Transcript Cardiovascular Therapeutic Management 2013

MS II
Objectives
 Describe the functions of a temporary pacemaker and
an implantable cardioverter-defibrillator.
(continued)
Temporary Pacemakers
 Electronic devices used to initiate the heartbeat when
the heart’s intrinsic rhythm cannot effectively generate
a rate adequate to support cardiac output
 Uses
 Temporarily
 Supportively
 Prophylactically
 Permanently
 Duration – until the condition responsible for the rate
or conduction disturbance resolves.
Indications
 Bradydysrhythmias
 Tachydysrhythmias
 Causes
 Drug toxicity
 Acute MI
 Acute Coronary Syndromes
 Following cardiac surgery
Pacemaker System
 Simple electrical circuit consisting
of a pulse generator and a pacing
lead with one, two or three
electrodes.
 Pulse generator is designed to
generate an electrical current that
travels through the pacing lead and
exits through an electrode (exposed
portion of the wire) that is in direct
contact with the heart.
 The electrical current initiates a
myocardial depolarization.
 The current returns to the pulse
generator to complete the circuit.
 Power source is a 9-volt alkaline
battery
Pacing Lead Systems
FIGURE 13-1 The Components of a Temporary Bipolar Transvenous Catheter. A, Singlechamber temporary
(external) pulse generator. B, Bridging cable. C, Pacing lead. D, Enlarged view of the pacing lead tip. (A,
Courtesy Medtronic Inc., Minneapolis, Minn.)
Pacing Routes
 Transcutaneous use of two large
skin electrodes
 One placed on the anterior
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chest the other on the
posterior chest
These are connected to an
external pulse generator
Rapid, noninvasive procedure
First line intervention that
nurses can initiate in the ACLS
algorithm – for the treatment
of symptomatic bradycardia
Used as an emergency shortterm therapy until the
situation resolves or another
route of pacing can be
established
Epicardial Pacing
 Insertion of temporary
epicardial pacing wires is a
routine procedure during
most cardiac surgical cases
 Ventricular and in some case
atrial pacing wires are loosely
sewn to the epicardium.
 The terminal wires are pulled
through the skin before the
chest is closed.
 These are removed several
days after surgery by gentle
traction at the skin surface
with minimal bleeding risk
Transvenous Pacing
http://rnbob.tripod.com/transven.htm
 Temporary – transvenous
endocardial pacing is
accomplished by
advancing a pacing
electrode wire through the
subclavian or internal
jugular and into the right
atrium or right ventricle.
 Insertion
 Fluoroscopy
 Through a pacing swan
 Through a central line
cordis
Pacing Modes
 Synchronous – pacemaker only delivers a stimulus
when the heart’s intrinsic pacemaker fails to function
at a predetermined rate.
 Atrial/Ventricular Pacing
 Most physiologic
 Mimics the sequential relationship between the atrium
and the ventricle
 Increases cardiac output
Pacing Modes
 Asynchronous pacing
 Fixed rate
 Ignores the patient’s intrinsic rate
 Used in emergencies when the patient is in asystole as a
life saving measure
 Sometimes used in the operating room when
electromagnetic interference from electrocautery and
other electrical equipment can interferer with normal
pacemaker function.
Nursing Care of the patient with an
emergent pacemaker
 Continuous ECG monitoring – patent IV access (two sites
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at least)
Set monitor on pacing to sense pacer energy or spikes
Assess vitals regularly depending on patient status
Assess perfusion – check a radial pulse while watching
the monitor. Does the pacer spike generate a pulse
Reassure the patient
Provide pain medication/sedation for a patient with
transcutaneous pacing
Prepare for transfer or for transvenous pacing/permanent
pacer insertion depending on the setting.
Permanent
Implanted
pacemaker
Paces the atrium and the
ventricle
Nursing Care of the patient with a
pacemaker
 Prevention of pacemaker
malfunction
 Assessment – ECG
monitoring
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Secure pacing leads and
bridging cable to the body
Secure the external pulse
generator

Have extra batteries
available
Stray electricity
 Protecting against micro-shock
 Even a small amount of stray
electrical current from other
equipment can precipitate
ventricular fibrillation a lethal
arrhythmia
 Nurses should wear rubber
gloves – non-latex variety
when caring for the patient
 Cover terminal pacing pins
with caps or gloves as well
 Use a non-electric grounded
bed
 Keep all electrical equipment
away from the bed
 Only rechargeable electric
razors
Pacemaker Problems
 Failure to Capture
 See page 222
 Failure to Pace
 See page 222
 Undersensing
 See page 222
 Oversensing
 See page 222
Risk for infection
 Assess site for s/s of infection – manifested by
 _______________________________________________
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 Endocarditis is a risk for a patient with epicardial
pacing wires in place
Myocardial Perforation
 Very rare but can occur
 Symptoms
 Rhythmic
hiccoughs
 Cardiac
Tamponade
Patient education temporary
pacemakers
 Instruct the patient to not handle the exposed portion
of the lead wire.
 Notify the nurse if the dressing over the insertions site
becomes soiled, wet, or dislodged.
 Done use any electrical devices brought in from home
that could interfere with pacemaker function.
 Restrict movement of the affected extremity to avoid
displacement.
http://missinglink.ucsf.edu/lm/p
acemaker_module/index.htm