A pacemaker (PM) is a small electronic device that detects intrinsic arrhythmias and stimulates the heart with electrical impulses to restore its regular heartbeat.
PM therapy is typically indicated for patients with cardiac disorders, cardiac rhythm irregularities, cardiac failure, and abnormalities in electrical activity, such as in the case of a heart block (in which the atrioventricular node cannot generate enough impulse) and sick sinus syndrome.
Indications Of Pacemaker Therapy
- Class I. Conditions which necessitate pacemaker therapy.
- Class II. Pacemaker therapy may be appropriate in certain conditions; however, there is conflicting information regarding its efficacy. Class IIa favors efficacy, whereas, in Class IIb, the benefits outweigh or are equal to the risks.
- Class III. Conditions where permanent pacing is contraindicated.
The following conditions are indicated for permanent pacemaker insertion:
- Sinus Node Dysfunction
- Class I. Sinus bradycardia (SB) of less than 40 beats per minute, chronotropic incompetence, and recurrent sinus pauses are documented.
- Class II. For patients with SB exhibiting discrete symptoms, unexplained syncope, and a heart rate of less than 40.
- Acquired Atrioventricular (AV) conduction defect
- Class I. Third-degree and second-degree AV block (more than two P waves are blocked); Mobitz II with expanded QRS complex or bifascicular block (BS); exercise-induced second and third-degree heart block.
- Class II. First degree AV block with hemodynamic instability; persistent bi or trifascicular block with ambiguous syncope; nonsymptomatic Mobitz II with a narrow QRS complex
- Neurocardiogenic Syncope
- Class I. Documented carotid hypersensitivity resulting in recurrent syncope and ventricular asystole lasting longer than three seconds.
- Class II. For patients with unexplained or unclear syncope and longer than 3 seconds of asystole following sinus massage, recurrent vasovagal syncope with spontaneously recorded bradycardia.
- Congenital heart disease
- Class I. For patients with persistent or advanced second and third-degree heart block accompanied by bradycardia, ventricular dysfunction, and diminished cardiac output, and congenital third-degree heart block with a wide ventricular escape rhythm
- Class II. For patients with SB and congenital heart disease (CHD), to prevent recurrent episodes of Intra-atrial re-entrant tachycardia (IART); third-degree atrioventricular block past the first year of life (average HR is less than 50 beats per minute); abrupt ventricular rate pauses; for nonsymptomatic SB following biventricular repair in patients with CHD (with a resting HR of 40 bpm or >3 seconds pauses in ventricular rate).
How a Pacemaker Works
PM functions by modulating cardiac rhythm through the transmission of electrical signals to regulate heartbeat and correct arrhythmias such as bradycardia. It saves and transmits information about the patient’s cardiac function and is often implanted to evaluate therapy.
The handling physician may also adjust its settings if necessary and check its battery during follow-up appointments.
Pacemakers consist of two parts:
- Pulse generator. Contains a compact computer system powered by a metal battery. It is typically implanted within the chest tissue (between the skin and pectoralis major) and transmits electrical impulses to the myocardium.
- Leads (wires or electrodes). Contains three insulation-wrapped wire conductors. It is available in two varieties, active leads and passive leads. The former is equipped with small screws to anchor the electrodes in position, whereas the latter is generally wedged into the trabeculae, which may increase the risk of dislodgement. These leads are positioned in one or more cardiac chambers to allow depolarization of the myocardium. In response to myocardial stimulation, the impulse will spread and result in a QRS duration greater than 0.2 seconds.
PM can also utilize bipolar spacing (a positive and negative electrode) and unipolar pacing. It should be mentioned that PM should be replaced when the battery wears out.
Types of Pacemakers
- Single chamber. Uses one lead to deliver electrical impulses to the right ventricle of the heart (upper or lower chamber).
- Double chamber. Uses two leads to provide electrical impulses to the right atrium and ventricle, thereby regulating the contractions between the upper and lower chambers.
- Biventricular pacemakers. Used in cardiac resynchronization therapy to stimulate both sides of the lower cardiac chamber (right and left ventricles), resulting in more efficient heartbeats.
Risks of Having A Pacemaker
- Bleeding
- Infection at the site of implantation
- Pneumothorax
- Scarring, bleeding and swelling around the site
- Injury to blood vessels or nerves surrounding the PM
- Thromboembolism near the site
- Hemothorax
- Cardiac perforation due to displacement of device or lead
Diagnostic Tests Prior to Pacemaker Therapy
- Electrocardiogram (ECG). Measures the electrical activity of the heart and determines whether the heartbeat is excessively rapid, slow, or absent.
- Echocardiogram. A noninvasive diagnostic procedure that uses sound waves to provide images of the heart’s anatomy, activity, and function.
- Stress test. Monitors blood pressure and heart rhythm in response to external stress (e.g., walking on a treadmill, riding a stationary bike). Typically, ECG is obtained prior to and following the test.
- Holter monitoring. Utilizes a Holter monitor, a portable, wearable device that records and detects arrhythmias and cardiac rhythm. It is frequently conducted in conjunction with the conventional ECG and may be worn for one to two days per the doctor’s instructions.
Procedure of Pacemaker Insertion
- Pacemaker Insertion: Preoperative Procedure
- Patient evaluation. Before beginning PM therapy, a physician conducts a thorough examination and takes note of any medications the patient is currently taking. For instance, diabetics are contraindicated three days prior to surgery. The cardiologist or surgeon will also discuss the general procedure and any required preparations. Additionally, they will convey expectations and precautions to avoid complications. The nurse also takes the patient’s vital stats, including height and weight, into consideration. Blood tests may also be conducted to confirm that surgery is not contraindicated by any underlying conditions.
- Completion of the appropriate documentation. Along with the medical history form, the patient must sign a consent form declaring that they understand the procedure’s goals and implications.
- Chest shaving. Exposes the ideal site for implantation
- Pulse oximetry. Uses a fingertip-mounted pulse oximeter to check blood oxygen levels.
- ECG monitoring. Sticky electrode patches are applied to various chest regions to monitor the heart.
- Sedation. An anesthetic is usually required for most invasive procedures to numb the incision site and help the patient relax. It is also possible to inject the sedative intravenously, combined with an intravenous antibiotic, to limit the risk of infection.
- Fasting. Eating and drinking are avoided prior to surgery to prevent the risk of aspiration.
- Pacemaker Insertion: During the Procedure
- Removal of foreign objects. Remove jewelry, piercings, and all other accessories (e.g., metal hair clips, hairpins) to prevent injury, vascular restriction, damage, and conduction of electricity.
- Sterilization. After the anesthetic has taken effect, the chest is sanitized with an antibiotic solution and draped in sterile material to prevent cross-contamination and infection.
- Implantation. The PM is positioned, and an incision is made to insert the device beneath the skin of the chest. A fluoroscope or X-ray is utilized to guide the implantation of one or more wires. The leads are attached to the pulse generator beneath the skin of the collarbone, and the device is then tested. After validating its functionality, the incision is closed with stitches or adhesive strips. A sling is applied to the arm and shoulder to prevent lead dislodgement.
- Pacemaker Insertion: Post-operative Procedures
- Hospitalization. A one-day stay in the hospital is indicated to allow configuration of PM to meet the patient’s cardiac rhythm needs and monitor for any complications.
- Preventive measures and home care. The physician or healthcare practitioner provides information about wound care, dietary intake, and pain management. It is recommended to refrain from excessive exercise and heavy lifting for a month to prevent placing pressure on the pacemaker site. Normal routines can usually be resumed within a few days; however, if the following symptoms persist, immediately seek medical attention: chills, dyspnea, fever, pain, dyspnea, and palpitations.
Precautions Of Having a Pacemaker
- Security systems. Be mindful when passing through airport security systems such as metal detectors, as PM may trigger an alarm. Carry an identification card stating the presence of the pacemaker to avoid potential conflicts.
- Diagnostic Equipment. Ensure that the healthcare providers are aware that the patient has a pacemaker, as some medical procedures, such as magnetic resonance imaging and computed tomography scans, can interfere with PM functionality.
- Cellphones. Phones should be kept at least six inches away from the PM site and should not be kept in a shirt pocket.
- High voltage and power generating equipment. Maintain a minimum distance of two feet from high voltage transformers, electric welders, high tension cables, motor generating equipment, and radar machines. Large magnetic fields, such as those found at power plants, can also disrupt PM signals.
Pacemaker Nursing Diagnosis
Nursing Care Plan for Pacemaker 1
Nursing Diagnosis: Impaired Physical Mobility related to pacemaker therapy secondary to cardiac dysrhythmias, as evidenced by diminished muscle strength, pain, incapacity to move as intended, and restricted range of motion.
Desired Outcome: The patient will achieve optimal range of motion within the disease’s limitations and have improved limb function.
| Nursing Interventions for Pacemaker | Rationale |
| Assess the patient’s level of mobility | If the pacemaker is implanted in an emergency operation, the patient may be less educated, and experience increased fear and anxiety. The psychological impact of pacemaker placement may result in disproportionate emotional responses to a change in status and may prevent the patient from exercising autonomy and movement, as well as reduce performance. |
| Provide the patient with a sling, arm board, or other immobilization aids for extremities proximal to the pacemaker site. | Allow for lead stability and limit the chance of dislodgement brought by movement. |
| Inform the patient that he/she may resume normal or range of motion (ROM) activities after a week of permanent pacemaker insertion. Encourage active and passive ROM exercises to unaffected extremities after pacing placement, as indicated. | Increases tolerance to activity gradually. It also prevents joint and shoulder stiffness which may cause pain and immobility. However, stretching is avoided until the lead wires are adequately secured. |
| Encourage the patient to perform extension-dorsiflexion movements on the feet every one to two hours. | This intervention promotes venous return, discourages blood pooling, and lowers the risk of thrombophlebitis. |
| Reposition the patient as needed or every 2 hours as needed. | Physical therapy may be prescribed to maintain autonomy and movement, especially if there is a significant level of immobility. |
| Attach a trapeze bar to the patient’s bed and encourage deep breathing exercises every 2 hours. | These measures enhance mobility, promote lung expansion to reduce the risk of atelectasis, and prevent leads from becoming dislodged as a result of coughing. |
Nursing Care Plan for Pacemaker 2
Nursing Diagnosis: Disturbed Body Image related to pacemaker therapy secondary to cardiac dysrhythmias, as evidenced by concern for rejection, fear of being rejected by others, negative feelings about appearance, noncompliance to care, and social withdrawal.
Desired Outcome: The patient will be able to identify physical body changes and appropriately manage negative body image.
| Nursing Interventions for Pacemaker | Rationale |
| Assess the patient’s understanding of the pathophysiology, diagnosis, and management of the disease. Note his or her anxiety level. | Determines the scope of the problem and permits the development of an individualized care plan. |
| Evaluate the level of damage or loss to the patient and his or her family and its significance. | The patient may react differently to the placement of a pacemaker, or he or she may not have received adequate information to deal with the changes in his or her physical appearance. They may also exhibit anxiety about their health status and loss of control. |
| Evaluate the current stage of grieving and take note of grief reactions. | Denial, disbelief, rage, and depression are all common responses to loss and grieving. Understanding the stages of grieving promotes more efficient therapeutic approaches. Also, prolonged grief may necessitate more care. |
| Assess for withdrawal symptoms such as non-compliance with care and increased dependency. | Set limits on maladaptive behaviors and assist the patient in adopting healthy behaviors that will aid in rehabilitation. This intervention will also indicate the need for adjustments to the patient’s care plan to address grief reactions to functional loss and concerns about others accepting the patient’s new status or condition. |
| Reward the patient or offer positive reinforcement when he or she follows instructions and makes progress toward their goals. Avoid giving false reassurance. | Establishes rapport with the patient and allows contingency for the planning of activities |
| Assure the patient that the pacemaker will not affect sexual activity. | It clarifies the situation and alleviates anxiety. |
| Discuss the possibility of mood swings upon discharge (e.g., anger, grief). And encourage them to get assistance if the problem persists for an extended period. | Allows for the identification of grief reactions and the provision of strategies for improving mood |
Nursing Care Plan for Pacemaker 3
Nursing Diagnosis: Risk For Injury related to pacemaker therapy secondary to cardiac dysrhythmias.
Desired Outcome: The patient will have a reduced risk of complications related to pacemaker implantation.
| Nursing Interventions for Pacemaker | Rationale |
| Assess the patient for any signs of bleeding in the pacemaker site. | The patient’s coagulation status may lead to postoperative bleeding. For the control of bleeding, manual pressure or pressure dressings are indicated. |
| Observe carefully for muscular twitches and hiccups. | These indicators may imply cardiac perforation. |
| Assess physiologic responses to injury (e.g., diminished breath sounds, chest pain, cyanosis, dyspnea, pallor, tracheal deviation). | May signal the presence of pneumothorax and accidental lung puncture, causing an air leak. Both are complications following the implantation of PM lead utilizing the subclavian puncture procedure. Prolonged hospitalization and oxygen supplementation may be warranted to mitigate the risk of additional complications and gross cardiac bleeding. |
| Observe for signs and symptoms of cardiac tamponade (e.g., hypotension, pulsus paradoxus) | A possible indication of perforation requiring immediate medical attention |
| Obtain vital sign readings and monitor for agitation, dyspnea, and diaphoresis. | Maintaining a close watch on the patient’s vitals is imperative to minimize further complications. Monitoring allows the healthcare provider to provide the patients with the care they require. Relevant markers include hypotension and other signs, indicating probable hemothorax and hemoptysis. |
| Instruct the patient to report any signs or symptoms, including chest pain, dyspnea, restlessness, and syncope. Ensure that the patient is aware of these indications and their implications | Educating and informing patients about these signs and symptoms can facilitate early recognition of potential complications and allow the healthcare provider to administer treatment in a timely manner. These signs and symptoms may also indicate malposition of lead that irritates the myocardium. |
| Instruct the patient and significant others (SO) to report any signs of discharge, redness, or swelling at the pacemaker site. | Rapid recognition enables the healthcare team to treat the infection with antimicrobials to lower the risk of sepsis and prevent other complications. |
Nursing Care Plan for Pacemaker 4
Nursing Diagnosis: Ineffective Tissue Perfusion related to pacemaker therapy secondary to cardiac dysrhythmias, as evidenced by low blood pressure, decreased heart rate, low cardiac output, changes in mentation, and inappropriate pacing.
Desired Outcome: The patient will exhibit an absence of dysrhythmias and be able to comply with all activity restrictions.
| Nursing Interventions for Pacemaker | Rationale |
| Assess the patient’s ECG patterns, noting any irregular rhythms or rate variations, and administer treatment as required. | Ischemia may be indicated by dynamic variations in ST and T waves. This intervention also facilitates prompt treatment in the event of a pacemaker malfunction. |
| Examine the rhythm strip every four hours or as needed. Notify the physician immediately of any irregularities. | Determines whether the pacemaker is operating appropriately. Undersensing and the inability to generate stimuli are indicators of a hardware malfunction, an exit block, or other issues. |
| Examine reports of chest pain and the presence of pericardial friction or rub upon auscultation. Observe for a sudden drop in systolic blood pressure during inspiration (pulsus paradoxus) and jugular distention. | May indicate perforation in the pericardial sac and fluid build-up in pericardial space (cardiac tamponade) |
| Keep patients away from induction hobs and electronic devices (e.g., ovens, diathermies) | Electronic devices can emit radio waves and impede pacemaker function. Other electromagnetic interferences can also interfere with the electrical stimulus. |
| Instruct the patient to avoid excessive stretching, bending, lifting, and strength exercises and restrict activity length and intensity. | Extreme/intense exercises and activities could dislodge leads. |
| Avoid moving extremities close to the insertion site. | Ensures that lead wires do not become disconnected or dislodged as soon as they are inserted. |
| Provide and explain the relevance of wearing a medical alert bracelet with pacemaker type and rate information. | This bracelet will offer healthcare providers information about the patient’s health and condition and pacemaker details if the patient is disabled or unable to communicate for themselves. |
Nursing Care Plan for Pacemaker 5
Nursing Diagnosis: Risk For Infection related to pacemaker therapy secondary to cardiac dysrhythmias.
Desired Outcome: The patient will exhibit no indication of infection at the pacemaker site.
| Nursing Interventions for Pacemaker | Rationale |
| Examine the site of insertion for local signs of infection, including redness, swelling, drainage, warmth, and tenderness. | Recognizing and responding to local site changes is critical to ensuring timely treatment or intervention |
| Change dressings as prescribed or per hospital protocol. Employ sterile techniques for every change. | This is a standard infection control measure that permits the area to be examined for the presence of local inflammation. And due to the opening of the skin barrier, aseptic procedures, and regular sterilization will help prevent cross-contamination and the risk of systemic infection. |
| Inform the patient of the necessary wound care for the pacemaker site and to avoid taking showers for two weeks following implantation. | Increases adherence to treatment and decreases the risk of infection. Moreover, prolonged dressing and retained moisture from bathing promote the growth of bacteria and fungi. |
| Provide information about pacemaker use, the need for replacement or removal, and the complications that may arise. Immediately report to the physician in case local pacemaker site changes and pain are observed. | Patients need to be informed to ensure optimal healing and recovery and to avoid complications |
| Instruct the patient to wear loose clothing and avoid restrictive garments until the affected area has fully healed. | May cause discomfort at the incision site due to pressure and friction. |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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