PACEMAKERPRESENTED BY

ABHILASHA CHAUDHARY

Pacemakers are the electrode devices that can be used to initiate the heartbeat when the hearts intrinsic electrical system cannot effectively generate a rate adequate to support cardiac output.

INTRODUCTION

Pacemakers is an electronic device used to pace the heart when the normal conduction pathway is damaged or diseased.

PACEMAKER

Pulse generator Pacemaker electrodes

COMPONENTS OF PACEMAKER

HOW PACEMAKER WORKS ?

Videographic_ Electric Beats - Pacemakers and the Human Heart.mp4

A pacemaker consists of a battery, a computerized generator and wires with sensors at their tips(called as electrodes). The battery powers the generator and both are surrounded by a thin metal box. The wires connect the generator to the heart.

A pacemaker helps monitor and control the heartbeat. The electrodes detect heart’s electrical activity and send data through the wires to the computer in the generator. If heart rhythm is abnormal, the computer will direct the generator to send electrical pulses to heart. The pulses travel through the wires to reach the heart.

a)Permanent pacemaker b)Temporary pacemaker

TYPES OF PACEMAKER

Implanted totally in the body. Power source is implanted subcutaneously

usually over the pectoral muscle on the patient non dominant side.

Permanent pacemaker

Single-chamber pacemaker. In this type, only one pacing lead is placed

into a chamber of the heart, either the atrium or the ventricle

Types of permanent pacemaker

Dual-chamber pacemaker.

Wires are placed in two chambers of the heart

One lead paces the atrium and one paces the ventricle

Closely resembles the natural pacing of the heart.

Rate-responsive pacemaker. It has sensors that detect changes in the

patient's physical activity and automatically adjust the pacing rate to fulfill the body's metabolic needs.

Indication of permanent pacemaker therapy

Chronic atrial fibrillation with slow ventricular response

Hypersensitive carotid sinus

syndrome

Fibrosis or sclerotic changes

of cardiac conduction

system

Sick sinus syndrome

Tachyarrhythmia

Third degree AV block

It is one that has the power source outside the body.

Temporary pacemaker

There are 3 types of temporary pacemaker.

Transvenous invasive pacemaker (endocardial)

It consists of lead or leads that are threaded transvenously to the right atrium and or right ventricle and attached to external power source.

TYPES OF TEMPORARY PACEMAKER

Transthoracic invasive pacing(Epicardial pacing )

It is achieved by attaching an atrial and ventricle and attached to epicardium during heart surgery . The leads are passed through the chest wall and attached to the external power source.

Trans cutaneous pacemaker(Non-invasive pacing)

It is used to provide adequate heart rate and rhythm to the patient in and emergency situation.

Maintenance of adequate heart rate and rhythm during special circumstances such as surgery and postoperative recovery, cardiac catheterization or coronary angioplasty .

Before implantation of a permanent pacemaker.

INDICATIONS OF TEMPORARY PACING

As prophylaxis after open heart surgery.

Acute anterior MI with second degree or third degree AV block or bundle branch block.

Acute inferior MI with symptomatic bradycardia and AV block

Preoperative care Financial Explain the procedure ,type and technique

of pacemaker to the patientExplain Cost of the procedure and Hospital

stay. Psychological Explain the Process of the pacemaker

insertion . Reassure the patient

Nursing management

Physical Obtain written consent from the patient

andfrom nearest relative Remove dentures,jewellery and contact

lens. Clean and shave the area . Check vital signs: temperature, BP, pulse

and respiration

Intraoperative care Check serology: HIV, HbsAg, HCV and others Start an IV line with 5% Dextrose solution or

normal saline solution. Check the battery in pulse generator Prepare the emergency cart, the

defibrillator and jelly , and the ECG monitor Set up all equipment for the insertion of the

pacemaker

The nurse should know about the pacemaker generator including the power switch, indicator light for pacing and sensing, stimulus output dial, sensitivity dial, and their proper settings.

Assist the doctor and the scrub nurse during the procedure step by step

Observe vital signs and observe ECG monitor carefully for arrhythmias and other complications.

Post operative care Receive the patient Keep the patient in comfort position Record the pacing parameters. -Receiving time -patient’s heart rate -Other routine care

Immobilize the affected part and keep in supine position but allow the movement of finger and ankle joint.

Monitor heart rate and rhythm. Monitor vitals signs and level of

consciousness of patient. Prevent infection. Take ECG and X-ray chest.. Watch for complications

Maintain follow up care with a physician to check the pacemaker site and begin regular pacemaker function checks .

Watch for signs of infection at incision site redness, swelling dressing.

Keep incision dry for 1 week after implantation.

Avoid lifting operative side arm above shoulder level until approved by care provider.

Patient and family teaching

Avoid direct blows to generators or to large magnets such as MRI scanner . These device can reprogram a pacemaker.

Microwave oven are safe to use and do not threaten pacemaker function.

The patient should be taught how to take the pulse .

Carry pacemaker information card at all the times.

Hematoma Pneumothorax Failure to sense or capture Perforation of atrial or ventricle septum Ventricular atrophy and tachycardia Movement or dislocation of lead Cardiac perforation

Complications

Infection (endocarditis)

A study done on “Pacemaker Endocarditis: Clinical Features and Management of 60 Consecutive Cases “ 89% cases were found to be endocarditis related to pacemaker and the causative agent was staphyloccus .

Acute pain related to insertion site and prescribed post procedure immobilization.

Disturbed self concept related to perceived loss of health and dependence on pacemaker.

Impaired physical mobility related to incisional site pain,activity restrictions.

Risk for infection related to operative site. Risk for ineffective therapeutic regimen

management related to insufficient knowledge of activity restrictions,precautions.

NURSING DIAGNOSIS

-Definition -Components of pacemaker-Working of pacemaker-Types of pacemaekr-Permanent pacemaker-Temporary pacemaker-nursing management• Preoperative• Intraoperative • Postoperative

Summary

A pacemaker is an electronic device that provides repetitive electrical stimuli to heart muscle when the patient’s intrinsic pacemaker fails to provide perfusing rhythm.

Conclusion

Topic : Trends in the incidence and prevalence of cardiac pacemaker insertions in an ageing population.

Journal name : journal list open heart Year of publication: 2014(Jan) Author name: Pamela J Bradshaw, Paul

Stobie ,Matthew W Knuiman, Thomas G Briffa, and Michael S T Hobbs

objectives: To determine the prevalence of cardiac

permanent pacemaker (PPM) insertions.

RESEARCH EVIDENCE

Methods A population-based observational study using

linked hospital morbidity and death registry data from Western Australia (WA) to identify all incident cases of PPM insertion for adults aged 18 years or older. Prevalence rates were calculated by age and sex for the years 1995–2009 for the WA population.

Results There were 9782 PPMs inserted during 1995–2009. Prevalence rose across the study period, exceeding

1 in 50 among people aged 75 or older from 2005

This was underpinned by incidence rates which rose with age, being highest in those 85 years or older; over 500/100 000 for men throughout, and over 200/100 000 for women. Rates for patients over 75 were more than double the rates for those aged 65–74 years. Women were around 40% of cases overall.

Conclusions Rates of insertion and prevalence of PPM

continue to rise with the ageing population in WA

Smeltzer Suzanne C, Barebrenda G, Hinkle Janice L, Cheever Kerry H. Textbook of medical surgical nursing, 12th ed. Newdelhi: Lippincot wolter’s kluwer; p.113-114(vol-1)

Lewis Sharan mantik, Heitkemper Margaret Mclean, Shannon Ruff Dirksen,Obrien Patrical, Giddens Jean Foret, Bucher Linda. Medical surgical nursing. 6th ed.Mosby; p.874-78

Best practices A guide to excellence in nursing care. lippincott William and wikins. P.252-53.

Pamela J Bradshaw, Paul Stobie ,Matthew W Knuiman, Thomas G Briffa, Michael S T Hobbs. Trends in the incidence and prevalence of cardiac pacemaker insertions in an ageing population.  2014; 1(1)

www.nhlbi.nih.gov/health/healthtopics/topics/pace/howdoes.

REFERENCES