PACEMAKER

INTRODUCTION

A pacemaker is an electronic device that provides electrical stimuli to the heart muscles.
Pacemaker are usually used when a patients has a slower than normal impulse formation or a
conduction disturbances that causes symptoms. They may also be used to control some
tachydysrhythmias that do not respond to medication therapy. Biventricular pacing may be
used to treat advanced heart failure that does not respond to medication therapy.

Pacemaker can be permanent or temporary. Permanent pacemakers are used to most

commonly for irreversible complete heart block. Pacemaker implantation is one of the most
common types of heart surgery carried out in the UK. During 2012-13 in England, more than
40,000 people had a pacemaker fitted.

DEFINITION-

“A pacemaker is a small electronic device that’s place in the chest or abdomen to help control
abnormal heart rhythm. This device uses electrical pulses to prompt the heart to beat at a
normal rate”.

“A pacemaker is a small device ,about the size of a half dollar piece, that’s placed under the
skin near the heart to help control heart beat. A pacemaker is implanted as part of what’s
often referred to as ‘cardiac resynchronization therapy’.

PURPOSES-

 To initiate heart rate when the heart naturals pacemaker unable to do so.
 To maintain the heart beat and heart function.
 To control the heart rate.
COMONENTS OF PACEMAKER-

 A battery - which usually last 6 to 10 years depending on how advanced the device is
(more advance pace maker tends to use more energy so have a shorter battery life.
 A pulse generator-the pulse generator has several controls. They are energy output,
heart rate and pacing mode.
 A tiny computer circuit: - it converts energy from the battery in to electrical
impulses, which flow down the wires and stimulate heart to contract.

TYPES OF PACEMAKER-

1. TEMPORARY PACEMAKERS
2. PERMANENT PACEMAKERS

INDICATIONS:-

 Bradycardia or supraventricular tachycardia- An abnormal slow heart beat or an

abnormal fast heart beat caused by damage to past of the heart called the sinoatrial
node(SA node).
 Adams strokes attack (syncope secondary to third degree AV block ).
 Third degree AV block with slow ventricular rate.
 Acute myocardial infarction with mobitz AV block.
 Right bundle branch block plus left atrial hemi block or left posterior hemi block.
 New left bundle branch block associated with acute MI.
 Atrial fibrillation with slow ventricular rate in the patients who requires digitalis
therapy.
 Carotid sinus syncope.
 Suppression of dyarrhythmias (artrial or ventricular).
 Dyarrhythmias occurring during or after cardiac surgery.
 Sick sinus syndrome.
 Prophylaxis before surgery in patients with history of cardiac arrest.

BASIC PRINCIPLE – These include sensing, pacing and capture.

1. Sensing refers to the ability of pacemaker to detect intrinsic myocardial electrical

activity. The pacemaker will either be inhibited from delivering a stimulus or will
initiate an electrical impulse, based on sensed activity.
2. Pacing occurs once the permanent pacemaker is activated and the requisite level
of energy travels from the pacemaker to transvenous lead wire to the myocardium.
This is known as pacer “firing”.
3. Capture refers to the successful stimulation of the myocardium by the pacemaker
impulses that result in depolarization.
GENERIC PACEMAKER CODE-

I II III IV V
Chamber Chamber Response to Programmability Antitachycardia
paced sensed sensing rate modulation function
O = None O = None O = None O = None O = None
A= A = ATRIUM T = triggered P = Simple P = Pacing
ATRIUM programmable
V= V= I = Inhibited M = Multi S = Shock
VEMTRICLE VEMTRICLE programmable
D = DUAL D = DUAL D = Dual (T R = Rate modulation D = dual (P and
CHAMBER CHAMBER and I ) S)
(A and V ( A and V )
)

TEMPORARY TRANSCUTANEOUS PACING-

Temporary tranctaneous pacing is a method of stimulating myocardial depolarization through

the chest wall via two large placing electrodes. The electrodes are placed on the anterior or
posterior chest wall and are attached by a cable to external pulse generator that houses the
pacemaker controls.

PURPOSES-

 To stimulate myocardial depolarization through the chest wall.

 Established an adequate cardiac output and blood pressure.
 To reduces the possibilities of ventricular dysarhythmias.

EQUIPMENTS-

 External pacing generator and monitor unit.

 Pacing cable and pacing patches.
 Pacemaker electrodes.
 An ECG electrode patches.
 ECG monitor and cable.

Additional equipments-

 Scissors to remove body hairs.

 Emergency medication.
 Resuscitation equipments.
PATIENTS ASSESMENT AND PREPRATION-

PATIENTS ASSESMENT-

 Assess cardiac rhythm for the presence of bradydysrhythmias or trachydysrhythmias.

 Determine hemodynamic response to the dysrhythmias such as a systole blood
pressure of less than 90 mm Hg.
 Review of current medication.
 Review current laboratory studies, including chemistry or electrolyte profile and
digoxin and other cardio active drugs level.

PATIENTS PREPRATION-

 Ensure that the patients and family understand preprocedural teaching.

 Select chest and back placement sites and prepare the chest and back skin for
placement of electrodes. Avoid contact with ECG electrodes, wires, and nitroglycerin
patches and paste.

PROCEDURE

S.N. STEPS RATIONALE

1 Wash hands. Reduce transmission of
microorganism.
2 Turn on pulse generator and monitor. Ensure that equipment is functional.
3 Prepare the skin on the chest and back by Remove of skin oils, lotion, and
washing with soap and water and trimming moisture will improve patch
body hair with scissors, if necessary. adherence and maximize delivery of
pacing energy through the chest
wall.

4 Apply ECG electrode of conventional three Check intrinsic rhythm and pacer
lead, single channel monitoring system. sensing function.
5 Adjust ECG lead and size to maximum R Detection of intrinsic rhythm is
wave size. necessary for proper demand
pacing.
6 Apply the back (posterior, + ) pacing Placement of pacing patches in the
electrode between the spine and left recommended anatomic location
scapula at the level of heart. will enhance the potentials for
successful pacing.
7 Apply the front (anterior, -) pacing Placement of the pacing patches in
electrode at the left, fourth intercostals the recommended anatomic location
space, midclavicular line. will enhance the potentials for
successful pacing.
8 When the patients is too unstable to allow Facilitates ease of electrode
posterior placement, the back electrode placement for emergent pacing.
may be placed over the patients right
sternal area at the second or third
intercostals space. The front electrode will
be maintained at the apex.
9 Connect pacing electrodes to cable and Necessary for the delivery of
connect to external pulse generator. electric energy.
10 Consider administering sedation before Transcutaneous pacing can be
initiate pacing. uncomfortable for the patients.
11 Set pacemaker settings as prescribed by the Each patients may require different
physicians or advanced practice nurse, pacemaker setting to provide safe
including rate, level of energy, and mode, if and effective external pacing.
available (demand/synchronous, non- Pacing should be maintained at a
demand / asynchronous) rate that maintains adequate cardiac
output but does not induce
ischemia.
12 Initiate pacing by slowly increasing the Use of lowest amount of energy that
energy level (mA) delivered until consistently results in myocardial
consistent capture occurs at the prescribed capture and contraction to minimize
rate. discomfort.
13 Monitor ECG tracing artifact and Ensures adequate functioning of the
associated capture or sensing. pacer.
14 Palpate patient’s femoral and carotid pulse. Ensures adequate blood flow with
paced complexes.
15 Evaluate patients comfort. Pacing may be tolerated or
uncomfortable for the patients.
16 Discards used supplies, and wash hands. Reduce transmission of
microorganism.

TEMPORARY TRANSVENOUS PACEMAKER INSERTION-

A transvenous pacemaker is inserted as a temporary measure when the normal

conduction system of the heart fails to produce an electrical impulse, resulting in
hemodynamic compromise or other debilitating symptoms in the patients. Temporary cardiac
pacing is to ensure or restore adequate heart and rhythm.

INDICATION-

 Ventricular standstill or cardiac arrest.

 Drug toxicity.
 Postoperative cardiac surgery.
EQUIPMENTS-

 Antiseptic skin preparation solution.

 Local anesthetics.
 Sterile drapes, towels, mask, gown, gloves, and dressing.
 Balloon tipped pacing catheter.
 Pacing lead wire.
 Pulse generator.
 Connecting tubes.
 Percutaneous introducer needle.
 Introducer sheath with dilator.
 Guide wire.
 Alligator tape.
 Suture with needle, syringes.
 ECG monitor and recorder.
 Supplies for dressing.

ADDITIONAL EQUIPMENTS-

 Emergency equipment.
 Fluoroscopy.
 12- Lead ECG.

PROCEDURE

S.N. STEPS RATIONALE

1 Wash hands. Reduce transmission of microorganism.

2 Connect patient to bedside monitoring Monitoring intrinsic rhythm as well as

system, and monitor ECG continuously. rhythm during and after the procedure to
evaluate for adequate rate and
pacemaker function.
3 Assess pacemaker functioning. Ensures functional pacemaker pulse
generator.
4 Attach the connecting cable to the pulse Prepare the pacing system.
generator.
5 Check the placement of the central venous Central venous access is needed for
access by chest x-ray. transverse pacing.
6 Prepare insertion site by clipping hairs Essential to prevent infection.
close to the skin in the area surrounding
the insertion site.
7 All personnel performing and assisting Prevents infection. And maintained
with the procedure should done mask, standard precautions.
gown, gloves and caps.
8 Cleanse site with antiseptic solution such Prevents infection.
as povidone –iodine solution.
9 Drapes the site with the sterile drapes. Provides a sterile field and reduce the
 transmission of microorganisms
10 Administer local anesthetic to numb the A large gauge introducer is used.
insertion site.
11 Make a percutaneous puncture through the Allow for direct placement of the
vein selected for the procedure. introducer.
12 Insert the balloon tipped catheter through
the introducer, and advance the pacing
lead.
13 Inflate the balloon when the tip of the The air-filled balloon allows the blood
pacing lead is in the venacava. flow to carry the catheter tip into the
desired position in the right ventricles.
14 Verify transvenous pacing lead placement The negative pacing electrode is
by positioned in the apex of the right
A) Using the V lead of the bedside ventricles.
monitoring system or the 12-lead ECG
machine.
B) Connect the patients to the limb leads.
C) An alligator clip may be needed.
D) Attach the V lead of the ECG
monitoring system or the 12- lead ECG
machine to the negative electrode
connector pin.
E) Set the monitoring system to
continuously record the V lead.
F) Observe the ECG for ST segment
elevation in the V lead recording.
G) Observe for left bundle branch block
pattern and left axis deviation that can
usually be identified.
15 After the electrodes are properly Energy from the pulse generator is
positioned, deflate the balloon and connect directed to the negative electrode in
the external electrode pins to the pulse connect with the ventricles. The pacing
generator via the connecting cable. circuit is completed as energy reaches
the positive electrodes.
16 Set pacemaker settings as prescribed by Each patient may require different
the physicians or advanced practice nurse, pacemaker setting to provide safe and
including rate, level of energy, and mode, effective external pacing. Pacing should
if available (demand/synchronous, non- be maintained at a rate that maintains
demand / asynchronous) adequate cardiac output but does not
induce ischemia.
17 Initiate pacing by slowly increasing the Use of lowest amount of energy that
energy level (mA) delivered until consistently results in myocardial
consistent capture occurs at the prescribed capture and contraction to minimize
rate. discomfort.
18 Suture the pacing lead in place. Prevents dislodgement.
19 Apply a sterile, occlusive dressing over the Prevents infection.
site.
20 Secure necessary equipment to provide The pulse generator should be protected
some stability for the pacemaker, such as from falling.
hanging pulse generator on the intravenous
poles.
21 Discard used supplies and wash hands. Reduce transmission of
microorganisms.
22 Obtain chest x-ray. In the absence of fluoroscopy , an x-ray
is essential to detect potentials
complications.

TEMPORARY TRANSVENOUS EPICARDIAL PACING-

The transvenous and epicardial pacing are initiated as temporary measure when there
has been a failure of the normal conduction system of the heart to produce an electrical
impulse, resulting in hemodynamic compromise or other debilitating symptoms in the
patients.

PURPOSE-

 To ensure and restore an adequate heart rate and rhythm.

 Established an adequate cardiac output and blood pressure to ensure tissue perfusion
to vital organs.
 To reduce the possibility of ventricular dysrhythmias.

INDICATION-

 Ventricular standstill or cardiac arrest.

 Drug toxicity.
 Postoperative cardiac surgery.
 Sinus node dysfunction.
 Alternating bundle branch block.
EQUIPMENTS-

1. Antiseptic skin preparation solution.

2. Local anesthetics.
3. Sterile drapes, towels, mask, gown, gloves, and dressing.
4. Balloon tipped pacing catheter.
5. Pacing lead wire.
6. Pulse generator.
7. Connecting tubes.
8. Percutaneous introducer needle.
9. Introducer sheath with dilator.
10. Guide wire.
11. Alligator tape.
12. Suture with needle, syringes.
13. ECG monitor and recorder.
14. Supplies for dressing.
ADDITIONAL EQUIPMENTS-

1. Emergency equipment.
2. Fluoroscopy.
3. 12- Lead ECG.

PROCEDURE

S.N. STEPS RATIONALE

1 Wash hands. Reduce transmission of microorganism.

Connect
2 patient to bedside monitoring system, and Monitoring intrinsic rhythm as well as
monitor ECG continuously. rhythm during and after the procedure to
evaluate for adequate rate and
pacemaker function.
3 Assess pacemaker functioning. Ensures functional pacemaker pulse
generator.

4 Attach the connecting cable to the pulse Prepare the pacing system.
generator.

5 Don gloves. Examination gloves should we warm

whenever handling the epicardial wires
to prevents microshock.

6 Expose the epicardial pacing wires and Identify correct chamber for pacing.
identify the chamber of origin. Wires
exiting to the right of the sternum are
arterial in origin. Wires exiting to the right
of the sternum are ventricular origin.
7 Connects the epicardial wires to the pulse The epicardial wires must be securely
generator via connecting cable. Ensure that connected to the pulse generator to
the positive and negative electrodes are ensure appropriate sensing and capture
connected to the respective positive or as well as to prevent in advertent
negative terminals on the pulse generator disconnection.
via the connecting cable.
8 Set pacemaker settings as prescribed by the Each patient may require different
physicians or advanced practice nurse, pacemaker setting to provide safe and
including rate, level of energy, and mode, effective external pacing. Pacing should
if available (demand/synchronous, non- be maintained at a rate that maintains
demand / asynchronous) adequate cardiac output but does not
induce ischemia.
9 Assess patient’s response to pacing Pacemakers setting are determined by
including blood pressure, level of patient’s response.
consciousness, heart rhythm, and other
hemodynamic parameters.

10 After the pacing lead is sutured into place, Prevents infection.

apply a sterile dressing over the insertion
site.

11 Throughout the procedure, assess the The procedure is anxiety producing as

patients need for sedative and analgesic well as uncomfortable for patients.
medication.

12 Secure necessary equipment to provide The pulse generator should be protected

some stability for the pacemaker, such as from falling.
hanging pulse generator on the intravenous
poles.

13 Discard used supplies and wash hands. Reduce transmission of microorganisms.

14 Obtain chest x-ray. In the absence of fluoroscopy, an x-ray

is essential to detect potentials
complications.

PERMANENT PACEMAKER

The pulse generator is implanted underneath skin in subcutaneous tissue in the

pectoral region below the clavicle and some time an abdominal site is selected, and electrical
stimulation is passed to the heart through the pacing catheters.

PURPOSES

 To established and adequate heart rate and cardiac output.

 To maintain normal conduction system of the heart.
INDICATION

 Irreversible complete heart block.

 Left ventricular heart failure.
 Ectopic rhythms.
 Chronic atrial fibrillation.
 Atrial flutter.
 Supraventricular tachycardia.
  Sick sinus syndrome.

CONTRAINDICATION-
 Active infection.(endocarditis)
 Bleeding.

PROCDURE FOR ASSESSING FUNCTION OF PERMANENT PACEMAKER

S.N. Nursing steps Rationale

1 Wash hands. Reduce transmission of
microorganism.
2 Prepare skin for application of ECG Proper skin preparation is essential
electrode by washing with soap and to maintain skin to electrode
water. contact.
3 Attach ECG lead to electrode, place Necessary to assess cardiac rhythm.
electrode on patient’s chest, and record
ECG.
4 Assess cardiac rhythm for the presence Allow the determination of
of pacemaker activity. pacemaker function.

A) Identify atrial activity. Electrical response of atria.

B) If there is no intrinsic atrial Troubleshooting program of the

activity present determine pacemaker and atrial response.
whether the pacemaker is
programmed to pace the atrium.

C) Look for ventricular activity. Determine the presence of

ventricular activity and response to
pacemaker actions.
D) If there is no intrinsic
Troubleshooting the relationship
ventricular activity present
determine whether the between pacemaker programming
pacemaker is programmed to and ventricular response.
pace the ventricular.

E) If Antitachycardia Pacing is Determine appropriate pacemaker

programmed determine whether function.
the tachycardia detection
criterion has been met.
5 Assess the patients hemodynamic It is possible for the patients to have
response. the electrical activity of pacing
occurring without the associated
 mechanical activity of cardiac
conduction.
6 If inappropriate pacemaker function is Inappropriate pacemaker function
detected, notify the physician may compromise the cardiac output
immediately. and require immediate adjustment
of setting or replacement of
malfunctioning components.

POST OPERATIVE CARE-

 Monitor vital sign and pacemaker function.
 Explain about bed rest for 24 hours and reduced activity for another 48 hours.
 Connects patients to cardiac monitor and check rhythm.
 Check operative site for excessive swelling and redness.
 Check vital sign and wound hourly.
 Continue ECG monitoring for 24 hours.

COMPLICATION
 Local infection at entry site.
 Bleeding and hematoma at the lead entry site.
 Hemothorax or pneuomothorax.
 Failure to sense.
 Failure to capture.
 Atrial and ventricular septal perforation.
 Atelectasis.
 Pericardial fluid accumulation.
 Diaphragmatic stimulation.

PATIENTS MONITORING AND CARE-

 Monitor vital signs as needed.
 Monitor level of comfort.
 Monitor the ECG continuously for the presence of the cardiac rate and rhythm
that is consistent with the programmed parameters.
 Evaluate the hemodynamic response to pacemaker therapy.
 Assess insertion site for evidence of manipulation.
 Monitor for sign and symptoms of infection.
 REFERENCES:-

BOOKS REFERENCES:-
 Bottinger B W, Rauch H, Bohrer H, Motsch J, Soder M, Fleischer F, Martin E.
Continous versus intermittent cardiac output measurement in cardiac surgical patients
undergoing hypothermic cardiopulmonary bypass. J CardiothoracVascAnesth. (1995);
9(4):405–411.
 Nelson L D. The new pulmonary arterial catheters. Crit Care Clinics. (1996);
12(4):795–818.
 Nettina M. Sandra (2010), Lippincott Manual of Nursing Practice, New Delhi,
Wolters Kluwers.
 Ansari Javed (2012), Examination Master in Medical Surgical Nursing- II, New
Delhi, S. Vikas & Company.
 Knight P Bradley (2016), Patient information: Cardioversion (Beyond the Basics),
 Mayo clinic(2014),Tests and Procedures Cardioversion

INTERNET REFERENCES:-
 [Link]/pubmed/12024086
 [Link]
 [Link] › Medical Encyclopedia
 [Link]
MAR BASELIOS COLLEGE OF NURSING, BHOPAL

SUBJECT: ADVANCE NURSING PRACTICE

ASSIGNMENT ON
PACEMAKER

SUBMITTED TO : SUBMITTED BY:

Mrs. Blesson Thomas Mr. Vijay S. James
Asso. Professor [Link]. Nursing I year
Date: 14/03/2019