Mapua Institute of Technology

San Lorenzo School of Health Sciences

Makati City

A Case Study in NCM 364L – BN01

Submitted to
The Philippine Heart Center
Quezon City

In Partial Fulfilment
of the Requirements
for NCM364L
Curative and Rehabilitative Nursing Care Management 2 – Part A (RLE)

Submitted by
Cantong, Rinolucy
Dela Cruz, Katrina Paola
Dela Peňa, Marco
Fadrigo, Kevin
Haidar, Nahida
Leonardo, Roddy Levin
Lim, Carmina Bianca
Nicolas, Katherine Anne
Sison, Francis
Tan, Joan Rae
Tomines, Guthrie
Villaos, Donna Pia

September 7, 2007
 TABLE OF CONTENTS

I. Overview of the Study 1

II. Profile of the Patient 2

III. Nursing Care Assessment

IV. Physical Assessment 7

V. Significant Laboratory & Diagnostic Findings

VI. Electrical Conduction of the Heart 13

VII. Pathophysiology of Complete Heart Block

15

VIII. Treatment and Management

16

IX. Drug Interpretation and Study

21

X. Nursing Care Plan

33

XI. Discharge Planning 42

XII. Supporting Background Re: Amphetamine Use in CHB

46
 I. OVERVIEW OF THE STUDY

• Heart block, also called atrioventricular

block or A-V block, is an abnormality of
the spread or flow of electrical activity
from the upper heart chambers, the
atria, to the lower heart chambers, the
ventricles.
• Heart block results in an abnormality or
disturbance in the rate or rhythm of the
heartbeat.
• Heart block occurs in three levels of
severity. First-degree block is a delay of
the signal that stimulates the ventricles
to contract, and second-degree block is
a partial or intermittent interruption of
the signal that stimulates the ventricles
to contract. Third-degree block is a
complete interruption of the signal that
stimulates the heart to contract.

Heart block is a disorder of impulse conduction, meaning that an electrical

impulse is impaired from traveling along its normal pathway. Heart block is
also called atrioventricular block, because it often occurs in the
atrioventricular, or A-V, node, which transmits electrical signals from the atria
(the upper chambers of the heart) to the ventricles (the lower chambers of
the heart). Depending on its severity, A-V block may be an abnormal delay, a
partial interruption, or a complete interruption of the impulse. Delays often
have no symptoms, but can cause the heart rate to fall so far below normal
that it causes dizziness or fainting. Certain forms of intermittent block may
occur in normal people during sleep and cause heart rates of 40 beats per
minute and even lower.

Third-degree heart block: Also called complete heart block, each sinus node
impulse is completely interrupted in the A-V node or beyond, and the ventricles must
generate their own impulse to contract. Depending on its cause, third-degree block
may be transient (temporary) or permanent.
 II. PROFILE OF THE PATIENT

Patient Profile:

Name: Villareal, Margarita Gelacio Ward: MW/WW, Bed L

Registration #: 1P087363
Age: 29 years old Sex: Women
Date of Birth: 08-07-1978 Place of Birth: Quezon City
Civil Status: Single Religion: Mormon (LDS)
Ethnicity: Asian
Home Address: #21 Lakandula st. Parang, Marikina City, 1800
Educational Attainment: College undergraduate
Occupation: Government employee

Client Complaint:

Dizziness, DOB, near syncopal attack

Admitting Diagnosis:

Complete Heart Block with ventricular asystole S/P “e” TPI

Final Diagnosis

Complete heart block S/P PPI

Patient History:

History of Present Illness:

Patient is non-hypertensive, non-diabetic, non-asthmatic, smoker (2-10 sticks

per day), and an alcoholic drinker for 10 years. She had a history of
amphetamine use and last intake was a month ago.

Patient is apparently well until 10 years prior to admission when she had her
second pregnancy. She experienced episodes of dizziness and near syncopal
attack. Also, she had a syncopal attack twice when she was still a child. The
first incident was when she was 8 years old and the other was when she was
12 years old. The doctor advised her to consult a cardiologist but she did not
comply. 8 years prior to admission, she had another episode of syncopal
attack. She sought for medical help and it was found out that her heart rate is
slow. According to her 2D-echo was done but the result was unrecalled. She
was given Bricanyl as a maintenance medication. 3 years prior to admission,
the patient had frequent episodes of dizziness, near syncopal attack and easy
fatigability. No consultation was done. She just continued her maintenance
medication. 6 hours prior to admission, patient had continuous episodes of
dizziness, DOB, and near syncopal attack thus she was immediately brought
to PHC-ER.
At the ER, patient is drowsy and confused. BP then was 90/60, cardiac rate
30, clear breath sounds. Atropine was given and BP went up but after 10
minutes patient had another episode of syncope. Thus, emergency TPI was
done. Patient was then admitted to the ward.

On admission, patient is conscious, coherent, afebrile, not in distress with BP

140/90, CR 60 (paced rhythm), RR 18. Pink palpebral sclera, adynamic
precordium, normal rate regular rhythm, no murmurs, flabby abdomen, soft
and non-tender, NABS, no edema in the extremities, and weak pulses on all
extremities.

I. Pertinent Family Medical History:

(-) Tuberculosis (+) Cancer (-) Asthma (+) Hypertension

(-) Diabetes Mellitus

II. Social History:

(+) heavy smoker (+) heavy alcoholic drinker
(+) amphetamine user for 10 years

The patient has no family background on cancer from her uncle and
hypertension from her mother. She is a heavy alcohol drinker and cigarette
smoker. For the past 10 years, she has used amphetamine occasionally.

Narrative Summary:

The patient is Margarita Gelacio Villareal. 29 years old, born on August

07, 1978 at Quezon City. A Mormon (LDS), a single mother living with her
mom and 3 daughters at 21 Lakandula Street parang Marikina City.

The patient has a negative family background on Tuberculosis,

Asthma, and Diabetes Mellitus. However, hypertension and Cancer runs in
the family. The patient was a heavy smoker, heavy alcoholic drinker, and an
occasional amphetamine user for almost 10 years.

Patient is apparently well until 10 years prior to admission when she

had her second pregnancy. She experienced episodes of dizziness and near
syncopal attack. The doctor advised her to consult a cardiologist but she did
not comply. 8 years prior to admission, she had another episode of syncopal
attack. She sought for medical help and it was found out that her heart rate is
slow. According to her 2D-echo was done but the result was unrecalled. She
was given Bricanyl as a maintenance medication. 3 years prior to admission,
the patient had frequent episodes of dizziness, near syncopal attack and easy
fatigability. No consultation was done. She just continued her maintenance
medication. 6 hours prior to admission, patient had continuous episodes of
dizziness, DOB, and near syncopal attack thus she was immediately brought
to PHC-ER.
 18 of August 2007, Margarita Gelacio Villareal, were admitted at
Philippine Heart Center. Upon admission the patient was temporarily ordered
nothing per orem (NPO). She underwent Chest X-ray, Electrocardiogram
(ECG), and 2D echo with Doppler. Medicine (Atropine) was also administered
1 mg, IV, for 3 doses. After the proper evaluation of her case, the cardiologist
confirmed that Margarita Gelacio Villareal needs a Permanent Pacemaker
Insertion (PPI).
However, due to the unavailability of PPI; an emergency Temporary
Pacemaker Insertion (TPI) was done to temporarily normalize her heart
rhythm and cardiac rate. It was on September 3, 2007 that she finally had her
PPI.
 III. NURSING CARE ASSESSMENT

Health-Perception/Health Management Patterns

The client thinks that she’s healthy enough to consult a doctor. She manages
her health through self care. She doesn’t believe in faith healers/albularyos.
Too much happiness and anger causes her chest pain which she actually
ignores.

Nutritional/ Metabolic Pattern

The client usually eats 3 times a day. She drinks 5 glasses of water a day.
She prefers to eat fatty foods. She takes “Centrum” as her daily supplement.
She is now on low salt low fat diet. Her skin is warm. No various interruptions
in skin integrity are found. She has pasta on her right molar.

Elimination pattern
The client has normal urinary output but abnormal bowel movement (twice a
week). She urinates without discomfort.

Activity/Exercise Pattern
The client has a sufficient energy for completing her desired required
activities. She has the ability to do full self-care She doesn’t have any
musculoskeletal problems.

Sleep/ Rest Pattern

The client has an adequate amount of sleep every night. She doesn’t
experience any disturbances and nightmares in her sleep.

Cognition/ Perception Pattern

The client has a normal eye vision. She noticed that there are changes in her
memory lately. She has no hearing difficulty.

Self perception/ Self control pattern

The client describes herself as God-fearing and naughty. She’s currently
happy cause God gave her a second life. She became emotional during the
times when her past was being tackled.

Role/ Relationship pattern

The client lives with her mother, uncle and children. She’s a single parent and
she has 3 children. She’s close to her friends and family. She’s working as a
government employee.

Sexuality/ Reproductive Pattern

Menarche at 13 years of age. Her menstruation is on regular intervals with 1
week duration, consuming 2 pads a day, mildly soaked. Three years ago,
client and her husband used condom as a contraceptive.

Coping/ Stress Pattern

The most helpful in talking things over is her mother and God. Before, she
used to depend on her friends. She cope up with her problems through
prayers and she’s a fan of the saying “Laughter is the best medicine”. She
has a history of drug abuse, Amphetamines specifically and she loves to drink
alcoholic beverages. She did this, because of peer pressure and family-
related problems.

Value-belief Pattern
The patient is a mormon (LDS) and handles things by talking to God. She
believes in the wonders of herbal medicine. She is not against blood
transfusion. She’s looking forward to go home.
 IV. PHYSICAL EXAMINATION

General Information
Client is female,29 years old,currently residing at 21 Lakandula St. Marikina
City. She is presently confined in Female ward at Bed “L”.

Vital Signs (current)

Client’s temperature is 36.5 per axilla; afebrile. Respiratory rate is 17
breaths/min; regular. Blood pressure is 110/90; taken on the right arm while
lying. Client’s cardiac rate is 60 bpm; at radial pulse.

General Survey
Client is conscious, coherent and not in distress. Client is oriented to person,
time and place. Client’s body is mesomorph and well-developed. Her looks is
appropriate to her age. She’s is well nourished. She is calm and happy so far.

Skin
Client’s skin is pallor and smooth with good skin turgor. The client’s skin is
warm to touch. Edema or lesions are not present.

Head
Client’s head is normocephalic. Closed fontanelles were noted. Hair is evenly
distributed. Scalp is clean and intact.

Eyes
Client’s eyelids are symmetrical. Conjunctiva is pale. Client’s sclera is
anicteric. Her cornea is smooth and clear. Pupil size is equal (R=3mm; L=
3mm). Client’s visual acuity is normal.

Ears
Client has 2 ear piercings (1 Right and 1 Left). External pinnae are normoset
and symmetrical. External canal is clean. Tympanic membrane is intact.
Gross hearing is symmetrical

Nose
Nasolabial fold is symmetrical. External nose is not tender and there’s no
presence of lesions. There is no discharge or nasal flaring. Air moves freely as
the client breathes through the nares. Mucosa is pinkish with clear, water
discharge. There are no lesions. Nasal septum is intact and in midline. The
maxillary and frontal sinuses are not tender. Client’s gross smell is
symmetrical

Mouth
Client’s outer lips are pale and dry. Client’s gums are pale and with a moist
and firm texture. The tongue is on central position. It moves freely and there
is no presence of tenderness. It is smooth with no palpable nodules. Client’s
speech is intact.

Pharynx
The uvula is positioned in midline of soft palate. Client’s mucosa is pale.
Tonsils are not inflamed.

Neck
Client’s neck is head centered. Lymph nodes are not palpable. Trachea is
placed in midline of the neck.

Chest and Lungs

Client’s inspiration/ expiration ratio is 1:1. Chest expansion is symmetrical.
The anterior-posterior- lateral ratio diameter is 2:1.

Heart
Heart sounds are distinct. She has an adynamic precordium, normal rate
regular rhythm, no murmurs.

Breast and Axillae

Client’s breast is equal. Skin is uniform in color and intact. There is no
tenderness. Masses and nodules are not present. The nipples are round,
everted and equal in size.

Abdomen
Client’s abdomen is uniform in color. Abdomen is symmetrical.Umbilicus is
sunken. Bowel sounds are audible.

Genito-urinary System
Not Performed.

Back and Extremities

Peripheral pulses are weak and irregular. Nails and nail beds are pink. There
is decreased ROM at her lower extremities due to temporary pacemaker
insertion. Muscle tone normal. Spine is located midline and is vertically
aligned. Costovertebral angle tenderness is not noted.
 V. SIGNIFICANT LABORATORY AND DIAGNOSTIC FINDINGS

Complete Blood Count with Differential (September 3,2007)

Test Test Result Normal values
Red Blood Cell (RBC) 4.30x10/L 4.00-4.50x10/L
Mean Corpuscular 333L g/L 334 – 335 g/L
Hemoglobin
Concentration (MCHC)
White Blood Cell Count and Differential
White Blood Cells (WBC) 16.70H 5.00 – 10.00
Neutrophils 91 55 – 65 L %
Lymphocytes 6 25 – 35 H %
Monocytes 3 2–6%
Complete Blood Count with Differential (August 23,2007)
Test Test Results Normal Values
Red Blood Cell (RBC) 4.55x10 /L 4.00 – 4.50x10 /L
Mean Corpuscular 331 L g/L 334 – 335 g/L
Hemoglobin
Concentration (MCHC)
White Blood Cell Count and Differential
White Blood Cells (WBC) 10.40H 5.00 – 10.00
Neutrophils 44 L % 55 – 65 L %
Lymphocytes 48 H % 25 – 35 H %
Monocytes 7% 2–6%
Eosinophils 1L% 2–4%

Interpretation:

 Red Blood Cells – principal means of delivering oxygen to the blood. In

the case of our client, there is a slight increase in the number of the red
blood cells on August 23, 2007 but it is still considered within normal
range.

 MCHC – is a measure of the average concentration or the percentage

of hemoglobin within a single RBC. A great decrease in MCHC could
stimulate hypochromic anemia but since there is only a 4% decrease it
could still be considered normal.

 White Blood Cells – major function is to fight infection and react

against foreign bodies or tissues. The test shows a 10% increase in the
WBC. This could result from the insertion of the temporary pacemaker.
The procedure is invasive and it could stimulate increase production of
antibodies to prevent infection.

 Neutrophils – primary function is phagocytosis. In the case of Mrs.

Margarita Villareal, the Neutrophils decrease at 11% on the August 23,
2007. This decrease may result from dietary deficiency.
 On the September 3, 2007 WBC result, the neutrophils show an elevation
to the count. The client might have experienced physical and emotional
stress which can cause the elevation.

 Lymphocytes – main function is to fight chronic bacterial infection and

acute viral infection. The White Blood Count shows a slight elevation of
the lymphocytes. The elevation could be cause by the insertion of the
temporary pace marker. It triggered the body mechanism to production
antibodies.

 Monocytes – have similar functions to neutrophils. There were an

increase number of the monocytes in the test result. This could result to
the temporary insertion of a pacemaker which is the case of our client.

 Eosinophils – are involved in allergic reaction. Decreased in counts are

due to the increased adrenosteriod production.

 Other laboratory results such as electroyte serum levels does not

show any significant findings which may be correlated to the occurrence
of the complete heart block.

Electrocardiogram

ECG result of August 23, 2007

Rate A:86 QRS: 0.10 QT:0.56

V: 53 QRS: +75 QTc: 0.41
Axis: Normal
Rhythm: Sinus
Interpretation:
Third degree atrioventricular block
Septal fibrosis
Non-specific St T-wave changes

*The ECG in the case of Ms. Margarita Villareal the rhythm of the Atrial and
Ventricular are usually regular. The Atrial rate is 86 beats per minute while
the ventricular rate is 53 beats per minute. The Atrial conduction produced
normal P waves but occur more frequently than the QRS complex. The P-R
intervals are inconsistent to each other. The QRS complex produced are
normal with a 0.10 per seconds. Since there is a complete dissociation
between the SA and the AV node, the ventricular depolarization is slowed
because the ventricles use its intrinsic ability to contract without the aid of
impulse conduction.

Normal ECG:

P wave – represent the normal electrical impulse starting in the sinus node
and spreading through the atria. It is normally 2.5 mm or less in height and
0.11 sec in duration.

QRS wave – represents ventricular depolarization. It is normally less than

0.12 seconds in duration.

T wave – represents ventricular repolarization. It follows the QRS wave but

sometimes it cannot be since at the ECG because it occurs at the time as the
QRS wave.

PR interval – measures from the start of the P wave to the beginning of the
QRS complex and represent the time needed for sinus node stimulation, atrial
depolarization and conduction through the AV node before ventricular
depolarization. Normal ranges from 0.12 to 0.20 seconds.
ECG Post Temporary Pacemaker as of August 24, 2007

With the aid of a temporary pacemaker,

the patient’s heart rhythm is stabilized
thereby depending on the impulse
conducted by the pulse generator.

Pacemaker uses the heart’s remaining

capabilities and stimulates the normal
electrophysiological functioning of the
heart as closely as possible to produce
the best cardiac output.
 VI. ELECTRICAL CONDUCTION SYSTEM OF THE HEART

The heart’s electrical system controls all the events that occur when your
heart pumps blood. The electrical system also is called the cardiac
conduction system. The EKG/ECG (electrocardiogram), is a graphical picture
of the electrical activity of the heart.

The heart’s electrical system is made up of three main parts:

• The sinoatrial (SA) node located in the right atrium of your heart
• The atrioventricular (AV) node located on the interatrial septum close
to the tricuspid valve
• The His-Purkinje system located along the walls of your heart’s
ventricles
•
A heartbeat is a complicated series of events that take place in your heart. A
heartbeat is a single cycle in which your heart’s chambers relax and contract
to pump blood. This cycle includes the opening and closing of the two inlet
and outlet valves of the right and left ventricles of the heart.

Each heartbeat has two basic parts: diastole, and atrial and ventricular
systole. During diastole, the atria and ventricles of the heart relax and begin
to fill with blood. At the end of diastole, the heart’s atria contract (atrial
systole), pumping blood into the ventricles, and then begin to relax. The
heart’s ventricles then contract (ventricular systole), pumping blood out of
your heart.
Each beat of the heart is set in motion by an electrical signal from within your
heart muscle. In a normal, healthy heart, each beat begins with a signal from
the SA node. This is why the SA node is sometimes called the heart’s natural
pacemaker. The pulse, or heart rate, is the number of signals the SA node
produces per minute.
The signal is generated as the two vena cava fill your heart’s right atrium
with blood from other parts of the body. The signal spreads across the cells of
the heart’s right and left atria. This signal causes the atria to contract. This
action pushes blood through the open valves from the atria into both
ventricles.

The signal arrives at the AV node near the ventricles, where it slows for an
instant to allow the heart’s right and left ventricles to fill with blood. The
signal is released and moves to the His bundle located in the walls of the
heart’s ventricles.

From the His bundle, the signal fibers divide into left and right bundle
branches through the Purkinje fibers that connect directly to the cells in the
walls of the heart’s left and right ventricles. As the signal spreads across the
cells of the heart’s ventricle walls, both ventricles contract, but not at exactly
the same moment. The left ventricle contracts an instant before the right
ventricle. This pushes blood through the pulmonary valve (for the right
ventricle) to your lungs, and through the aortic valve (for the left ventricle) to
the rest of the body.

As the signal passes, the walls of the ventricles relax and await the next
signal. This process continues over and over as the atria refill with blood and
other electrical signals come from the SA node.
 PHYSIOLOGY OF THE ELECTRICAL CONDUCTION SYSTEM
Coronary Arteries supply blood to the
myocardium

Sino-Atrial Nodes sends electrical stimulus through the intranodal

pathways

Internodal Pathways relay the electrical stimulus throughout the Atrial

Myocardium

Atrial Contraction occurs and stimulus is further sent towards the Atrio-
Ventricular Nodes

Electrical stimulus reaches the Atrio-Ventricular Node

Atrial Node Delay

Bundle of His
separates into the

Left Bundle Branch Right Bundle Branch

Posterior fascicle Anterior fascicle

Stimulus Reaches the Pukinje Fibers all throughout the ventricular

myocardium

Ventricular Myocardium Contraction Occurs Legend:

•••••• Mechanism
Ventricular •••••• P wave (atrial depolarization)
Repolarization •••••• PR interval
•••••• QRS complex (ventricular
depolarization)
•••••• T wave (ventricular repolarization)
 VII. PATHOPHYSIOLOGY OF COMPLETE HEART BLOCK

Pre-existing cardiac Occasional Heavy alcoholic drinker

pathology: CHD methamphetamine user for & cigarette smoker
(idiopathic) 10 years

Increased catecholamine activity of

the PNS

Narrowing & spasm of the blood Contributes

vessels to

Inadequate O2 delivery Over stimulation of the

vagus nerve

Ischemia
Decreased rate at SA
node

Decrease excitability of
Exacerbation AV junction fibers

Deterioration of Progresses to a
cardiac nodal conduction block at the
fibers level of AV

Absence of impulse
conduction

Ventricles contract at their own

intrinsic rate (20-40 bpm)

Decreased pumping action of the

heart

Legend:
•••••• Etiology/Predisposing
factors
•••••• Mechanism
 VIII. TREATMENT AND MANAGEMENT

Diagnostics and Evaluation

Intervention Rationale
Continuous monitoring with the use The ECG is generally used to
of an electrocardiogram evaluate and monitor anesthesia,
angina pectoris, anxiety,
dysrhythmias, bradycardia, carbon
monoxide posisoning, chest pain.

In relation to the patient’s condition,

the use of ECG was helpful in the
diagnosis of a 3rd Degree AV Block
(Complete Heart Block) and the
evaluation of the paced rhythm
coming from the transvenous
pacemaker & permanent
pacemaker.

Medical Intervention/s
Intervention Rationale
Administration of Atropine 1mg The administration of Atropine
every 3-5 mins. for 3 doses sulfate is indicated to the patient’s
case to be used as a treatment of
bradycardia (an extremely low heart
rate), asystole and pulseless
electrical activity (PEA) in cardiac
arrest.

This works because the main action

of the vagus nerve of the
parasympathetic system on the
heart is to slow it down. Atropine
blocks that action and therefore
may speed up the heart rate.

Surgical Intervention/s
Intervention Rationale
“E” Temporary Pacemaker Insertion Temporary pacing may be used in
via femoral vein (transvenous) emergency or elective situations
that require limited, short-term
pacing. In this form of pacing, the
pulse generator is external.

Transvenous pacing is used in the

patient for the pacing the heart
since it is an emergency situation.
The pacing electrode is inserted via
the femoral vein which threads the
 electrode in the right
atrium/ventricle so that it will be in
direct contact with the
endocardium.
Permanent Pacemaker Insertion via Permanent pacing with an
subclavian vein implantable pacemaker involves
placement of one or more pacing
wires within the chambers of the
heart. One end of each wire is
attached to the muscle of the heart.
The other end is screwed into the
pacemaker generator. The
pacemaker generator is a
hermetically sealed device
containing a power source and the
computer logic for the pacemaker.

In the patient’s case the generator

is placed below the subcutaneous
fat of the chest wall, above the
muscles and bones of the chest.

The outer casing of pacemakers is

so designed that it will rarely be
rejected by the body's immune
system. It is usually made of
titanium, which is very inert in the
body.

PACEMAKERS

The heart has an electrical system that controls how fast or slow it beats. The
natural pacemaker sends electrical impulses from the top of the heart (the
atria), towards the bottom of the heart (the ventricles). When electrical
signals reach these chambers, the heart contracts and then relaxes. The
heart pumps blood to all parts of the body. This pumping makes waves of
pressure that are felt as our pulse.

When the electrical signal is intermittent or slow, you may need an artificial
pacemaker. You may have had one of the following symptoms:

• Dizziness – when the heart rate drops, even for a few seconds, you
may feel dizzy or faint. You may fall down;
• Blackouts or fainting spells;
• Blurred vision;
• Shortness of breath; and
• Chest pain
The heartbeat is usually 50 to 110 beats per minute. However, it may be as
low as 30 to 40 beats per minute if you have a condition called “heart block”.
There are different types of heart block.

• Complete heart block – your natural pacemaker cannot send impulses

between the atria and ventricles.
• Intermittent heart block – your natural pacemaker works some of the
time.
• Sick sinus syndrome – sometimes the natural pacemaker is too slow or
races uncontrollably and dizziness or fainting may result.

Types of Pacing

Temporary Pacing - Temporary pacing may be used in emergment or elective

situations that require limited, short-term pacing. In this form of pacing, the
pulse generator is external.
• Transvenous pacing – this provides the most common means for
pacing the heart in emergency situations. The surgeon inserts the
pacing electrode via the transvenous route (either antecubital,
femoral, jugular, or subclavian veins) and threads the electrode into
the right atrium or right ventricle so that it comes into direct contact
with the endocardium.

Permanent Pacing - is indicated in individuals who are experiencing

irreversible bradychardia due to advanced AV block, sick sinus syndrome, or
tachyarryhthmias refractory to pharmacologic intervention. The surgeon
inserts electrode via the transvenous rate or by direct application to the
epicardial surface during thoracotomy. The surgeon then places the
permanent pulse generator into the small tunnel burrowed within the
subcutaneous tissue below the right clavicle or, less often the left clavicle.

Artificial Cardiac Pacemaker – an electronic apparatus, initiates the heart

beat when the heart’s intrinsic conduction system fails or is unreliable.
Problems with the conduction system develop when (a) the SA node is
damaged and unable to promote a reliable rhythm or (b) impulses from the
SA node and atria are not adequately transmitted through the AV junction to
the ventricles.

Artificial Pacemaker Design – Every pacemaker must consist of a pulse

generator and a lead-electrode system. The pulse generator is essentially
the pacemaker’s power source. The output circuit controls the current pulse
delivery rate, pulse duration, and refractory period. The sensing circuit is
responsible for identifying and analyzing any spontaneous intrinsic electrical
activity and responding appropriately. The lead-electrode system delivers the
electrical impulse from the pulse generator to the myocardium.

Electrical Current Flow – An electrical circuit is completed when electricity

(electrons) flows from a negative pole to a positive pole via a conducting
material. Voltage refers to the driving force that pushes the electrons to the
circuit. Current is the number of electrons moving through the circuit. And
the stimulation threshold refers to the smallest intrinsic electrical signal to
activate the pacemaker’s sensing circuit.

Classification of Pacemakers –The classification uses a three-letter code: first

letter denotes the cardiac chamber to be paced; the second letter reflects the
chamber to be sensed; and the third letter indicates the type of response to
occur.

1st letter 2nd letter 3rd letter

Mode (how pacemaker
Chamber is paced Chamber is sensed respond to intrinsic
heart pulses)
I = inhibited response
V = Ventricle T = trigger response
V = Ventricle
A = Atrium D = dual response
A = Atrium
D = Dual R = reverse
D = Dual
O = no sensing O = no response to
sensed impulses

Modes of Pacing

1. Fixed Rate Pacing – this mode delivers an electrical impulse to the

heart at a pre-set fixed rate regardless of cardiac activity.
2. Demand Pacing – the pacemaker fires only on demand or when needed
to stimulate atrial or ventricular contraction.
3. Synchronous Pacing – operates in a manner similar to demand pacing.
In syncrhronous pacing, the sensing electrode is placed in the atrium
and the pacing electrode is placed in the ventricle.
4. Bifocal Pacing – Both atrial and ventricular pacing occur, depending on
the appearance of QRS.

PACEMAKER THERAPY

Electronic Pacemakers

An electronic pacemaker is made up of two parts.

• Pulse Generator – contains the circuitry and battery that generate the
electrical signal. The battery can last from 6 to 15 years, depending on
the type of pacemaker and how much you use it.
• Leads – the wires that carry the electrical signal from the pulse
generator to the heart. An electrode is located at the end of the lead.
Through this, the pacemaker monitors (senses) the heart’s electrical
activity and sends out electrical impulses (paces) only when needed.
 Leads

Pulse
Generator

Preparation for the Procedure

1. Explain procedure to patient and relatives

2. Patient NPO for four to six hours prior to surgery
3. Get informed consent about the procedure
4. Check patient for dentures, nail polish, jewelries, contact lens, etc.
5. A chest x-ray, electrocardiogram (ECG) and blood work may be
obtained.
6. An intravenous (IV) line will be inserted through which fluids and
medicines can be given.
7. An antibiotic (e.g. Cefuroxime) will be given through the IV to reduce
the possibility of infection.

Procedure

The procedure is a same day admission. It is performed under sterile

conditions in the catheterization laboratory or operating suite. The patient
will be asked to lie flat on a cushioned table under a large, C-shaped x-ray
machine. The patient will be attached to a blood pressure cuff and heart
monitor. The pacemaker is usually placed on the left or right upper chest
(depending on whether you are left or right handed, so as not to interfere
with activity). This area is shaved (if applicable), cleaned with antiseptic and
covered with a sterile drape. It is then numbed with local anesthesia after
which a small 1-1.5 inch incision is made. The arm vein is then carefully
entered using a needle so that the leads (wires) can be threaded down to the
desired location in your heart (atrium or ventricle or both). The pulse
generator is then attached and the incision is closed with stitches or staples.
The patient will be exposed to intermittent low doses of x-rays during the
procedure. X-rays are necessary to ensure the best placement of leads. An
uncomplicated pacemaker procedure usually takes about 1 hour. The patient
will be kept relaxed and sedated throughout the entire procedure.

After the Procedure

(See Discharge Planning)

 IX. DRUG STUDY INTERPRETATION

DRUGS TAKEN IMPLICATION

ATROPINE In the ER, the patient was given
atropine with a dose of 1 mg IV for 3
doses in order to increase her cardiac
rate by inhibiting the vagal
stimulation with the help of the
parasympathetic nervous system.
MEFENAMIC ACID After the surgical procedure was
made the patient experiences pain on
the site of the operation so as her
post-operative medication the patient
was given this drug with a dosage of
500 mg/cap every 6 hours.
NUBAIN This is a pre-op medication given to
the patient as an opiate analgesic to
relieve pain with the dosage of 5 mg
via IM administration.
DIPHENHYDRAMINE An anti-histamine and is a pre-op
HYDROCHLORIDE medication that is used to sedate and
prevent allergic reactions. The dose
given was 25 mg via IM
administration.
CEFUROXIME This is an antibiotic given to the
patient prior to surgery to prevent
occurrence of infection. The dosage
was 1.5 gm via IV.
DIAZEPAM Another pre-op medication given as
an anti-anxiety drug with the dose of
10 mg/IV.

(See comprehensive table of drugs)

 IX. DRUG STUDY (continuation)

BRAND NAME/
GENERIC MECHANISM OF ADVERSE NURSING
CHEMICAL NAME/ INDICATION CONTRAINDICATION
NAME ACTION EFFECTS CONSIDERATIONS
AVAILABILITY
NUBAIN GN: NALBUPHINE An opiate Management of Patients with a history CNS Effects: Advise patient or
HDROCHLORIDE analgesic with moderate-to- of hypersensitivity to Nervousness, caregiver that
medication will
Dose: 5mg both narcotic severe pain; any ingredients of the depression, usually be prepared
and administered by
IM AVAILABILITY: 10 agonist and preoperative drug restlessness, a health care
mg/mL, 10 mL antagonist and crying, provider in a health
care setting.
multiple dose vials actions. Analgesic postoperative euphoria,
(box of 1) IM, SQ potency is about analgesia; floating,
Caution patient or
equal to that of supplement to hostility, caregiver that
morphine, and balanced unusual medication may be
habit forming and, if
antagonist anesthesia; dreams, used at home, to
potency is about obstetrical confusion, use exactly as
prescribed and not
1/ 25 that of analgesia during faintness, to change the dose
or discontinue
naloxone. May labor and hallucinations, therapy unless
cause sphincter delivery. dysphoria, advised by health
care provider.
of Oddi spasm. feeling of Advise patient or
Does not increase heaviness, caregiver to notify
health care provider
pulmonary artery numbness, if medication does
pressure, tingling, not adequately
control pain.
systemic vascular unreality.
resistance, or Advise patient or
myocardial work Cardiovascular: caregiver that if
medication needs to
load. Hypertension, be discontinued
hypotension, after prolonged use
that it will usually
bradycardia, slowly be withdrawn
tachycardia. unless safety
concerns (eg, rash)
require a more rapid
Gastrointestina withdrawal.
l: Cramps,
dyspepsia, Advise patient or
caregiver to notify
bitter taste. health care provider
if any of the
 Respiratory: following occur:
Depression, excessive sedation
or drowsiness; slow
dyspnea, or shallow
asthma. breathing; low BP;
slow heart rate;
severe constipation.
Dermatologic:
Itching, Instruct patient to
burning, get up slowly from
lying or sitting
urticaria. position and to
avoid sudden
position changes to
prevent postural
hypotension.

Advise patient to
report dizziness with
position changes to
health care
provider.

Caution patient that

hot tubs and hot
showers or baths
may make dizziness
worse.

Caution patient that

drug may cause
dizziness or
drowsiness and to
use caution while
driving or
performing other
tasks requiring
mental alertness or
coordination until
tolerance is
determined.
BENADRYL GN: Narcotic Symptomatic Hypersensitivity to GI: Nausea, Advise patient that
DIPHENHYDRAMINE antitussive, relief of antihistamines; diarrhea, if allergy symptoms
are not controlled
Dose: 25 Anticholinergic, perennial and asthmatic attack; MAO dyspepsia and not to increase the
dose of medication
mg Im AVAILABILITY: Nonselective seasonal allergic inhibitor therapy; upper or frequency of use
ADULT: 25 to 50 ethanolamine rhinitis, history of sleep apnea; abdominal but to inform their
mg three or four vasomotor use in newborn or pain. health care
times daily. rhinitis and premature infants and provider. Caution
patient that larger
10 to 50 mg allergic in nursing women; use Others: Edema, doses or more
frequent dosing
intravenously or conjunctivitis; as a local anesthetic. dizziness, does not increase
deep temporary relief hypertension, effectiveness and
may cause
intramuscularly, of runny nose headache, excessive
100 mg if required; and sneezing fatigue and drowsiness or other
side effects.
maximum daily caused by increases in
dosage is 400 mg. common cold; liver enzymes. Instruct patient to
CHILDREN: 12.5 dermatographis stop taking drug
to 25 mg three to m; treatment of and immediately
report any of these
four times daily urticaria and symptoms to health
care provider:
One to two angioedema; persistent dizziness;
teaspoonfuls three amelioration of excessive
drowsiness; severe
to four times daily. allergic reactions dry mouth, nose, or
Maximum daily to blood or throat; flushing;
unexplained
dosage not to plasma; adjunct shortness of breath
exceed 300 mg. to epinephrine or difficulty
breathing; unusual
and other tiredness or
weakness; sore
standard throat, fever, or
measures in other signs of
infection; bleeding
anaphylaxis; or unusual bruising;
relief of fast or irregular
heartbeat;
uncomplicated excitability,
allergic confusion, or
changes in thinking
conditions of or behavior; chest
tightness.
immediate type
when oral
Advise patient that
therapy is medication may
impossible or cause drowsiness or
dizziness and not to
contraindicated drive or perform
(parenteral other activities
requiring mental
form); treatment alertness until
and prophylactic tolerance is
determined.
treatment of
 motion sickness
(injection only); Advise patient to
nighttime sleep take sips of water,
suck on ice chips or
aid; sugarless hard
management of candy, or chew
sugarless gum if dry
parkinsonism mouth occurs.
(including drug-
induced) in Caution patient that
elderly who are alcohol and other
CNS depressants
intolerant of (eg, sedatives) will
have additional
more potent sedative effects if
agents, in mild taken with
diphenhydramine.
cases in other
age groups and
in combination
with centrally
acting
anticholinergics;
control of cough
from colds or
allergy (syrup
formulations).
ATROPINE GN: Atropine Inhibits action of Administration Documented Dryness of Advise patient that
Sulfate acetylcholine or prior to hypersensitivity to the mouth medication, with
exception of auto-
other cholinergic anesthesia to atropine or belladonna blurred injector, will be
prepared and
AVAILABILITY: stimuli at reduce or alkaloids or related vision, administered by a
ADULT: 0.5 mg postganglionic prevent products; concomitant photophobia health care provider
in a medical setting.
rapid IV push, cholinergic secretions of acute myocardial tachycardia
mg can be receptors, respiratory tract; infarction/ischemia; commonly
Review the patient
administered; including smooth to control thyrotoxicosis; narrow- occur with information leaflet
maximal IV dose is muscles, rhinorrhea; angle glaucoma; chronic and instruction
guide with potential
0.04 mg/kg secretory glands, treatment of congestive heart administratio user of auto-
PEDIATRIC: 0.02 and CNS sites. parkinsonism; failure; tachycardia n of injector. Ensure that
potential user of the
mg/kg IV push, 1 restoration of therapeutic auto-injector
understands the
mg maximal total Enhances sinus cardiac rate and doses indications for and
IV dose is 0.04 node arterial pressure palpitation,
mg/kg automaticity. In in some dilated use of the auto-
addition, blocks situations; pupils, injector, including
symptoms of
effects of treatment of difficulty in poisoning and
acetylcholine at peptic ulcers; swallowing preparation and use
of the auto-injector.
AV node, thereby management of hot dry skin,
decreasing the hypersecretion, thirst, Emphasize to
refractory time irritation, or dizziness, potential user of
and speeding inflammation of restlessness, auto-injector that
medical attention
conduction stomach, tremor, must be sought
immediately after
through AV node. intestines, or fatigue and use of the auto-
pancreas; ataxia. injector.
treatment of palpitation,
diarrhea; relief restlessness
of infant colic; and
management of excitement,
spasms of bile hallucination
tract; treatment s,
of hypertonicity delirium
of small Depression
intestine and and
uterus; circulatory
management of blood
hypermotility of pressure
colon; declines
prevention of death due to
spasm of respiratory
pylorus, biliary failure
tree, ureters,
and bronchi;
treatment of
frequent
urination and
bed-wetting;
therapy for
certain
bradycardias
and heart
blocks;
treatment of
closed head
injury with
acetylcholine
release;
reduction of
laughing and
crying
associated with
brain lesions;
treatment of
alcohol
withdrawal
symptoms; relief
of motion
sickness.
Antidote for CV
collapse in
certain
overdoses or
poisonings (eg,
organophosphor
ous nerve
agents having
cholinesterase
activity,
organophosphor
ous or
carbamate
insecticides,
muscarinic
 symptoms of
insecticide or
nerve agent
poisonings).
Short-term
treatment and
prevention of
bronchospasm
associated with
chronic
bronchial
asthma,
bronchitis, and
COPD
PONSTEL GN: MEFENAMIC Decreases Relief of Patients in whom Warn patient about
ACID inflammation, moderate pain aspirin, iodides, or any Cardiovascular: potential for
bleeding, and
pain, and fever, lasting less than NSAID has caused Edema; advise patient to
notify other health
AVAILABILITY: probably through 1 week allergic-type reactions; weight care professionals
250 mg blue- inhibition of preexisting renal gain; that drug is being
taken.
banded, ivory cyclooxygenase disease; active CHF;
capsules, imprinted activity and ulceration or chronic altered Advise patient to
with " FHPC 400" prostaglandin inflammation of GI BP; discontinue
and "PONSTEL®". synthesis. tract. palpitati medication if rash
develops and to
ons; contact health care
chest provider.
pain;
bradyca Instruct patient to
report the following
rdia; symptoms to health
care provider: rash,
tachyca visual problems,
rdia. dark stools,
decreased urinary
output, persistent
CNS: headache or
stomach pain and
Headac unusual bruising or
bleeding.
he;
vertigo;
Advise patient to
 drowsin avoid intake of
ess; alcoholic beverages.
dizzines
s; Instruct patient that
drug may cause
insomni drowsiness and to
a. use caution while
driving or
performing other
Dermatologic: activities requiring
mental alertness.
Rash;
urticaria Caution patient to
; avoid prolonged
exposure to sunlight
purpura and to use
. sunscreen or wear
protective clothing
to avoid
EENT: Blurred photosensitivity
reaction.
vision;
tinnitus; Instruct patient not
salivatio to take OTC
medications,
n; including aspirin
glossitis and ibuprofen or
other prescription
. drugs, without
consulting health
care provider.
GI: Diarrhea;
dry
mouth;
vomitin
g;
abdomi
nal
pain;
dyspeps
ia; GI
bleedin
g;
 nausea;
constipa
tion;
flatulen
ce.

Genitourinary:
Hematu
ria;
proteinu
ria;
dysuria;
renal
failure.

Hematologic:
Decreas
ed
hemato
crit;
bleedin
g;
neutrop
enia;
leukope
nia;
pancyto
penia;
eosinop
hilia;
thrombo
cytopen
ia.
 Hepatic: Mild
elevatio
ns in
LFT
results.

Respiratory:
Broncho
spasm;
larynge
al
edema;
rhinitis;
dyspnea
;
pharyng
itis;
hemopt
ysis;
shortne
ss of
breath.
Miscellaneous:
Autoimmune
hemolytic
anemia may
occur if used
long term.
DIAZEPAM GN: Diazepam The skeletal Management of Hypersensitivity to Somnolence, Document
Intensol effect of anxiety benzodiazepines; Suppression of indications for
Dose: 10 diazepam may be disorders; relief psychoses; acute REM sleep or therapy and time for
mg IV AVAILABILITY: due to of acute alcohol narrow-angle dreaming, anticipated results.
Injection: 5 enhancement of withdrawal glaucoma; use in Addiction,
mg/ml, GABA-mediated symptoms; relief children younger than Impaired motor Determine any
Oral Solution: 1 presynaptic of preoperative 6 mo of age; lactation. function, depression or drug
mg/ml inhibition at the apprehension Depression, abuse. Avoid
Tablet: 2 mg, 5 spinal level as and anxiety and Anterograde simultaneous use of
mg, 10 mg well as in the reduction of amnesia CNS depressants.
brain stem memory recall; (especially
reticular treatment of pronounced in Reduce Drug
formation. muscle spasms, higher doses), gradually to avoid
convulsive Reflex withdrawal
disorders (used tachycardia symptoms such ad
adjunctively), anxiety, tremors,
and status anorexia, insomnia,
epilepticus. weakness,
headache and N&V.

The antidote for

diazepam overdose
is Flumazenil.

Tell the patient that

the drug may cause
dizziness, and
drowsiness. Avoid
activities that
require mental
alertness until drug
effects realized.

Instruct the patient

avoid alcohol and
any other CNS
depressants.

Smoking may
increase drug
metabolism; thus
 requiring higher
dose than the
nonsmoker. Do not
stop drug abruptly.

Inform the patient

to report any
adverse side effects
or lack of response.
CEFUROXIME GN: Cefuroxime Inhibits Treatment of Hypersensitivity to Instruct patient to
Injection mucopeptide infections of cephalosporins. GI: Nausea; report these
Dose synthesis in lower respiratory vomitin symptoms to health
1.5 mg/IV AVAILABILTY: bacterial cell wall tract, urinary g; care provider:
tract, skin and diarrhea nausea, vomiting,
skin structures, ; diarrhea, skin rash,
bone and joint; anorexi sore throat,
preoperative a; bruising, hives,
prophylaxis; abdomi muscle or joint pain.
treatment of nal pain
septicemia, or Instruct patient to
gonorrhea, and cramps; report signs of
meningitis flatulen superinfection:
caused by ce; black “furry”
susceptible colitis, tongue, white
strains of includin patches in mouth,
specific g foul-smelling stools,
microorganisms. pseudo vaginal itching or
membra discharge.
nous
colitis. Warn patient that
diarrhea that
Genitourinary: contains blood or
Pyuria; pus may be a sign
renal of serious disorders.
dysfunc Tell patient to seek
 medical care and
tion; not to treat at
dysuria; home.
reversib
le Instruct patient to
interstiti seek emergency
al care immediately if
nephriti wheezing or
s; difficulty breathing
hematur occurs.
ia; toxic
nephrop
athy.

Hematologic:
Eosinop
hilia;
neutrop
enia;
lymphoc
ytosis;
leukocyt
osis;
thrombo
cytopen
ia;
decreas
ed
platelet
function
;
anemia;
aplastic
anemia;
hemorr
 hage.

Hepatic:
Hepatic
dysfunc
tion;
abnorm
al LFT
results.

Miscellaneous:
Hyperse
nsitivity,
,
erythem
a
multifor
me,
toxic
epiderm
al
necrolys
is;
candidal
overgro
wth;
serum
sickness
–like
reaction
s (eg,
skin
rashes,
polyarth
ritis,
arthralgi
a,
fever);
phlebitis
,
thrombo
phlebitis
, and
pain at
injection
site.
 X. NURSING CARE PLAN

Nursing problem #1: Immobility

Focus Assessment Criteria Clinical Significance

1. ROM of affected extremity (left arm) Pain and activity restrictions may serve as signals to client to
2. Pain at the incision site immobilize the affected extremity.
3. Understanding activity restrictions, fears regarding Fear of lead displacement may magnify the significance of
movement these signals to such a degree that the client inappropriately
immobilizes the arms.

Cues Nursing Diagnosis Goal/s Evaluation

Subjective: Impaired physical mobility Goal: The client is able to
The patient verbalized, related to incisional site perform ADLs and
“Hindi ako ganon ka- pain, activity restrictions, After 1 day of nurse-patient interaction, the client will express prescribed
kumportable dahil hindi ko and fear of lead demonstrate the ability to perform ADLs by: restrictions to be
pwedeng gamitin ang displacement - Demonstrating the ability to maintain arm beneficial for her
kaliwang kamay sa restriction limitations recovery.
ngayon dahil sariwa pa Inference: - Verbalizing prescribed restrictions
ang pagkakakabit ng Placement of Permanent
panibagong pacemaker Pacemaker Nursing Interventions:
ko. Kumikirot lang ang
tahi ko tuwing Independent Rationale
nabubunggo lang.” Incisional site pain Interventions
Restricted activity
Explain the need to Bed rest is prescribed to
Fear of lead displacement
Objective: remain on bed rest for up allow fibrosis to occur
to 24 hours post around the pacemaker
• Guarding and restricted procedure (or as and electrodes; this
Impaired physical mobility
movement prescribed) helps to prevent
• Facial mask of pain dislodgement
when the area of Medicate with prescribed Judicious use of pain
surrounding the incision analgesics before client medication keeps pain
is touched engages in any activity signals from
• Self-focusing discouraging use of

Explain that incision and
subcutaneous pocket
should feel sore for 3 to 4
weeks but discomfort
eventually disappears
Explain that affected arm
and shoulder should not
be moved in an
overzealous manner (i.e.,
over the head) for 48
hours or as prescribed.
Encourage client to
perform active ROM
(except for overzealous
movements) in affected
arm following physician’s
instructions
Encourage early and
complete participation in
ADLs
Reinforce physician-
prescribed post-operative
activity restrictions; these
may include no driving,
no lifting, no golfing, no
bowling, etc., for 4 to 6
weeks after surgery
Provide written
information on activity
instructions and
restrictions
affected arm
Understanding that
discomfort is temporary
encourages client to
accept the pacemaker
and participate in
activity
Overzealous arm
movements may
potentially cause lead
dislodgement, but
regular active ROM
exercises maintains
joint function and
prevents muscle
contractures
Self-care increases
independence and a
sense of well-being
Activity restrictions
allow continued fibrosis
around pacemaker and
electrodes to provide
increased stabilization
Written materials can
serve as a valuable
resource for
postdischarge care at
home
Nursing Problem #2: Expression of changes in one’s self

Focus Assessment Criteria Clinical Significance

1. Accuracy of client’s perceptions regarding pacemaker
2. Client’s self concept before pacemaker insertion
3. Availability of support system
The implantation of a pacemaker may implicate a sense of
loss, which can negatively affect the client’s self concept.
Acceptance of pacemaker can be affected by many factors;
however, a person’s ability depends on his/her own personal
strengths still present, compensate for what is lost, and view
himself/herself as a unique person.
A strong support system can greatly help in the patient’s
adjustment.

Cues Nursing Diagnosis Goal/s Evaluation

Subjective: Disturbed self-concept Goal: The client participates
The patient verbalized, related to perceived in self care and
“Nag-aalala ako kasi baka changes associated with Throughout the course of treatment, the client will expresses that
magkaroon ng pagbabago the presence of a participate in self care through: dependence on the
sa aking mga gawain ang pacemaker - Verbalizing an intent to follow the prescribed pacemaker is helpful
pagkakaroon ko ng medical regimen in her day to day
pacemaker.” Inference - Verbalizing recognition that despite the living as a unique
PPI physical loss, he or she remains much the same person.
person

Dependence on impulse Nursing Interventions:

conduction
Independent Rationale
Interventions
Use of Permanent Pacemaker Identify and correct any Incorrect assumptions
misinformation client may can cause doubt and
have regarding uncertainty and
Perceived changes pacemakers contribute to poor self
concept. Many times
client and family have
 Express concern in one’s self
Encourage client to share
feelings and concerns
about living with a
pacemaker
Expose client to other
people who is currently
dependent to pacemaker
Assist client in
distinguishing areas of
life in which he or she is
not dependent on others
Help client to identify
personal strengths that
might aid coping
Nursing Problem #3: Risk for Ineffective Adherence
Focus Assessment Criteria Clinical Significance
information related to
old pacemakers.
Today’s pacemakers can
be well-adjusting
(versus fixed rate) and
require less frequent
battery changes (e.g.
10yrs)
Sharing gives nurse the
opportunity to identify
and clarify
misconceptions and
address areas of
concern
To provide assurance
that the pacemaker will
not affect his/her day to
day living
This measure
emphasizes areas for
control and self-
determination in
learning to
accept the pacemaker
and
altered body image
Discussing strengths
encourages client to
de-emphasize the
disability
1. Readiness and ability to learn and retain information A client or family failing to achieve learning goals requires a
referral for assistance post discharge.

Cues Nursing Diagnosis Goal/s Evaluation

Risk for Ineffective Goal: The client verbalizes
Therapeutic Regimen the value of
Management related to Before hospital discharge, the client will be able to: compliance to the
Insufficient Knowledge of - Understand the importance of the adhering to therapeutic
Activity Restrictions, the therapeutic regimen and acknowledge management and
Precautions, Signs and possible consequences of regimen complies to the
Symptoms of mismanagement discharge instructions
Complications and Follow- - Demonstrate compliance to post-operative given by the health
up Care teaching and plans for discharge care provider.

Inference Nursing Interventions:

PPI
Independent Rationale
Post-PPI teachings not yet done
Interventions
Review post procedural Reviewing enables
Risk for Ineffective Therapeutic routine as needed nurse to evaluate
Regimen
whether or not client
needs additional
teaching
Instruct on incisional care Proper incision care
including the following: helps to prevent
a. wound cleansing infection and other
b. suture removal if complications.
present (usually
after 7days)
c. Expected swelling
for 2 to 4 weeks
d. Recognizing signs
and symptoms of
infection
e. For a woman,
 wearing brassiere
for support with
gauze pad over
the pulse
generator to
decrease rubbing
over the suture
line
Instruct client on home Understanding home
care measures. care enables client to
comply with the
a. Keep affected arm regimen.
immobile for 24 to 48 a. Arm movement
hours postprocedure. could cause traction
on the lead and
possible lead
displacement.
Teach client and family to Early detection enables
watch for and promptly prompt treatment to
report the following: prevent serious
complications.
a. Redness, a. These signs and
swelling, symptoms point to
warmth, wound infection.
drainage, or
pain at the
surgical wound
or temperature b. Joint stiffness,
greater than pain and muscle
101°F weakness may
b. Joint stiffness, indicate
pain and neurovascular
muscle compression.
weakness in c. Light-
affected arm headedness,
 c. Light fainting, dizzy
headedness, spelss, or chronic
fatigue may result
fainting, from cerebral
dizzy spells hypoxia owing to
or chronic insufficient cardiac
fatigue output secondary to
pacemaker
malfunction.
d. Pulse changes
may indicate
pacemaker failure.
d. Very rapid or e. Chronic hiccups
slow pulse or chest muscle
twitching may
e. Chronic indicate lead
hiccups or displacement and
chest muscle electrical stimulation
twitching of diaphragm or
intercostals muscles.
f. Swelling ankles
or hands may
indicate congestive
f. Swollen ankles heart failure related
of hands to insufficient
cardiac output
Reassure that pacemaker Specifically discussing
should not interfere with sexual activity can
sexual activity reduce fears and let
client share
Instruct client to carry a Pacemaker identification
pacemaker identification card and Medic-Alert
card at all times. bracelet provide
Encourage client to apply important information to
for a Medic-Alert bracelet caregivers in emergency

Instruct client to notify
physicians, nurses, and
dentist about his or her
pacemaker so that
prophylactic antibiotics
may be given before
invasive procedures if
needed
Instruct client to avoid
strong electromagnetic
fields including magnetic
resonance imaging
equipment are welding
equipment, high-intensity
power lines, dental
ultrasonic cleaners, drills,
internal combustion
engines and poorly
shielded microwave
ovens.
a. Instruct client to
avoid learning
over open hood of
a running car
engine.
Warn that pacemaker
triggers magnetic
detection alarms such as
those found at airport.
Instruct client to carry
situations.
Because the pulse
generator increases
tissues susceptibility to
infection, prophylactic
therapy is indicated
before many invasive
procedures.
Electromagnetic fields
can interfere with
pacemaker function. A
client with any anxiety
about using a
microwave open should
stand about 6 feet away
from oven when it is
operating.
a. Anything that
revolves at high
revolutions can
cause an
electromagnetic
field; therefore,
this could lead to
pacemaker
malfunction
Anything that revolves
at high revolutions can
cause an
electromagnetic field;
therefore, this could
pacemaker identification
card to verify pacemaker
placement with airport
security personnel.
Emphasize the necessity
of long-term follow-up
care; reinforce
physician’s instructions.
Explain that the battery is
not lifelong and
replacement might be
necessary (average
battery life is 5 to 10
years).
Teach pulse taking if
appropriate and instruct
client to notify physician
if pulse rate falls below
pacemaker set rate.
Explain transtelephonic
follow-up care, a system
in which a client uses a
transmitter at home to
check the pacemaker
over the phone.
Explain the importance of
lead to pacemaker
malfunction
Regular follow-up care is
essential for ongoing
evaluation.
Understanding the need
for battery replacement
assists with coping
should replacement be
needed.
Pulse taking may help to
enhance client’s sense
of control over the
situation.
Knowing what to expect
after discharge may
decrease client’s
anxiety. Transtelephone
monitoring provides
reassurance to the
patient that the
pacemaker is working
properly & can
determine the need for
battery replacement. It
does not preclude the
need for physician
follow-up visits.
Further evaluation may
seeking medical care or be needed.
advice (phone) if shock
function occurs.
Provide written Written information
instructional materials at reinforces teaching and
discharge. serves as a resource at
home.
Provide client with names This can help to
and phone numbers of reassure client that
persons to call should directs access for
questions or an assistance is always
emergency arise (day or available.
night).
 XI. PATIENT DISCHARGE PLAN/INSTRUCTIONS

MEDICATIONS
Mefenamic Acid
• One (1) tablet 500mg to be taken orally/by mouth

• To be taken every six (6) hrs. a day

• For the management of pain due to post surgical procedure.

• Take mefenamic acid as exactly as it was prescribed by the doctor.

• Should be taken together with food or milk as mefenamic would

probably cause an upset stomach.

• Instruct the patient to take the missed dose as soon as you

remember. If it is almost time for the next dose, skip the missed
dose and take the medicine at the next regularly scheduled time.
He/she should not take extra medicine to make up the missed dose.

• The patient may experience side effects while taking mefenamic

acid such as upset stomach, mild heartburn or stomach pain,
diarrhea, constipation; bloating, gas, dizziness, headache,
nervousness; skin itching or rash, dry mouth ,increased sweating,
runny nose and blurred vision.

EXERCISE AND REHABILITATION

• May return to doing normal activities within six (6) weeks after
the surgery.
• Any exercise is fine after 4-5 weeks
• No heavy lifting (usually five pounds[5lbs.] or more) or strenuous
arm exercise for about 2 to 3 weeks.
• May still be able to drive or at least travel unless the physician
has instructed you not to do so.
• May still go to work unless the physician has instructed you
not to do so.
• May still do almost all the household activities.
• May still participate in sports and other recreational activities
except contact sports that may increase the chance of
receiving a blow on the chest or the pacemaker device.

TREATMENT

A. Wound Care
• Proper hand washing should be carried and observe
cleanliness at all times.
• Observe wound daily, instruct patient to report any signs of
inflammation to your doctor.
 • Clean the wound daily using prescribed antiseptic solution
(Betadine).
• Avoid wearing constrictive clothing like tight bra straps which
puts excessive pressure in the wound and the pulse
generator.
• Advise the patient to avoid getting the incision wet until the
sutures have been removed (1 week). If on a shower, cover
the incision with plastic wrap.
• If the patient sees a suture sticking out of his/her incision,
have the doctor remove it.

B. Pacemaker Management
• Regularly ensure that the pacemaker is properly placed by:
i. Taking the pulse daily either radial or carotid. The
pulse can be found on the side of the lower neck, on
the inside of the elbow, or at the wrist.); notify the
doctor if pulse is slower than the set rate. Also, report
for excessive palpations, vertigo or fainting.

How to check the pulse:

• Using the first and second fingertips, press firmly but gently
on the arteries until you feel a pulse.
• Begin counting the pulse when the clock's second hand is on
the 12
• Count your pulse for 60 seconds (or for 15 seconds and then
multiply by four to calculate beats per minute).
• When counting, do not watch the clock continuously, but
concentrate on the beats of the pulse.
• If unsure about your results, ask another person to count for
you.
ii. Check your "pacing lead" (the lead which sends
information from the heart to the pacemaker) with an
electrocardiogram (ECG) at your physician's office. In
addition, you may participate in a telephonic check up
for your pacemaker on a periodic basis. Your physician
will provide special instructions.
iii. The table below lists various electrical and magnetic
sources that are safe and sources that you should
avoid.

Electrical or magnetic Electrical or magnetic

sources that are SAFE to sources that should be
be used by people with AVOIDED by people with
pacemakers and ICDs pacemakers and ICDs
• Televisions, video Stay at least 12 inches away
cassette recorders from the following:
(VCRs), and their remote
controls • Stereo speakers
 • AM/FM radios • Magnets
• Kitchen appliances • Magnetic wands used
(toasters, blenders, at airports
electric can openers, • Industrial power
refrigerators) generators
• Microwave ovens • Arc welders
• Conventional ovens • Battery-powered
• Bathroom appliances cordless power tools
(electric razors, curling (drills, screwdrivers)
irons, hair dryers) • Cellular phones
• Washing machines and
dryers Avoid completely:
• Heating pads, electric
blankets • Large magnets
• Household phones • MRI machines
(including portable • CB or ham radios
models) • Radio transmitters
• Personal computers, fax (including those used in
machines, copying toys)
machines, printers, • High-voltage power
electric typewriters lines [keep at least 25
• Garage door openers ft away]
• Automobiles (unless
your doctor has
restricted your driving)
• Lawn and garden
equipment (mowers, leaf
blowers)
• Electric tools (drills,
table saws)
• Most medical tests (X-
ray, CT scan,
mammogram)

• Dental procedures
iv. Ensure the patient to carry a pacemaker identity card
at all times because equipment used by doctors and
dentists can affect the pacemaker.
v. Airport security systems will not affect the pacemaker,
but the pacemaker may set off the alarm. Inform the
patient to tell the guard regarding the use of a
pacemaker.

HYGIENE

• Maintain cleanliness at all times by doing the following

i. Take a bath daily (the incision line should be tightly
covered with a plastic)
 ii. Practice good oral hygiene by regularly brushing your
teeth
iii. Keep finger/toe nails properly trimmed
iv. Make sure that the perineal area is cleaned daily.
• Wear clean and comfortable clothing and footwear.
• Wear supportive bra and place a gauze pad over the pulse
generator to decrease rubbing over the suture line.

OUT PATIENT FOLLOW UP

• Before leaving the hospital, the patient will usually have a full
evaluation, including a chest X-ray, electrocardiography (EKG, ECG),
and a pacemaker check. One week to 10 days after discharge, the
incision will be checked.
• In 6 to 8 weeks after placement of the pacemaker, a full evaluation,
including an EKG, and a pacemaker will be checked.
• About every 1 to 3 months, the patient will be asked to have the
pacemaker checked over the phone.
• In 3 to 6 months after placement, the patient should either visit the
doctor or clinic in person or have the pacemaker checked over the
phone. Information can be sent directly over the phone to a
computer on the other end of the line. This computer prints the
information, and it can be reviewed by your doctor.
• Once or twice per year, the patient will be asked to visit his/her
doctor to have a full evaluation of the pacemaker.
• If the battery life is low, the battery will need to be replaced his
involves a surgical procedure similar to the initial implantation,
except that the battery change is often a more simple procedure
since the leads are already in place.

DIET (Nutrition)

• Diet: Low salt/Low fat

FOODS TO TAKE FOODS TO AVOID

Vegetables Cholesterol rich foods (chicharon,
lechon, sisig.)
Fruits
Alcoholic and caffeinated
Fiber Rich foods (oatmeal, beverages
cereal, whole grain wheat
bread.) Junk foods

Avoid using salty

condiments(patis, toyo and
bagoong)

• Always be conscious of the food labeling and read its contents.

SEXUALITY / SOCIAL / SPIRITUAL

• May continue sexual activity after 6 weeks of surgery.

• May join support groups concerning patients also with pacemakers.
• You must practice healthy habits like:
i. Take enough rest and sleep (at least 7-8hrs.)
ii. Drinking plenty of water (at least 8 glasses of water.)
iii. Avoiding vices such as alcohol drinking and cigarette smoking.
• Pacemakers have very reliable technology, and the patient can
have confidence that it will work to improve his/her heart rhythm.
He/she should be able to return to a full and active lifestyle. If there
are any questions or concerns, seek consultation from the the
doctor, nurse or rehabilitation team.
 XII. SUPPORTING BACKGROUND REGARDING SIGNIFICANCE
OF AMPHETAMINE USE IN COMPLETE HEART BLOCK

CARDIOTOXICITY ASSOCIATED WITH METHAMPHETAMINE

USE
AND SIGNS OF CARDIOVASCULAR PATHOLOGY AMONG
METHAMPHETAMINE USERS

TECHNICAL REPORT NO 238

Sharlene Kaye and Rebecca McKetin

BACKGROUND
The use of methamphetamine is widespread and, in many countries,
is a major drug of abuse. As such, it is important to identify and
understand the adverse health effects associated with
methamphetamine use and consider the risk of such consequences
for users. Although methamphetamine has effects on multiple organ
systems, this report will focus on the cardiovascular effects of
methamphetamine. Specifically, the aim of this report is to review
the evidence for methamphetamine-related cardiovascular
pathology and discuss the implications for methamphetamine users.

Methamphetamine cardiotoxicity
Methamphetamine increases catecholamine activity in the branch of
the peripheral nervous system responsible for modulating heart rate
and blood pressure. Excessive catecholamine activity is thought to
be the primary mechanism underlying the cardiotoxic effects of
methamphetamine. High catecholamine levels are known to be
cardiotoxic, causing narrowing and spasm of the blood vessels,
rapid heart rate (tachycardia), high blood pressure (hypertension),
and possible death of the heart muscle. Other features of
catecholamine toxicity include the formation of fibrous tissue and an
increase in the size of heart muscle cells.

Evidence of cardiotoxicity among methamphetamine users

The most widely reported adverse cardiovascular effects of
methamphetamine use are chest pain, tachycardia and other
cardiac arrhythmias, shortness of breath and high blood pressure.
The less frequently observed, but more severe, acute cardiovascular
complications of methamphetamine use are acute myocardial
infarction, acute aortic dissection, and sudden cardiac death. The
medical literature contained several single case reports and case
series reports of acute myocardial infarction. Acute myocardial
infarction often occurred in the absence of identifiable coronary
artery disease.
The forms of chronic cardiovascular disease that are most
commonly associated with methamphetamine use are coronary
artery disease and cardiomyopathy. Studies of methamphetamine-
related fatalities have suggested that methamphetamine users are
at risk of the premature and accelerated development of coronary
artery disease. Clinical and experimental evidence alike suggest
that the use of methamphetamine, particularly long-term use, can
induce cardiomyopathy. As with acute myocardial infarction,
cardiomyopathy has been associated with various routes of
methamphetamine administration (e.g. oral, smoking and
intravenous).

Factors influencing the cardiovascular effects of

methamphetamine
The necessary and sufficient dose to produce serious cardiovascular
complications or death - that is, the “toxic” dose - is unclear, as the
response to a specific dose varies due to individual differences in
responsiveness and variations in degree of tolerance. The literature
indicates that cardiovascular complications associated with
methamphetamine use can occur with all of the major routes of
administration: that is, intranasal, oral, smoking, and injecting.
While there is no evidence to suggest that any one route of
methamphetamine administration should be more strongly
associated with cardiotoxicity than another, the risk of
complications may be higher with patterns of use that are
associated with frequent use and taking higher doses, such as
injecting and smoking crystalline methamphetamine. Previous
research also suggests that the risk of cardiovascular problems
among methamphetamine users is increased when the drug is
combined with alcohol, cocaine or opiates. Of particular concern is
the concomitant use of methamphetamine and other
psychostimulant drugs, such as cocaine, due to their potential
synergistic effect on catecholamine activity.

Conclusions and recommendations

Low level use of methamphetamine - for example, sporadic, low
dosage use - does not appear to be associated with major acute
complications, such as myocardial infarction, or chronic
cardiovascular disease, in an otherwise healthy user.
Methamphetamine may, however, exacerbate pre-existing
underlying cardiac pathology, such as coronary atherosclerosis or
cardiomyopathy, thereby increasing the risk of an acute event such
as myocardial infarction or even sudden cardiac death. Long-term
methamphetamine users appear to be most at risk of cardiovascular
damage, such as premature, accelerated coronary artery disease.
As such, methamphetamine toxicity is more likely to have a fatal
outcome with chronic use.
Given their high levels of polydrug use, methamphetamine users
should also be made aware of the increased risk of adverse
cardiovascular effects when methamphetamine is used with other
drugs, particularly other psychostimulant drugs. Because of the
individual variation in sensitivity to methamphetamine’s cardiotoxic
properties, treating methamphetamine toxicity should be based on
the symptom presentation rather than the reported dose
administered.

Further research is needed to establish the risk of serious cardiac

events among methamphetamine users, whether there is evidence
of a dose-response relationship between methamphetamine use and
cardio toxicity in humans, and also the relative contribution of
methamphetamine over other concurrent risk factors, such as
tobacco smoking, alcohol and other drug use, obesity, and pre-
existing cardiac pathology.