ARTIFICIAL PACEMAKER

Prepared by: Judith Angelica Lappay Maria Lourdes Luzuriaga Jenelyn Mallillin Marineth Kaye Paguirigan

Presented to: Mr. Eladio Martin Gumabay, RN, MSN

ARTIFICIAL PACEMAKER

 Definition: An artificial cardiac pacemaker is an electronic device that delivers direct stimulation to theheart, causing electrical depolarization and cardiac contraction.  Significance: The pacemaker initiates and maintains the heart rate when the natural pacemakers of the heart are unable to do so.  Clinical Indications: 1. Symptomatic bradyarrhythmias a. Sinoatrial bradyarrhythmias b. Sinoatrial arrest c. Sick sinus syndrome 2. Heart block a. Second degree heart block b. Complete heart block 3. Prophylaxis a. Following acute MI; arrhythmias and conduction defects b. Before or following cardiac surgery c. During coronary arteriography d. Before permanent pacing 4. Tachyarrhythmias a. Supraventricular b. Ventricular

ARTIFICIAL PACEMAKER THERAPY  Settings: 1. A synchronous or demand pacemaker senses the clients rhythm and paces only if the clients intrinsic rate falls below the set pacemaker rate. 2. Asynchronous or fixed rate paces at a preset rate regardless of the clients intrinsic rhythm. 3. Overdrive pacing suppresses the underlying rhythm in tachydysrhythmias so that the sinus node will regain control of the heart.  Spikes: 1. When a pacing stimulus is delivered to the heart, a spike (straight vertical line) is seen on the monitor or electrocardiogram strip. 2. The spike should be followed by a P wave indicating atrial depolarization, or a QRS complex indicating ventricular depolarization; this pattern is referred to as capture indicating that the pacemaker successfully depolarized, or captured, the chamber. 3. If the electrode is in the ventricle, the spike is in front of the QRS complex; if the electrode is in the atrium, the spike is before the P wave. 4. If the electrode is in the atrium and the ventricle, the spike is before the P wave and the QRS complex.  Temporary Pacemakers 1. Noninvasive temporary pacing a. Noninvasive temporary pacing is used as an emergency measure or when a client is being transported and the risk of bradydysrhythmia exists. b. A large electrode patch is placed on the chest and back. c. Wash the skin with soap and water before applying electrodes.

d. Do not shave the hair or apply alcohol or tincture to the skin. e. Place the posterior electrode between the spine and left scapula behind the heart, avoiding placement over bone. f. Place the anterior electrode between V2 and V5 positions over the heart. g. Do not place the anterior electrode over female breast tissue; rather, displace breast tissue and place under the breast. h. Do not take the pulse or BP on the left side; the results will not be accurate because of the muscle twitching and electrical current. i. Ensure that electrodes are in good contact with the skin. 2. Transvenous invasive temporary pacing a. Pacing lead wire is placed through antecubital, femoral, jugular, or subclavian vein into the right atrium for atrial pacing or through the right ventricle and is positioned in contact with the endocardium. b. Monitor cardiac rhythm continuously. c. Monitor vital signs. d. Monitor pacemaker insertion site. e. Restrict client movement to prevent lead wire displacement. 3. Epicardial invasive temporary pacing: applied by using a transthoracic approach; the lead wires are threaded loosely on the epicardial surface of the heart after cardiac surgery. 4. Reducing the risk of microshock a. Use only inspected and approved equipment. b. Insulate the exposed portion of wires with plastic or rubber material (fingers of rubber gloves) when wires are not attached to the pulse generator, and cover with nonconductive tape. c. Ground all electrical equipment using a three-pronged plug. d. Wear gloves when handling exposed wires. e. Keep dressing dry.  Permanent pacemakers 1. Pulse generator is internal and surgically implanted in a subcutaneous pocket under the clavicle or abdominal wall. 2. The leads are passed transvenously via the cephalic or subclaavian vein to the endocardium on the right side of the heart. 3. Permanent pacemakers may be single chambered in which the lead wire is placed in the chamber to be paced, or may be dual chambered, with lead wires placed in the atrium and right ventricle. 4. A permanent pacemaker is programmed when inserted and can be reprogrammed if necessary by noninvasive transmission from an external programmer to the implanted generator. 5. Pacemakers are powered by a lithium battery that has an average life span of 10 years, are nuclear powered with a life span of 20 years or longer, or are designed to be recharged externally. 6. Pacemaker function can be checked in the physicians office or clinic by a pacemaker interrogater/programmer or from home using telephone transmitter devices. 7. The client may be provided with a device that is placed over the pacemaker battery generator with an attachment to the telephone; the heart rate then can be transmitted to the clinic.

COMPLICATIONS OF PACEMAKER USE a. b. c. d. e. f. g. h. i. Local infection Bleeding and hematoma Hemothorax Ventricular ectopy and tachycardia Movement or dislocation of the lead placed transvenously (perforation of myocardium) Phrenic nerve, diaphragmatic or skeletal muscle stimulation Cardiac tamponade from bleeding Dislodgment of the pacing electrode Improper pacemaker functioning NOTE in patient chart/record: i. Model of pacemaker ii. Type of generator iii. Date and time of insertion iv. Location of pulse generator v. Stimulation threshold vi. Pacemaker settings (e.g. Rate, energy output[m/A], and duration between atrial and ventricular impulses (AV delay)

PACEMAKERS: CLIENT EDUCATION a. b. c. d. e. f. g. h. i. j. k. Instruct the client about the pacemaker, including the programmed rate. Instruct the client in the sign of battery failure and when to notify the physician. Instruct the client to report any fever, redness, swelling, or drainage from the insertion site. Report signs of dizziness, weakness or fatigue, swelling of the ankles or legs, chest pain, or shortness of breath. Keep a pacemaker identification card in the wallet and obtain and wear a Medic-Alert bracelet. Instruct the client in how to take the pulse, to take the pulse daily, and to maintain a diary of pulse rates. Wear loose fitting clothes. Avoid contact sports. Inform all health care providers that a pacemaker has been inserted. Instruct the client to inform airport security that he or she has a pacemaker because the pacemaker may set off the security detector. Instruct the clients that most electrical appliances can be used without any interference with the functioning of the pacemaker; however, advise the client not to operate electrical appliances directly over the pacemaker site. Avoid transmitter towers and antitheft devices in stores. Instruct the client that if any unusual feelings occur when near any electrical devices to move 5 to 10 feet away and check the pulse. Instruct the client about the methods of monitoring the function of the device. Emphasize the importance of follow-up with the physician.

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NURSING PROCESS: THE PATIENT WITH A PACEMAKER Assessment: a. Monitor heart rate and rhythm, pacemaker setting noted and compared with the ECG recordings. b. Assess cardiac output and hemodynamic stability c. Assess appearance or increased frequency of dysrhythmia d. Assess incision site and observe for bleeding, hematoma formation or infection e. TEMPORARY PACEMAKER: i. Assess electrical interference and development of micro shock. ii. Observe for potential sources of electrical hazards. iii. ALL electrical equipment used in the vicinity of the patient should be GROUNDED.

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iv. Exposed wires must be carefully covered with nonconductive material. v. Ensure with biomedical engineer or electrician an electrically safe environment. PERMANENT PACEMAKER: i. Assess for anxiety ii. Assess level of knowledge and learning needs of the patient and the family. iii. History of adherence to the therapeutic regimen should be identified.

Diagnosis: a. Risk for infection related to pacemaker lead or generation insertion. b. Risk for ineffective coping. c. Deficient knowledge regarding self-care program. Planning: a. Major goals for the patient may include absence of infection, adherence to self-care program, effective coping and maintenance of pacemaker functioning. Nursing Intervention: Preventing infection a. Change dressing regularly b. Inspect insertion site for redness, swelling, soreness or any unusual drainage. c. Increased in temperature and change in wound appearance should be reported to the physician. Promoting effective coping a. Nurse must recognize the patients emotional state and assist patient to explore his/her feelings. b. Help patient identify perceived changes, those emotional response to the change, and how the patient responded to that emotion. c. Reassure patient that the responses are normal, then assist the patient to identify realistic goals and to develop a plan to attain those goals. d. Teach patient easy-to-use stress reduction techniques to facilitate coping. e. Educate to assist patient cope with changes that occur with pacemaker treatment. Promoting home and community-based care Teaching patients self-care a. Nurses often need to include home caregivers in the teaching and provide printed materials for use by patient and caregiver. b. Priorities for learning are established with the patient and caregiver. c. Teach importance of periodic pacemaker monitoring, promoting safety, avoiding infection and sources of electromagnetic interference. Evaluation: Expected patient outcomes 1. Remains free of infection a. Has normal temperature. b. Has WBC count within normal range(5,000-10,000/mm3) c. Exhibits no redness or swelling of pacemaker insertion site. 2. Adheres to self-care program a. Responds appropriately when queried about the signs and symptoms of infection. b. Identifies when to seek medical attention. c. Adheres to monitoring schedule. d. Describes appropriate methods to avoid electromagnetic interference. 3. Maintains pacemaker function a. Measures and records pulse rate at regular intervals. b. Experience no abrupt changes in pulse rate or rhythm.