jp's pacemaker
TRANSCRIPT
GOOD MORNING…
Jyothis Prakash
CARDIAC PACING
JYOTHIS PRAKASHFIRST YEAR M.Sc
NURSING
By the end of this lecture you will be able to:
define pacemaker differentiate types of pacemaker list functions of pacemaker assist and monitor pt undergoing
pacing identifying pt’s educational needs
Clinical objectives:
Introduction Definition of cardiac pacing Clinical Indication Pacemaker design Pacemaker function Types of pacing Nursing diagnosis Nursing intervention Pt’s education
Out line:
Normal conductive system of the heart:
“It is an electric device that delivers direct electrical stimulation to stimulate the myocardium to depolarize, initiating a mechanical contraction”.
Definition of Cardiac Pacing:
1. Symptomatic bradycardia2. Symptomatic heart block 2nd degree heart block 3rd or complete heart block Bifasicular or transfasicular bundle
branch blocks3. Prophylaxis4. Poisoning (cerbera odollam-cerberin)5. Some tachycardias
Clinical Indication:
Pulse generator: power source or battery
Leads or wires
Cathode (negative electrode)
Anode (positive electrode)
Body tissue
Pacemaker Design:
In permanent pacemaker, is encapsulated in a metal can ,to protect the generator from electromagnetic interference.
Pacemaker Design:
Pulse generator Temporary pacing system
generator is externally contained in a small box.
Pulse generator Transcutaneous external pacing
system house the generator in a piece of equipment similar to portable ECG monitor.
Deliver electrical impulses from the pulse generator to the heart.
Sense cardiac depolarization.
Leads Are Insulated Wires That:
Endocardial or transvenous leads
Myocardial/ Epicardial leads
Types of Leads:
Conductor Connector Pin Insulation Electrode
Pacing lead Components:
Tip electrode
conductor
insulation connector pin
Passive fixation ◦ The tines become lodged in the trabeculae
(fibrous meshwork) of the heart.
Transvenous Leads Have Different “Fixation” Mechanisms:
Active Fixation ◦ The helix (or screw) extends into the endocardial
tissue
◦ Allows for lead positioning anywhere in the heart’s chamber
Transvenous Leads:
Leads applied directly to the heart
◦ Fixation mechanisms include:
Epicardial stab-in
Myocardial screw-in
Suture-on
Myocardial and Epicardial Leads:
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
An electrode that is in contact with the heart tissue.
Negatively charged when electrical current is flowing.
Cathode:
An electrode that receives the electrical impulse after depolarization of cardiac tissue.
Positively charged when electrical current is flowing.
Anode:
Body tissues and fluids are part of the conduction pathway between the anode and cathode.
Conduction Pathways:
Begins in the pulse generator. Flows through the lead and the cathode (–). Stimulates the heart. Returns to the anode (+).
During Pacing, the Impulse:
Single chamber (unipolar):
Single chamber (unipolar):
Flows through the tip electrode (cathode)
Stimulates the heart
Returns through body fluid and tissue to the IPG (anode)
A Unipolar Pacing System Contains a Lead with Only One Electrode Within the Heart. In This System, the Impulse:
ANODE (+)
CATHODE (-)
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.
Dual-chamber (bipolar) pacemaker:
Flows through the tip electrode located at the end of the lead wire
Stimulates the heart
Returns to the ring electrode above the lead tip
A Bipolar Pacing System Contains a Lead with Two Electrodes Within the Heart. In This System, the Impulse:
Devised to simplify the naming of pacemaker generators.
3-Letter or 5-Letter Code:
Indicates the chamber being paced
A: Atrium
V: Ventricle
D: Dual (Both A and V)
O: None
First letter:
Indicates the chamber being sensed
A: Atrium
V: Ventricle
D: Dual (Both A and V)
O: Asynchronous or does not apply
Second Letter:
Indicates the generator’s response to a sensed signal/R wave
I: Inhibited
T: Triggered
D: Dual (T & I)
O: Asynchronous/ does not apply
Third Letter:
Indicates programming information
O: No programming
P: Programming only for output and/or rate
M: Multiprogrammable
C: Communicating
R: Rate modulation
Fourth Letter:
This letter indicates tachyarrhythmia functions
B: Bursts
N: Normal rate competition
S: Scanning
E: External
O: None
Fifth Letter:
Modes and Codes: NBG Code
Stuart Allen 06
IChamber
Paced
IIChamberSensed
IIIResponseto Sensing
IVProgrammableFunctions/Rate
Modulation
VAntitachy
Function(s)
V: Ventricle V: Ventricle T: Triggered P: Simple programmable
P: Pace
A: Atrium A: Atrium I: InhibitedM: Multi- programmable
S: Shock
D: Dual (A+V) D: Dual (A+V) D: Dual (T+I) C: Communicating D: Dual (P+S)
O: None O: None O: None R: Rate modulating O: None
S: Single (A or V)
S: Single (A or V)
O: None
Sinus Node Disease - AAI (R)
AVB - DDD
SND + AVB - DDDR + DDIR
Chronic AF + AVB - VVI (R)
CSS / MVVS - DDI
Optimal Pacing Mode (BPEG):
Sinus Node Disease - AAI
AVB - VDD
SND + AVB - DDD + DDI
Chronic AF + AVB - VVI
CSS - DDD / VVI
MVVS - DDD
Alternative Pacing Mode:
Unipolar and Bipolar Leads:
Unipolar leads may have a smaller diameter lead body than bipolar leads.
Unipolar leads usually exhibit larger pacing artifacts on the surface ECG.
Unipolar leads:
Bipolar leads are less susceptible to over sensing noncardiac signals (myopotentials and EMI).
Bipolar leads:
Coaxial Lead Design
Lead Insulation May Be Silicone or Polyurethane:
Single-Chamber and Dual-Chamber Pacing Systems:
The pacing lead is implanted in the atrium or ventricle, depending on the chamber to be paced and sensed.
Single-Chamber System:
Paced Rhythm Recognition:
Advantages and Disadvantages of Single-Chamber Pacing Systems:Advantages Implantation of a
single lead.
DisadvantagesSingle ventricular lead does not provide AV synchrony.Single atrial lead does not provide ventricular backup if A-to-V conduction is lost.
One lead implanted in the atrium.
One lead implanted in the ventricle.
Dual-Chamber Systems Have Two Leads:
Paced Rhythm Recognition:
1. Pacing function2. Sensing function3. Capture function
Pacemaker function:
Stimulate cardiac depolarization.
Sense intrinsic cardiac function.
Respond to increased metabolic demand by providing rate responsive pacing.
Provide diagnostic information stored by the pacemaker.
Most Pacemakers Perform Four Functions:
Atrial pacing: Stimulation of right atrium
produce spic on ECG preceding P wave.
Pacing function:
Ventricle pacing: Stimulation of right or left ventricle
produce a spic on ECG preceding QRS complex.
Pacing function:
AVpacing: Direct stimulation of RT atrium and
either ventricles mimic normal heart conduction.
Pacing function:
Sensing : Ability of the cardiac pace maker
to see intrinsic cardiac activity when it occurs.
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.
Sensing function:
Capture: Ability of the pacemaker to
generate a response from the heart (contraction) after electrical stimulation.
Capture function:
1. Electrical capture : indicated by P or QRS following and
corresponding to a pacemaker spike.
2. Mechanical capture: palpable pulse corresponding to
the electrical event.
Capture function:
Permanent
Temporary
Biventricular
Pacing types:
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.
Types of pacing:
Permanent pacemaker:
Temporary pacemaker Placed during emergencies. Indicated for pts’ high degree heart
block or unstable bradycardia. Can be placed transvenously,
epicardially, transcutaneously or transthoracically.
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.
Types of pacing:
Equipments:
Transvenous pacing catheter
ECG machine
Pacemaker generator with battery and cable
Emergency crash cart
Defibrillator, lidocaine
(2) 5cc syringe with 22 and 25 gauge needles
External Pacer
Sterile gown, gloves, mask
Left Subclavian (most reliable)
Internal jugular (lower incidence of pneumothorax)
Femoral vein
Brachial vein
Insertion sites:
Check that patient has a patent IV, and that the defibrillator, emergency cart and appropriate medications are available.
Obtain consent ( spouse/near relatives ).
Obtain vital signs and ECG rhythm strip prior to insertion. Connect to 12 lead EKG and continuously monitor before, during and after procedure.
Insertion procedure:
Anesthetize the area locally.
Prepare the external temporary generator.
Portable Chest X-ray is required to confirm placement.
Insertion procedure:
Anterior/lateral; Anterior/posterior(pacing pads)
Selects pacing rate;↑ the pacing current(mA).
Increase milliamp until a pacing spike and corresponding QRS are seen.
Use only as an emergency procedure.
Applying transcutaneous pacing:
Movement and dislocation of the lead.
Injury Bleeding and hematoma. Ventricular ectopy or VT from wall
stimulation. Infection Cardiac tamponade
Complications:
FAILURE TO PACE:-
FAILURE TO SENSE:-
FAILURE TO CAPTURE:-
Decreased cardiac output related to potential pacemaker malfunction.
Acute pain related to surgical incision or external pacing stimuli.
Impaired physical mobility related to restriction of movement.
Disturbed body image related to pacemaker implementation.
Risk for injury related to pneumothorax.
Nursing diagnosis:
1. Maintain adequate cardiac output
Record information after insertion regarding 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.
Nursing intervention:
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.
Nursing intervention:
3. Monitor for evidence of lead migration and perforation of heart
Observe for muscle twitching and hiccups .
Evaluate chest pain.
Auscultate for friction rub.
Observe for signs of cardiac tamponade.
Nursing intervention:
4. Provide electrically safe environment
Protect exposed parts of electrode leads with rubber.
Wear rubber gloves when touching a temporary pacing lead.
Nursing intervention:
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.
Nursing intervention:
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
Nursing intervention:
Place a sign over pt's bed alerting personnel to the presence of pacemaker.
Evaluate transcutaneous pacing every 2 hrs.
Monitor for electrolyte imbalances, hypoxia and myocardial infarction.
Nursing intervention:
7. Preventing infection
Take temp every 4 hrs. Observe for sign and symptoms of
infection. Clean incision site with sterile
technique. Monitor vein which pacing placed in
for phlebitis. Administer antibiotic as ordered.
Nursing intervention:
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.
Nursing intervention:
1. Anatomy and physiology of the heart2. Pacemaker function3. Activity Specific instruction include: Not to lift items over 1.4kg or perform
difficult arm maneuver. Avoid excessive stretching or bending
excessive. Avoid contact sports, tennis, golf until
advised by doctor. Sexual activity can be resumed when
desired.
Patient education:
4. 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 card.
Patient education:
5. Electromagnetic interference
Caution pt that EMI could interfere with pacemaker function.
Explain that high energy radar, TV and radio transmitters, 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.
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.
Patient education:
6. 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.
Patient education:
CONCLUSION
THANK YOU…