Pacemakers

NURS 3305
Copyright 2014 by Mosby, an
imprint of Elsevier Inc.

Pacemakers
Deliver an electrical current to stimulate
depolarization when the normal
conduction pathway is damaged
Either temporary or permanent

Copyright 2014 by Mosby, an

imprint of Elsevier Inc.

Pacemakers
Pacing circuit:
Programmable pulse generator (power source)

One or more pacing wires (leads) to

myocardium

Copyright 2014 by Mosby, an

imprint of Elsevier Inc.

Indications

symptomatic bradycardia
severe asymptomatic bradycardia
AV block
complete block
atrial flutter/atrial fib with slow ventricular
response
sick sinus syndrome
Tachy-brady syndrome

Pacemaker Terminology
Rate
Mode
Demand/synchronous
Fixed rate/asynchronous
AV-sequential (dual chamber)

Electrical output: milliamperes (mA)

Sensitivity
Sense-pace indicator
AV interval
Copyright 2013, 2009, 2005, 2001, 1997,
1993 by Saunders, an imprint of Elsevier Inc.

Functions
Sensing:
The ability to detect or see patient's intrinsic heart
rhythm (cardiac depolarization).
If the rate is sufficient, the pacemaker is inhibited
(i.e., prevented from firing).
Sensing prevents the pacemaker from firing randomly
or in competition with the heart's inherent rhythm.

Functions (continued)
Pacing:
Stimulates the heart to contract via myocardial cell
depolarization
Maintains primary control of pacing function of the
heart (i.e., Heart Blocks, Symptomatic Brady, Some
Tachycardias)

Chamber Paced
Atrial Pacing

Figure 7-58. Atrial paced rhythm.

Copyright 2013, 2009, 2005, 2001, 1997,

1993 by Saunders, an imprint of Elsevier Inc.

Atrial Pacing

Chamber Paced
Ventricular Pacing

Figure 7-59. Ventricular paced rhythm.

Copyright 2013, 2009, 2005, 2001, 1997,

1993 by Saunders, an imprint of Elsevier Inc.

10

Ventricular Pacing

Biventricular (Dual-Chamber)
Pacing

Figure 7-60. Dual-chamber (AV) paced rhythm. A, Atrial pacer spike; AV, AV pager
spike interval; V, Ventricular paced spike.

Copyright 2013, 2009, 2005, 2001, 1997,

1993 by Saunders, an imprint of Elsevier Inc.

12

Pacemaker Codes
Position

II

III

IV

Category

Chamber
(s) Paced

Chamber(
s) Sensed

Response
to Sensing

Rate
Modulatio
n

Multisite
Pacing

O=None
A=Atrium
V=Ventricl
e
D=Dual
(A+V)

O=None
A=Atrium
V=Ventricle
D=Dual
(A+V)

O=None
T=Triggere
d
I=Inhibited
D=Dual
(T+I)

O=None
R=Rate
Modulation

O=None
A=Atrium
V=Ventricle
D=Dual
(A+V)

S=Single
(A or V)

S=Single
(A or V)

Manufacture
rs
Designation
Only

13

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imprint of Elsevier Inc. All rights
reserved.

Temporary Pacemakers
Transcutaneous
Transvenous
Epicardial

Copyright 2014 by Mosby, an

imprint of Elsevier Inc.

Transcutaneous Pacing
For emergent pacing needs and used
temporarily (less than 24 hours)
Noninvasive
Bridge until transvenous pacer can be inserted
Use lowest current that will capture
Patient may need analgesia/sedation

Copyright 2014 by Mosby, an

imprint of Elsevier Inc.

Transcutaneous Pacing

Fig 10-9. Anterioposterior placement of adhesive electrode pads for defibrillation or transcutaneous pacing.
From: Sole et al. Introduction to Critical Care Nursing, 5th Edition. W.B. Saunders

Copyright 2014 by Mosby, an

imprint of Elsevier Inc.

Temporary Transvenous Pacemaker

Copyright 2014 by Mosby, an

imprint of Elsevier Inc.

Pacemaker System
Temporary, transvenous

Settings Temporary Pacemaker

Rate

Usually 60-80 ppm

Output (milliamperes) mA
Amount of electrical current delivered
to reachthreshold (depolarization)
and achieve capture
Sensitivity (millivolts) mV
The degree to which the pm is
responsive to electrical activity of
heart

AV interval control

Time interval between atrial &

ventricle pacing stimuli

Epicardial Pacing
Leads placed on epicardium during heart
surgery
Passed through chest wall and attached to
external power source as needed

Copyright 2014 by Mosby, an

imprint of Elsevier Inc.

Temporary Pacemaker Care

Insulate exposed temporary pacing leads
on epicardial wires (post-op patients)
Avoid microshocks
Gloves, plastic needle covers
Wear gloves when handling wires
Assure proper grounding for all electrical devices

Exit site care per policy of facility

Ensure proper skin care with

transcutaneous pacing.
Change pads every 24 hours

Temporary Pacemaker Care

(continued)

Assess for & prevent pacemaker malfunction

Monitor ECG
Secure pacing wires to prevent displacement
Check for loose connections
Have an new battery available
Monitor for infection
Exit site care per policy of facility
Monitor for site drainage, redness, edema

Permanent Pacemaker

Copyright 2014 by Mosby, an

imprint of Elsevier Inc.

Cardiac resynchronization therapy (CRT)

Resynchronizes the cardiac cycle by
pacing both ventricles
Biventricular pacing
Used to treat patients with heart failure
Can be combined with ICD for maximum
therapy

Copyright 2014 by Mosby, an

imprint of Elsevier Inc.

Cardiac Resynchronization
Biventricular pacing
Useful in patients with severe
heart failure
3 lead wires
Right Atrium
Right ventricle
Left ventricle

Permanent Pacemakers
Insertion & Care
Postprocedure care
OOB once stable
Limit arm and shoulder activity
Monitor insertion site for bleeding and
infection
Patient teaching important

Copyright 2014 by Mosby, an

imprint of Elsevier Inc.

Permanent Pacemakers
Complications
Infection
Hematoma formation
Pneumothorax
Atrial or ventricular septum perforation
Lead misplacement

Copyright 2014 by Mosby, an

imprint of Elsevier Inc.

Permanent Pacemakers
Patient and Caregiver Teaching
Follow-up appointments
for pacemaker function
checks
Incision care
Arm restrictions
Avoid direct blows
Avoid high-output
generator

No MRIs unless pacer

approved
Microwaves OK
Avoid antitheft devices
Air travel
Monitor pulse
Pacemaker ID card
Medic Alert ID

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Trouble shooting
Pacemakers
Monitor ECG for pacemaker malfunction
Failure to pace
Failure to capture
Failure to sense
Undersensing
Oversensing (underpacing)

Copyright 2014 by Mosby, an

imprint of Elsevier Inc.

Failure to Pace

Figure 7-61. Failure to pace/fire.

Copyright 2013, 2009, 2005, 2001, 1997,
1993 by Saunders, an imprint of Elsevier Inc.

30

Failure to Pace
Failure to pace (failure to fire):
Absence of pacing spikes and return of underlying
rhythm
Causes:
Action:
-Check connections of pacing wire/extension cable
attached to pulse generator
-Check/change pulse generator battery
-Replace pulse generator unit
-Remove source of electromagnetic interference

Failure to Capture

Figure 7-62. Failure to capture: ventricular

pacemaker.

Copyright 2013, 2009, 2005, 2001, 1997,

1993 by Saunders, an imprint of Elsevier Inc.

32

Failure to Capture

Failure to capture:

Pacemaker spikes not followed by P waves (electrode in atrium) or

QRS complexes (if electrode in ventricle)

Actions: Reposition patient to left side

Increase the output setting (mA) until
capture occurs

Failure to Sense
(Oversensing)

Figure 7-63. Failure to sense.

Copyright 2013, 2009, 2005, 2001, 1997,

1993 by Saunders, an imprint of Elsevier Inc.

34

Oversensing
Over-sensing:

Absence of pacing spikes

Action: Decrease sensitivity setting

Failure to Sense
(Undersensing)
Failure to sense:

Not sensing pts intrinsic electrical activity. Results in pacing spikes

that occur after or are unrelated to intrinsic rate.
Can result in R-on-T phenomenon, dangerous.

Action: Increase sensitivity setting

Replace pulse generator battery
Replace or reposition pacing lead

References
Aehlert, B. (2013). ECGs made easy. (5th ed.). St Louis,
MO: Elsevier Mosby.
Lewis, et al. (2013). Medical Surgical Nursing (9th ed.) St.
Louis: Elsevier.
Sole, M., Klein, D., Mosley M. (2013) Introduction to
critical care nursing (6th ed.) St Louis: Mosby.