By

Fatimah Abu-Dayah
2008/F.ABUDAYAH

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 pts educational needs
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Out line

Introduction
Definition of cardiac pacing
Clinical Indication
Pacemaker design
Pacemaker function
Types of pacing
Nursing diagnosis
Nursing intervention
Pts education
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Normal conductive system of the

heart

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Definition of cardiac pacing

It is an electric device that
delivers direct electrical
stimulation to stimulate the
myocardium to depolarize
,initiating a mechanical
.contraction

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Clinical Indication
1.
2.

3.

Symptomatic bradycardia
Symptomatic heart block
2nd degree heart block
3rd or complete heart block
Bifasicular or transfasicular
bundle branch blocks.
Prophylaxis

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Pacemaker Design
1.
2.

Pulse generator
leads

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Pacemaker Design
Pulse generator
In permanent pacemaker is
encapsulated in a metal can ,to
protect the generator from
electromagnetic interference

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Pacemaker Design
Pulse generator
Temporary pacing system
generator is externally
contained in a small box

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Pacemaker Design
Pulse generator
Transcutanus external pacing
system house the generator in a
piece of equipment similar to
portable ECG monitor.

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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
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Single chamber (unipolar

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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.
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Dual-chamber (bipolar) pacemaker

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Pacemaker function
1.
2.
3.

Pacing function
Sensing function
Capture function

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Pacing function
:Atrial pacing
stimulation of RT atrium produce spic
on ECG preceding P wave

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

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Pacing function
:AVpacing
direct stimulation of RT atrium
and either ventricles mimic
normal heart conduction

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Sensing function
:Sensing
Ability of the cardiac pace maker
to see intrinsic cardiac activity
.when it occurs

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

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Capture function
1.

2.

Electrical capture :
indicated by P or QRS
following and corresponding to
a pacemaker spike.
Mechanical capture:
palpable pulse corresponding
to the electrical event.

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Pacing types

Permanent
Temporary
biventricular

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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

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Permanent pacemaker

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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

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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
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Equipments

Transvenous pacing
catheter
EKG machine
Pacemaker generator
with battery and cable
Emergency crash cart

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Lidocaine

Defibrill

ator
(2) 5cc syringe with 22
and 25 gauge needles
External Pacer
Sterile gown, gloves,
mask
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INSERTION SITES

Left Subclavian (most reliable)

Internal jugular (lower
incidence of pneumothorax)
Femoral vein
Brachial vein

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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
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INSERTION PROCEDURE

Anesthetize the area locally.

Prepare the external temporary
generator:
Portable Chest X-ray is required
to confirm placement.

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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

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Complication

Movement and dislocation of the lead

Injury
Bleeding and hematoma
Ventricular ectopy or VT from wall
stimulation
Infection
Cardiac tamponad

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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.

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Nursing intervention
1.

Maintain adequate cardiac output

Record information after insertion
pacemaker model ,mode, program
setting,pts rhythm
Attach ECG for continues monitoring
Analyze rhythm strips as per
protocol
Monitor vital signs
Monitor urine output
Observe for dysrhythmia

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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
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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

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Nursing intervention
4.

Provide electrically safe

environment
Protect exposed parts of
electrode leads with rubber
Wear rubber gloves when
touching a temporary pacing
lead

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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.
Pts 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
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Nursing intervention
6.

Prevent accidental pacemaker

malfunctions
Use external plastic covering
over external generator all
times
Secure temporary pace maker
over pts chest or wrist never
hang it over iv pole

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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.

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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.

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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
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Patient education
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
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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.
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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.

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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.
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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.
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References
Sandra M. Nettina
MSN, APRN, BC, ANP

Manual of Nursing Practice

Eighth Edition
Braunner&SuDDARTHS
Textbook of medical surgical
nursing 10th edition
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