1. General information
    1. A pacemaker is an electronic device that provides repetitive electrical stimulation to the heart muscle to control the heart rate.
    2. Artificial pacing system consists of a battery-powered generator and a pacing wire that delivers the stimulus to the heart.
  2. Indications for use
    1. Adams-Stokes attack
    2. Acute MI with Mobitz II AV block
    3. Third-degree AV block with slow ventricular rate
    4. Right bundle branch block
    5. New left bundle branch block
    6. Symptomatic sinus bradycardia
    7. Sick sinus syndrome
    8. Arrhythmias (during or after cardiac surgery)
    9. Drug-resistant tachyarrhythmia
  3. Modes of pacing
    1. Fixed rate: pacemaker fires electrical stimuli at preset rate, regardless of the client's rate and rhythm.
    2. Demand: pacemaker produces electrical stimuli only when the client's own heart rate drops below the preset rate per minute on the generator.
  4. Types of pacemakers
    1. Temporary
      1. Used in emergency situations and performed via an endocardial (transvenous) or transthoracic approach to the myocardium.
      2. Performed at bedside or using fluoroscopy.
    2. Permanent
      1. Endocardial or transvenous procedure involves passing endocardial lead into right ventricle with subcutaneous implantation of pulse generator into right or left subclavian areas. Usually done under local anesthesia.
      2. Epicardial or myocardial method involves passing the electrode transthoracically to the myocardium where it is sutured in place. The pulse generator is implanted into the abdominal wall.
  5. Nursing interventions
    1. Assess pacemaker function
      1. Monitor heart rate, noting deviations from the preset rate.
      2. Observe the presence of pacemaker spikes on ECG tracing or cardiac monitor; spike before P wave with atrial pacemaker; spike before QRS complex with ventricular pacemaker
      3. Assess for signs of pacemaker malfunction, such as weakness, fainting, dizziness, or hypotension.
    2. Maintain the integrity of the system
      1. Ensure that catheter terminals are attached securely to the pulse generator (temporary pacemaker)
      2. Attach pulse generator to client securely to prevent accidental dislodgment (temporary pacemaker)
    3. Provide safety and comfort
      1. Provide safe environment by properly grounding all equipment in the room.
      2. Monitor electrolyte level periodically, particularly potassium.
    4. Prevent infection
      1. Assess vital signs, particularly temperature changes.
      2. Assess catheter insertion site daily for signs of infection.
      3. Maintain sterile dressing over catheter insertion site.
  6. Provide client teaching and discharge planning concerning
    1. Fundamental concepts of cardiac physiology
    2. Daily pulse check for one minute
    3. Need to report immediately any sudden slowing or increase in pulse rate
    4. Importance of adhering to weekly monitoring schedule during first month after implantation and when battery depletion is anticipated (depending on type of battery)
    5. Wear loose-fitting clothing around the area of the pacemaker for comfort
    6. Notify physician of any pain or redness over incision site
    7. Avoid trauma to area of pulse generator
    8. Avoid heavy contact sports
    9. Carry an identification card/bracelet that indicates physician's name, type and model number of pacemaker, manufacturer's name, pacemaker rate
    10. Display identification card and request scanning by hand scanner when going through weapons detector at airport
    11. Remember that periodic hospitalization is necessary for battery changes/pacemaker unit replacement