epic

2. PACEMAKER
PRINCY FRANCIS M
II Yr MSc (N)
JMCON

3. • 1932 - Albert Hyman coined term “Artificial
pacemaker”
• 1958 – first implantable pacemaker
designed by Rune Elmquist

4. Definition
A pacemaker is an electronic device that provides
electrical stimuli to the heart muscle.

5. INDICATION
- ACC, AHA and Heart Rhythm Society
 Class I (procedure to be performed)
• Sinus node dysfunction
• Acquired atrioventricular block
• Chronic bifascicular block
• After acute MI

6. INDICATION cont…
•Hypersensitive carotid sinus syndrome and
neurocardiogenic syncope
•After cardiac transplantation
•Pacing to prevent tachycardia
•Patients with congenital heart disease

7.  Class II procedures can be performed
but additional studies are needed
• Sustained VT
• Unexplained Syncope
• Nonischemic cardiomyopathy
• Permanent pacemaker that automatically detect and
pace to terminate tachycardia
• Cardiac sarcoidosis, Chagas disease
• Brugada syndrome
Class III procedures should not be performed

8. TYPES
Permanent pacemakers
Temporary pacemakers

9. PERMANENT PACEMAKER
• The permanent pacemaker source is implanted subcutaneously
usually over the pectoral muscle on the patient’s nondominant side
• It is attached to pacing leads, which are threaded intravenously to
the right atrium and one or both ventricles.

10. TEMPORARY PACEMAKER
• Temporary pacemaker are used to support the patient
until patient condition improve or receive a permanent
pacemaker.

11. TYPES OF PACING
•Transvenous pacing –
internal jugular /
subclavian/ femoral
vein
•Epicardial pacing
•Transcutaneous pacing

12. TYPES BASED ON CHAMBER BEING PACED
• Single chamber pacing: one lead
• Dual chamber pacing : 2 lead
• Biventricular pacing / Cardiac resynchronization
therapy : 3 leads connecting to right atrium and both
ventricles

13. Components
Electronic pulse generator – circuit and
battery
Rate (beats/mt)
Output (mA)
Sensitivity (mV)
Pacemaker electrodes - leads

14. PACEMAKER CODE
• Universal code – NASPE and BPEG
First letter
Chamber
paced
Second letter
Chamber sensed
Third letter
Response after
Sensing
Fourth letter
Rate modulation
Fifth letter
Multisite pacing
A – Atrium A – Atrium I - Inhibited O - No rate
responsiveness
A – Atrium
V - Ventricle V - Ventricle T - Triggered R – Rate
modulation
V - Ventricle
D - Dual D - Dual D - Dual D - Dual
O – None O - None O – None

15. Pacemaker spikes

16. MAGNET INHIBITION
Used to inhibit the device
Reprograms the pacer into an asynchronous pacing
mode; it does not turn the pacemaker off.
Determine the pacer’s battery to be replaced.

17. COMPLICATION
• Local infection at entry site
• Bleeding and hematoma
• Hemothorax
• Ventricular ectopy
• Dislocation of lead
• Phrenic nerve, diaphragmatic stimulation
• Cardiac tamponade
• Pacemaker syndrome
• Twiddler syndrome

18. PACEMAKER MALFUNCTION
• Loss of capture : complex doesnot follow pacing site
• Under sensing : pacing spike occurs at preset intervals despite of
patient’s rhythm.
• Oversensing : pacing doesn’t occur at preset interval
• Lack of pacing : total absence of pacing spikes
• Rhythmic diaphragmatic or chest wall twitching

19. NURSING MANAGEMENT
• Preoperative care
Assess knowledge and understanding level
Collect blood reports, Chest Xray, ECG, Echo,
Holter report
Get informed consent signed
Place ECG monitor electrodes away from
potential incision sites

20. Post operative care
• Provide postoperative monitoring, analgesia and care
• Obtain postop chest Xray to identify lead location and detect possible
complication
• Provide comfortable position. Restricting movement of extremities
• Assist with gentle ROM exercise atleast 3 times daily, beginning 24 hrs
after pacemaker implantation
• Monitor pacemaker function with cardiac monitoring and report
pacemaker problems to physician.
• Assess for dysrrhythmia and treat as indicated
• Provide pacemaker identification card.

21. Patient teaching
 Placement of the pacemaker generator and leads
 How the pacemaker works and rate at which it is set.
 Battery replacement
 How to take and record pulse rate.
 Incision care and signs of infection
 Signs of pacemaker malfunction to report including
dizziness, fainting, fatigue, weakness, chestpain or
palpitation.

22.  Activity restrictions. Limit to contact sports and avoid heavy
lifting for 2 months after surgery
 Avoid tight fitting clothings
 Notify all care providers of the pacemaker
 Carry pacemaker ID card
 Do not hold or use certain electrical devices over pacemaker
site including household appliances , antitheft devices.
 Maintain follow up care with physician

23. BIBLIOGRAPHY
• Woods LS, Froelicher SSE, Motzer US, Bridges EJ.
Cardiac Nursing. 6th edition. Baltimore: Wolters Kluwer
Publication; 2010
• Smeltzer S C, Bare B , Brunner &suddarth’s Medical
surgical nursing, edition 10th, ( 2000), Westline Industrial
drive, Missouri.
• Pacemaker - American Heart Association
www.heart.org/HEARTORG/Conditions/.../Pacemaker_U
CM_448480_Article.jsp