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Pacemakers & ICDs.
Terms in this set (83)
What does ICD stand for?
Implantable Cardioverter Defibrillator.
How does a pacemaker work?
Paces the heart muscles by providing an electrical impulse.
What is the function of a pacemaker?
Provides an electrical impulse in the absence of a heart's normal conduction system.
How does a pacemaker present on an EKG?
The pacemaker impulse is seen as a spike followed by a P wave and/or QRS complex.
If the pacemaker spike is seen right before the P wave, what does this indicate?
Atrial pacing; atrial response.
If the pacemaker spike is seen right before the QRS complex, what does this indicate?
Ventricular pacing; ventricular response.
What are the three kinds of temporary pacing?
What is permanent pacing?
An implanted device that contains batteries.
How long do pacemaker batteries generally last?
About 10 years.
What is transcutaneous pacing?
AED pads are placed on the outside of the body to deliver the pacing.
What is transvenous pacing?
A jugular pacing lead is inserted through the venous system and into the heart.
What is epicardial pacing?
Electrodes are placed on the outside of the heart but are internal; the leads will exit the body on the outside of the client's chest.
For how long are transvenous and/or epicardial pacing used?
3 days or less; used for urgent situations.
In regards to the temporary pacemaker generator, what does the AV delay mimic?
What are some uses for a temporary pacemaker?
1. Drug toxicity.
2. Post MI.
3. After open heart surgery.
What should a nurse do every shift for a client who has a temporary pacemaker?
1. Check the underlying rhythm.
2. Change the battery to the generator.
What physical limitations should a client with temporary pacing be placed on?
Bed rest unless the client is receiving epicardial pacing and is able to move.
What is epicardial pacing fixed to?
Where does a transvenous lead sit?
On the right ventricle.
Where are the leads for epicardial pacing placed?
What are the colors of the leads for epicardial pacing?
White and Peach (both dark and pale peach).
What charge is the pale peach epicardial lead?
What charge is the dark peach epicardial lead?
What color is the atrial epicardial lead?
Which parts of the heart can a permanent pacemaker pace?
Atria and Ventricles.
What are the types of permanent pacemakers?
1. Single Chamber
2. Dual Chamber
4. Rate Adaptive
What are biventricular permanent pacemakers used for?
Poor left ventricle (LV) function.
A lead can be either . . .
Unipolar or bipolar.
How common are rate adaptive permanent pacemakers?
Not very common; not seen a lot.
How do rate adaptive permanent pacemakers work?
They sense the electrical impulses of the heart and change the rates of the pacemaker as needed.
What are single chamber permanent pacemakers used for?
For poor atrial and/or ventricular function.
What type of telemedicine can be used for permanent pacemakers?
The parameters of the permanent pacemaker can be tested; the client calls a number and holds the phone to the pacemaker and the pacemaker can be read; detects issues with rate settings, battery life, etc.
What education/instructions should you inform patients of who have had or will have a permanent pacemaker placed?
1. No MRIs or high magnetic field exposure.
2. No pushing or pulling for 6-8 weeks after insertion.
3. They will be sedated locally in the cath lab for insertion.
4. Wound care (to prevent infection).
5. Carry card or have bracelet on at all times, especially when going to the airport.
6. Monitoring/telemedicine phonecalls to check on rate, battery, etc.
7. Symptoms to report to the provider.
What should a client who has had a permanent pacemaker placed not push or pull anything for 6-8 weeks after insertion?
The client could pull the leads out by pushing and pulling motions.
On what side of the client's heart is a permanent pacemaker normally placed?
The left side.
What conditions may necessitate a client needing pacing?
1. Symptomatic Bradycardia.
2. Symptomatic Heart Blocks.
3. Sick Sinus Syndrome (low HR).
4. Cardiac support for the treatment of arrhythmias that requires ablation and/or medications that result in bradycardia.
What is Sick Sinus Syndrome cause?
Do antiarrhythmics always work?
What can antiarrhythmics cause?
Dysrhythmias and/or bradycardia.
What is threshold?
The minimal amount of electrical impulse that is needed to make the heart beat.
What is capture?
How we know that the pacer is working; noted by the presence of a spike and wide QRS complex; the presence of adequate carotid pulse and blood pressure and an increased level of consciousness.
What is output control?
The amount of electrical impulse to make the heart beat; start out at a low level and increase as needed.
What is sensing?
The capability of a pacemaker to recognize inherent electrical conduction system activity.
What is sensitivity control?
There is provided a pacemaker having automatic adjustment of the sensitivity for sensing cardiac signals such as QRS, T and P waves. The pacemaker has software for examining each inputted signal, obtaining a measure of the peak amplitude, e.g. one-half, comparing such measure with a stored software sensitivity level, and adjusting the software sensitivity level each beat so that it effectively tracks beat-to-beat changes in the signal amplitude. The adjusted software sensitivity level is used for determining when an input signal is to be accepted as a true signal, or rejected.
What are the modes that pacemakers can be set as?
What is asynchronous?
What is synchronous?
Based on demand; only as you need it.
How would a client who has a asynchronous pacemaker be described?
What is a common mode setting for a pacemaker?
Where would the Pacemaker Parameter Testing form that has been scanned be located in E-Health?
What are some common pacemaker malfunctions?
1. Failure to Pace
2. Failure to Capture
3. Failure to Sense (undersensing)
What is Failure to Pace?
The EKG shows nothing; the pacemaker didn't do anything about not having activity during that time.
What is Failure to Capture similar to?
Failing to Pace.
What is Failure to Sense (undersensing)?
Fires at whim; dangerous.
How safe is a pacemaker that is failing to sense?
What is the nursing care that should occur with a temporary pacemaker?
1. Validate the mode, rate, AV interval, etc. and troubleshoot as needed.
2. VS assessment; may indicate a mechanical malfunction.
3. EKG monitoring; watch to prevent pacer spikes on T waves.
4. Assess the underlying rhythm every shift.
5. Change the battery daily.
6. Site and wire care; prevent infection and dislodgement.
What is the purpose of monitor vital signs for a client with a temporary pacemaker?
To determine if there are mechanical malfunctions.
What is a bad sign to see on an EKG for a client with a temporary pacemaker?
Pacer spikes on T waves.
What is the pre-op care for a client having a permanent pacemaker inserted?
1. NPO at midnight the day before their insertion.
2. IV ABX.
3. Skin preparation.
What is the post-op care for a client having a permanent pacemaker implanted?
1. Ice Pack
2. Restart anticoagulants (as per doctor's orders)
3. CXR to confirm placement, bleeding, and pneumothorax from puncture.
4. Pain meds
5. Chest tubes
Why is a chest x-ray completed after a permanent pacemaker is inserted?
To confirm placement, determine if there is any bleeding present, as to determine if pneumothorax is present from puncture.
What population is pneumothorax common in?
Thin, frail old ladies.
Why are chest tubes placed?
To remove air in the chest cavity.
What is the purpose of a chest tube that is placed high?
To get rid of drainage.
What is the purpose of a chest tube that is placed low?
To get rid of air.
What nursing care should you provide to a client who just had a permanent pacemaker placed?
1. EKG Monitoring.
2. VS Assessment.
3. Check the Insertion Site.
4. Restrict Arm Movement.
5. Discharge Teaching.
What are some immediate post-procedure complications of permanent pacemaker placement?
2. Cardiac Tamponade
4. Cardiac Dysrhythmias
5. Air Embolism
7. Nerve Damage (from insertion)
What are some long-term complications of permanent pacemakers?
1. Site Infection
2. Electrode Displacement
3. Lead Fracture
5. Battery Failure
6. Heart Failure
What are signs and symptoms of cardiac tamponade?
1. Muffled heart sounds
2. Distention of the jugular vein
3. Narrowing pulse pressure
4. Hypotension (may be extreme)
6. Weak, rapid pulse
8. Widening between the top and bottom numbers of blood pressure readings.
What is Beck's Triad?
The three main signs and symptoms of cardiac tamponade: muffled heart sounds, jugular venous distention, and narrowing pulse pressure.
What discharge teaching should you do for a client who had a pacemaker inserted?
1. Tell all doctors and dentists that you have a pacemaker.
2. Avoid electromagnetic interference (EMI).
3. Carry ID card at all times.
4. No MRIs (unless the individual has a new MRI safe pacer).
5. Avoid contact sports (shooting).
6. Arm ROM exercises.
7. Keep a pulse diary and know parameters.
8. Monitor the incision site for infection.
9. Signs and symptoms to report: SOB, dizziness, chest pain, hiccups, edema, muscle twitching, and arm swelling.
10. Follow up appointment attendance.
Why is it concerning if a client who had a pacemaker placed has the hiccups?
It could mean that the pacemaker has been displaced and is now pacing the diaphragm, causing the hiccups to occur.
What are signs and symptoms of infection?
What could arm swelling indicate in a client who had a pacemaker inserted?
A DVT in the arm.
What are some other (less common) uses for pacemakers?
1. Biatrial Pacing (used to minimize bouts of A-Fib).
2. Biventricular Pacing (treatment of heart failure, resynchronization therapy).
What are the indications for an ICD?
1 or more episodes of spontaneous sustained VT or VF (cardiac arrest).
What is an ICD capable of (what can it do)?
1. Antitachycardial pacing (ATP) for VT.
4. Bradycardia Pacing.
What does ATP stand for?
What does VT stand for?
What discharge teaching should you complete for a client who has had a defibrillator placed?
1. Consult Cardiac Rehab.
2. Have the client know/understand what their rate cut off is.
3. What to do if a shock occurs.
4. Driving is okay only after a period of time has passed.
5. The client should know what the patient alert tones are.
6. No airport wand security screenings.
7. Importance of doctor follow up visits.
8. Notify EMS in your community that there is an individual who has a pacemaker living there.
9. ICD support groups (such as the zapper club; individuals with ICDs need a lot of emotional support).
10. Avoid activities that raise heart rate.
What should you tell a client to do who has an ICD and a shock occurs?
Call 911 and physician; wait for the ambulance - don't have a family member drive them into the hospital.
What are some activities that a client who has had an ICD inserted avoid?
Swimming or hiking alone.
What ethical dilemma is present with ICDs and pacemakers?
We have all of this technology, but that doesn't mean that we always have to use it; nurses need to give a holistic picture to the client - how an ICD/pacemaker will impact their life so the client is able to get accurate information and make an informed decision.
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