By Fatimah Abu-Dayah 2008 F ABUDAYAH 1 Clinical

By Fatimah Abu-Dayah 2008/F. ABUDAYAH 1

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 pt’s educational needs 2 2008/F. ABUDAYAH

Out line ¡ ¡ ¡ ¡ ¡ Introduction Definition of cardiac pacing Clinical Indication Pacemaker design Pacemaker function Types of pacing Nursing diagnosis Nursing intervention Pt’s education 2008/F. ABUDAYAH 3

Normal conductive system of the heart 2008/F. ABUDAYAH 4

Definition of cardiac pacing It is an electric device that delivers direct electrical stimulation to stimulate the myocardium to depolarize , initiating a mechanical contraction. 2008/F. ABUDAYAH 5

Clinical Indication 1. 2. ¡ ¡ ¡ 3. 2008/F. ABUDAYAH Symptomatic bradycardia Symptomatic heart block 2 nd degree heart block 3 rd or complete heart block Bifasicular or transfasicular bundle branch blocks. Prophylaxis 6

Pacemaker Design 1. 2. 2008/F. ABUDAYAH Pulse generator leads 7

Pacemaker Design Pulse generator ¡ In permanent pacemaker is encapsulated in a metal can , to protect the generator from electromagnetic interference 2008/F. ABUDAYAH 8

Pacemaker Design Pulse generator ¡ Temporary pacing system generator is externally contained in a small box 2008/F. ABUDAYAH 9

Pacemaker Design Pulse generator ¡ Transcutanus external pacing system house the generator in a piece of equipment similar to portable ECG monitor. 2008/F. ABUDAYAH 10

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 2008/F. ABUDAYAH 11

Single chamber (unipolar 2008/F. ABUDAYAH 12

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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. 2008/F. ABUDAYAH 14

Dual-chamber (bipolar) pacemaker 2008/F. ABUDAYAH 15

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Pacemaker function 1. 2. 3. 2008/F. ABUDAYAH Pacing function Sensing function Capture function 17

Pacing function Atrial pacing: stimulation of RT atrium produce spic on ECG preceding P wave 2008/F. ABUDAYAH 18

Pacing function Ventricle pacing : stimulation of RT or LT ventricle produce a spic on ECG preceding QRS complex. 2008/F. ABUDAYAH 19

Pacing function AVpacing: direct stimulation of RT atrium and either ventricles mimic normal heart conduction 2008/F. ABUDAYAH 20

Sensing function Sensing : Ability of the cardiac pace maker to see intrinsic cardiac activity when it occurs. 2008/F. ABUDAYAH 21

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. 2008/F. ABUDAYAH 22

Capture function Capture: Ability of the pacemaker to generate a response from the heart (contraction) after electrical stimulation. 2008/F. ABUDAYAH 23

Capture function Electrical capture : indicated by P or QRS following and corresponding to a pacemaker spike. 2. Mechanical capture: palpable pulse corresponding to the electrical event. 1. 2008/F. ABUDAYAH 24

Pacing types Permanent ¡ Temporary ¡ biventricular ¡ 2008/F. ABUDAYAH 25

Types of pacing 1. ¡ ¡ ¡ 2008/F. ABUDAYAH 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 26

Permanent pacemaker 2008/F. ABUDAYAH 27

Types of pacing 2. ¡ ¡ ¡ Temporary pacemaker Placed during emergencies Indicated for pts’ high degree heart block or unstable bradycardia Can be placed transvenosly, epicardially, transcutanusly or transthorasicly 2008/F. ABUDAYAH 28

Types of pacing 3. ¡ ¡ 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 2008/F. ABUDAYAH 29

Equipments ¡ ¡ Transvenous pacing catheter EKG machine Pacemaker generator with battery and cable Emergency crash cart ¡ ¡ 2008/F. ABUDAYAH Lidocaine Defibri llator (2) 5 cc syringe with 22 and 25 gauge needles External Pacer Sterile gown, gloves, mask 30

INSERTION SITES Left Subclavian (most reliable) ¡ Internal jugular (lower incidence of pneumothorax) ¡ Femoral vein ¡ Brachial vein ¡ 2008/F. ABUDAYAH 31

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 ¡ 2008/F. ABUDAYAH 32

INSERTION PROCEDURE Anesthetize the area locally. ¡ Prepare the external temporary generator: ¡ Portable Chest X-ray is required to confirm placement. ¡ 2008/F. ABUDAYAH 33

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 ¡ 2008/F. ABUDAYAH 34

Complication ¡ ¡ ¡ Movement and dislocation of the lead Injury Bleeding and hematoma Ventricular ectopy or VT from wall stimulation Infection Cardiac tamponad 2008/F. ABUDAYAH 35

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. 2008/F. ABUDAYAH 36

Nursing intervention 1. ¡ ¡ ¡ 2008/F. ABUDAYAH Maintain adequate cardiac output Record information after insertion pacemaker model , mode, program setting, pt’s rhythm Attach ECG for continues monitoring Analyze rhythm strips as per protocol Monitor vital signs Monitor urine output Observe for dysrhythmia 37

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 2008/F. ABUDAYAH 38

Nursing intervention 3. ¡ ¡ 2008/F. ABUDAYAH 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 39

Nursing intervention 4. ¡ ¡ 2008/F. ABUDAYAH Provide electrically safe environment Protect exposed parts of electrode leads with rubber Wear rubber gloves when touching a temporary pacing lead 40

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. ¡ Pt’s 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 2008/F. ABUDAYAH 41 radiation therapy. 5.

Nursing intervention 6. ¡ ¡ 2008/F. ABUDAYAH Prevent accidental pacemaker malfunctions Use external plastic covering over external generator all times Secure temporary pace maker over pt’s chest or wrist never hang it over iv pole 42

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. ¡ 2008/F. ABUDAYAH 43

Nursing intervention 7. ¡ ¡ ¡ 2008/F. ABUDAYAH Preventing infection Take temp every 4 hrs 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. 44

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 2008/F. ABUDAYAH 45

Patient education Anatomy and physiology of the heart 2. Pacemaker function 3. Activity Specific instruction include ¡ Not to lift items over 1. 4 kg 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 when 2008/F. ABUDAYAH 46 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. 2008/F. ABUDAYAH 47

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. 2008/F. ABUDAYAH 48

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. ¡ 2008/F. ABUDAYAH 49

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. 2008/F. ABUDAYAH 50

References sandra m. nettina msn, a. Prn, bc, an. P manual of nursing Practice eighth edition braunner&suddarth’s textbook of medical surgical nursing 10 th edition 2008/F. ABUDAYAH 51