IDENTIFICATION DATA OF THE PATIENT

 Name of Patient : Mrs. Sangitaben D. Kanzariya

 Age : 52 year

 Gender : Male

 Education : 8th pass

 Occupation : Labour work

 Marital Status : Married

 Monthly income :

 Religion : Hindu

 Mother Tongue : Gujarati

 OPD no. : 457458

 IPD no. : 00262

 Date of Admission :

 Address : Virpur

 Clinical Area / Department :

 Diagnosis : Mayocardial Infarction

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 PACEMAKER INSERTION

 PACEMAKER INSERTION:
A pacemaker insertion is the implantation of a
small electronic device (artificial pacemaker) that is usually placed in
the chest (just below the collarbone) to help regulate the heart rate in
those patient who have temporary or permanent dysrhythmias.

 DEFINITION OF PACEMAKER:

An artificial pacemaker is a mechanical device that

electronically stimulates impulse initiation within the heart. The
artificial pacing system consists of a pulse generator and a pacing
wire that delivers the stimulus to the heart to control rate. The pacing
unit initiates and maintains the heart rate when the natural
pacemakers of the heart are unable to do so.

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 PURPOSES:
• To correctly pace the heart.

• To slow the heart.

• To correct abnormal rhythm.

• To coordinate electrical signaling between the ventricles.

• To coordinate electrical signaling between the upper and lower

chambers of the heart.

 INDICATIONS
• Arrhythmias—Atrial fibrillation

• Bradycardia

• Certain congenital heart disorders

• Heart failure with ejection fraction less than 35%

• Heart transplants

• History of cardiac arrest

• Long QT syndrome

• Syncope

• Tachycardia

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 COMPONENTS OF PACEMAKER:

1. Pulse Generator (Pacemaker box)

The pacemaker box is made up of several different parts including
the power supply (the battery) and the electronic circuit. It contains
special software and memory so that it can monitor and store
information about your heart rhythm and heart rate. It also has a
special circuit that allows the pacemaker to be checked and altered
by a computer at the hospital.

2. Electrode leads
These leads are thin pieces of insulated wire that deliver electrical
impulses to and from the heart.

 Types of pacemaker according to leads:

 single-chamber pacemakers:

Pacemakers with one lead are called single-chamber pacemakers.

They have only one lead that goes to right ventricle and right atrium

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  Dual-chamber pacemakers:

Pacemakers with two leads are called dual-chamber pacemakers.

They have two leads goes to right ventricle and right atrium.

 Bi-ventricular pacemakers:

Pacemakers with three leads are called bi-ventricular pacemakers.

They have three leads goes to right atrium, right ventricle and left
ventricle.

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  Mode of pacing:

There are two modes of artificial pacing :

1. Fixed mode: In the fixed rate mode, the pacemaker fires electrical
stimuli at a preset rate regardless of the person's inherent rhythm.
Asynchronous pacing is rarely used.

2. Demand mode: The most popular mode is demand or standby.

The electrode at the tip of the pacing wires able to sense the
person's heart beats. The pacemaker produces a stimulus only
when the persons own heart rate drops below the rate per minute
preset on the generator by the physician.

 METHODS OF INSRTION OF PAEMALKRS:

1. Transvenous implantation:
Also called endocardial implantation. The pacemaker is usually
implanted on your left side, as this is closer to the heart and allows
for the wires to be inserted easily into the heart.

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2. Epicardial implantation:
Here, the electrode lead is attached directly onto the outer surface of
the heart – the epicardium – through a small incision (cut) in the wall
of your abdomen or chest. The pacemaker box is often placed under
the skin of abdomen.

 TYPES OF PACEMAKERS:
Depening on the condition of the patient the pacemaker may be two
type:

1 Temporary pacemakers :
These are intended for short-term use during hospitalization. Are
used to support patients until they improve or reserve a Permanent
pacemakers.

• Epicardial wires and the endocardial may be Temporary.

• They are located outside the body, and may be taped tox
the skin or attached to a belt or to the patient's bed.
• The Temporary generator size is about the size of a small
paperback book.

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 2 Permanent pacemakers:
Permanent pacemakers are pacemakers that are intended for long
term use.

• Endocardial leads are permenant pacemakers

• The generator implanted in a subcutaneous pocket.
• They last approximately 6 to 12 years.
• The permanent generator it weighs less than 1 oz and is the size of
a thick

 TEMPORARY TRANSVNOUS PACEMAKER

IMPLANTATION PROCEDURE:

Definition:

 Temporary pacing is used in emergent or elective situations

that require limited, short-term pacing.

Equipment:

• Antiseptic skin preparation solution (e.g., 2% chlorhexidine-

based solution)
• Sterile drapes, gloves and gowns, and towels
• Masks, head cover, goggles, or face shields
• Balloon-tipped pacing catheter and insertion tray
• Pacing lead wire
• Pulse generator

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• 9-V battery for pulse generator
• Connecting cables
• Alligator clips or wires with connecting pins
• ECG monitor and recorder
• Supplies for dressing at insertion site
Additional equipment, to have available as needed, includes
the following:
• Local anesthetic
• Percutaneous introducer needle or 14-gauge needle
• Introducer sheath with dilator
• Guidewire (per physician or advanced practice nurse choice)
• Suture, syringes, needles, and scalpel
• Emergency equipment (i.e., automated external defi brilla-
tor [AED], defi brillator)
• Portable ultrasound scan equipment
• Fluoroscopy
• Lead aprons or shields
• 12-lead ECG machine

 Pre-temporary Pacemaker Care:

 Explain procedure and purpose

 Get consent from patient/relative
 Gather equipment required
 Check functioning of external pulse generator
 Assess vital signs and obtain rhythm strip
 Monitor ECG and vital signs continuously.

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  PROCEDURE OF TEMPORARY TRANSENOUS PACEMAKER INSRTION:
Steps of procedure Rationale

 1. HH 
2. PE 
3. Connect the patient to the bedside monitoring system, 3. Monitors the patient’s intrinsic heart rate and rhythm
and monitor the ECG continuously during and after the procedure to evaluate for adequate
rate and pacemaker function. 
 4. Dispose of used supplies and wash hands.   4. Minimizes the risk of infection. 
 5. Check the placement of the central venous access with 5. Central venous access is needed as the transvenous
chest radiography before starting the procedure.   pacing catheter is passed through the central venous
  system. 
6. Assess functioning of the temporary pacemaker, 6. Ensures a functional pacemaker pulse generator. 
and insert a new battery  into the pulse generator before.
 beginning therapy.  
7. Attach the connecting cable to the pulse generator, 7 Prepares the pacing system; the pacing stimulus travels
Connecting the “positive” on the cable to the “positive” from the pulse generator to the negative terminal, and
on the pulse generator and  the “negative” on the energy returns to the pulse generator via the positive
cable to the  “negative” on the pulse generator.  terminal. 

8. All personnel performing and assisting with the procedure 8. Minimizes the risk of infection and maintains standard
should wash hands and apply PE and sterile equipment  and sterile precautions. 
(e.g., masks, head covers, goggles or face shields, sterile
gowns, and gloves).  
 

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  continue...

Steps of procedure Rationale

9. Cleanse the site with antiseptic solution (e.g., 2% 9. Minimizes the risk of infection.
Chlorhexidine -based preparation).  
10. Provides a sterile field and reduces the transmission
10. Drape the site with the sterile drapes. of microorganisms.

11. Insert the balloon-tipped pacing catheter through the

introducer, and slowly advance the pacing lead, using the
following insertion technique:
*Fluoroscopy may be needed to permit direct
*Fluoroscopy guided technique: visualization of the pacing electrode.

i. Obtain fluoroscopy equipment.

ii. Continue advancing the pacing] lead.
iii. The balloon can be inflated when the tip of the pacing
lead can be visualized in the vena cava.
iv. Advance the pacing catheter to the desired intracardiac
position guided by fluoroscopy.

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 Continue...

Steps of procedure Rationale

12. After the electrodes are properly positioned: 12. Energy from the pulse generator is directed to the
negative electrode in contact with the ventricle.
A. Deflate the balloon.
The pacing circuit is completed as energy reaches the
B. Connect the pacing lead external electrode pins to the
positive electrode.
pulse generator via the connecting cables.
C. Ensure that the positive and negative electrodes are The lead wires must be connected securely to the
connected to the respective positive and negative pacemaker to ensure appropriate sensing and capture
terminals on the pulse generator via the connecting and to prevent inadvertent disconnection.
cables.

13. Set the pacemaker settings and initiate pacing

13. Initiates pacemaker therapy.
14. Suture the pacing lead in place
14. Minimizes the risk of dislodgment.
15. Apply a sterile occlusive dressing over the site. 15. Minimizes the risk of infection

16. Secure the pacemaker equipment such as strapping 16. The pulse generator should be protected from
the pulse generator to the patient ’ s torso or securing falling or becoming inadvertently detached by patient
the pulse generator in a carrying device. movement

17. Remove PE and discard used supplies in appropriate 17. Reduces the transmission of microorganisms;
receptacles Standard Precautions.
18. HH

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 After Care:

 Assess vital signs and emotional reactions to procedure

 Secure and check all connections
 Monitor battery and control setting
 Clean and dress incision site
 Keep pulse generator from electromagnetic interference
 Protect pulse generator from electromagnetic interference
 Check electrical equipment for adequate grounding
 Limit movement of extremity at insertion
 Stabilize arm, catheter and pacemaker to an arm board and
avoid movement of arm above shoulder level
 Do not lift patient from under arm
 If removal vein is used, limit movement of affected leg especially
hip flexion and outward rotation.
 Monitor pacemaker function
 Document location and type of pacing lead
 Instruct patient to report syncope, palpitation, light headedness
or chest pain.

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 PERMANENT PACEMAKER IMPLANTATION

Definition:

 Pacemaker is an electronic device that provides repetitive electrical

stimuli to heart muscles. Permanent pacemaker implantation (PPI)
is a procedure in which pacemaker is implanted surgically in the
deltopectoral pouch when conduction defect is irreversible

Purpose:

 To transmit impulses from sinus node to ventricles

 To generate impulses spontaneously
 To maintain primary control of pacing function of heart.

Equipment:

 Electronic cardiac monitor Pacemaker

 Catheters
 PPI tray with articles such as forceps,
 scissors,
 retractors
 Local anesthesia.
 scalpel blade,
 cleaning solution
 Dynaplast and emergency resuscitation equipment.

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 Pre – PPI Care:

 Explain procedure to patient and relative with help of audiovisual

aids and handouts Get consent for procedure
 Explain that procedure will be performed in cardiac catheterization
laboratory and patient will be transferred to CCU for 1 day for close
monitoring
 Explain about starvation required for 8 to 10 hours prior to
procedure
 Enquire whether patient has allergy to drug or food and report to
doctor if any
 Shave following areas:
 Anterior chest from neck to umbilicus
 Nape of neck to loins of back
 Both arms and axilla
 Advise to take bath with antiseptic scrub and water for 2 days before
procedure and on day of procedure
 Provide clean gown Remove jewellery, dentures/contact lens if any.
Start IV line with heparin lock
 Administer pre-medications and first dose of antibiotics Explain that
one relative can stay in CCU waiting area
 Send patient to cath lab with following items:
Normal saline 1 pint, disposable needle 21G. Dynaplast 1 roll,
Betadine solution 100 ml x 2 bottles, injection gentamicin and
injection cefazolin 1 dose, if not administered with premeditation.

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 Post PM Care:

 Keep patient in supine position and ask to maintain adduction of

affected extremity
 Explain about bed rest for 24 hours and reduced activity for another
48 hours
 Connect patient to cardiac monitor and check rhythm
 Take 12 leak ECG with and without magnet
 Check wound for excess swelling or bleeding
 Get chest X-ray done
 Be alert for complications Bleeding
 Infections
 Cardiac tamponade
 Diaphragm stimulation
 Failure to capture.
 Inform the doctor if any complication occurs
 Check vital signs and observe wound hourly 4 hours then if stable, 4
hourly for 24 hours
 Discourage patient from vomiting, coughing or rolling into affected
side
 Patient may gently roll into left side for pressures are care
 Roll a patient immediately onto left side, if failure. to capture occurs.
If unsuccessful and patient is asymptomatic inform and administer IV
atropine 0.6 mg as ordered
 Allow the patient to sit up slightly to eat (30-45 degrees) Administer
analgesic as ordered
 Administer IV antibiotics usually 3 doses then remove
 Transfer to ward after 12 to 24
 Remove tight bandage after 48 hours and change dressing if required
 Allow to walk after 48 to 72 hours of rest
 Assist and encourage beginning range of motion exercises for
affected shoulder as ordered, usually to 7 hours after pacemaker
insertion
 Remove suture after 72 hours and patient is discharged with proper
follow-up arranged Patient usually does not require any follow-up
drags.
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Patient Education:

 Report to physician as recommended, so that of pacemaker and

its function can be monitored. This is especially important
during first month after implantation
 Check pulse daily. Report immediately of any sudden slowing
increasing of pulse rate occurs. This may indicate pacemaker
malfunction
 Resume weekly monitoring when battery depletion anticipated
 Wear loose fitting clothing around area of pacemaker
 Inform reason for slight bulge over implantation site
 Notify physician if area becomes red or painful
 Avoid trauma to area of pacemaker
 Study operating instructions and become familiar sods
 Resume normal physical activity after 6 weeks, including
pacemaker sexual activity
 Avoid moving affected hand and shoulder vigorously for 6
weeks Avoid heavy sport
 Avoid carrying 5-10 pounds weight on affected side. Carry an
identification card indicating manufactur name, pacemaker
model and hospital where pacemaker was inserted
 Avoid close exposure to microwave ovens, MRI and other
sources of magnetic fields.
 Show identification card and request scanning by hand
scanner when passing through security gates, e.g. airports,
government buildings
 Avoid using cell phone on same side where implantaties has
been done.

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