PACEMAKER

PRINCY FRANCIS M
II Yr MSc (N)
JMCON
• 1932 - Albert Hyman coined term “Artificial
pacemaker”
• 1958 – first implantable pacemaker
designed by Rune Elmquist
Definition

A pacemaker is an electronic device that provides

electrical stimuli to the heart muscle.

INDICATION
- ACC, AHA and Heart Rhythm Society
 Class I (procedure to be performed)
• Sinus node dysfunction
• Acquired atrioventricular block
• Chronic bifascicular block
• After acute MI
INDICATION cont…
• Hypersensitive carotid sinus syndrome and
neurocardiogenic syncope
• After cardiac transplantation
• Pacing to prevent tachycardia
• Patients with congenital heart disease
 Class II procedures can be performed
but additional studies are needed
• Sustained VT
• Unexplained Syncope
• Nonischemic cardiomyopathy
• Permanent pacemaker that automatically detect and
pace to terminate tachycardia
• Cardiac sarcoidosis, Chagas disease
• Brugada syndrome

Class III procedures should not be performed

 Permanent pacemakers
TYPES Temporary pacemakers
PERMANENT PACEMAKER

• The permanent pacemaker source is implanted subcutaneously

usually over the pectoral muscle on the patient’s nondominant side

• It is attached to pacing leads, which are threaded intravenously to

the right atrium and one or both ventricles.

 TEMPORARY PACEMAKER
• Temporary pacemaker are used to support the patient
until patient condition improve or receive a permanent
pacemaker.
TYPES OF PACING

• Transvenous pacing –
internal jugular /
subclavian/ femoral
vein
• Epicardial pacing
• Transcutaneous pacing
 TYPES BASED ON CHAMBER BEING PACED

• Single chamber pacing: one lead

• Dual chamber pacing : 2 lead

• Biventricular pacing / Cardiac resynchronization

therapy : 3 leads connecting to right atrium and both
ventricles
Components

 Electronic pulse generator – circuit and

battery
Rate (beats/mt)
Output (mA)
Sensitivity (mV)
 Pacemaker electrodes - leads
 PACEMAKER CODE
• Universal code – NASPE and BPEG
First letter Second letter Third letter Fourth letter Fifth letter
Chamber Chamber sensed Response after Rate modulation Multisite pacing
paced Sensing
A – Atrium A – Atrium I - Inhibited O - No rate A – Atrium
responsiveness
V - Ventricle V - Ventricle T - Triggered R – Rate V - Ventricle
modulation
D - Dual D - Dual D - Dual D - Dual

O – None O - None O – None

Pacemaker spikes
MAGNET INHIBITION
Used to inhibit the device
Reprograms the pacer into an asynchronous pacing
mode; it does not turn the pacemaker off.
Determine the pacer’s battery to be replaced.
COMPLICATION
• Local infection at entry site
• Bleeding and hematoma
• Hemothorax
• Ventricular ectopy
• Dislocation of lead
• Phrenic nerve, diaphragmatic stimulation
• Cardiac tamponade
• Pacemaker syndrome
• Twiddler syndrome
PACEMAKER MALFUNCTION
• Loss of capture : complex doesnot follow pacing site
• Under sensing : pacing spike occurs at preset intervals despite of
patient’s rhythm.
• Oversensing : pacing doesn’t occur at preset interval
• Lack of pacing : total absence of pacing spikes
• Rhythmic diaphragmatic or chest wall twitching
NURSING MANAGEMENT

• Preoperative care
Assess knowledge and understanding level
Collect blood reports, Chest Xray, ECG, Echo,
Holter report
Get informed consent signed
Place ECG monitor electrodes away from
potential incision sites
 Post operative care

• Provide postoperative monitoring, analgesia and care

• Obtain postop chest Xray to identify lead location and detect possible
complication
• Provide comfortable position. Restricting movement of extremities
• Assist with gentle ROM exercise atleast 3 times daily, beginning 24 hrs
after pacemaker implantation
• Monitor pacemaker function with cardiac monitoring and report
pacemaker problems to physician.
• Assess for dysrrhythmia and treat as indicated
• Provide pacemaker identification card.
Patient teaching
 Placement of the pacemaker generator and leads
 How the pacemaker works and rate at which it is set.
 Battery replacement
 How to take and record pulse rate.
 Incision care and signs of infection
 Signs of pacemaker malfunction to report including
dizziness, fainting, fatigue, weakness, chestpain or
palpitation.
 Activity restrictions. Limit to contact sports and avoid heavy
lifting for 2 months after surgery
 Avoid tight fitting clothings
 Notify all care providers of the pacemaker
 Carry pacemaker ID card
 Do not hold or use certain electrical devices over pacemaker
site including household appliances , antitheft devices.
 Maintain follow up care with physician
 BIBLIOGRAPHY

• Woods LS, Froelicher SSE, Motzer US, Bridges EJ.

Cardiac Nursing. 6th edition. Baltimore: Wolters Kluwer
Publication; 2010
• Smeltzer S C, Bare B , Brunner &suddarth’s Medical
surgical nursing, edition 10th, ( 2000), Westline Industrial
drive, Missouri.
• Pacemaker - American Heart Association
www.heart.org/HEARTORG/Conditions/.../Pacemaker_U
CM_448480_Article.jsp