CARDIAC PACING - It is an electric device that delivers Ability of the cardiac pace maker to see intrinsic cardiac

direct electrical stimulation to stimulate the myocardium activity when it occurs.

to depolarize ,initiating a mechanical contraction. Demand:
Clinical Indication:  pacing stimulation delivered only if the heart rate
1. Symptomatic bradycardia falls below the preset limit.
2. Symptomatic heart block Fixed:
 2nd degree heart block  no ability to sense. constantly delivers the preset
 3rd or complete heart block stimulus at preset rate.
 Bifasicular or transfasicular bundle branch blocks. Triggered:
3. Prophylaxis  delivers stimuli in response to (sensing) cardiac
event.
PACEMAKER DESIGN Capture function:
1. Pulse generator Ability of the pacemaker to generate a response from the
2. leads heart (contraction) after electrical stimulation.
Pulse generator 1. Electrical capture :
 In permanent pacemaker is encapsulated in a indicated by P or QRS following and corresponding to a
metal can ,to protect the generator from pacemaker spike.
electromagnetic interference 2. Mechanical capture:
 Temporary pacing system generator is externally palpable pulse corresponding to the electrical event.
contained in a small box
 Transcutanus external pacing system house the Pacing types
generator in a piece of equipment similar to  Permanent
portable ECG monitor.  Temporary
Pacemaker lead  biventricular
1. Single chamber (unipolar) pacemaker Types of pacing
 Lead placed in atrium or ventricle 1. Permanent pacemaker
 Produce large spic on the ECG  Used to treat chronic heart condition
 Sensing and pacing in the chamber where the lead  Surgically placed transvenuosly under local
is located anesthesia
 More likely to be affected by electromechanically  Pulse generator placed in a pocket subcutaneously
interference ,can be adjusted externally
2. Dual-chamber (bipolar) pacemaker 2. Temporary pacemaker
 One Lead located in the atrium and one in the  Placed during emergencies
ventricle  Indicated for pts’ high degree heart block or
 Sensing and pacing in both chambers mimicking unstable bradycardia
the normal heart function  Can be placed transvenously, epicardially,
 Produce in visible spic in the ECG transcutanusly or transthorasicly
 Less affected by electromechanical interference. 3. Biventricular pacemaker
 Used in sever heart failure
Pacemaker function  Utilize three leads in right atrium, right ventricle
1. Pacing function and left ventricle to coordinate ventricular
2. Sensing function coordination and improve cardiac output
3. Capture function Equipments
 Transvenous pacing catheter
Atrial pacing:  EKG machine
Stimulation of RT atrium produce spic on ECG preceding P  Pacemaker generator with battery and cable
wave  Emergency crash cart
Ventricle pacing :  Lidocaine
Stimulation of RT or LT ventricle produce a spic on ECG  Defibrillator
preceding QRS complex.  (2) 5cc syringe with 22 and 25 gauge needles
AV pacing:
Direct stimulation of RT atrium and either ventricles mimic  External Pacer
normal heart conduction  Sterile gown, gloves, mask
Sensing function : INSERTION SITES
 Left Subclavian (most reliable)
  Internal jugular (lower incidence of
pneumothorax)
 Femoral vein
 Brachial vein
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
 Anesthetize the area locally.
 Prepare the external temporary generator:
 Portable Chest X-ray is required to confirm
placement.
Applying transcutaneous pacing
 Anterior/posterior:
 Module on stand by. minimal out put
 Connect pacing to external module
 Increase milliamp until a pacing spike and
corresponding QRS are seen. Palpate pulse
Complication
 Movement and dislocation of the lead
 Injury
 Bleeding and hematoma
 Ventricular ectopy or VT from wall stimulation
 Infection
 Cardiac tamponade
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.
Nursing intervention
1. Maintain adequate cardiac output
 Record information after insertion pacemaker
model ,mode, program setting,pt’s rhythm
 Attach ECG for continues monitoring
 Analyze rhythm strips as per protocol
 Monitor vital signs
 Monitor urine output
 Observe for dysrhythmia
2. 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
3. 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
4. Provide electrically safe environment
 Protect exposed parts of electrode leads with
rubber
 Wear rubber gloves when touching a temporary
pacing lead
5. 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.
 Pt’s 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.
6. Prevent accidental pacemaker malfunctions
 Use external plastic covering over external
generator all times
 Secure temporary pace maker over pt’s chest or
wrist never hang it over iv pole
 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.
7. 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.
8. Relieving anxiety
9. Reliving pain.
10. Maintaining a positive body image
11. Minimizing the effect of immobility
 Rest for 24-48 hrs post pacing insertion
 Deep breathing exercise
 Restrict movement of affected extremity
Patient education
1. Anatomy and physiology of the heart
2. Pacemaker function
3. 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  CT Scan
doctor.  Coronary Angiograph
 Sexual activity can be resumed when desired
4. Pacemaker failure Coronary Angioplasty with Stents
 Teach pt to check own pulse at least weekly for 1  Common treatment for Coronary Artery Disease
min  Process:
 Report slowing on the pulse less or greater than  Blockage is defined through coronary
the setting rate angiography
 Report sign and symptom as palpitation, fatigue  Incision is made
,dizziness, prolonged hiccups  Cardiac catheter is guided to the heart
 Wear identification bracelet and carry a through an artery of the groin or arm
pacemaker identification cared.  Guide wire is manipulated to
5. Electromagnetic interference lie across the blockage
 Caution pt that EMI could interfere with  Heparin is a given to thin the
pacemaker function. blood and prevent clotting
 Explain that high energy radar, TV and radio  Stent balloon catheter is transported
transmetters,MRI,large motors may affect the along the guide wire and is positioned
pacemaker function. over the blockage
 Teach pt to move 4-6 m away from source and  Saline is pumped into the balloon to
check pulse. it should return to normal. Most inflate it
pacemaker equipped with internal filters to  Balloon is inflated for 30 to 60 seconds to
prevent interaction with cell phone. expand the stent
 Tell pt that antitheft devices and airport security Stents
alarms may affect pacemaker and trigger security  Expandable
alarm.  Mesh-like tube
 Household and kitchen appliance will not affect  Invented to overcome short comings of regular
pacemaker.
coronary angioplasty
6. Care of pacemaker site.
 Stays in artery permanently
 Wear loose-fitting clothes around pacemaker
Kinds of Stents
 Watch sign and symptom of infection
 Uncoated Stents
 Keep incision site clean and dry. not to scrub site
 Bare metal
 Advise well balanced diet.
 Drug-coated Stents
 Coated with Sirolimus
 Controlled release of medicine into tissue
Coronary Stents
 Drug limits overgrowth of natural tissue
Coronary Artery Disease - Leading cause of death in
 Anti-rejection-type medicine (10% vs
United States for men and women
26%)
 Caused by buildup of plaque in arteries
Pros & Cons
 Heart tissue is deprived of nutrients
 Pros
 Risk factors:
 Less invasive than open heart
 Age
surgery
 Gender
 Short procedure
 Genes
 Failure rate 1%
Symptoms and Tests for Coronary Artery Disease
 Cons
 Symptoms:
 Not a cure
 Vary in strength
 Aggravates kidney function
 Chest pain
 Stents can’t be used in every
 Fatigue
surgery
 Shortness of breath
 Can be rejected by body
 Weakness
 Tests:
I WILL NOT WORRY ABOUT WHAT IS BEYOND MY
 ECG
CONTROL. GOD IS FULLY IN CONTROL OF MY
 Exercise Stress Test EXAMS, MY DESTINY, MY RESULTS.
 Nuclear Stress Test