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ByBy Fatimah Abu-DayahFatimah Abu-Dayah

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Clinical objectives

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 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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Normal conductive system of the heart

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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

1. Symptomatic bradycardia2. Symptomatic heart block 2nd degree heart block 3rd or complete heart block Bifasicular or transfasicular

bundle branch blocks.3. Prophylaxis

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Pacemaker Design

1. Pulse generator2. leads

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Pacemaker Design

Pulse generator In permanent pacemaker is

encapsulated in a metal can ,to protect the generator from electromagnetic interference

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Pacemaker Design

Pulse generator Temporary pacing system generator is externally contained in a small box

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Pacemaker Design

Pulse generator Transcutanus external pacing

system house the generator in a piece of equipment similar to portable ECG monitor.

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Pacemaker Design

Pacemaker lead1. Single chamber (unipolar)

pacemaker Lead placed in atrium or ventricle 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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Pacemaker Design

2. 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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Dual-chamber (bipolar) pacemaker

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Pacemaker function

1. Pacing function2. Sensing function3. Capture function

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Pacing function

Atrial pacing:

stimulation of RT atrium produce spic on ECG preceding P wave

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Pacing function

Ventricle pacing:

stimulation of RT or LT ventricle produce a spic on ECG preceding QRS complex.

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Pacing function

AVpacing:

direct stimulation of RT atrium and either ventricles mimic normal heart conduction

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Sensing function

Sensing:

Ability of the cardiac pace maker to see intrinsic cardiac activity when it occurs.

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Sensing function

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 function

Capture:

Ability of the pacemaker to generate a response from the heart (contraction) after electrical stimulation.

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Capture function

1. Electrical capture : indicated by P or QRS

following and corresponding to a pacemaker spike.

2. Mechanical capture: palpable pulse corresponding

to the electrical event.

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Pacing types

Permanent Temporary biventricular

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Types of pacing

1. 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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Types of pacing

2. 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. 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

Types of pacing

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Equipments

Transvenous pacing catheter  

  EKG machine Pacemaker generator

with battery and cable  Emergency crash cart

Lidocaine                        Defibrillator

(2) 5cc syringe with 22 and 25 gauge needles                 

  External Pacer Sterile gown, gloves,

mask

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INSERTION SITES

Left Subclavian (most reliable) Internal jugular (lower

incidence of pneumothorax) Femoral vein Brachial vein

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INSERTION PROCEDURE 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

Anesthetize the area locally. Prepare the external temporary

generator: Portable Chest X-ray is

required to confirm placement.

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Applying transcutaneous pacing

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

Movement and dislocation of the lead Injury Bleeding and hematoma Ventricular ectopy or VT from wall

stimulation Infection Cardiac tamponad

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Nursing diagnosis

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

1. 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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Nursing intervention2. Avoid injury Obtain chest x-ray to check lead wire position

Monitor for sign and symptom of hemothorax

Monitor for sign and symptom of pneumothorax

Evaluate evidence for bleeding

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Nursing intervention

3. 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. 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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Nursing intervention5. Be aware of hazards in the facility

that can interfere pacemaker and cause failure

Avoid use of electrical razor 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.

Caution must be used if pt will receive radiation therapy.

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Nursing intervention

6. 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 Place a sign over pt's bed

alerting personnel to the presence of pacemaker.

Evaluate transecutanuse pacing every 2 hr

Monitor for electrolyte imbalances, hypoxia and myocardial infarction.

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Nursing intervention

7. 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. Relieving anxiety9. Reliving pain.10. Maintaining a positive body image11. 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. Anatomy and physiology of the heart

2. Pacemaker function3. ActivitySpecific instruction include

Not to lift items over 1.4kg or perform difficult arm maneuver.

Avoid excessive stretching or bending excessive.

Avoid contact sport,tennis,gulfing until advised by doctor.

Sexual activity can be resumed when desired

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Patient education

4. 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

5. 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 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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Patient education

6. 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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References

Sandra M. Nettina

MSN, APRN, BC, ANP

Manual of Nursing PracticeEighth Edition

Braunner&SuDDARTH’STextbook of medical surgical

nursing 10th edition