead
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5.
Nursing intervention
Be aware of hazards in the facility that can interfere pacemaker and cause failure
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Avoid use of electrical razor
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Avoid direct placement of defibrillator paddles over the generator, should be placed 4-5 inches away.
Pt ’ s with permanent pacemaker should never exposed to MRI because it may alter and erase the program memory.
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Nursing intervention
6.
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Prevent accidental pacemaker malfunctions
Use external plastic covering over external generator all times
Secure temporary pace maker over pt ’ s chest or wrist never hang it over iv pole
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Nursing intervention
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Place a sign over pt's bed alerting personnel to the presence of pacemaker.
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Evaluate transecutanuse pacing every 2 hr
Monitor for electrolyte imbalances, hypoxia and myocardial infarction.
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Nursing intervention
7.
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Preventing infection
Take temp every 4hrs
Observe for sign and symptoms of infection
Clean incision site with sterile technique
Monitor vein which pacing placed in for phlipaitis
Administer antibiotic as ordered.
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Nursing intervention
8.
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Relieving anxiety
Reliving pain.
Maintaining a positive body image
Minimizing the effect of immobility
Rest for 24-48 hrs post pacing insertion
Deep breathing exercise
Restrict movement of affected extremity
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Patient education
1.
2.
Anatomy and physiology of the heart
Pacemaker function
3.
Activity
Specific instruction include
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Not to lift items over 1.4kg or perform difficult arm maneuver.
Avoid excessive stretching or bending excessive.
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Avoid contact sport,tennis,gulfing until advised by doctor.
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4.
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Patient education
Pacemaker failure
Teach pt to check own pulse at least weekly for 1 min
Report slowing on the pulse less or greater than the setting rate
Report sign and symptom as palpitation ,fatigue ,dizziness
,prolonged hiccups
Wear identification bracelet and carry a pacemaker identification cared.
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Patient education
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Electromagnetic interference
Caution pt that EMI could interfere with pacemaker function.
Explain that high energy radar, TV and radio transmetters,MRI,large motors may affect the pacemaker function.
Teach pt to move 4-6 m away from source and check pulse. it should return to normal.
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Patient education
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Most pacemaker equipped with internal filters to prevent interaction with cell phone.
Tell pt that antitheft devices and airport security alarms may affect pacemaker and trigger security alarm.
Household and kitchen appliance will not affect pacemaker.
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6.
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Patient education
Care of pacemaker site.
Wear loose-fitting clothes around pacemaker
Watch sign and symptom of infection
Keep incision site clean and dry. not to scrub site
Advise well balanced diet.
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Sandra M. Nettina
MSN, APRN, BC, ANP
Manual of Nursing Practice
Eighth Edition
Braunner&SuDDARTH’S
Textbook of medical surgical nursing 10 th edition
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