Definition
A pacemaker is an electronic device that provides repetitive electrical stimuli to heart muscles when the patient’s intrinsic pacemaker fails to provide a perfusing rhythm.
Classification of pacemakers
- Temporary pacemaker (external pacemaker).
- Permanent pacemaker (internal pacemaker)
Temporary Pacemaker
- Pulse generators are outside the body, and this is used for short-term therapy
- Temporary pacemakers are used frequently during emergency situations requiring immediate cardiac pacing.
- Temporary pacing systems use batteries, which need replacement based on use of device. The transcutaneous system has rechargeable battery circuit.
Classification of Temporary Pacemakers
- Noninvasive pacing (transcutaneous).
- Transvenous invasive pacing (endocardial)
- Transthoracic invasive pacing (pericardial).
Indications
- Symptomatic brady dysrhythmias.
- During diagnostic testing:
- Cardiac catheterization.
- Electrophysiological studies.
- Percutaneous transluminal coronary angioplasty.
- Before permanent pacing.
- Postoperatively following major cardiac surgeries.
- Post-myocardial infarction
- Prophylaxis after open heart surgery
- Suppression of ectopic activity.
Procedure
| S.No | Nursing Action | Rationale |
| 1 | Explain the procedure to the patient and family. Explain that there will be a sensation of discomfort with external pacing. | Allays anxiety and helps in cooperation of patient. Discomfort is felt with each firing but can be relieved by analgesics. |
| 2 | Get informed consent for the procedure. | Informed consent protects the health-care personnel from legalities relating to procedure. |
| 3 | Remove jewelry, dentures, and contact lens. | Jewelry will act as a source of infection and may be lost during the procedure. Removing dentures prevents trauma to patient if any emergency occurs. |
| 4 | Shave area depending upon the site selected. | Reduces risk of infection caused by microorganisms settling in hair follicles |
| 5 | Provide clean gown. | Prevents unnecessary exposure. |
| 6 | Start good IV access with heparin lock. | Ensures a patent IV line to administer fluids and medications. |
| 7 | Record ECG before procedure and obtain a rhythm strip. | Helps in comparison after procedure. |
| 8 | Administer premedication and send patient to cardiac catheterization lab with patient’s chart, X-ray films, lab forms, ECG strip, and other items depending upon agency policy. | Gives information about patient’s baseline data. |
| 9 | Reassure the patient during procedure. | Provides psychological support. |
| 10 | When the pacing catheter is in vein, alligator clips can be used to connect the exposed tip of the catheter to an ECG machine. Larger P waves are seen as the catheter passes through the atrium and larger QRS complexes when catheter is in ventricles. The stimulus and sensitivity settings are set and maintained according to cardiologist’s orders. The electrode is taped or sutured at the insertion site. | Monitors the progression of catheter through the heart. |
Post procedure Care
- Check vital signs frequently.
- Check for heart rhythm and emotional reactions to procedure and pacing.
- Check whether connections are secured or not.
- Monitor battery and control setting.
- Clean and dress incision site according to hospital policy.
- Keep the pulse generator clean and dry and prevent mishandling.
- Use rubber gloves when exposed wires are handled.
- Check electrical equipment for adequate grounding.
- Keep patient in supine position and ask to maintain adduction of affected extremity for 12 hours.
- Stabilize arm, catheter, and pacemaker an arm board and avoid movement of the arm above shoulder level to prevent dislodgement, when brachial artery is used for catheterization.
- If the leg is the insertion site, limit movement, especially hip flexion and outward rotation.
- Explain that bed rest for 24 hours and reduced activity for another 48 hours is required.
- Connect patient to cardiac monitor and monitor rhythm.
| Pacemaker malfunctions and nursing intervention | ||
| Problem | Possible cause | Nursing intervention |
| Failure to space properly: | ||
| Intermittent or complete absence | Battery failure. A break or loose connection anywhere along the system. Pulse generator failure. | Replace pulse generator. Replace battery unit. Check and connect all connections between pulse generator and leads. |
| Rapid inappropriate firing of pacemaker (pacemaker, mediated tachycardia). | Circulatory failure. “Oversensing” or “under sensing” by pacemaker. | Reduce or increase sensitivity threshold of pacemaker unit. Assess patient’s tolerance of pacemaker failure. Have emergency medications at hand. Perform CPR, if indicated. |
| (ii) Failure to capture: | ||
| Pacing artifact present but is not followed by a QRS complexes or P waves. | Decreased conductivity by the myocardial tissue due to electrolyte imbalance, infarction, drug toxicity, perforation or excessive fibrosis of tissue at electrode site.Lead displacement due to migration or idle manipulation. of pulse generator (“Twiddler’s syndrome”). | increase voltage by 1-2 mA. Increase amplitude of pacemaker output. Reposition patient to either side in an attempt to improve contact of electrode with endocardium. Intemporary lead, try moving arm if Lead wire is inserted in antecubital area. Obtain chest film to determine lead position. Have emergency drugs at hand. Initiate CPR, If necessary. |
| (iii) Failure to sense: | ||
| Pacing artifact present despite the presence of QRS complexes and P waves. A competitive rhythm may develop. | sensitivity threshold set too low. Intrinsic beats of too-low voltage may go undetected by pacemaker’s sensing mechanism. Dislodged or fractured lead.Circulatory failure. Electromagnetic interference. | Increase sensitivity threshold on pulse generator. Reposition patient, If patient’s intrinsic rhythm/rate is adequate, turn off pacemaker. Increase pacing rate to overdrive patient’s intrinsic heart rate. Give antidysrhythmic to decrease ectopy… Notify physician. Obtain chest film to determine electrode placement. |
| (iv) oversensing | ||
| pacemaker senses electrical activity within the myocardium or myopotential. | Sensitivity threshold set too high. T-wave sending myopotentials. Electromagnetic interference. Two leads touching. | Decrease sensitivity threshold. Correct conditions that produce large T waves. |
Permanent Pacemaker
The pulse generator is implanted underneath the skin in subcutaneous tissue in the pectoral region below the clavicle and sometimes an abdominal site is selected, and electrical stimulation is passed to the heart through pacing catheters.
The pulse generator is implanted underneath the skin in subcutaneous tissue in the pectoral region below the clavicle and sometimes an abdominal site is selected, and electrical stimulation is passed to the heart through pacing catheters
Indication
- Irreversible complete heart block
- Left ventricular heart failure.
- Ectopic rhythms.
- Chronic atrial fibrillation.
- Atrial flutter.
- Supraventricular tachycardia,
- Hypersensitive carotid sinus syndrome
- Sick sinus syndrome
- Prophylactic implantation in patients after myocardial infarction complicated by advanced AV block, during the acute stages of infarction
Types of Permanent Pacemakers
Pacemakers are classified by uniform codes according to a classification system. The classification originally uses a three-letter code.
- The first letter denotes the cardiac chamber to be paced.
- The second letter reflects the chamber to be sensed.
- Third letter indicates the type of response to occur, that is, sensed myocardial electrical activity will cause the pacemaker’s impulse to be “triggered” (T) or “inhibited” (1) or both/dual (D).
In clinical practice, usually the three-letter classification is used commonly. For example, in VVI pacemaker, the letters used indicate following:
V-Ventricle is paced.
V-Ventricle is sensed.
I-The pacemaker will inhibit pacing when the patient’s own impulse is sensed.
Later two more categories were added, i.e. (1) programmability and rate modulation (R), and (2) anti-tachydysrhythmia functions.
Symbols used:
A-Atrium.
V-Ventricle.
O-None.
D-Dual (both chambers).
T-Triggered.
I-Inhibited.
Preparation of the Patient for Permanent Pacemaker Insertion
| S.No | Nursing Action | Rationale |
| 1 | Explain the procedure and purpose to the patient and family and explain to him how he has to cooperate. | Allays anxiety and helps in obtaining cooperation of the patient. |
| 2 | Get informed consent for the procedure. | Prevents litigation for health workers. |
| 3 | Explain about the need to avoid food and fluids for 8-10 hours prior to the procedure. | An empty stomach prevents the risk of aspiration during the procedure. |
| 4 | Shave following areas: Anterior chest from neck to umbilicus, Nape of neck to loins of back. Both arms and axilla. | Reduces risk of infection. |
| 5 | Advise to take bath with antiseptic scrub and water for 2 days before the procedure and on the day of the procedure. | Reduces risk of infection |
| 6 | Provide clean gown. | Obtain a preoperative ECG. |
| 7 | Remove jewelry, dentures, and contact lens. | Jewelry acts as a source of infection. |
| 8 | Start good IV access with heparin lock. | Ensures patent IV line to administer fluid and medications. |
| 9 | Start good IV access with heparin lock. | Ensures patent IV line to administer fluid and medications. |
| 10 | Administer prophylactic antibiotic as per physician’s order. | |
| 11 | Send the patient to OT with patient’s chart, X-ray film, lab forms, ECG, and others depending upon hospital policy. | Gives details about patient’s baseline data. |
Procedure
Permanent pacing: This is indicated in long term management of symptomatic or life-threatening dysrhythmias The surgeon inserts the pacing electrode either via the transvenous route or by direct application to the epicardial surface during thoracotomy. The surgeon places the permanent pulse generator into a small tunnel burrowed within the subcutaneous tissue below the right clavicle or less often the left clavicle.
The pulse generator is a small hermetically sealed (to prevent ingress of body fluids) lithium battery.
Postprocedural Care
- Monitor vital signs and pacemaker function.
- Explain about bed rest for 24 hours and reduced activity for another 48 hours.
- Connect the patient to cardiac monitor and check rhythm.
- Check vital signs and wound hourly.
- Check operative site for excessive swelling, redness, bleeding, etc.
- Discourage patient from rolling on to affected side.
- Continue ECG monitoring for 24 hours.
Recording
Record the location and type of pacing lead, pacing mode, stimulus threshold, sensitivity setting, pacing rate and intervals, and intrinsic rhythm.
Patient Education
- Assess wound daily.
- Report any signs of inflammation to the physician.
- Avoid constrictive clothing which puts excessive pressure on the wound and pulse generator.
- Avoid “toying” with pulse generator because this may cause pacemaker malfunction and local skin inflammation.
- Explain to the patient how to check pulse in wrist and instruct him to report sudden slowing or increase of pulse rate which indicates pacemaker malfunction.
- Report any abnormal signs of dizziness, fatigue, swelling of ankles, legs, chest pain, and shortness of breath.
- Avoid being near areas with high voltage, magnetic force field or radiation, standing near large running motors, high tension wires, power plants, radio transmitters, large industrial magnets, welding machines, standing in open areas during thunderstorms, etc.
- Safely operate most appliances and tools that are properly grounded and in good repair including microwave ovens, televisions and video recorders show identification card and request scanning by hand scanner when passing through security gates.
- Carry an identification card indicating manufacturer’s name, pacemaker model, and hospital where pacemaker was inserted.
- Do not lift more than 5-10 pounds weight for the first 6 weeks after surgery.
- Normal activity including sexual activity can be resumed in 6 weeks.
- The importance of regular physician or clinic visits (for evaluation of pacemaker function and possible reprogramming)
- Mobile phones should not be kept on affected side.
- Keep incision dry for 1 week after implantation.
- Avoid lifting operative side-arm above shoulder level for 1 week after implantation.
Complication
- Local infection at the entry site of the leads for temporary pacing.
- Bleeding and hematoma at the lead entry sites.
- Hemothorax and pneumothorax from puncture of the subclavian vein.
- Failure to sense.
- Failure to capture.
- Atrial and ventricular septal perforation.
- Atelectasis.
- Pericardial fluid accumulation.
- Diaphragmatic stimulation (hiccupping or twitching at the pacemaker site).
Special consideration
If external defibrillation is required, it is essential that defibrillation paddles are not to be placed directly over an implanted device. Anteroposterior paddle position may be used.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
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