Pacemaker Indications - ANS-arrhythmia or conduction defect compromise electrical system and hemodynamic response ex.) heart block Pacemaker Teaching - ANS-1. carry pacemaker ID care that has brand and model of pacemaker, date of insertion, implanting physician, and manufacturer contact info 2. take pulse once daily after awakening 3. report pulse 5 beats/minute different than programed setting 4. be mindful of return of symptom you experienced before pacemaker implantation 5. follow-up to avoid battery depletion and no replacement Pacemaker Capture - ANS-indicates depolarization of atria or ventricle in response to pacing stimulus Pacing Threshold - ANS-minimal amount of voltage required from pacemaker to initiate consistent capture Pacemaker: *Failure to Discharge* - ANS-problem: no evidence of pacing stimulus, patient's HR below programed rate causes: *battery depletion*, pulse generator failure, circuit failure, loos cable connection intervene: replace battery or generator, check all connections for tightness Pacemaker: *Failure to Capture* - ANS-problem: pacing stimulus not followed by ECG evidence of depolarization causes: *lead dislodgment*, broken cables, incompatible cables, output settings (mA) too low, perforation, increase in pacing threshold related to medication or metabolic changes intervene: review chest film, turn patient to left lateral decubitus position until lead can be replaced, connect wire directly to eliminate cable problem, replace cables, ensure tight connection, review ECG for perforation, review lab results for metabolic alterations and medications Pacemaker: *Oversensing* - ANS-definition: device detects noncardiac electrical events and interprets them as depolarization causes: oversensitive settings, device detecting tall T waves and interpreting them as R waves intervene: reduce sensitivity, increase ventricular refractor period beyond T waves Pacemaker: *Undersensing* - ANS-definition: device fails to detect intrinsic cardiac activity and fires inappropriately causes: asynchronous mode settings, small intrinsic amplitude, lead dislodgment, lead insulation break intervene: reprogram to synchronous mode, increase sensitivity Pacemaker: sign of failure - ANS--unexplained dizzy spells, fatigue, or slow pulse -decreased perfusion to brain, heart, or skeletal muscles -be mindful of symptoms you experienced before pacemaker implantation Pacemaker Complications - ANS-1. pneumothorax 2. ventricular irritability 3. perforation of ventricular wall or septum 4. catheter or lead dislodgement 5. infection and phlebitis 6. hematoma formation 7. abdominal twitching or hiccups 8. pocket erosion A patient is experiencing a malfunction with his permanent implanted pacemaker, and the nurse is examining his electrocardiogram strip. The patients pacemaker has a ventricular unipolar catheter and is in VVI mode. Which of the following findings should the nurse be most concerned about? A) Pacing spikes absent B) Pacing spike followed by a QRS complex C) Tall pacing spikes D) A narrow QRS - ANS-A) Pacing spikes absent A patient has a permanent pacemaker and complains of redness and swelling over the site of the generator implantation. The patient also has fever and leukocytosis. What is the most appropriate nursing action? A) Assess for any patient action causing pressure on the site. B) Assure the patient that these are signs of normal healing. C) Ensure that pacemaker is working correctly. D) Facilitate administration of intravenous antibiotics. - ANS-D) Facilitate administration of intravenous antibiotics. The patient has a newly inserted VVI pacemaker set at a demand rate of 70. What cardiac monitor reading, if found by the nurse, most indicates a pacemaker malfunction? A) Patient pulse is 75 with no pacing stimuli seen on cardiac monitor. B) Patient pulse is 70 with pacing stimulus seen before each R wave. C) Patient pulse is 65 with no pacing stimuli seen on cardiac monitor. D) Patient pulse is irregular with pacing stimuli seen before some R waves. - ANS-C) Patient pulse is 65 with no pacing stimuli seen on cardiac monitor. A patient who had a transvenous pacemaker placed in the subclavian vein 24 hours ago is experiencing pleuritic pain, hypotension, and respiratory distress. What complication does the nurse suspect in this patient? A) Perforation of ventricular wall B) Pneumothorax C) Lead dislodgment D) Phlebitis - ANS-B) Pneumothorax The patient recently experienced a Myocardial Infarction and is considering placement of a pacemaker. The patient asks the nurse why he needs a pacemaker. Which of the following is the most accurate and appropriate response by the nurse? A. Although your heart is fine now, a pacemaker will prevent another heart attack. B. The heart needs to be shocked to increase the strength of each contraction. C. Your heart's muscle has been damaged and needs time to heal. D. The heart attack damaged your heart's ability to stimulate regular heart beats. - ANSD. The heart attack damaged your heart's ability to stimulate regular heart beats. Rationale: Cardiac pacing is most commonly indicated for conditions that result in failure of the heart to initiate or conduct an intrinsic electrical impulse at a rate adequate to maintain perfusion. Pacemakers are necessary when arrhythmias or conduction defects compromise the electrical system and the hemodynamic response of the heart. Implantable Cardioverter Defibrillator (ICD) Indications - ANS-1. ventricular tachycardia 2. ventricular fibrillation 3. LV dysfunction with EF less than 35% 4. cardiomyopathy ICD Functioning - ANS-tiered therapy approach: 1. antitachycardia pacing (ATP) 2. synchronized cardioversion 3. defibrillation (6 attempts max) functions first as a defibrillator, second as a pacemaker ICD Teaching - ANS-1. carry ICD identification card 2. safety electrical precautions 3. call physician immediately if you get more than one shock or several in succession