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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

Definition of cardiac pacing Out line

An electric device Clinical Indication  Definition of cardiac pacing
that delivers 1. Symptomatic  Clinical Indication
direct electrical bradycardia
Symptomatic heart  Pacemaker design
stimulation to 2.
block
stimulate the  Pacemaker function
 2nd degree heart
myocardium to block  Types of pacing
depolarize, 3rd or complete heart
initiating a

block
 Nursing diagnosis
mechanical  Bifasicular or  Nursing intervention
contraction. transfasicular bundle
branch blocks.  Pt’s education
3. Prophylaxis

Pacemaker Design Pacemaker Design: Pulse generator

Pacemaker lead  Permanent pacemaker  Temporary pacing

1. Single chamber  Generator is system

encapsulated in a metal generator is externally
(unipolar) pacemaker can, to protect the contained in a small box
 Lead placed in atrium or generator from
ventricle electromagnetic
 Transcutanus external
interference
 Produce large spic on the ECG pacing system house the
generator in a piece of
 Sensing and pacing in the equipment similar to
chamber where the lead is portable ECG monitor.
located
 More likely to be affected by
electromechanically interference

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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.

Pacing function Pacemaker function

Atrial pacing: Ventricle pacing :
1. Pacing function
stimulation of RT stimulation of RT or LT
atrium produce spic ventricle produce a 2. Sensing function
on ECG preceding P spic on ECG preceding 3. Capture function
wave QRS complex.

Sensing function Pacing function

Sensing :
AVpacing:
Ability of the cardiac pace maker to see
direct stimulation of RT atrium and either
intrinsic cardiac activity when it occurs.
ventricles mimic normal heart conduction

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
Pacing types

 Permanent Capture:
Ability of the pacemaker to generate a
 Temporary
response from the heart (contraction) after
 Biventricular electrical stimulation.

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.
/ 2008F.ABUDAYAH 14

Types of pacing
Types of pacing
2. Temporary pacemaker
1. Permanent pacemaker
 Placed during emergencies  Used to treat chronic heart condition
 Indicated for pts’ high degree heart  Surgically placed transvenuosly under
block or unstable bradycardia local anesthesia
 Can be placed transvenosly,  Pulse generator placed in a pocket
epicardially,transcutanusly or subcutaneously ,can be adjusted
transthorasicly externally

Types of pacing
Complication
3. Biventricular pacemaker
 Movement and dislocation of the lead
 Used in sever heart failure
 Injury
 Utilize three leads in right
 Bleeding and hematoma atrium, right ventricle and
 Ventricular ectopy or VT from wall left ventricle to coordinate
stimulation
ventricular coordination
 Infection
and improve cardiac
 Cardiac tamponad out put

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Nursing intervention Nursing diagnosis

1. Maintain adequate
cardiac output
 Record information after
insertion pacemaker model
,mode, program setting, pt’s
rhythm
 Attach ECG for continues
monitoring
2. Avoid injury  Decreased cardiac output related to
 Obtain chest x-ray potential pacemaker mal function
to check lead wire  Risk for injury related to peumothorax
position
 Impaired physical mobility related to
Monitor for sign and

symptom of
restriction of movement.
Acute pain related to surgical incision or
hemothorax 

 Analyze rhythm strips as per
protocol
 Monitor vital signs
 Monitor urine output
 Observe for dysrhythmia
 Monitor for sign and external pacing stimuli.
symptom of  Disturbed body image related to
pneumothorax pacemaker implementation.
 Evaluate evidence for
bleeding

Nursing intervention Nursing intervention

4. Provide electrically 5. Be aware of hazards in the 3. Monitor for evidence of lead
safe environment facility that can interfere
 Protect exposed pacemaker and cause failure
migration and perforation of
parts of electrode  Avoid use of electrical razor heart
leads with rubber  Avoid direct placement of  Observe for muscle twitching
Wear rubber

gloves when
defibrillator paddles over the and hiccups
generator, should be placed
touching a 4-5 inches away.  Evaluate chest pain
temporary pacing
lead
 Pt’s with permanent  Auscultate foe friction rub
pacemaker should never
exposed to MRI because it  Observe for signs of cardiac
may alter and erase the tamponade
program memory.
 Caution must be used if pt will
receive radiation therapy. / 2008F.ABUDAYAH 21

Patient education
Nursing intervention
1. Anatomy and physiology of the heart
2. Pacemaker function 6. Prevent accidental 7. Preventing infection
pacemaker Take temp every
3. Activity malfunctions

4hrs
 Use external plastic  Observe for sign and
Specific instruction include covering over external symptoms of
 Not to lift items over 1.4kg or perform difficult arm generator all times infection
maneuver. Secure temporary pace
  Clean incision site
 Avoid excessive stretching or bending excessive. maker over pt’s chest with sterile technique
 Avoid contact sport,tennis,gulfing until advised by doctor. or wrist never hang it  Monitor vein which
 Sexual activity can be resumed when desired over iv pole pacing placed in for
 Place a sign over pt's phlipaitis
bed alerting personnel  Administer antibiotic
to the presence of
as ordered.
pacemaker.

 Evaluate
transecutanuse pacing
every 2 hr
 Monitor for electrolyte
imbalances, hypoxia
and myocardial
infarction.
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Patient education 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.
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.

/ 2008F.ABUDAYAH 26

Patient education Patient education

6. Care of pacemaker site.  Most pacemaker equipped with internal filters to
 Wear loose-fitting prevent interaction with cell phone.
clothes around pacemaker  Tell pt that antitheft devices and airport security
 Watch sign and symptom alarms may affect pacemaker and trigger security
alarm.
of infection
 Household and kitchen appliance will not affect
 Keep incision site clean pacemaker.
and dry. not to scrub site
 Advise well balanced diet.

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