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Cardiac Pacing

Cardiac Pacing

A cardiac pacemaker is an electronic device that delivers direct electrical stimulation to stimulate the myocardium to depolarize, initiating a mechanical contraction. The pacemaker initiates and maintains the heart rate when the heart’s natural pacemaker is unable to do so.

  • Pacemakers can be used to correct bradycardia, tachycardia, sick sinus syndrome, and second- and third-degree heart blocks, and for prophylaxis
  • Pacing may be accomplished through a permanent implantable system, a temporary system with an external pulse generator and percutaneously threaded leads, or a transcutaneous external system with electrode pads placed over the chest.

Clinical Indications

  1. Symptomatic bradydysrhythmias
  2. Symptomatic heart block
  • Mobitz Il second-degree heart block
  • Complete heart block
  • Bifascicular and trifascicular bundle branch blocks

Prophylaxis

  • After acute MI: dysrhythmia and conduction defects
  • Before or after cardiac surgery
  • During diagnostic testing
  • Cardiac catheterization
  • EPS
  • Percutaneous transluminal coronary angioplasty (PTCA)
  • Stress testing
  • Before permanent pacing

Tachydysrhythmias; to break rapid rhythm disturbances

  • Supraventricular tachycardia
  • Ventricular tachycardia

Types of Pacing

Permanent Pacemakers

  • Used to treat chronic heart conditions surgically placed, utilizing a local anesthetic the leads are placed transvenously in the appropriate chamber of the heart and the anchored to the endocardium.
  • The pulse generator is placed in a surgically made pocket in subcutaneous tissue under the clavicle.
  • Once placed and programmed it can be adjusted externally as needed.

Temporary Pacemakers

  • Temporary pacemakers are usually placed during an emergency, such as when a patient demonstrates signs of decreased cardiac output (CO) until the temporary condition are resolved
  • Indicated for patients with high-grade AV blocks, bradycardia, or low CO. They serve as a bridge until the patient becomes stable enough for placement of a permanent pacemaker
  • Can be placed transvenously, epicardially, transcutaneously, and transthoracically.
  • Transvenous pacemakers are inserted transvenously (into a vein, usually the subclavian, internal jugular, antecubital, or femoral) under fluoroscopy into the right ventricle or right atrium, or both chambers for dual-chamber pacing, and then attached to an external pulse generator
  • Epicardial pacemakers wires are attached to the endocardium of the heart, brought out through a surgical incision onto the chest, connected to an external pulse generator, and are commonly used when a patient is undergoing cardiac surgery
  • In transcutaneous pacemakers noninvasive electrodes are placed either anterior-posterior (anterior chest wall right of the upper sternum below the clavicle and to the back of the patient) or anterior- apex (left of the left nipple with the center of the electrode in the midaxillary line), and electrical impulses flow through the electrodes and subcutaneous skin to the heart.
  • The transthoracic pacemaker is a type of temporary pacemaker that is placed only in an emergency via a long needle, using a subxiphoid approach. The pacer wire is then placed directly into the right ventricle

Biventricular Pacemakers

  • Biventricular pacemakers are also referred to as cardiac resynchronization therapy
  • Biventricular pacing is used to treat moderate to severe heart failure as a result of left ventricular dyssynchrony.
  • Intraventricular conduction defects result in an uncoordinated contraction of the left and right ventricle, which causes a wide QRS complex and is associated with worsening heart failure and increased mortality
  • Biventricular pacemakers utilize three leads (one in the right atrium, one in the right ventricle, and one in the left ventricle) to coordinate ventricular contraction and improve CO.
  • Biventricular pacemakers can incorporate implantable cardiac defibrillators or be used alone.

Nursing Diagnoses

  • Decreased Cardiac Output related to potential pacemaker malfunction and dysrhythmias.
  • Risk for Injury related to pneumothorax, Hemothorax, bleeding, micro shock, and accidental malfunction.
  • Risk for Infection related to surgical implantation of pacemaker generator and/or leads.
  • Anxiety related to pacemaker insertion, fear of death, lack of knowledge, and role change
  • Impaired Physical Mobility related to imposed restrictions of arm movement and bed rest
  • Acute Pain related to surgical incision and transcutaneous external pacing stimuli
  • Disturbed Body Image related to pacemaker implantation

Nursing Interventions

Maintaining Adequate Cardiac Output

  • Record the following information after insertion of the pacemaker.
  • Pacemaker manufacturer, model, and lead type
  • Operating mode
  • Programmed settings: lower rate limit, upper rate limit; AV delay: pacing thresholds
  • Patient’s underlying rhythm
  • Patient’s response to procedure
  • Attach ECG electrodes for continuous monitoring of heart rate and rhythm.
  • Set alarm limits 5 beats below lower rate limit and 5 to 10 beats above upper rate limits (ensures immediate detection of pacemaker malfunction (or failure).
  • Keep alarms on at all times.
  • Analyze rhythm strips per protocol and as necessary
  • Identify presence or absence of pacing artifact.
  • Differentiate paced P waves and paced QRS complexes from spontaneous beats.
  • Measure AV delay (if pacemaker has dual chamber functions).
  • Determine the paced rate.
  • Analyze the paced rhythm for presence and consistency of capture (every pacing spike is followed by atrial and/or ventricular depolarization)
  • Analyze the rhythm for presence and consistency of proper sensing. (After a spontaneous beat, the pacemaker should not fire unless the interval between the spontaneous beat and the paced beat equals the lower pacing rate and/or the paced beat follows the programmed AV delay).
  • Monitor vital signs as per facility protocol, and as necessary
  • Monitor urine output and level of consciousness to ensure adequate cardiac output achieved with paced rhythm
  • Observe for dysrhythmias (ventricular ectopic activity can occur because of irritation of ventricular wall by lead wire).
  • Monitor for competitive rhythms, such as runs of atrial fibrillation or flutter, accelerated junctional or idioventricular or ventricular tachycardia
  • Report dysrhythmias.
  • Administer antidysrhythmic therapy as directed.
  • Obtain 12-lead ECG, as ordered.

Avoiding Injury

  • Note that a post insertion chest X-ray has been taken to ensure correct lead wire position and that no fluid is in lungs.
  • Monitor for signs and symptoms o hemothorax
  • Monitor for signs and symptoms of pneumothorax.
  • Evaluate continually for evidence of bleeding.
  • Check incision site frequently for bleeding
  • Apply manual pressure and pressure dressing to control bleeding
  • Palpate for pulses distal to insertion site. (Swelling of tissues from bleeding may impede arterial flow.)
  • Monitor for evidence of lead migration and perforation of heart.
  • Observe for muscle twitching and/or hiccups (may indicate chest wall or diaphragmatic pacing).
  • Evaluate patient’s complaints of chest pain (may indicate perforation of pericardial sac).
  • Auscultate for pericardial friction rub.
  • Observe for signs and symptoms of cardiac tamponade: distant heart sounds distended neck veins, pulsus paradoxus.
  • Provide an electrically safe environment for patient. Stray electrical current can enter the heart through temporary pacemaker lead system and induce dysrhythmias.
  • Protect exposed parts of electrode lead terminal in temporary pacing systems with a rubber glove. (Newer external generators have the lead terminals enclosed in a case; a rubber glove is not necessary.)
  • Wear rubber gloves when touching temporary pacing leads. (Static electricity from hands can enter the patient’s body through the lead system.)
  • Make sure all equipment is grounded with three-prong plugs inserted into a proper outlet; biomedical engineer should routinely check room to ensure safe environment.
  • Temporary epicardial pacing wires (most common after cardiac surgery) should have the terminal needles protected by a plastic tube; place tube in rubber glove to protect it from fluids or electrical current.
  • Be aware of hazards in the facility that can interfere with pacemaker function or cause pacemaker failure and permanent pacemaker damage.
  • Avoid use of electric razors.
  • Avoid direct placement of defibrillator paddles over pacemaker generator; anterior placement of paddles should be 4 to 5 inches (10 to 12.5 cm) away from pacemaker; always evaluate pacemaker function after defibrillation.
  • Electrocautery devices and transcutaneous electrical stimulator (TENS) units pose a risk.
  • Patients with permanent pacemakers should never be exposed to MRI because the strength of the magnetic field may alter or erase pacemaker program memory.
  • Caution must be used if patient will receive radiation therapy; the pacemaker should be repositioned if the unit lies directly in the radiation field

Prevent accidental pacemaker malfunctions

  • Use clear plastic covering over external temporary generators at all times (eliminates potential manipulation of programmed settings).
  • Secure temporary pacemaker generator to patient’s chest or waist; never hang it on an I.V. pole.
  • Transfer of patient from bed to stretcher should only be attempted with an adequate number of personnel, so that patient can remain passive; caution personnel to avoid underarm lifts.
  • Place a sign over patient’s bed alerting personnel to presence of temporary pacemaker
  • Evaluate transcutaneous pacing electrodes every 2 hours for secure contact to chest wall; change electrode pads as directed or if patient is diaphoretic.

Note: Transcutaneous pacing should not be used continuously for more than 2 hours.

  • Monitor for electrolyte imbalances, hypoxia, and myocardial ischemia. (The amount of energy the pacemaker needs to stimulate depolarization may need adjustment if any of these are present.)

Preventing Infection

  • Take temperature every 4 hours; report elevations. (Suspect pacemaker system for infection source if temperature elevation occurs.)
  • Observe incision site for signs and symptoms of local infection: redness, purulent drainage, warmth, soreness
  • Be alert to manifestations of bacteremia.
  • Clean incision site as directed, using sterile technique.
  • Monitor vein through which the pacing lead wire was placed for evidence of phlebitis.
  • Evaluate patient’s complaints of increasing tenderness and discomfort at incision site.
  • Administer antibiotic therapy as prescribed.

Relieving Anxiety

  • Offer careful explanations regarding anticipated procedures and treatments, and answer the patient’s questions with concise explanations.
  • Encourage patient to use coping mechanisms to overcome anxieties.
  • Encourage patient to accept responsibility for care.
  • Review care plan with patient
  • Encourage patient to make decisions regarding a daily schedule of self-care activities
  • Engage patient in goal setting. Establish with patient priorities of care and time frames to accomplish goals up until discharge
  • Monitor for unwarranted fears expressed by patient (commonly, pacemaker failure), and provide explanations to alleviate fear. Explain to patient life expectancy of batteries and the measures taken to check for failure.

Minimizing the Effects of Immobility

  • Explain the purpose of bed rest (24 to 48 hours) and immobilization of extremity nearest to permanent or temporary pacemaker lead implant (allows stabilization of lead in heart and prevents lead dislodgement)
  • Encourage patient to take deep breaths frequently each hour to promote pulmonary function; caution against vigorous coughing (lead dislodgement may occur)
  • Instruct patient in dorsiflexion exercises of ankles and tightening of calf muscles. This promotes venous return and prevents venous stasis. Exercises should be done hourly
  • Restrict movement of affected extremity
  • Place arm nearest to permanent pacemaker implant in sling as directed; extremity with temporary pacing wire should be immobilized and kept straight as prescribed.
  • Instruct patient to gradually resume range of motion (ROM) of extremity as directed (usually 24 hours for permanent implants); avoid over-the-head motions for approximately 5 days
  • Evaluate patient’s arm movements to ensure normal ROM progression; assist patient with passive ROM of extremity as necessary (prevents development of shoulder stiffness caused by prolonged joint immobility); consult physical therapy as directed if stiffness and pain occur
  • Assist patient with activities of daily living (ADLs) as appropriate.

Relieving Pain

  • Prepare patient for discomfort he may experience after pacemaker implant or initiation of transcutaneous pacing.
  • Explain to patient that Incisonal pain will occur after procedure; pain will subside after the first week, but he may have some soreness for up to 4 weeks.
  • Explain to patient the potential for discomfort during transcutaneous pacing; assure patient that the lowest energy possible will be used and analgesics will be given.
  • Administer analgesics as directed; attempt to coincide peak analgesic effect with performance of ROM exercises and ADLs.
  • Offer back rubs to promote relaxation.
  • Provide patient with diversional activities.
  • Evaluate effectiveness of pain-relieving modalities

Maintaining a Positive Body Image

  • Encourage patient to express concerns regarding self-image and pacer implant.
  • Reassure patient that sexual activity and modes of dressing will not be altered by pacemaker implantation.
  • Offer patient the opportunity to talk to others who have had a pacemaker implantation.
  • Encourage spouse or significant other of patient to discuss concerns of self-image with patient.

Activity

  • Reassure patient that normal activities will be able to be resumed.
  • Explain to patient that it takes about 2 months to develop full ROM of arm (fibrosis occurs around the lead and stabilizes it in heart).
  • Specific instructions include
  • Instruct patient not to lift items over 3 lb (1.4 kg) or perform difficult arm maneuvers.
  • Caution patient against excessive stretching or bending exercises.
  • Avoid contact sports, tennis, golfing, bowling, and yard work until resumption of these activities is permitted by physician
  • Caution patient not to fire a rifle with it resting over pacemaker implant.
  • Sexual activity may be resumed when desired
  • Instruct patient to gauge activities according to sensations of moderate pain in arm or site of implant and stretching sensation in and around implant site.

Patient Education

Patients are placed on a cardiac monitor and strict bed rest for 12 to 24 hours after insertion of a pacemaker. The patient’s apical pulse is monitored frequently to detect changes in the heart rhythm. Irregular heart rhythms or a rate slower than the pacemaker’s set rate can indicate pacemaker malfunction. The dressing at the pacemaker insertion site is monitored every 2 to 4 hours for signs of bleeding. Any change in heart rhythm, complaints of chest pain, or changes in vital signs must be reported immediately. Patients may have a sling on the operative side arm for 24 to 48 hours to help prevent dislodgement of the pacemaker lead from the cardiac wall.

Patient education for pacemaker care before discharge includes the following

  1. Incision care. The patient should check the incision daily and report evidence of inflammation or infection (redness, swelling warmth, tenderness, pain, fever, or discharge) to a physician.
  2. Methods for taking a radial pulse: The patient should call a physician if the pulse is slower than the pacemaker’s set rate.
  3. The patient should report symptoms of dizziness, fainting, irregular heartbeats or palpitations
  4. The patient should understand the importance of wearing medical alert jewelry and carrying a pacemaker information card
  5. The patient should avoid radiation, magnetic fields (e.g., magnetic resonance imaging [MRI], industrial magnets), high voltage (e.g. power plant, arc welding, high-tension wires) antitheft devices, and large running motors (e.g., distributor coil of running engine).
  6. The patient will need to tell airport security about the pacemaker; because it may trigger metal detectors (they do not harm the pacemaker)

Care of Pacemaker Site

  • Advice patient to wear loose-fitting clothing around the area of pacemaker implantation until it has healed.
  • Watch for signs and symptoms of infection around generator and leads fever, heat, pain, and skin breakdown at implant site.
  • Advise patient to keep incision clean and dry.
  • Encourage tub baths rather than showers for the first 10 days after pacemaker implantation
  • Instruct patient not to scrub incision site or clean site with bath water.
  • Teach patient to clean incision site with antiseptic as directed.
  • Explain to patient that healing will take approximately 3 months.
  • Instruct patient to maintain a well- balanced diet to promote healing.
  • Inform patient that there is no increased risk of endocarditis with dental cleaning or procedures, so antibiotic prophylaxis is not necessary

Pacemaker Failure

  • Teach patient to check own pulse rate at least every week for 1 full minute at rest to be sure that preset rate remains constant. (Patients check pulse daily to ensure all is well and promote a sense of control.)
  • Teach the patient to:
  • Report immediately slowing of pulse lower than set rate, or greater than 100.
  • Report signs and symptom of dizziness, fainting, palpitation, prolonged hiccups, and chest pain to health care provider immediately. These signs are indicative of pacemaker failure.
  • Take pulse while these feelings are being experienced.
  • Encourage patient to wear identification bracelet and carry pacemaker identification card that lists pacemaker type, rate, health care provider’s name, and facility where the pacemaker was inserted; encourage significant other to keep a card with patient’s pacemaker information so someone else will have it.

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