By Fatimah 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 pts 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 Pts 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.

2.

3.

Symptomatic bradycardia Symptomatic heart block 2nd degree heart block 3rd or complete heart block Bifasicular or transfasicular bundle branch blocks. Prophylaxis

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Pacemaker Design
1.

2.

Pulse generator 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 lead 1. 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.

2.
3.

Pacing function Sensing function 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.

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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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
Temporary pacemaker Placed during emergencies Indicated for pts high degree heart block or unstable bradycardia Can be placed transvenosly, epicardially,transcutanusly or transthorasicly

2.

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Types of pacing
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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3.

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,pts 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 intervention
Avoid injury Obtain chest x-ray to check lead wire position
2.

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 intervention
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. Pts 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 /2008F.ABUDAYAH 41 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 pts 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.

9.
10. 11.

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
Anatomy and physiology of the heart 2. Pacemaker function 3. Activity Specific 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 /2008F.ABUDAYAH 46 when desired
1.

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 Practice Eighth Edition Braunner&SuDDARTHS Textbook of medical surgical nursing 10th edition
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