PACEMAKER

INTRODUCTION: -
A pacemaker is composed of three parts: a pulse generator, one or more leads,
and an electrode on each lead. A pacemaker signals the heart to beat when the heartbeat is too
slow or irregular. A pulse generator is a small metal case that contains electronic circuitry
with a small computer and batteries that regulate the impulses sent to the heart. The lead (or
leads) is an insulated wire that is connected to the pulse generator on one end, with the other
end placed inside one of the heart's chambers. The lead is almost always placed so that it runs
through a large vein in the chest leading directly to the heart. The electrode on the end of a
lead touches the heart wall.
The lead delivers the electrical impulses to the heart. It also senses the heart's
electrical activity and relays this information back to the pulse generator. Pacemaker leads
may be positioned in the atrium (upper chamber) or ventricle (lower chamber) or both,
depending on the medical condition. If the heart's rate is slower than the programmed limit,
an electrical impulse is sent through the lead to the electrode and causes the heart to beat at a
faster rate. When the heart beats at a rate faster than the programmed limit, the pacemaker
generally monitors the heart rate and will not pace.

Pacemakers generally treat two types of arrhythmias:

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 tachycardia, a heartbeat that’s too fast
 bradycardia, a heartbeat that’s too slow

A pacemaker regulates body’s electrical system

This controls your heart rhythm

With each heartbeat, an electrical impulse travels from the top of your heart to the bottom

Signaling your heart’s muscles to contract.

A pacemaker can also track and record your heartbeat. A record can help your doctor better
understand your arrhythmia.

Not all pacemakers are permanent. Temporary pacemakers can control certain types of
problems. May need a temporary pacemaker after a heart attack or heart surgery.

DEFINITION:-
A pacemaker is a medical device which uses electrical impulses, delivered by electrodes
contracting the heart muscles, to regulate the beating of the heart.
A pacemaker is a small device about the size of a matchbox that weighs 20-50g. It consists of
a pulse generator – which has a battery and a tiny computer circuit – and one or more wires,
known as pacing leads, which attach to your heart.

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CLASSIFICATION:-
A variety of types of pacemakers and modes of pacing have been developed to restore
or sustain a regular heartbeat in different ways. All contemporary pacemakers sense the
intrinsic activity and stimulate the heart only when the intrinsic heart rate falls below the
programmed pacing rate. Essentially all contemporary pacemakers also incorporate rate
responsive capability. This depends on a "sensor" incorporated into the pacemaker that can
sense activity or respiratory rate and can alter the heart rate based on the perceived
physiologic need.
Temporary pacemakers:-Temporary pacemakers are intended for short-term use during
hospitalization. They are used because the arrhythmia is expected to be temporary and
eventually resolve, or because the person requires temporary treatment until a permanent
pacemaker can be placed.
A temporary pacemaker to treat a bradyarrhythmia or tachyarrhythmia is
used when the condition is temporary and when a permanent pacemaker is either not
necessary or is not immediately available. Complications are common and include infection,
local trauma, pneumothorax, arrhythmias and cardiac perforation.

Indications: - Specific guidelines have been established concerning the conditions when a
permanent pacemaker is

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(I) Definitely beneficial, useful, and effective,
(II) May be indicated
(III) Is not useful or effective and, in some cases, may be harmful. Patients should speak
with their healthcare provider concerning these guidelines and how they apply to
their specific case.
An implanted electronic pacemaker mimics the action of your natural pacemaker. An
implanted pacemaker consists of two parts:

 The pulse generator. This small metal container houses a battery and the electrical
circuitry that regulates the rate of electrical pulses sent to your heart.

 Leads (electrodes). One to three flexible, insulated wires are each placed in a chamber,
or chambers, of your heart and deliver the electrical pulses to adjust your heart rate.
Pacemakers monitor your heartbeat and, if it's too slow, the pacemaker will
speed up your heart rate by sending electrical signals to your heart. In addition, most
pacemakers have sensors that detect body motion or breathing rate, which signals the

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pacemaker to increase your heart rate during exercise to meet your body's increased need for
blood and oxygen.
SINGLE CHAMBER PACEMAKER
This type of pacemaker usually carries electrical impulses from the pulse generator
to the right ventricle of your heart.
DUAL CHAMBER PACEMAKER
A dual chamber pacemaker carries electrical impulses from the pulse generator to
both the right ventricle and the right atrium of your heart. The impulses help control the
timing of contractions between the two chambers.
BIVENTRICULAR PACEMAKER
A biventricular pacemaker is a treatment option for people with heart failure whose
hearts' electrical systems have been damaged. Unlike a regular pacemaker, a biventricular
pacemaker stimulates both of the lower chambers of the heart (the right and left ventricles) to
make the heart beat more efficiently

 PERMANENT PACEMAKER
A pacemaker is a small, battery-powered device that sends out small electrical impulses to
make the heart beat in a regular rhythm and at a normal speed. A pacemaker consists of
a pulse generator and battery that create the electrical impulses, and wires (leads) that transmit
electricity to the hear.

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INDICATION:-
 Symptomatic bradydysrhythmias.
 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.
CONTRAINDICATION:-
Contraindications for permanent pacemaker insertion include the following:
 Local infection at implantation site
 Active systemic infection with bacteremia
 Severe bleeding tendencies (relative contraindication)
 Active anticoagulation therapy (relative contraindication)
 Severe lung disease and positive end-expiratory pressure ventilation (relative
contraindication for internal jugular and subclavian access)

PREPARATION OF THE PATIENT AND PATIENT:-

Before your doctor decides if you need a pacemaker, you'll have several tests done to find
out the cause of your irregular heartbeat. These could include:

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  Electrocardiogram:- In this noninvasive test, sensor pads with wires attached, called
electrodes, are placed on your chest and sometimes your limbs to measure your heart's
electrical impulses. Your heart's beating pattern can offer clues to the type of irregular
heartbeat you have.

 Holter monitoring:- Also known as an ambulatory monitor, a Holter monitor records

your heart rhythms for an entire 24-hour period. Wires from electrodes on your chest
go to a battery-operated recording device carried in your pocket or worn on a belt or
shoulder strap.

 Echocardiogram:- This noninvasive test uses harmless sound waves that allow your
doctor to see your heart without making an incision. During the procedure, a small
instrument called a transducer is placed on your chest. It collects reflected sound
waves (echoes) from your heart and transmits them to a machine that uses the sound
wave patterns to compose images of your beating heart on a monitor.

 Stress test:- Some heart problems occur only during exercise. For a stress test, an
electrocardiogram is taken before and immediately after walking on a treadmill or
riding a stationary bike. In some cases, an echocardiogram or nuclear imaging may be
done.

 Anesthesia:-Implantation of pacing systems usually involves a combination of local

anesthesia and conscious sedation. Infiltration of skin and subcutaneous tissue at the
implant site with 1-2% lidocaine or bupivacaine provides sufficient local anesthesia
for the majority of implant procedures. Conscious sedation may be administered in
the form of carefully titrated IV midazolam and fentanyl by trained and qualified
personnel. On rare occasions, general anesthesia may be required in an extremely
uncooperative or high-risk patient.

 Positioning:-The patient is usually positioned on his or her back, with the arms
tucked. If air embolism occurs, the patient should be placed in the Trendelenburg
position with a left lateral decubitus tilt; this may prevent the movement of air into the
right ventricle and onward into the left side of the heart.
ARTICLES:-
Equipment required for permanent pacemaker insertion includes the following:

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  Fluoroscope
 Instrument tray
 Pacing system analyzer
 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/defibrillator

BEFORE PROCEDURE:-

1. Surgery to implant the pacemaker is usually performed while you're awake and
typically takes a few hours.
2. Before the procedure, you are taken to a special room (called a preparation room or
holding area) to start an intravenous (IV) line.
3. Most pacemaker implantations are done using local anesthesia to numb the area of
any incisions. You may receive additional IV medication to help you relax.
4. The implantation is done in a room with special X-ray equipment.
5. Clean chest is cleaned with an antibacterial soap, and an IV line is placed in your arm
on the same side as the pacemaker

PROCEDURE:-
NURSING ACTION RATIONALE
Explain procedure to patient and family. Allays anxiety and helps in cooperation of
Explain that there will be a sensation of patients. Discomfort is felt with each firing,
discomfort with external pacing. but can be relived by analgesics.
Get informed consent for procedure. Informed consent protects the health care
personnel from legalities relating to

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 procedure.
Remove jewellery, dentures and contact lens. Jewellery will act as a source of infection and
may be lost during procedure. Removing
denture prevent trauma to patient if any
emergency occurs.
Shave area depending upon the site selected. Reduces risk of infection caused by
microorganism settling in hair follicles.
Provide clean gown. Prevent unnecessary exposure.
Start good IV access with heparin lock. Ensure a patent IV line to administer fluids
and medications.
Record ECG before procedure and obtain a Helps in comparison after procedure.
rhythm strip.
Administer premedication and send patient to Gives information about patient’s baseline
cardiac catheterization lab with patient’s data.
chart, x-ray films, lab forms, ECG strip and
other items depending upon agency policy.
Reassure the patient during procedure. Provides psychological support.
When the pacing catheter is in vein, alligator Monitors the progression of catheter through
clips can be used to connect the exposed tip the heart.
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 ventricle. The stimulus and
sensitivity settings are set and maintain
according to cardiologist’s orders.
The electrode is taped or sutured at the
insertion site.

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.
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  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 task to maintain adduction of affected extremity
for 12 hours.
 Stabilize arm, catheter and pacemaker to an armboard 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 another48 hours is
required.
 Connect patient to cardiac monitor and monitor rhythm.

SPECIAL PRECAUTIONS

It's unlikely that your pacemaker would stop working properly because of electrical
interference. Still, you'll need to take a few precautions:

 Cellphones. It's safe to talk on a cellphone, but avoid placing your cellphone directly
over your pacemaker implantation site when the phone is turned on. Although unlikely,
your pacemaker could misinterpret the cellphone signal as a heartbeat and withhold
pacing, producing symptoms, such as sudden fatigue.

 Security systems. Passing through an airport metal detector won't interfere with your
pacemaker, although the metal in it may sound the alarm. But avoid lingering near or
leaning against a metal-detection system.
If security personnel insist on using a hand-held metal detector, ask them not to hold
the device near your pacemaker any longer than necessary or ask for an alternative

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 form of personal search. To avoid potential problems, carry an ID card stating that you
have a pacemaker.

 Medical equipment. If a doctor is considering any medical procedure that involves

intensive exposure to electromagnetic energy, tell him or her that you have a
pacemaker. Such procedures include magnetic resonance imaging, therapeutic radiation
for cancer treatment and shock wave lithotripsy, which uses shock waves to break up
large kidney stones or gallstones.
If you're having surgery, a procedure to control bleeding (electrocautery) also can
interfere with pacemaker function.

 Power-generating equipment. Stand at least 2 feet (60 centimeters) from welding

equipment, high-voltage transformers or motor-generator systems. If you work around
such equipment, your doctor can arrange a test in your workplace to determine whether
it affects your pacemaker.

RECORDING:-
Record the location and type of 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 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.

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  Show identification card and request scanning by hand scanner when passing through
security gates.
 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 must be stressed.
 Mobile phones should not be kept on affected side.
 Keep incision dry for one week after implantation.
 Avoid lifting operative side arm above shoulder level for one week after
mpplantation.
COMPLICATION:-

Local infection at the entry site of the leads for temporary pacing.
Bleeding and hematoma at lead entry sites.
Failure to sense.
Failure to capture.
Atrial and ventricular septal peroration.
Atelectasis.
Pericardial fluid accumulation.
Diaphragmatic stimulation.
Hemothorax and pneumothorax from puncture of the subclavian vein.

NURSING RESPONSIBILTY

 The complication of post pacer placement is needed to be assessed, document,

implement, and re-evaluate the patient.

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  Monitor ECG for changes in rhythm, rate, and presence of dysrhythmias. Treat as
indicated.

 Ensure that all electrical equipment are grounded. Avoid touching equipment and
patient at the same time.

 Limit movement of extremity involved near insertion site as ordered.

 Instruct patient in checking pulse rate every day for 1 month, then every week, and to
notify physician if rate varies more than 5 beats /minute.

BIBLIOGRAPHY

 Elakkuvana Bhaskara Raj D, ”MSc. Nursing Solved Question Papers”, first

edition, published by jaypee, page no.66.

 Neelam Kumari,”A Textbook Of Nursing Education”, first edition, published

by PV, page no.10.

 Shebeer P.Basheer,S.Yaseen khan ,”A Concise Textbook Of Advanced

Nursing Practice”, first edition, published by Emeses Medical, page no.6-7.

 Wilkins And Williams Lippincott, A Textbook of Nursing Diagnosis

Application To Clinical Practice, Published by Wolters Kluwer Health (India) Pvt.
Ltd, New Delhi, First Edition (2006).Pp-6-9

 Basheer P.Shebeer; A textbook of Advance Nursing Practice ; Published by

EMMESS Medical Publisher Bangalore ; 2012 first edition . Pp.:- 397-405.

NET REFRENCES:-

 http://www.heartcarevictoria.com.au/for-patients/procedures-testing/
permanent-pacemaker-implantation

 https://www.mayoclinic.org/tests-procedures/pacemaker/about/pac-20384689

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 https://www.healthline.com/health/heart-pacemaker#followup

 https://www.nhs.uk/conditions/pacemaker-implantation/risks/

 https://academic.oup.com/icvts/article/8/4/444/810967

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