Definition
Pacemaker is an electric device which regulates the heartbeat by generating electrical signals or pacing pulses through the leads into the heart muscles resulting in cardiac contractions during periods of inappropriately slow or absent intrinsic cardiac electrical activity.
Types of Pacemakers
- Single-Chamber Pacing
Either the right atrium (upper chamber) or the right ventricle (lower chamber) is paced. Only one pacing lead is used. - Dual-Chamber Pacing
Both the right atrium and the right ventricle are paced. This requires two pacing leads. One lead is placed in the right atrium, and the other lead is placed in the right ventricle. - Temporary Pacemaker (External Pacemaker)
In a temporary pacemaker system, pulse generators are present outside the body. Temporary pacemakers are frequently used for short-term therapy during emergency situations requiring immediate cardiac pacing. These systems use batteries, which need replacement based on use of devices. The transcutaneous system has rechargeable battery circuit. It can be applied as follows:- Noninvasive pacing (transcutaneous).
- Transvenous invasive pacing (endocardial).
- Transthoracic invasive pacing (epicardial).
- Permanent Pacemaker (Internal 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. Permanent pacing systems use reliable power sources such as lithium or nuclear batteries. Lithium batteries have a life span of 8-12 years and nuclear power sources have a life span of 20 years.
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.
- The third letter indicates the type of response to occur, which is sensed with the myocardial activity that will cause the pacemaker’s impulse to be “triggered” (T) or “inhibited” (I) or both/dual (D).
Purposes
- To maintain heart rate when the heart is not able to do so.
- To treat heart blocks, bradycardia, tachycardia, or sick sinus syndrome.
- To coordinate electrical signaling between ventricles and between upper and lower chambers of heart.
- To adjust the heart rate according to the demand.
- To prevent breakthrough ectopy which occurs as a result of slow rate.
- To treat heart failure.
- When standby pacing is required for heart block.
Indications
Temporary Pacemaker
- Symptomatic bradydysrhythmias/tachydysrhythmias.
- 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
Permanent Pacemaker (Internal Pacemaker)
- Long QT syndrome.
- Hypertrophic obstructive cardiomyopathy (HOCM).
- Dysrhythmias that are unresponsive to drug therapy.
- Conduction disturbances secondary to valvular surgery.
- Atrial fibrillation and flutter.
- Sick sinus syndrome.
- Irreversible complete heart block.
- Ectopic rhythms.
- Supraventricular tachycardia.
- Hypersensitive carotid sinus syndrome.
- Prophylactic implantation in patients after MI complicated by advanced AV block, during the acute stages of infarction.
Contraindications
- Hemodynamically stable patients.
- Extreme hypothermia.
- Skin not intact at the site of lead placement.
Articles
| Articles | Purpose |
| Resuscitation supplies | To manage in case of emergency. |
| External pacing kit | To provide impulses. |
| Defibrillator | To treat arrhythmias. |
| ECG | To identify the electrical activity. |
| Electrodes (two sets) | One for ECG monitoring and one for pacing electrode pads |
| Surgical clips | To clip the hair in the chest area and to minimize the infection. |
Procedure
Transcutaneous Cardiac Pacing
| Nursing Action | Rationale | |
| 1. | Explain the procedure to the patient. | Decreases anxiety and enhances cooperation. |
| 2. | Obtain informed consent. | To avoid ethical and legal issues. |
| 3. | Explain that some sense of discomfort will be experienced during external pacing. | Early explanation enhances better acceptance. |
| 4. | Obtain ECG. | Serves as a baseline for comparison. |
| 5. | Explain the benefits and risk which may occur if pacing not attempted. | Allays anxiety. |
| 6. | Administer supplemental oxygen. | To promote oxygenation. |
| 7. | Turn monitor onto pacing mode. | To start pacing. |
| 8. | Apply monitor cable leads to the patient. | To monitor rhythm. |
| 9. | Place the electrodes as follows: White electrode on the right side below the right clavicle. Black lead below the left clavicle on the left chest. Red lead in the left midaxillary line below the expected point of maximal impulse (PMI) of heart. | Correct placement is essential for current to flow through the myocardium. |
| 10. | Place the pads as follows: Anterior/posterior: Place the negative electrode pad on the anterior chest at V3-V6 position. Place the positive electrode pad on the patient’s back directly behind the anterior pad. Anterior/lateral: Place the negative electrode pad under the clavicle on the upper right chest. Place the positive electrode pad at V3-V6 position. | For current to flow through the myocardium. |
| 11. | Ensure that pacing module is off or in standby mode before the electrodes are connected to the external module. | To prevent accidental shock. |
| 12. | Connect the pads to the cable and cable to pacer, check the connections again. | To ensure connectivity. |
| 13. | Select the pacing rate; normally the rate is set at 70-80. | If heart rate does not drop, fixed rate can be set. |
| 14. | Choose output/power. | To deliver the correct rate. |
| 15. | If the patient has bradycardia and is hemodynamically unstable but has no cardiac arrest, start at 0 mA, Increase the output slowly until capture is attained. | When demand mode is used, rate should be set higher than the patient’s rate to ensure correct capture and output. |
| 16. | In case of cardiac arrest, start at maximum output and decrease gradually once capture is attained. Capture is confirmed by presence of pacer spikes following each QRS complex. | |
| 17. | Monitor vital signs Q15min. | To ensure that cardiac output is adequate. |
| 18. | Monitor ECG tracings continuously. | To identify malfunction in case of electrode loosening. |
| 19. | Check pad placement frequently. | Perspiration may result in loosening/slipping of leads. |
| 20. | If needed, prepare the patient for permanent/ transvenous pacing as per instructions. | Continuous use of transcutaneous pacing is uncomfortable. |
| 21. | Change multifunction electrode pads every day (Q24h). | Efficacy of gel pad changes after 24 hours. |
Permanent Pacemaker Implantation
| Nursing Action | Rationale | |
| Preprocedure | ||
| 1. | Explain about the procedure to the patient. | To win confidence and cooperation from the patient. |
| 2. | Obtain informed consent. | To avoid ethical and legal issues. |
| 3. | Check history of allergies to medications, iodine, latex tape, or anesthetic agents (local and general). | To take precautions. |
| 4. | Check for present history of all medications, and herbal or other supplements. | To prevent overdosage of drugs and prevent complications. |
| 5. | Check for history of medications such as anticoagulant (blood-thinning) medications, aspirin, or other medications (affect blood clotting). | It may be necessary to stop some of these medications prior to the procedure, to prevent from further complications. |
| 6. | Skin preparation should be done by removing the hair preferably with a surgical clipper (chest area). | Reduces the chance of infection. |
| 7. | Educate and assist in taking bath at least 12 hours prior to surgery. | Preoperative shower reduces the skin’s microbial colony counts. |
| 8. | Remove all jewels or other objects. | Jewels may interfere with the procedure. |
| 9. | Make the patient wear surgical gown. | Prevents cross-infection. |
| 10. | Instruct the patient to empty the bladder prior to the procedure. | May interfere with the procedure. |
| 11. | Intravenous (IV) line should be started prior to the procedure. | To administer medication and to administer IV fluids. |
| During procedure | ||
| 12. | Monitor the records of the electrical activity of the heart by connecting electrocardiogram and also monitor the heart rate during the procedure using small adhesive electrodes. | To monitor the vital signs during procedure and to know the function of the vital organs. |
| 13. | Large electrode pads will be placed on the front and back of the chest. | To know the electrical activity of the heart. |
| 14. | A local anesthetic will be injected into the skin at the insertion site. | It helps the physician to make a small incision at the insertion site. |
| 15. | Sterile towels and a sheet will be placed around the area. | Prevents contamination and reduces the chance of infection. |
| 16. | A sheath, or introducer, is inserted into a blood vessel, usually under the collarbone. The sheath is a plastic tube through which the pacer lead wire will be inserted into the blood vessel and advanced into the heart. | Ensures that the catheter does not move out of the place and prevents damage to the insertion site. |
| 17. | Obtain fluoroscopy during procedure after the lead wire is inserted inside the heart. | To check for proper location of the pacemaker and the functioning of pacemaker. |
| 18. | The generator will be placed on the nondominant side. If the patient is right-handed, the device will be placed in the upper left chest. If the patient is left-handed, the device will be placed in the upper right chest. | To detect or to identify the affected side and allow for motion of the dominant hand. |
| 19. | The skin incision will be closed with sutures and adhesive strips. Sterile bandage or dressing will be applied. | Prevents infection and covers the wound site. |
| Documentation | ||
| 20. | Document the following: Reason for pacingPre paced rhythmECG findings before pacingMedications givenOutput during pacingPost-ECG findingsPatient’s status | For future reference and planning of care. |
Care of a Patient with Permanent Pacemaker
Instruct the patient to
- Come for follow-up care to check pacemaker site and function.
- Report any signs of infection at incision site for swelling, redness, fever, drainage, etc.
- Keep incision site dry for 4 days after implantation.
- Avoid lifting the arm in which pacemaker is placed above the heart level unless allowed.
- Avoid direct blow to the pacemaker site.
- Avoid close proximity to high-output electric generators/large magnets-MRI scanners.
- Avoid strenuous activity.
- Avoid submerging the wound in a bath tub or swimming pool for at least 3-4 weeks, until the incision has completely closed.
- Check pulse and inform if rate is less.
- Carry ID card containing details about pacemaker at all times.
- Abstain from diathermy.
- Avoid proximity to devices which may affect pacemaker function by creating a magnetic field such as electric razors, ultrasonic dental instrument cleaners, engines of car and tractor, welding units, smelting induction furnace, high-energy radar, TV, and radio transmitters.
Special Considerations
- Monitor for complications such as hematoma, infection, or lead displacement.
- Assess pacemaker function via ECG and telemetry.
- Check for signs of pacemaker syndrome (fatigue, dizziness, hypotension).
- Avoid heavy lifting (>10 lbs) for 2–3 weeks post-implantation.
- Limit arm movement on the pacemaker side to prevent lead displacement.
- Gradually resume physical activity under medical guidance.
- Monitor for battery depletion (typically lasts 6–12 years).
- Check for electromagnetic interference (avoid strong magnets, MRI machines).
- Educate the patient on recognizing pacemaker malfunction symptoms (dizziness, syncope, irregular heartbeats).
- Keep the incision site clean and monitor for redness, swelling, or drainage.
- Avoid submerging in water until the wound heals.
- Report fever or signs of infection immediately.
- Regular follow-ups for device checks and adjustments.
- Carry a pacemaker identification card for medical emergencies.
- Be cautious with security scanners (inform airport personnel).
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
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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