1. 2008/F.ABUDAYAH1 By By Fatimah Abu-Dayah

2. 2008/F.ABUDAYAH 2 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

3. 2008/F.ABUDAYAH3 Out line  Introduction  Definition of cardiac pacing  Clinical Indication  Pacemaker design  Pacemaker function  Types of pacing  Nursing diagnosis  Nursing intervention  Pt ’ s education

4. 2008/F.ABUDAYAH4 Normal conductive system of the heart

5. 2008/F.ABUDAYAH5 Definition of cardiac pacing It is an electric device that delivers direct electrical stimulation to stimulate the myocardium to depolarize,initiating a mechanical contraction.

6. 2008/F.ABUDAYAH6 Clinical Indication 1. Symptomatic bradycardia 2. Symptomatic heart block  2 nd degree heart block  3 rd or complete heart block  Bifasicular or transfasicular bundle branch blocks. 3. Prophylaxis

7. 2008/F.ABUDAYAH7 Pacemaker Design 1. Pulse generator 2. leads

8. 2008/F.ABUDAYAH8 Pacemaker Design Pulse generator  In permanent pacemaker is encapsulated in a metal can,to protect the generator from electromagnetic interference

9. 2008/F.ABUDAYAH9 Pacemaker Design Pulse generator  Temporary pacing system generator is externally contained in a small box

10. 2008/F.ABUDAYAH10 Pacemaker Design Pulse generator  Transcutanus external pacing system house the generator in a piece of equipment similar to portable ECG monitor.

11. 2008/F.ABUDAYAH11 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

12. 2008/F.ABUDAYAH12 Single chamber (unipolar

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14. 2008/F.ABUDAYAH14 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.

15. 2008/F.ABUDAYAH15 Dual-chamber (bipolar) pacemaker

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17. 2008/F.ABUDAYAH17 Pacemaker function 1. Pacing function 2. Sensing function 3. Capture function

18. 2008/F.ABUDAYAH18 Pacing function Atrial pacing: stimulation of RT atrium produce spic on ECG preceding P wave

19. 2008/F.ABUDAYAH19 Pacing function Ventricle pacing : stimulation of RT or LT ventricle produce a spic on ECG preceding QRS complex.

20. 2008/F.ABUDAYAH20 Pacing function AVpacing: direct stimulation of RT atrium and either ventricles mimic normal heart conduction

21. 2008/F.ABUDAYAH21 Sensing function Sensing : Ability of the cardiac pace maker to see intrinsic cardiac activity when it occurs.

22. 2008/F.ABUDAYAH22 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.

23. 2008/F.ABUDAYAH23 Capture function Capture: Ability of the pacemaker to generate a response from the heart (contraction) after electrical stimulation.

24. 2008/F.ABUDAYAH24 Capture function 1. Electrical capture : indicated by P or QRS following and corresponding to a pacemaker spike. 2. Mechanical capture: palpable pulse corresponding to the electrical event.

25. 2008/F.ABUDAYAH25 Pacing types  Permanent  Temporary  biventricular

26. 2008/F.ABUDAYAH26 Types of pacing 1. 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

27. 2008/F.ABUDAYAH27 Permanent pacemaker

28. 2008/F.ABUDAYAH28 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

29. 2008/F.ABUDAYAH29 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 Types of pacing

30. 2008/F.ABUDAYAH30 Equipments  Transvenous pacing catheter  EKG machine  Pacemaker generator with battery and cable  Emergency crash cart  Lidocaine Defibrillator  (2) 5cc syringe with 22 and 25 gauge needles  External Pacer  Sterile gown, gloves, mask

31. 2008/F.ABUDAYAH31 INSERTION SITES  Left Subclavian (most reliable)  Internal jugular (lower incidence of pneumothorax)  Femoral vein  Brachial vein

32. 2008/F.ABUDAYAH32 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

33. 2008/F.ABUDAYAH33 INSERTION PROCEDURE  Anesthetize the area locally.  Prepare the external temporary generator:  Portable Chest X-ray is required to confirm placement.

34. 2008/F.ABUDAYAH34 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

35. 2008/F.ABUDAYAH35 Complication  Movement and dislocation of the lead  Injury  Bleeding and hematoma  Ventricular ectopy or VT from wall stimulation  Infection  Cardiac tamponad

36. 2008/F.ABUDAYAH36 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.

37. 2008/F.ABUDAYAH37 Nursing intervention 1. 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

38. 2008/F.ABUDAYAH38 Nursing intervention 2. Avoid injury  Obtain chest x-ray to check lead wire position  Monitor for sign and symptom of hemothorax  Monitor for sign and symptom of pneumothorax  Evaluate evidence for bleeding

39. 2008/F.ABUDAYAH39 Nursing intervention 3. 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

40. 2008/F.ABUDAYAH40 Nursing intervention 4. Provide electrically safe environment  Protect exposed parts of electrode leads with rubber  Wear rubber gloves when touching a temporary pacing lead

41. 2008/F.ABUDAYAH41 Nursing intervention 5. 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 radiation therapy.

42. 2008/F.ABUDAYAH42 Nursing intervention 6. 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

43. 2008/F.ABUDAYAH43 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.

44. 2008/F.ABUDAYAH44 Nursing intervention 7. Preventing infection  Take temp every 4hrs  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.

45. 2008/F.ABUDAYAH45 Nursing intervention 8. Relieving anxiety 9. Reliving pain. 10. Maintaining a positive body image 11. Minimizing the effect of immobility  Rest for 24-48 hrs post pacing insertion  Deep breathing exercise  Restrict movement of affected extremity

46. 2008/F.ABUDAYAH46 Patient education 1. Anatomy and physiology of the heart 2. Pacemaker function 3. Activity Specific instruction include  Not to lift items over 1.4kg 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 desired

47. 2008/F.ABUDAYAH47 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.

48. 2008/F.ABUDAYAH48 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.

49. 2008/F.ABUDAYAH49 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.

50. 2008/F.ABUDAYAH50 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.

51. 2008/F.ABUDAYAH51 References Sandra M. Nettina MSN, APRN, BC, ANP Manual of Nursing Practice Eighth Edition Braunner&SuDDARTH’S Textbook of medical surgical nursing 10 th edition