CARDIAC PACING

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CARDIAC PACING
By Fatimah Abu-Dayah
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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

• 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. Pulse generator
2. 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
• 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

• 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. Pacing function
2. Sensing function
3. 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

• 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

• 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

• Temporary pacemaker
• Placed during emergencies
• Indicated for pts high degree heart block or
  unstable bradycardia
• Can be placed transvenosly, epicardially,transcuta
  nusly or transthorasicly

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Types of pacing

• 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

• Lidocaine                        Defibrillator
• (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

• 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
• Monitor for sign and symptom of hemothorax
• Monitor for sign and symptom of pneumothorax
• Evaluate evidence for bleeding

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Nursing intervention

• 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

• 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

• 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 radiation
  therapy.

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Nursing intervention

• 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

• 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

• 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
• Pacemaker function
• 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

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Patient education

• 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

• 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

• 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
• BraunnerSuDDARTHS
• Textbook of medical surgical nursing 10th edition