An artificial pacemaker uses an electronic device to stimulate the heart when the normal conduction pathway is damaged. It consists of a battery-powered pulse generator connected to pacing leads that deliver electrical signals to the heart muscle. Temporary pacemakers can be inserted transvenously, epicardially, or transcutaneously in emergency situations. Permanent pacemakers are implanted surgically and have programmable functions to treat various arrhythmias. Common pacemaker complications include infection, failure to sense or capture intrinsic heartbeats, and oversensing of extraneous signals. Nurses monitor for complications and make adjustments to optimize pacemaker function.

1. PACEMAKER
Anjali
M.Sc. Nursing 1st year

2. Introduction
• The artificial cardiac pacemaker is an electronic device used to
pace the heart when the normal conduction pathway is damaged.
• The basic pacing circuit consists of a power source (battery-
powered pulse generator) with programmable circuitry, one or
more pacing leads, and the myocardium.

3. • The electrical signal (stimulus) travels from the pulse generator,
through the leads, to the wall of the myocardium. The heart
muscle is "captured” and stimulated to contract. Recently a
leadless pacemaker that is fully implanted in the right ventricle
has been approved by the FDA.
• Current pacemakers are small, sophisticated, and physiologically
precise. They pace the atrium and/or one or both of the
ventricles. Most pacemakers are demand pacemakers. This means
that they sense the heart's electrical activity and fire only when
the HR drops below a preset rate.

4. Demand pacemakers have two distinct features:
• A sensing device that inhibits the pacemaker when the HR is
adequate
• A pacing device that triggers the pacemaker when no QRS
complexes occur within a preset time

5. Temporary Pacemaker.
• Transvenous
• Epicardial
• Transcutaneous

6. Transvenous (endocardial) pacemaker
• Most common mode of pacing in the heart is emergency
situations
• The cardiologist inserts the pacing electrode via the
transvenous route ( the antacubital, femoral, jugular or
subclavian vein).
• The electrode into the right atrium or right ventricle
• This procedure can be done at the bedside under
fluoroscopic control or in a cardiovascular.

8. Epicardial (Transthoracic) pacing
• With this method of artificial pacing, the electrical energy travels
through lead wires from an external pulse generator through the
thoracic muscle directly to the epicardium. Epicardial pacing is
most commonly used during the immediately after open heart
surgery because there is direct access to the epicardium at this
time.

9. Transcutaneous pacemaker (TCP)
• It is used to provide adequate HR and rhythm to the patient in an
emergency situation.
• Non invasive and temporary

11. Indication for temporary pacemakers
• Maintenance a adequate HR and rhythm during special circumstances
such as surgery and postoperative recovery, during cardiac
catheterization or coronary angioplasty, during drug therapy that may
cause bradycardia, and before implantation of a permanent pacemaker
• As prophylaxis after open heart surgery
• Acute anterior MI with second- or third-degree AV block or bundle
branch block
• Acute inferior MI with symptomatic bradycardia and AV block
• Electrophysiologic studies to evaluate patient with bradysrhythmias and
tachydysrhythmias

12. Monitoring of Patients With Pacemakers
• Patients with sedation while the TCP is in use.
• ECG monitoring
• To sense occurs when the pacemaker fails to recognize spontaneous
atrial or ventricular activity, and it fires inappropriately. This can
result in the pacemaker firing during the excitable period of the
cardiac cycle, resulting in VT.
• Failure to sense is caused by fibrosis around the tip of the pacing
lead, battery failure, sensing set too high, or dislodgment of the
electrode.

13. Monitoring of Patients With Pacemakers
• Failure to capture occurs when the electrical charge to
the myocardium is insufficient to produce atrial or
ventricular contraction. This can result in serious
bradycardia or asystole. Failure to capture is caused by
pacer lead damage, battery failure, dislodgment of the
electrode, electrical charge set too low, or fibrosis at the
electrode tip.

14. Permanent Pacemaker
• A permanent pacemaker is implanted totaly within the
body. The power source is placed subcutaneously, usually
over the pectoral muscle on the patient's non-dominant
side. The pacing leads are placed transvenously to the
right atrium and/or one or both ventricles and attached to
the power source.

16. Pacemaker modes
• There are two basic types of pacemakers.
1. Fixed rate (non demand or asynchronous)
2. Demand pacemakers

17. Fixed rate (non demand or asynchronous)
• Fixed rate pacemakers are designed to fire constantly at a
present rate without regard to the electrical activity of the
client’s heart.
• This mode of pacing is appropriate in the absence of any
electrical activity (asystole) but is dangerous in the presence of
an intrinsic rhythm because of the potential of the pacemaker to
fire during the vulnerable period of repolarization and initiate
lethal ventricular dysrhythmias.

18. Demand pacemakers
• Demand pacemakers contains device that senses the heart’s
electrical activity and fires at a preset rate only when the
heart’s elctrical activity drops below a predetermined rate.

19. Classification system for pacemaker
• Permanent pacemaker now have special programmable and anti-
tachycdysrhythnic function that are quite complex.
• To communicate all the functions of the individual pacemakers,
international codes were developed. Pacemakkers are identified
with a five digit letter code.
• The last two letter contain pertinent information, commonly a
pacemaker is referred to only by its first three letters

21. FIRST LETTER: CHAMBER PACED
• Indicates which chamber(s) of the heart will be
stimulated:
• V = Ventricle
• A = Atrium
• D = Dual-chamber (both atria and ventricles stimulated)

22. SECOND LETTER: CHAMBER SENSED
• Indicates the chamber(s) of the heart in which the lead
is capable of recognizing intrinsic electrical activity:
V = Ventricle
A = Atrium
D = Dual-chamber (sensing capabilities in atria and
ventricles)
O = No sensing capability

23. THIRD LETTER: MODE OF RESPONSE
• Indicates how the pacemaker will act based on the
information it senses:
• T = Triggered (may have energy output triggered)
• I = Inhibited (pacing output inhibited by intrinsic
activity)
• D = Dual-chamber (may be either inhibiting or triggering
of both chambers)

24. FOURTH LETTER: PROGRAMMABLE FUNCTIONS
• Indicates ability to change function once the pacemaker
has been implanted:
• P = Programmable for one or two functions
• M = Multiprogrammable ability to change functions
other than the rate or output

25. FIFTH LETTER: TACHYDYSRHYTHMIC FUNCTIONS
• Indicates specific methods of interrupting
tachydysrhythmias:
• B = Bursts of pacing
• N = Normal rate competition
• S = Scanning

26. Indication for permanent pacemakers
1.Acquired AV block
2.Second degree AV block
3.Third degree AV block
4.Atrial fibrillation with slow ventricular response
5.Bundle branch block
6.Cardiomyopathy
7.Heart failure
8.SA node dysfunction
9.Tachydysrhythmias (e.g. Ventricular tachycardia)

27. PACEMAKER FAILURE/ MALFUNCTION AND
NURSING INTERVENTION
1. Failure to pace properly
Intermittent or complete absence of pacing artifact
Rapid, inappropriate firing of pacemaker (pacemaker mediated
tachycardia)
Possible cause
• Battery failure
• A break or loose connection anywhere along system
• Pulse generator failure
• Circuitry failure

28. PACEMAKER FAILURE/ MALFUNCTION AND
NURSING INTERVENTION cont..
Nursing interventions
• Replace pulse generator
• Replace battery unit
• Check and tighten all connections between pulse generator and
leads
• Reduce or increase sensitivity threshold of pacemaker unit
• Assess client’s tolerance of pacemaker failure; have emergency
drugs on hand; perform CPR as indicated

29. PACEMAKER FAILURE/ MALFUNCTION AND
NURSING INTERVENTION cont..
2. Failure to capture
Pacing artifact present but not followed by ORS complex or P wave
Possible cause
• Increased pacing threshold; can be related to electrolyte
imbalance, ischemia, drug toxicity, perforation, or excessive
fibrosis of tissue at electrode site

30. PACEMAKER FAILURE/ MALFUNCTION AND
NURSING INTERVENTION cont..
Nursing interventions
• Increase voltage by 1-2 mA ( temporary pacemaker).
• Increase amplitude of pacemaker output/ pulse width.
• Reposition client to either side in attempt to improve contact of
electrode with endocardium; in temporary pacemaker, try moving
arm if lead wire is inserted in antecubital area.
• Obtain chest film to determine pacemaker position
• Have emergency drugs on hand; initiate CPR if necessary

31. PACEMAKER FAILURE/ MALFUNCTION AND
NURSING INTERVENTION cont..
3. Failure to sense
Pacing artifact present despite presence of ORS complexes and P waves
A competitive rhythm may develop
Possible cause
• Sensitivity threshold set too low intrinsic beats are of too-low voltage
and go undetented bu pcemaker,s sensing mechanism
• Dislodged or fractured lead
• Circuitry failure
• Electromagnetic interference

32. PACEMAKER FAILURE/ MALFUNCTION AND
NURSING INTERVENTION cont..
Nursing interventions
• Increase sensitivity threshold on pulse generator
• Reposition client
• If client’s intrinsic rhythm or rate is adequate, turn off
pacemaker.
• Increase pacing rate to overdrive client’s intrinsic heart rate
• Give antidysrhythmic to decrease ectopy
• Notify physician
• Obtain chest x-ray to determine electrode placement

33. PACEMAKER FAILURE/ MALFUNCTION AND NURSING
INTERVENTION cont..
4. Oversensing
Result from inappropriate sensing of extraneous electrical signals or
myopotentials ( which should be ignored)
Possible cause
• Sensitivity threshold set too high
• T wave sensing myopotentials
• Electromagnetic interference
• Two leads touching

34. PACEMAKER FAILURE/ MALFUNCTION AND NURSING
INTERVENTION cont..
Nursing interventions
• Decrease sensitivity threshold
• Correct condition that produce large T waves

35. Client With a Permanent Pacemaker
WOUND CARE
1.Assess your wound daily, and keep the incision clean and dry until it
heals.
2.Report any fever, redness, drainage, warmth, discoloration, or
swelling to the physician.
3.Avoid constrictive clothing (e.g., tight brassiere straps), which puts
excessive pressure on the wound and the pulse generator.
4.Avoid extensive "toying" with the pulse generator because this may
cause pacemaker malfunction and local skin inflammation.

36. Complications
1.Infection and hematoma formation at the insertion site,
2.Pneumothorax,
3.Failure to sense or capture,
4.Perforation of the atrial or ventricular septum by the pacing lead,
and
5.Appearance of "end-of-life" battery power on testing the
pacemaker.

37. Several measures can prevent or assess for
complications
• These include prophylactic IV antibiotic therapy before and after
insertion
• Postinsertion chest x-ray to check lead placement and to rule out a
pneumothorax, careful observation of insertion site
• Continuous ECG monitoring of the patient's rhythm.
• Patient limit arm and shoulder activity
• Observe the insertion site for signs of bleeding

38. Several measures can prevent or assess for
complications cont.…
• Provide teaching in addition to observing for complications after
pacemaker insertion.
• The patient with a newly implanted pacemaker and the caregiver may
have questions about activity restrictions and fears concerning body
image after the procedure.
• provide specific advice on activity restrictions
• EPS (Electrophysiological study) laboratory.

39. Nursing Management
Before the procedure
• explain the purpose of the temporary pacemaker to the client and
family.
• Ensure that a permit for the procedure has been signed and that all
questions have been answered.
• Necessary equipment is gathered, and the external generator is
checked (battery and sense and pace modes).
• Assess the client's vital signs and oxygen saturation; obtain a rhythm
strip. Assess the need for sedation or analgesics, the client's level of
anxiety, and the risk for bleeding.

40. Nursing Management
During the procedure
• monitor the client's ECG and vital signs continuously.
• Large P waves are seen as the catheter passes through the
atrium, and larger QRS complexes are seen in the ventricles.
• Set and maintain the stimulus and sensitivity settings according to
the physician's orders. Tape or suture the electrode at the
insertion site.

41. Nursing Management
After the procedure
• assess vital signs and peripheral pulses routinely along with emotional
reactions to the procedure and pacing.
• Clients with temporary pace- makers must be placed on a cardiac
monitor.
• Document the location and type of pacing lead.
• Note the pacing mode, stimulus threshold, sensitivity setting, pacing
rate and intervals, and intrinsic rhythm.
• Pacing intervals

42. Nursing Management
• Secure and check all connection.
• Monitor battery and control settings
• Clean and dress the incision site according to protocols.
• Limit the motion of the extremity at the insertion site. Stabilize the
arm, catheter, and pacemaker to an arm board and avoid movement
of the arm above shoulder. Do not lift the client from under the arm.
• If the leg is the insertion site, limit its motion, especially hip flexion
by limiting elevation of the head of the bed.

43. Instruction for the patient/client
1. Measure your pulse rate as instructed by your physician in your
wrist or on your neck. You will be taught how to do this before
leaving the hospital.
2. Notify the physician if your pulse rate is slower than the set rate;
also report sensations of feeling your heart "racing," beating
irregularly, fatigue, or dizziness.
3. Avoid being near areas with high voltage, magnetic force fields, or
radiation; this can cause pacemaker problems.

44. 4. Avoid being near large running motors (gas or electric) and
standing near high-tension wires, power plants, radio transmitters,
large industrial magnets, and arc welding machines. Riding in a car is
safe, but do not bring the pacemaker to within 6 to 12 inches of the
distributor coil of a running engine.
5. You can continue to operate safely most appliances and tools that
are properly grounded and in good repair, including microwave
ovens, televisions, video recorders, AM and FM radios, electric
blankets, lawn mowers, leaf blowers, and cars.
6. You can safely operate office and light industrial equipment that is
properly grounded and in good repair, such as electric typewriters,
copying machines, and personal computers.

45. 7.An airport's metal detector can be triggered by the pacemaker's metal casing and the programming
magnet. Mention your pacemaker to security guards. The metal detector itself does not harm the
pacemaker.
8. At all times carry a pacemaker identity card (including programming information, pacemaker
manufacturer, emergency phone numbers). Wear a medical alert bracelet.
9.Avoid activity that might damage the pulse generator, such as playing football or firing a rifle with
the butt end against the affected shoulder.
10.Some stores sell antitheft devices that may affect pacemaker function. If you suddenly become
dizzy, move away from the area and notify the store clerk about the pacemaker.
11. If radiation therapy has been prescribed to the area in which the pulse generator was implanted,
the pulse generator must be relocated.

46. 12.Do not lift more than 5 to 10 pounds (equivalent to a full grocery sack or a
gallon of milk) for the first 6 weeks after surgery. Do not move your arms and
shoulders vigorously for the first 6 weeks. Normal activities (including sexual
activity) can be resumed in 6 weeks.
13.Discuss with the nurse the purpose, dose, schedule, and possible side effects of
prescribed medications. Consult your written information sheets to reinforce
learning.
14.Plan to see your physician to test your pacemaker. Your cardiologist periodically
will reevaluate pacemaker function and can reprogram it if needed. You may also
be able to check your pacemaker by telephone. If this is soit possible, you will
receive instructions.

47. THANK YOU