JASMINE OUSEPH
F.Y.MSc Nursing
Dr.D.Y.Patil CON
Definition
Pacemakers are an electronic device used to
pace the heart when the normal conduction
pathway is damaged or diseased
COMPONENTS OF PACEMAKER
• Pulse generator
• Pacemaker electrodes
WORKING OF PACEMAKER
TYPES OF PACEMAKER
a) Temporary pacemaker
b) Permanent pacemaker
TEMPORARY PACEMAKER
It is one that has the power source outside the body.
Trans venous invasive pacemaker(endocardial)
It consists of lead or leads that are threaded transvenously to the right
atrium and or right ventricle and attached to external power source.
Transthoracic invasive pacing(Epicardial pacing )
It is achieved by attaching an atrial and ventricle and attached to
epicardium during heart surgery.
The leads are passed through the chest wall and attached to the external
power source.
Trans cutaneous pacemaker(Non-invasive pacing)
It is used to provide adequate heart rate and rhythm to the patient in and
emergency situation.
INDICATIONS OF TEMPORARY PACEMAKER THERAPY
Maintenance of adequate heart rate and rhythm
during special circumstances such as surgery and
postoperative recovery, cardiac catheterization or
coronary angioplasty.
Before implantation of a permanent pacemaker.
As prophylaxis after open heart surgery.
Cont.…….
Acute anterior MI with second degree or third degree
AV block or bundle branch block.
Acute inferior MI with symptomatic bradycardia and
AV block
Transvenous Pacemaker (invasive)
PROCEDURE
TRANSCUTANEOUS PACEMAKER (NON-
INVASIVE PACING)
EQUIPMENTS
• Disposable pacing
• ECG
• Jelly
• Electrode pads
• External pacing module s
• Resuscitative equipment
• External pacing module s
Nursing Action Rational
Preparatory phase
1. Explain procedure to patient. 1. Allays anxiety.
2.Explain sensation of discomfort with
2.Discomfort is felt with each firing but can
external pacing
be relieved with analgesic
Performance phase
1. Place multifunction electrode pads as 1. Electrodes must be placed so the current
follows: passes through as much of the myocardium
A.Anterior/posterior:The negative as possible with the least distance between
multifunction electrode pad is placed on the pads.
the anterior chest at the V3 –V6 position;
the positive multifunction electrode pad is
placed directly behind the anterior pad on
the patient’s back.
b. Anterior/lateral: The positive
multifunction electrode pad is placed on
the upper right chest under the clavicle;
the negative multifunction electrode pad is
placed at the V3 –V6 position
2. Make sure that pacing module is off or on 2. Prevents accidental shock on connection.
standby and that milliamperes (mA) output is
set at the minimal level before connecting
electrodes to external module
3. Connect multifunction pacing electrode
pads to external module.
4. Determine rate setting according to 4. Can be set at a fixed rate or on demand to
instructions and patient condition. If patient’s pace only if heart rate falls below the set rate
heart rate is consistently too low to maintain
adequate cardiac output, set rate at 70–80. If
the patient’s rate falls only intermittently and
the pacemaker will be used in the demand
mode, set rate at 60
5. Gradually increase mA output until a pacing 5. If using the demand mode, set the rate
spike and a corresponding QRS complex is higher than the patient’s rate to establish the
seen (perhaps as high as 70 mA or more correct output and capture, then return the
6. Palpate pulse on right side to ensure rate to 60. 6. Choose either right radial or
adequate response to electrical event brachial pulse since muscular contractions
that may be transferred down the left arm
can cause misinterpretation
7. Patient perspiration may cause pads to
7. Check pad placement frequently loosen or slip
Follow-up phase
1. Check vital signs at least every 15 minutes 1. Determines if cardiac output is adequate.
while continuous pacing is employed. Check Muscle contraction from pacing may interfere
blood pressure in right arm with blood pressure reading on left
2. Monitor ECG continuously for pacer 2. Detects malfunction (may occur due to
functioning. electrode loosening).
3. Assure patient that treatment is temporary 3. Should only be used continuously for 2
and prepare patient for transvenous or hours because sensation may be
permanent pacemaker insertion as indication. uncomfortable
4.Change the multifunction electrode pads 4. Decreased efficacy of gel pad after 24 hours
every 24 hours or per manufacturer guidelines
PERMANENT PACEMAKER
Implanted totally in the body.
• Power source is implanted subcutaneously usually over the
pectoral muscle on the patient non dominant side
World’s smallest pacemaker implanted without
surgery -Medtronic Micra
since Micra TPS comes with two tiny prongs that directly touch the
heart, there’s no need for leads – wires that wind their way to the
heart to keep it beating. “Because of its small size and unique design,
the Micra TPS can be introduced directly into the heart via a
minimally invasive procedure, without the need for leads,
Medtronic, this device is the smallest in the whole world.
At just 24 millimeters and less than 1 centimeter in
volume, it’s one-tenth the size of average pacemakers.
New Piezoelectric Nanoribbon Implant Powers
Pacemakers
Wilson Greatbatch was a medical researcher and inventor
The new device is made of lead zirconate titanate
nanoribbons wrapped in a flexible, biocompatible plastic
Doctors sew the nanoribbon device directly to the patient’s
heart, lung, or diaphragm. As the body parts move the
ribbons bend slightly creating small amounts of electricity.
However, this implantable device can generate energy for as
long as the patient is alive, allowing it to run for a lifetime and
preventing the need for additional surgeries.
Implantable Pacemaker
Types of Permanent Pacemaker
Single-chamber pacemaker.
In this type, only one pacing lead is placed into a chamber of the heart,
either the atrium or the ventricle.
Dual-chamber pacemaker.
Wires are placed in two chambers of the heart. One lead paces the
atrium and one paces the ventricle. Closely resembles the natural
pacing of the heart.
Rate-responsive pacemaker
It has sensors that detect changes in the patient's physical
activity and automatically adjust the pacing rate to fulfil the
body's metabolic needs
INDICATIONS OF PERMANENT PACEMAKER
Chronic atrial fibrillation with slow ventricular response
Hypersensitive carotid sinus syndrome
Fibrosis or sclerotic changes of cardiac conduction system
Sick sinus syndrome
Tachyarrhythmia
Third degree AV block
PERMANENT PACEMAKER
EQUIPMENTS
Equipment required for permanent pacemaker insertion includes:
Fluoroscope
Instrument tray
Pacing system analyser
Introducer kit
1-2% lidocaine or bupivacaine
Antimicrobial flush and saline for pocket irrigation
Emergency crash cart with medications
Battery or electric cautery
Suture material
External pacemaker
ECG
NURSING MANAGEMENT
Preoperative care
Financial
Explain the procedure, type and technique of pacemaker to the patient.
Explain Cost of the procedure and Hospital stay.
Psychological
Explain the Process of the pacemaker insertion.
Reassure the patient.
Physical
Obtain written consent from the patient and from nearest relative
Remove dentures, jewellery and contact lens.
Clean and shave the area.
Check vital signs: temperature, BP, pulse and respiration.
Intraoperative care
Check serology: HIV, HbsAg, HCV and others
Start an IV line with 5% Dextrose solution or normal saline solution.
Check the battery in pulse generator
Prepare the emergency cart, the defibrillator and jelly, and the ECG monitor
Set up all equipment for the insertion of the pacemaker.
The nurse should know about the pacemaker generator including the power
switch, indicator light for pacing and sensing, stimulus output dial, sensitivity dial,
and their proper settings.
Assist the doctor and the scrub nurse during the procedure step by step
Observe vital signs and observe ECG monitor carefully for arrhythmias and other
complications.
Post-operative care
Receive the patient
Keep the patient in comfort position
Record the pacing parameters.
Receiving time, patient’s heart rate, other routine care.
Immobilize the affected part and keep in supine position but allow the
movement of finger and ankle joint.
Monitor heart rate and rhythm.
Monitor vital signs and level of consciousness of patient.
Prevent infection.
Take ECG and X-ray chest.
Watch for complications.
Patient Family and Teaching
Maintain follow up care with a physician to check the pacemaker site and
begin regular pacemaker function checks
Watch for signs of infection at incision site redness, swelling dressing.
Keep incision dry for 1 week after implantation.
Avoid lifting operative side arm above shoulder level until approved by care
provider.
Avoid direct blows to generators or to large magnets such as MRI scanner.
These device can reprogram a pacemaker. Microwave oven are safe to use and
do not threaten pacemaker function.
The patient should be taught how to take the pulse.
Carry pacemaker information card at all the times
COMPLICATIONS
Hematoma
Pneumothorax
Failure to sense or capture
Perforation of atrial or ventricle septum
Ventricular atrophy and tachycardia
Movement or dislocation of lead
Infection (endocarditis)
Cardiac perforation
