Nursing care for

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Nursing care for the Pt. with Pacemaker
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Sub CCU Maharaj Nakorn Chiangmai Hospital
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?????????????????????????(Pacemaker)
An artificial pacemaker is an electronic device
to provide repetitive electrical stimuli to the
heart muscle in order to control the heart rate
Pacemaker system -???????????????????????? (pulse
generator) ??????? ????????? ???????????? -???????
(lead) ??????????????????????????????????????????
????????????????????? (electrode)
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Types of Pacemakers

• Temporary
• Prophylactic-used until the condition resolves in
  symptomatic bradycardia
• Pacemaker have the power source outside the body
• Permanent Pacemaker
• Conditioned persists despite adequate therapy
• implanted entirely within the body

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Pacemakers Code

• Identification Code - 5 letters
• 1st - Chamber(s) paced
• 2nd - Chamber(s) sensed
• 3rd - Response to sensing
• 4th - Rate Modulation Programmability
• 5th - Antitachycardia Pacing Function

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The NASPE/BPEG Generic (NBG) Code
Position
I
II
III
IV
V
Category
Chamber(s) Paced
Response to Sensing
Programmability, rate modulation
Antitachy- arrhythmia Function(s)
Chamber(s) Sensed
Letters Used
O-None P-Simple Programmable M-Multi- Programmab
le C-Communicating R-Rate modulation
O-None A-Atrium V-Ventricle D-Dual (AV)
O-None A-Atrium V-Ventricle D-Dual (AV)
O-None T-Triggered I-Inhibited D-Dual (TI)
O-None P-Pacing (antitachy- arrhythmia) S-Shock
D-Dual (PS)
Manufac- turers Designation Only
S- Single (A or V)
S- Single (A or V)
NASPE North American Society for Pacing
Electrophysiology BPEG British Pacing
Electrophysiology
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Pacing mode

• Single chamber modes
• -AAI
• -VVI
• -VVIR
• Dual chamber modes
• -DDD
• -DDDR

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AAI
I

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VVI
I

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DDD
T / I

I

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Pacemaker Indication

• Sinus node dysfunction (SSS)
• AV Block 3AVB Symptom, Intermittent
  Symptomatic 2AVB, Symptomatic Adv. AVB with AF or
  flutter
• Sinus node disease with AV Block
• Chronic Atrial fibrillation with AV Block

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Temporary Pacemakers

• Insertion
• External - applied emergently at the bedside
• Epicardial - leads are placed by the cardiac
  surgeon in the operating room
• Transthoracic - Usually attempted emergently, as
  a last resort, after other temporary pacing
  methods have failed. Physician inserts a
  pericardial needle through the subxyphoid area of
  the thorax into the right ventricle and advances
  the lead wire through the needle in order to
  achieve contact with the endocardium
• Transvenous - May be inserted at the bedside,
  preferably under fluroscopy. Usually inserted
  into the subclavian or jugular vein, but can be
  inserted into the antecubital or femoral vein

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Temporary Pacemakers

• Transvenous pacing
• If initiated through antecubital or femoral vein,
  limit mobility of the extremity
• Determine sensitivity and pacing thresholds
• Set pacemaker settings
• Initiate pacing
• Follow hospital procedure protocol for
  initiating and adjusting pacemaker settings

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Pacer-related Complications

• Pacer lead dislodgement/ broken lead
• Cardiac perforate tamponade
• Pneumothorax hemothorax
• Infection Phlebitis, pacer pocket ,
  endocarditis
• Ventricular arrhythmia after initial cath.
  Insertion
• Abdominal twitching or hiccups
• Pacemaker malfunction
• Pacemaker syndrome loss of AV synchrony,
  retrograde conduction, inappropriate AV delay
• - Low CO
• - S/S of HF Shortness of breath, dizziness,
  fatique, anxiety, palpitation, chest pain or
  confusion

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Failure to pace
Pacemaker programmed to 830 ms / 72 ppm
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Failure to pace
Pacemaker programmed to 830 ms / 72 ppm
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Failure to Capture
Automatic Interval
Escape Interval
QRS to QRS
800 ms
800 ms
1600 ms
Sensed
Sensed
Sensed
Noncapture
Noncapture
Noncapture
Noncapture
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UNDERSENSING
Intrinsic Refractory Period
Automatic Interval
800 ms
Undersensing
Capture
Capture
Capture
Capture
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OVERSENSING
Lack of Pacing Spike
Lack of Pacing Spike

• Sources
• Myopotentials
• Environment
• Intrinsic Cardiac Signals

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BATTERY DEPLETION
Automatic Interval
Intrinsic Refractory Period
Fusion
1000 ms
Capture
Undersensing
Capture
Undersensing
Pacemaker programmed to 830 ms / 72 ppm
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Temporary Pacemakers

• Troubleshooting
• Failure to pace- cant see pacemaker spikes
  during periods of asystole or bradycardia
• Loose connections in the pacing system
• Failure of pacemaker battery or pulse generator
• Fracture of the pacing lead wire
• Lead wire dislodgement
• Failure to capture - pacemaker spike is not
  followed by a P wave or QRS as appropriate
• Loose connections in the pacing system
• Increased pacing threshold
• Fracture of the pacing lead wire
• Lead wire dislodgement
• Failure of pacemaker battery or pulse generator

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Temporary Pacemakers

• . Undersensing - pacemaker fires with no regard
  to the patients own rhythm. Dangerous because it
  may lead to ventricular tachycardia and/or
  ventricular fibrillation
• Inadequate QRS signal
• Myocardial ischemia, fibrosis, electrolyte
  imbalances, bundle branch block, or a poorly
  positioned lead
• Oversensing - pacemaker thinks it detects a QRS
  complex, inhibits itself and doesnt fire
• Tall or peaked P waves or T waves
• Myopotentials (electrical signals produced by
  skeletal muscle contraction as with shivering or
  seizures)

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Temporary Pacemakers

• Patient Management
• ECG monitoring
• Hemodynamic monitoring
• Assess pacemaker function
• Electrical safety
• Reassess functioning after defibrillation
• Pacing insertion site care
• Assure pacemaker controls are protected from
  accidental adjustment
• Provide information regarding pacemaker therapy
  to the patient and family
• If temporary wires exist-coil and tape to chest
  when not in use

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Permanent Pacemakers

• Components
• Pulse generator - consists of lithium batteries
  and electrical micro circuitry encased in
  titanium. Lithium batteries last about 6-12
  years, depending on how much the pacemaker is
  used
• Lead wire - a catheter with electrodes at the
  tip. Ventricular wires are easier to secure than
  atrial wires
• Electrode(s) - remember the negative electrode is
  the one that paces

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BIPOLAR LEAD
UNIPOLAR LEAD
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BIPOLAR
UNIPOLAR
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Permanent Pacemakers

• Lead Placement
• Epicardial
• Usually placed during heart surgery
• Leads placed in contact with epicardium
• Pulse generator in a subcutaneous pocket in
  abdomen
• Endocardial (Transvenous)
• Most common
• Pacing catheter inserted percutaneously via
  subclavian vein and advanced to the right atrium
  or apex of right ventricle
• Leads placed in contact with endocardium
• Pulse generator in subcutaneous pocket in the
  subclavian area

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Dual chamber Pacemaker
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Permanent Pacemakers

• Examples
• Single Chamber VVI Pacemakers
• Advantages - simple one lead system where the
  lead wire is placed in the right ventricle
• Limitations - loss of AV synchrony, lack of rate
  variability
• usually placed in patients who have chronic
  atrial fibrillation with SVR
• VVIR pacers were developed to achieve rate
  variability - there is a sensor in the pulse
  generator that senses skeletal muscle activity

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Permanent Pacemakers

• Dual Chamber DDD Pacemakers
• Advantages - two lead system with one lead wire
  in the atrium and one lead in the ventricle,
  capable of pacing the atria and ventricles,
  preserves AV synchrony,
• Limitations -
• Patients with atrial fibrillation or atrial
  flutter - it cant capture the atrium. Pacer is
  confused by the atrial activity. This will not
  cause harm to the patient, but will deplete the
  batteries faster. Should be reprogrammed.
• Lack of rate variability - DDDR pacers were
  developed to achieve rate variability. As the
  sensor picks up skeletal muscle activity, the
  DDDR pacer will increase the atrial pacing rate.

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CXR Pt. With DDD
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Paced QRS Morphology
Lead Position QRS Morphology
QRS Axis
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Permanent Pacemakers

• Troubleshooting
• Failure to capture
• Reasons
• Lead dislodgement
• Lead fracture
• Loose connections between pulse generator and
  lead wire
• Fibrosis at the tip of the lead causing changes
  in the pacing threshold
• Treatment
• Obtain a chest x-ray to determine lead position
• Reposition or replace lead if dislodged or
  fractured
• Reprogram pacer if fibrosis is cause of failure
  to capture
• SQ pocket may need to be reopened to check
  connections
• Have atropine and external pacemaker at bedside
  in case patient develops a symptomatic bradycardia

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Permanent Pacemakers

• Failure to sense
• Reasons
• Electromagnetic interference
• Lead fracture
• Loose connections between the pulse generator and
  the lead wire
• Battery failure
• Treatment
• Move away from magnetic field
• Obtain a chest x-ray to determine lead position
• Reposition or replace lead if dislodged or
  fractured
• SQ pocket may need to be reopened to check
  connections
• Replace generator if needed
• If undersensing or oversensing and generator is
  programmable, need to reprogram

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Permanent Pacemakers

• Failure to pace
• Reasons
• Electromagnetic interference
• Lead fracture
• Loose connections between the pulse generator and
  the lead wire
• Circuitry or battery failure
• Treatment
• Move away from magnetic field
• Obtain a chest x-ray to determine lead position
• Reposition or replace lead if dislodged or
  fractured
• SQ pocket may need to be reopened to check
  connections
• Replace generator if needed
• Have atropine and external pacemaker at bedside
  in case patient develops a symptomatic
  bradycardia

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Permanent Pacemakers

• Patient Management
• Pre-op
• - Pre-op Physical Emotional social
• Avoid placing ECG monitoring electrodes over the
  right or left subclavian areas
• Assess S/S, Lab CBC,BUN Cr e,PT,PTT,AntiHIV,
  CXR, EKG
• Clean shave both shoulders groins
• On PSS locked or IV fluid
• Patient and family teaching
• NPO after midnight or before at least 4 hr.
• Where procedure will be done and about how long
  it will take
• Pre-op medications - sedative and antibiotic
• Local anesthesia rather than general

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Permanent Pacemakers

• Immediate Post-op
• Patient and family teaching
• Frequent vital signs until stable
• Bedrest up to 24 hours
• Limited range of motion in the affected arm and
  maintain pressure dressing 48 hr.
• Be careful about incision site
• Administration of antibiotics
• Encourage coughing and deep breathing

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Permanent Pacemakers

• Post-op Nursing Management
• Document type of pacer and settings
• Run an initial strip and then more often if
  pacing in noted on monitor 24 hours
• Record V/S every 15 4 times until stable
• Obtain a 12 leads ECG
• Monitor for signs symptoms of pacemaker
  malfunction
• Observe pressure dressing for signs of infection
  bleeding 48 hr then simple dressing OD 7 days
• Administer antibiotics as prescribed
• Assess pain and offer pain medicine prn if
  necessary
• Minimal arm shoulder activity prevent
  dislodgement of new leads 2 wk
• Follow up CXR PA lt. Lateral view
• D/C on day 4 after implantation if no
  complication

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Permanent Pacemakers

• Discharge Teaching
• Watch insertion site for signs of infection
• If sutures, they will be removed in one week. If
  steristrips, they will gradually fall off
• Avoid lifting affected arm for at least 2 weeks
• Return to activities gradually (prevent frozen
  shoulder)
• Activities allow avoid avoid contact sports
• How to take a pulse
• Signs symptoms of pacemaker malfunction
• Importance of follow-up visit to PPM check up
• Life of batteries usually 6-12 years
• New medications

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Permanent Pacemakers

• Carry Pacemaker ID card containing pacemaker
  information show to doctors, dentists, etc.
• Avoid electromagnetic interference (EMI)
• all household appliances, including microwave
  ovens, are OK to use
• avoid welding equipment power transmitters
  large generators radio, television, and radar
  towers - antennas at home are safe, but not CB
  and ham operator antennas
• avoid leaning directly over any running engines
  or motors - can create magnetic fields
• Avoid carrying cellular phones in pocket near
  pacemaker site 6 inch

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Permanent Pacemakers

• avoid electrocautery and diathermy
• No radiation therapy to the chest (pacemaker
  generator should be shield)
• No MRI scan performed for other medical
  conditions (Pt. Need to have CT scan done
  instead)
• Inform other physician that they have a
  pacemaker, particularly dentists
• ?????????????????? at airport metal detectors.
  Need to inform them to be careful of hand-held
  wands as they may have magnets in them and should
  therefore not be held over the pacemaker
  generator for a long period of time
• Defibrillation/cardioversion ??????
  paddles????????????????????????? 10 ??.

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Any Question?
Thank you
Common Rosefinch