Pacemakers are electronic devices that are implanted to initiate heartbeat when the heart's intrinsic electrical system cannot generate an adequate rate. They consist of a pulse generator, leads, and electrodes. Pacemakers have evolved significantly from early external and bulky models to current miniaturized implantable devices with enhanced functions. Nursing care involves assessing for pacemaker function and complications as well as educating patients.

1. MS.B.SHYLA MERCY
M.SC (N), MEDICAL SURGICAL NURSING
LECTURER
GANGA COLLEGE OF NURSING
COIMBATORE

2. PACEMAKER

3. INTRODUCTION
❖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.
❖It consists of a pulse generator, lead and appropriate
electrodes.
❖In the past few years electronic pacemaker systems have
become extremely important in saving and sustaining the
lives of cardiac patients whose normal pacing function of
the heart have been impaired.

4. NORMAL CONDUCTIVE SYSTEM OF THE HEART

6. EVOLUTION OF PACEMAKERS

7. HISTORY OF CARDIAC PACEMAKERS

8. HISTORY OF PACEMAKERS
▪ In 1838 Carlo Matteucci a Professor
of Physics at the University of Pisa -
discovered that an electric current
accompanies each heartbeat.
▪ 1926- Dr. Albert Hyman created an
electromechanical instrument which
many believe may be the first
successful pacemaker.

9. CONT..
▪ 1950 a Canadian electrical
engineer - John Hopps paired
with Dr. Wilfred Bigelow
▪ The externally placed electrode
sent electric impulses great deal
of pain for the patient.
▪ 1951-Dr. Paul Zoll a cardiologist
from Boston The pacemaker used
modern transistors but still was
large, heavy and relied on AC
power.

10. CONT..
▪ In 1956 Bekkan read an article
related to amplification of sound.
▪ He started to work on amplification
of battery for the power to
pacemaker.
▪ Created pacemaker with mercury
battery that supplied 9.4 volts and co
founded Medtronic's company.
▪ In 1957 - A part time TV repairmen
Earl Bakken,developed a smaller
pacemaker that could be worn
around the neck.

11. CONT..
▪ Rune Elmqvist developed the first
“Implantable Pacemaker” in 1958,
working under the direction of Ake
Senning, senior physician and
cardiac surgeon at the Karolinska
University Hospital in Solna,
Sweden.
▪ In 1958 Dr. Dr. Ake Senning and
team done first successful
pacemaker implantation to a
patient named “Arne Larsson with
stoke – Adam syndrome”.

12. CONT..
▪ 1960s – Demand pacemaker was
developed
▪ 1970- nuclear powered pacemaker
battery developed (plutonium) can last
up to 20 years but due to radiation
exposure and other complication
withdrawn from industry.
▪ CPI, a new company founded by a
group of former Medtronic employees,
released the first clinically reliable
lithium pacemaker as its initial product
in 1973.
▪ The third generation of dual-chamber
pacemakers, introduced in 1980 to 1981.

13. CONT..
▪ The third generation of dual-
chamber pacemakers, introduced
in 1980 to 1981.
▪ 1981 – In 1981, Zoll patented and
re-introduced a transcutaneous
external pacemaker with a longer
pulse width of 40 ms and a larger
electrode surface area of 80 cm.
▪ 1994 – Cardiac resynchronization
pacing
▪ 1998 – Automatic capture
detection .

14. CONT..
▪ 2016 - Leadless pacemaker.
▪ 2017 - Micra leadless
pacemaker, which is placed
directly into the heart, is the
newest and smallest of
Medtronic’s pacemakers.
▪ Tiny leadless pacemaker “in a
real-world setting” has shown a
high implant success rate and a
low risk of major complications
in the first 30 days.

15. CONT..
▪ J.P. Morgan Healthcare
Conference, CEO Omar
Ishrak​ indicated Medtronic
would launch its Micra AV
pacemaker .
▪ During year 2020, an
updated iteration of its
leadless pacemaker product
currently on the market.

16. DEFINITION
Artificial cardiac pacemaker is
an electronic device used to pace
the heart when the normal
conduction pathway is damaged
and it provides electrical stimuli
to the heart muscle.

17. COMPONENTS OF PACEMAKER
1) Implantable pulse generator that contains:
▪A power source -the battery within the pulse
generator that generates the impulse .
▪Circuitry -controls pacemaker operations.
2) Leads
▪ Insulated wires that deliver electrical
impulses from the pulse generator to the
heart.
▪ Endocardial leads and Epicardial wires.
3) Electrode - A conductor located at the end
of the lead; delivers the impulse to the heart.

18. PARTS OF PACEMAKER

20. PACEMAKER
DESIGN
Permanent pacemaker is
encapsulated in a metal
to protect the generator
from electromagnetic
interference.

21. PACEMAKER FUNCTIONS
1) Stimulate cardiac
depolarization.
2) Sense intrinsic cardiac
function.
3) Respond to increased metabolic
demand by providing rate
responsive pacing.
4) Provide diagnostic information
stored by the pacemaker.

22. FUNCTIONS OF PACEMAKER
1.PACING
3.CAPTURE2.SENSING

23. 1.PACING FUNCTION
1. It is the ability of the pacemaker to stimulate
either the atrium, Ventricle, or both
chambers in sequence and initiate electrical
Depolarization and cardiac contraction.
2. Placement of the pacing leads
▪ Atrial pacing – The Right Atrium.
▪ Ventricular pacing- apex of the right
ventricle.
▪ Dual Chamber pacing – Both RV and RA .

24. 2. SENSING FUNCTION
▪ Ability of the Cardiac Pacemaker to see intrinsic cardiac
activity when it occurs.
▪ Unipolar sensing detects electrical activity occurring
between the tip of the lead, and the metal shell of the
pulse generator.
▪ Bipolar sensing detects the intrinsic electrical activity
occurring between the tip electrode and the ring
electrode of the lead
▪ Under sensing: Failure to sense .
▪ Oversensing: Too sensitive to activity.

25. CONT..
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.

26. 3. CAPTURE FUNCTION
The ability of the pacemaker to generate
a response from the heart [contraction]
after electrical stimulation is referred as
capture.
▪ Electrical capture : Indicated by P or
QRS following and corresponding to a
pacemaker spike.
▪ Mechanical capture: Palpable pulse
corresponding to the electrical event.

27. TYPES OF PACEMAKERS
1. PERMANENT
PACEMAKER
2. TEMPORARY
PACEMAKER

28. 1. PERMANENT PACEMAKER
▪ A permanent pacemaker is
implanted totally within the body.
▪ The power source is placed
subcutaneously , usually over the
pectoral muscles on the patients
non dominant side.
▪ The pacing leads are placed
transvenously to the right atrium
and one or both ventricles and
attached to the power source.

29. INDICATIONS FOR PERMANAENT PACEMAKER
1) Acquired AV block.
2) Second degree AV block
3) Bundle branch block
4) Heart Failure
5) SA Node dysfunction
6) Third degree AV block
7) Cardiomyopathy
▪ Dilated and hypertrophic .

30. TYPES OF PERMANENT PACEMAKER
1.SINGLE CHAMBER
PACEMAKER :
▪In this type only one
pacing lead is placed
into heart chamber
either atrium or
ventricle.

31. 2. DUAL CHAMBER
PACEMAKER:
▪ In this type , wires are
placed in two chambers of
heart .
▪ One lead paces the atrium
and one paces ventricles .
▪ This closely resembles the
natural pacing of heart.

32. 3.CARDIAC RESYNCHRONIZATION
THERAPY :
• The CRT pacing device (also called a
biventricular pacemaker) is an
electronic, battery-powered device that
is surgically implanted under the skin.
• The device has 2 or 3 leads (wires) are
implanted through a vein in the right
atrium and right ventricle and into the
coronary sinus vein to pace the left
ventricle.

33. 4. RATE RESPONSIVE
PACEMAKER :
It has sensors that detect changes in
patient physical activity and
automatically adjust the pacing rate to
fulfil the body’s metabolic needs.

34. 2. TEMPORARY PACEMAKER
▪ A temporary pacemaker is one
that ha the power source outside
the body.
▪ It has 3 types:
1) Transvenous pacemaker.
2) Epicardial pacing.
3) Transcutaneous pacemaker

35. INDICATIONS FOR TEMPORARY PACEMAKER
1) Acute anterior MI
2) As prophylaxis after
open heart surgery.
3) Electrophysiologic
studies.
4) Maintenance of Heart
rate and rhythm during
cardiac catherization.

36. 1. TRANSVENOUS PACEMAKER
▪ Transvenous pacemaker consists
of lead that are threaded
transvenously to the right atrium
or right ventricle and attached to
the external power source.
▪ Theses are inserted in critical care
units in emergency situations.

37. 2. EPICARDIAL PACING
▪ Epicardial pacing involves
attaching an atrial and
ventricular pacing lead to
the epicardium during
heart surgery.
▪ The leads are passed
through the chest wall and
attached to the external
power source.
▪ It is placed prophylactically
in brady dysrhythmias.

38. 3. TRANSCUTANEOUS PACEMAKER
▪ Transcutaneous pacemaker is
used to provide adequate heart
rate and rhythm to patient in an
emergency situation.
▪ It consists of power source, rate
and voltage control device that
attach to two large ,
multifunction electrode pads.
▪ Position one pad on anterior
chest and other pad on back
between spine and left scapula at
the level of heart.

39. PACING MODES

40. NURSING MANAGEMENT
1) Assessment and prevention of
pacemaker malfunction.
2) The battery and security of connections
of temporary pacemakers shall be
checked every shift and documented in
the patient’s medical record.
3) The ECG is monitored very carefully to
detect pacemaker malfunction .
4) Monitor vital signs especially the heart
rate because the patient experiencing
pacemaker malfunction may develop
bradycardia.

41. CONT..
5) The sites is carefully inspected for purulent drainage, erythema, and
edema, and the patient is observed for the signs of systemic infection.
6) Assess sign and symptoms of pneumothorax, (hypoxia, shortness of
breath, pleuritic pain, and hypotension).
7) After implanted the pacemaker, nurses should minimize patient activity
to prevent dislodgment of the pacing electrode.
8) Post insertion chest x-ray.
9) Provide an electrically safe environment.
10) Prevent infection and helps to relieve anxiety.

42. PATIENT EDUCATION
1) Maintain follow-up- care with
your physician to check the
pacemaker site.
2) Report ant signs of infection at
incision site.
3) Keep incision dry for 4 days after
implantation.
4) Avoid lifting arm on pacemaker
side above shoulder .
5) Avoid direct blow to pacemaker
site.

43. CONT..
6) Avoid close proximity to high-
output electric generators or
large magnets.
7) Microwave ovens are safe to use.
8) Travel without restriction is
allowed.
9) Patient should be taught how to
take the pulse.
10)Carry pacemaker information
card at all times.

44. NURSING DIAGNOSIS
➢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.

45. PACEMAKER MALFUNCTION
❖ Failure to capture
❖Failure to output
❖ Sensing abnormalities(under
and over sensing)
❖Specific mode complications:
1. Pacemaker related
tachycardia
2. Pacemaker syndrome

46. COMPLICATIONS OF PACEMAKER
1) Cardiac perforation.
2) Twiddler syndrome.
3) Pacemaker syndrome.
4) Hematoma.
5) Ventricular ectopy.
6) Stimulation of phrenic nerve or
diaphragmatic nerve if lead is
dislocated.

47. CONCLUSION
❖A pacemaker is an electronic device that sends periodic
impulses to the heart to restore the rhythm of the heart.
❖Early devices provided only single-chamber,
asynchronous, nonprogrammable pacing coupled with
questionable reliability and longevity.
❖Today, advanced electronics afford dual-chamber
multiprogrammability, diagnostic functions, rate
response, data collection, and exceptional reliability, and
lithium-iodine power sources extend longevity to upward
of 10 years.

48. BIBLIOGRAPHY
➢Bare,G.Brenda, Smelter and C.Suzanne (2014).Brunner and
Suddarth’s “Text Book of Medical Surgical Nursing”10th
edition. Philadelphia. Lippincott publications.
➢Lewis’s (2016). “Medical Surgical Nursing Assessment and
Management of clinical problems”2nd .South Asia Edition . New
Delhi. Elsevier publications.
➢Richard David .R (2008) . “ Cardiac Nursing - A
Comprehensive guide” 2nd edition. United states of America
.Elsevier publications.