Collaborative Management (Pre-op Preparation)
Collaborative Management (Post-op)
- Continuous cardiac monitoring. A pacemaker-generated impulse should appear as a spike on ECG. Spike indicates pacemaker has fired.
- Pacemaker rhythm:
- Rate: Varies according to preset pacemaker rate and Pt’s native heart rate.
- Rhythm: Irregular for demand pacemaker unless Pt is 100% based with no native beats.
- P wave: None for ventricular pacemaker. P waves may be seen but unrelated to QRS. Atrial or dual chambered pacemakers should have P wave after each atrial spike.
- PR Interval: None for ventricular pacing. Atrial or dual chambered pacing should produce constant PR intervals.
- QRS: Wide (>0.10 sec) after each ventricular spike in a paced beat. Pt’s native QRS will look different from paced QRS. Atrial pacing only, QRS may be normal.
- Obtain a 12-lead ECG.
- Assess VS per hospital protocol. Assess peripheral pulses.
- Assess LOC.
- Administer antibiotics (cefazolin, vancomycin).
- Assess dressing for bleeding, drainage, or signs of infection.
- If epicardial wires present, clean site and cover wires per hospital policy.
- Monitor CBC, BMP.
- Administer oral pain medication as needed.
- Pts with pacemakers may be defibrillated. Avoid placing defibrillator paddles or pads closer than 5 in. from pacemaker battery pack or pulse generator.
- Pt education is crucial: activity level, signs of pacemaker malfunction, signs of infection, electrical safety precautions, medication usage. Provide Pt with identification card related to pacemaker. Consider telemonitoring of these Pts for compliance, pacemaker function, and avoidance of complications.
Complications
- Pacemaker malfunction:
- Failure to Discharge: Pacemaker fails to fire. Seen as Pt’s HR programmed rate.
- Failure to Capture: Pacing stimulus not followed by depolarization of atrium and/or ventricle.
- Oversensing: Pacemaker detects noncardiac electrical events (electromagnetic interference, large T waves) as depolarization.
- Undersensing: Pacemaker cannot sense Pt’s intrinsic beats, with resulting inappropriately placed pacemaker artifacts.
- Pneumothorax.
- Ventricular irritability.
- Perforation of ventricular wall or septum.
- Catheter or lead dislodgment.
- Infection.
- Hematoma.
- Abdominal twitching or hiccups.
- Pocket erosion.