Pace Making

8/13/2019 Pace Making

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PACEMAKING

After 4 hours of varied classroom activities, the level III students will be able to:

1. Define the following terms:1.1pacemaker1.2pacemaker lead1.3capture1.4pacing artifact1.5milliampere1.6sense1.7sensitivity1.8threshold

2. state the purpose of pacemaker3. enumerate the following of pacemaker insertion:

3.1 indications3.2contraindications

4. discuss the following:4.1types of pacemaker4.2types pacing4.3sites of pacemaker insertion4.4pacemaker failures and problems4.5 long term management of individuals with pacemakers

5. explain the common complications and its nursing interventions of having a pacemaker6. show the nursing responsibilities before, during and after pacemaking.


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I. DEFINITION OF TERMS:

1. Pacemaker- A pacemaker is a small device that's placed in the chest and abdomen to helpcontrol abnormal heart rhythms. This device uses electrical pulses to prompt the heart tobeat at a normal rate.

2. Pacemaker leadcarries the impulses created by the generator to the heart, can bethreaded by fluoroscopy through a major vein into the heart.

3. Capture- ability of a pacemaker to electrically stimulate a cardiac chamber.4. Pacing artifact voltage pulses that accompany the measurement of the hearts own

electrical activity at the skin surface measured on ECG leads. It is important to be able to

detect and identify pacing artifacts because they indicate the presence of the pacemaker

and help in evaluating its interaction with the heart.

5. Milliamperemeasurement of how much electricity a pacemaker uses to actually pace theheart. How much juice the box puts out through the wire with every pulse.

- Pulse widthmeans how long each pulse lasts. The electrical pulse has tobe strong enough, and last long enough, to capture the myocardium.


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6. Sensethe hearts ability to sense the output signal sent by the box to the heart whenheart rate is slow.

7. SensitivityThis is the pacemakers ability to sense the intrinsic rhythm of the heart. Alsothe generators circuit that can detect the intercardiac electrical activity to cause an

appropriate response.

8. Thresholdthe minimum amount of energy to stimulate depolarization.

- Capture threshold is the minimum amount of electricity that the box has toemit to pace the heart. Its measured in milliamps, and the twisty knob is

turned up until the heart is paced 100% then turned down again until the

minimum is determined.

II. PURPOSE OF PACEMAKER

A pacemaker can relieve some arrhythmia symptoms, such as fatigue and fainting. A pacemaker also can help a person who has abnormal heart rhythms resume a more active

lifestyle.

Help control an abnormal or fast heart rhythm. Coordinate electrical signaling between the upper and lower chambers of the heart. Prevent dangerous arrhythmias. Pacemakers also can monitor and record your heart's electrical activity and heart rhythm.

III. ENUMERATE THE FOLLOWING OF PACEMAKER INSERTION

3.1 Indications

Patients with myocardial infarction Patients with persistent bradyarrythmia Patients with heart block Patients who suffer stoke-adams syndrome Patients with wolf-parkinson-white syndrome


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3.2 Contraindications

Patients without cardiac problems

IV. DISCUSS THE FOLLOWING

4.1 Types of pacemakerTemporary

- This type of pacing can be removed days after. Attached to a temporarygenerator which is about a size of a paperback book. The energy source for

a temporary generator is a common household battery.

Types:

Transcutaneous spacing Epicardial pacing Transvenous pacing Transthoracic pacing

Permanent- A permanent pacing which can be passed the subclavian, axillary or cephalic

vein and connected to a permanent generator.

- Most have a fixation mechanism at the end of the lead to allow precise

positioning and avoidance of dislodgement.

- Generator weigh less than 1 oz. and a size of a thick credit card, usually

implanted in a subcutaneous pocket created in the pectoral region, below the

clavicle or behind the breast.

- The procedure takes about an hour, using local anesthesia and moderate

sedation.

- This is isulated to protect against body moisture and warmth and have filtersthat protect them from electrical interference from household devices

- Energy source is Lithium cell that lasts approximately 6-12 years depending on

the type, program and usage of the pacemaker


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4.2Types pacing- Pacemakers are generally set to sense and respond to intrinsic activity, which is called on-

demand pacing. If the pacemaker is set to pace but not to sense, it is called fixed or asynchronous

pacemaker. This is written as AOO or VOO

AOOstimulates only the atrium, it may be used in a patient who has undergone open heart

surgery and develops sinus bradycardia. This ensures synchrony between atrial stimulation and

ventricular stimulation, as long as the patient has no conduction disturbances in the AV node

VOOthis pacing is rare because of the risk that the pacemaker may deliver an impulse during the

vulnerable repolarization phase leading to ventricular tachycardia. The occurrence of this type of

pacing may indicate battery failure

4.3Sites of pacemaker insertion Femoral vein Subclavian vein Internal jugular vein Axillary vein Cephalic vein

4.4Pacemaker failures and problems- a malfunctioning pacemaker can lead to arrhythmias, hypotension, syncope and other signs andsymptoms of decreased cardiac output. Common problems with pacemaker that can lead to low

cardiac output and loss of AV synchrony include:

Failure to capture- Failure to capture appears on the ECG as a pacemaker spike without the

approximate atrial or ventricular responsea spike without a complex.

Think of it as pacemakers inability to stimulate the chamber

Causes:

- Acidosis- Electrolyte imbalance- Fibrosis- Incorrect leadwire position- low mA or oupput setting- depletion of battery- broken or cracked leadwire


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- perforation of leadwire through the myocardium Failure to pace

- is indicated by no pacemaker activity on an ECG when pacemaker activity isexpected. This can lead to asystole

Cause:

- battery or circuit failure- cracked or broken leads- interference between atrial and ventricular sensing in a dual chamber

pacemaker

Undersensing- Is indicated by a pacemaker spike when intrinsic cardiac activity is present.

In asynchronous pacemakers that have such codes as VOO or DOO,

undersensing is a programming limitation.

- When this occurs in synchronous pacemakers, pacing spike occur on theECG where they shouldnt. Although they may appear in any part of the

cardiac cycle, the spikes are especially dangerous if they fall on the T-wave,

where they can cause ventricular tachycardia or ventricular fibrillation.

In asynchronous pacemakers, undersensing may be caused:

- Electrolyte imbalance- Disconnected or dislodged leads- Improper lead placement- Increased sensing threshold from edema or fibrosis at the electrode tip- Drug interactions- Depleted pacemaker battery

Oversensing- if the pacemaker is too sensitive, it can misinterpret muscle movement or

other events in the cardiac cycle as intrinsic cardiac electrical activity. Pacing

wont occur when its needed, and the heart rate and AV synchrony wont be

maintained


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4.5 Long term management of individuals with pacemakers

Preventing infection- the nurse must change the dressing as needed and inspects the insertion

site for redness, swelling, soreness and any unusual drainage. Any change inthe wound appearance, an increase in the patients temperature, or an

increase in the patients WBC count should be reported to the physician.

Promoting effective coping- the patient may not only experience lifestyle and physical changes but also

emotional changes. At different times during the healing process, the

patient may feel angry, depress, fearful, anxious or combinations of these

emotions. The patient may have their own coping strategies.

- To promote effective coping the nurse must recognize the patient as well asthe familys perception of the situation and their resulting emotional state

and assist them to explore their reactions and feelings.

- The nurse may identify positive methods to deal with the actual orperceived limitationsand manage any any lifestyle changes needed.

- The family should be encouraged to talk with their feelings- The nurse reassures the patient that the responses are normal and helps the

patient identify changes.

- The nurse may also encourage the use if spiritual resources.- The nurse may teach the patient easy stress reduction techniques to

facilitate coping.

Promote home and community based care- Teach patient of periodic device monitoring, promoting safety, surgical site

care and avoiding EMI.

- In addition, the nurse can give the patient information about activities thatare safe and those that are dangerous.

- CPR training can be done to the family members of significant others withthe patient.


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V. EXPLAIN THE COMMON COMLICATIONS AND ITS NURSING INTERVENTIONS OF HAVING A

PACEMAKER.

Local infection at the entry site of leads or generator placementNursing interventions:

- Prophylactic antibiotics and antibiotic irrigation of subcutaneous pocket asprescribed by the physician. This is done prior to generator placement and

was found that it has a decrease in the infection rate to 2%.

PneumothoraxNursing interventions:

-

Current updated procedure and using of safe sheaths reduces the risk.- Properly locating the vein to be used to prevent mistakes upon insertion

Bleeding and hematomaNursing interventions:

- This can be managed by simple cold compress to reduce bleeding on thesite.

- If ever there are any antiplatelet or antithrombotic medications, it should bediscontinued.

HemothoraxNursing interventions:

- Properly locating the vein to be used to prevent mistakes upon insertion

Phrenic nerve stimulationNursing interventions:

- May be prevented by testing during device implantation.

Twiddler syndromeoccur when patient manipulates the generator causing lead dislodgementor fracture of lead.


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Pacemaker syndromehemodynamic instability caused by ventricular spacing and the loss ofAV synchrony.

V. SHOW THE NURSING RESPONSIBILITIES BEFORE, DURING AND AFTER PACEMAKING Before

- Tell patient what to expect post operatively- prepare the patient

During- Provide holistic care- Provide comfort- Provide positioning

After- Teach patient about pain management- Teach patient stress reducing therapies- Provide information about complications of the procedure

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Pace Making