Oxygenation: Cardiovascular : Permanent Pacemaker Care

Providing Permanent Pacemaker Care

Purpose

1. To care for a client with a permanent pacemaker, preoperatively and postoperatively, according to the standard of care.

Assessment

• Review client's medical history, medication history, and allergy status.
• Review the client's chart for a signed consent form and any special preoperative care.
• Postoperatively review the client's chart for the type of pacemaker. (See understanding pacemaker codes.)

Equipment

• Sphygmomanometer
• Stethoscope
• ECG monitor and strip-chart recorder
• Antiseptic ointment
• Clippers
• Sterile gauze dressing
• Hypoallergenic tape
• IV line

Procedure: Preoperative Care

1. Check the physician's order to confirm the exact timing and details for this procedure.
   Rationale: Verification of the order prevents potential errors.
2. Gather the necessary supplies.
3. Confirm the client's ID using two client identifiers according to your facility's policy. Verify the presence of an ID bracelet.
   Rationale: Checking identification ensures client safety through concept of correct procedure for correct client.
4. Confirm that the client or a responsible family member has signed the consent form and ask the client about allergies to anesthetics or iodine.
   Rationale: Confirmation of a signed consent for and allergies maintains client safety.
5. Provide privacy and explain the preoperative and postoperative care to the client. Provide and review literature from the manufacturer or the American Heart Association so that the client can learn about the pacemaker and how it works. Teach the client that, immediately after the procedure, he will have to limit motion on the surgical side.
   Rationale: Explaining procedure to client reduces anxiety and improves participation in care.
6. If the client is not in a hospital gown, assist him into one. Ask the client to remove all undergarments.
7. Remove nail polish, glasses, dentures, contact lenses, and other prostheses. Remove jewelry (a wedding ring may stay but wrap it with tape). Send valuables with the client's family or call security to secure the belongings.
   Rationale: These actions prevent loss of belongings and allow for visualization of nail beds.
8. Using a clipper, remove chest hair from the axilla to the midline and from the clavicle to the nipple line on the side selected by the physician.
   Rationale: Removing hair from surgical site prevents postoperative infection.
9. Establish an IV line at a keep-vein-open rate.
   Rationale: IV line will allow administration of sedatives and medications during procedure.
10. Obtain baseline vital signs and a baseline ECG, if not previously obtained.
    Rationale: A baseline ECG should be in medical record. If one is not present, call physician regarding an order. Preoperative ECG will be compared to postoperative ECG.
11. Provide sedation and any preoperative medications, as ordered.
    Rationale: Sedative medications may be given to help relax client. Confirm that consent is signed prior to administering any medications that can decrease a client's alertness.

Procedure: Postoperative Care

1. Wash your hands and don gloves.
   Rationale: Handwashing and gloves reduce transfer of microorganisms.
2. Monitor the client's ECG to check for arrhythmias and to ensure correct pacemaker functioning. Assess vital signs and level of consciousness (LOC).
   Rationale: Monitoring and assessment allow for early detection of postoperative complications.
3. Monitor the IV flow rate; the IV line is usually kept in place for 24 to 48 hours postoperatively.
   Rationale: Monitoring IV allows for possible emergency treatment of arrhythmias
4. Assess the dressing for signs of bleeding and infection (swelling, redness, or exudate). Prophylactic antibiotics may be ordered for up to 7 days after implantation.
   Rationale: Frequent site assessments and antibiotics aid in the prevention of infection.
5. Check the physician's orders for postoperative orders. Confirm that a chest X-ray and ECG were ordered and completed after the procedure.
   Rationale: A chest X-ray is performed after procedure to rule out that a pneumothorax did not occur during procedure. Often, two ECGs are requested postoperatively, one with a magnet and one without. The ECG with the magnet checks settings of pacemaker. ECG without magnet checks current functioning of heart.
6. Check vital signs and LOC every 15 minutes for the first 1 hour, every hour for the next 4 hours, every 4 hours for the next 48 hours, and then once every shift.
   Rationale: Checking vital signs and LOC allows for early detection of postoperative complications.
7. Change the dressing and apply antiseptic ointment at least once every 24 to 48 hours, or according to physician’s orders and your facility’s policy. If the dressing becomes soiled or the site is exposed to air, change the dressing immediately.
   Rationale: Prevents site contamination.
8. Document the type of pacemaker used and the pacing rate. Note whether the pacemaker successfully treated the client's arrhythmias and the condition of the incision site.

Sample Documentation
10/12/10	1530	Client returned from PACU. A DDD pacemaker inserted, set at 80, client’s heart rate is 80 paced in both the atrium and ventricles. Client is awake, alert, and oriented times three. Vital signs as per flow sheet. Client denies pain, left arm is immobilized in a sling, left chest dressing is CDI, ice applied to incision site. S. Roberts, RN

Lifespan Considerations

• Confused, elderly clients with second-degree heart block will not show immediate improvement in LOC.

Home Care Considerations

• Provide the client with an ID card that lists the pacemaker type and manufacturer, serial number, pacemaker rate setting, date the pacemaker was implanted, and the physician's name. (See Teaching the Client who has a Permanent Pacemaker.) Watch for signs of pacemaker malfunction.

Complications

• Watch for signs and symptoms of a perforated ventricle with resultant cardiac tamponade: persistent hiccups, distant heart sounds, pulsus paradoxus, hypotension with narrow pulse pressure, increased venous pressure, cyanosis, distended neck veins, decreased urine output, restlessness, or complaints of fullness in the chest. If the client develops any of these, notify the physician immediately.
• Insertion of a permanent pacemaker places the client at risk for certain complications, such as infection, lead displacement, a perforated ventricle, cardiac tamponade, or a lead fracture and disconnection.

UNDERSTANDING PACEMAKER CODES
A permanent pacemaker's three-letter (or sometimes five-letter) code simply refers to how it is programmed. The first letter represents the chamber that is paced; the second letter, the chamber that is sensed; and the third letter, how the pulse generator responds. The fourth letter denotes the pacemaker's programmability; the fifth letter denotes the pacemaker's response to a tachyarrhythmia. Typically, only the first three letters are shown.
First letter A = atrium V = ventricle D = dual (both chambers) O = not applicable	Second letter A = atrium V = ventricle D = dual (both chambers) O = not applicable	Third letter I = inhibited T = triggered D = dual (inhibited and triggered) O = not applicable
Fourth letter P = basic functions programmable M = multiprogrammable parameters C = communicating functions such as telemetry R = rate responsiveness - rate adjusts to fit the client's metabolic needs O = none	Fifth letter P = pacing ability S = shock D = dual ability to shock and pace O = none
Examples of two common programming codes:
DDD   Pace: atrium and ventricle Sense: atrium and ventricle Response: Inhibited and triggered This is a fully automatic, or universal, pacemaker.	VVI   Pace: ventricle Sense: ventricle Response: inhibited This is a demand pacemaker, inhibited.

CLIENT TEACHING TEACHING THE CLIENT WHO HAS A PERMANENT PACEMAKER

If the client is going home with a permanent pacemaker, make sure to teach him about daily care, safety and activity guidelines, and other precautions. Daily care Clean your pacemaker site gently with soap and water when you take a shower or a bath. Leave the incision exposed to the air. Inspect your skin around the incision. A slight bulge is normal, but call your physician if you feel discomfort or notice swelling, redness, a discharge, or other problems. Check your pulse for 1 minute as your nurse or physician showed you—on the side of your neck, inside your elbow, or on the thumb side of your wrist. Your pulse rate should be the same as your pacemaker rate or faster. Contact your physician if you think your heart is beating too fast or too slow. Take your medications, including those for pain, as prescribed. Even with a pacemaker, you still need the medication your physician ordered. Safety and activity Keep your pacemaker instruction booklet handy and carry your pacemaker ID card at all times. This card has your pacemaker model number and other information needed by health care personnel who treat you. You can resume most of your usual activities when you feel comfortable doing so. Do not drive until your physician gives you permission. Avoid heavy lifting and stretching exercises for at least 6 to 8 weeks or as directed by your physician. Try to use both arms equally to prevent stiffness. Check with your physician before you golf, swim, play tennis, or perform other strenuous activities. Electromagnetic interference Today's pacemakers are designed and insulated to eliminate most electrical interference. You can safely operate common household electrical devices, including microwave ovens, razors, and sewing machines. You can ride in or operate a motor vehicle without it affecting your pacemaker. Take care to avoid direct contact with large running motors, high-powered CB radios and other similar equipment, welding machinery, and radar devices. If your pacemaker activates the metal detector in an airport, show your pacemaker ID card to the security official. Because the metal in your pacemaker makes you ineligible for certain diagnostic studies, such as magnetic resonance imaging, be sure to inform your physicians, dentist, and other health care personnel that you have a pacemaker. Special precautions If you feel lightheaded or dizzy when you are near any electrical equipment, moving away from the device should restore normal pacemaker function. Ask your physician about particular electrical devices. Notify your physician if you experience any signs of pacemaker failure, such as palpitations, a fast heart rate, a slow heart rate (5 to 10 beats less than the pacemaker's setting), dizziness, fainting, shortness of breath, swollen ankles or feet, anxiety, forgetfulness, or confusion. If you feel like you are going to faint, immediately call 911 and lie down to prevent falling. Checkups Be sure to schedule a follow-up visit and keep regular checkup appointments with your physician. If your physician checks your pacemaker status by telephone, keep your transmission schedule and instructions in a handy place.