PACEMAKER VS THEIR TYPES, NURSING MANAGEMENT

 DEFINATION OF PACEMAKER 

Pacemakers are the electrode devices that can be used to initiate the heartbeat when the hearts intrinsic electrical system cannot effectively generate a rate adequate to support cardiac output.3.  Pacemakers is an electronic device used to pace the heart when the normal conduction pathway is damaged or diseased

HOW PACEMAKER WORKS ?

 A pacemaker consists of a battery, a computerized generator and wires with sensors at their tips(called as electrodes). The battery powers the generator and both are surrounded by a thin metal box. The wires connect the generator to the heart.

  A pacemaker helps monitor and control the heartbeat. The electrodes detect heart’s electrical activity and send data through the wires to the computer in the generator. If heart rhythm is abnormal, the computer will direct the generator to send electrical pulses to heart. The pulses travel through the wires to reach the heart.

 TYPES OF PACEMAKER 

a) Permanent pacemaker 

b)Temporary pacemaker

PERMANENT PACEMAKER 

*IT Implanted totally in the body.

* Power source is implanted subcutaneously usually over the pectoral muscle on the patient non dominant side.

TYPES OF PERMANENT PACEMAKER 

1.Single-chamber pacemaker. 

In this type, only one pacing lead is placed into a chamber of the heart, either the atrium or the ventricle

2.Dual-chamber pacemaker.

Wires are placed in two chambers of the heart

* One lead paces the atrium and one paces the ventricle 

* Closely resembles the natural pacing of the heart.

3.Rate-responsive pacemaker.

*It has sensors that detect changes in the patient's physical activity and automatically adjust the pacing rate to fulfill the body's metabolic needs.

INDICATION OF PERMANENT PACEMAKER 

*Chronic atrial fibrillation with slow ventricular response Hypersensitive carotid sinus syndrome

*Fibrosis or sclerotic changes of cardiac conduction system

* Sick sinus syndrome *Tachyarrhythmia

* Third degree AV block

TEMPORARY PACEMAKERS 

*It is one that has the power source outside the body.

* There are 3 types of temporary pacemaker. 

1.Transvenous invasive pacemaker (endocardial) 

*It consists of lead or leads that are threaded transvenously to the right atrium and or right ventricle and attached to external power source.

2.Transthoracic invasive pacing(Epicardial pacing ) 

It is achieved by attaching an atrial and ventricle and attached to epicardium during heart surgery . The leads are passed through the chest wall and attached to the external power source.

3. Trans cutaneous pacemaker(Non-invasive pacing)  It is used to provide adequate heart rate and rhythm to the patient in and emergency situation.

INDICATION OF TEMPORARY PACEMAKER 

 *Maintenance of adequate heart rate and rhythm during special circumstances such as surgery and postoperative recovery, cardiac catheterization or coronary angioplasty . *Before implantation of a permanent pacemaker.

*As prophylaxis after open heart surgery.  Acute anterior MI with second degree or third degree AV block or bundle branch block.

*Acute inferior MI with symptomatic bradycardia and AV block

NURSING MANAGEMENT IN PACEMAKER 

PREOPERATIVE CARE 

(a)Financial 

 *Explain the procedure ,type and technique of pacemaker to the patient 

* Explain Cost of the procedure and Hospital stay.

(b) Psychological 

* Explain the Process of the pacemaker insertion . 

*Reassure the patient

(c) Physical 

* Obtain written consent from the patient and from nearest relative 

* Remove dentures,jewellery and contact lens. 

*Clean and shave the area . 

* Check vital signs: temperature, BP, pulse and respiration

INTRAOPERATIVE CARE 

* Check serology: HIV, HbsAg, HCV and others 

*Start an IV line with 5% Dextrose solution or normal saline solution. 

*Check the battery in pulse generator

* Prepare the emergency cart, the defibrillator and jelly , and the ECG monitor

 * Set up all equipment for the insertion of the pacemaker

*The nurse should know about the pacemaker generator including the power switch, indicator light for pacing and sensing, stimulus output dial, sensitivity dial, and their proper settings.

*Assist the doctor and the scrub nurse during the procedure step by step

* Observe vital signs and observe ECG monitor carefully for arrhythmias and other complications.

POST OPERATIVE CARE 

* Receive the patient *Keep the patient in comfort position 

* Record the pacing parameters.

Receiving time -patient’s heart rate  -Other routine care

*Immobilize the affected part and keep in supine position but allow the movement of finger and ankle joint.

* Monitor heart rate and rhythm.

* Monitor vitals signs and level of consciousness of patient. 

*Prevent infection. 

* Take ECG and X-ray chest.. 

*Watch for complications

PATENT AND FAMILY TEACHING 

*Maintain follow up care with a physician to check the pacemaker site and begin regular pacemaker function checks . 

*Watch for signs of infection at incision site redness, swelling dressing.

* Keep incision dry for 1 week after implantation. 

*Avoid lifting operative side arm above shoulder level until approved by care provider.

*Avoid direct blows to generators or to large magnets such as MRI scanner . These device can reprogram a pacemaker. 

* Microwave oven are safe to use and do not threaten pacemaker function.

* The patient should be taught how to take the pulse . 

* Carry pacemaker information card at all the times.