In addition to being more comfortable for the patient, a transvenous pacemaker is more reliable than a transcutaneous pacemaker. Transvenous pacing involves threading an electrode catheter percutaneously into the right ventricle where it contacts the endocardium near the ventricular septum. The electrode then attaches to an external pulse generator. As a result, the pulse generator can provide an electrical stimulus directly to the endocardium.
Temporary pacemaker gloves 
sterile dressings adhesive tape povidone-iodine solution or designated skin prep nonconducting tape or rubber surgical glove pouch for external pulse generator emergency cardiac drugs intubation equipment defibrillator cardiac monitor with strip-chart recorder equipment to start a peripheral I.V. line, if appropriate I.V. fluids sedative bridging cable percutaneous introducer tray or venous cutdown tray sterile gowns sterile gloves mask goggles or face shield surgical caps linen-saver pad antimicrobial soap alcohol pads vial of 1% lidocaine 5-mL syringe fluoroscopy equipment including lead apron, if necessary fenestrated drape prepackaged cutdown tray (for antecubital vein placement only) sutures receptacle for infectious wastes optional: elastic bandage or gauze strips, restraints, clippers.
Identify the patient using two patient identifiers per the facility policy.
Explain the procedure to the patient and/or patient representative. Discuss the basic facts about the normal conduction system, temporary pacemaker insertion procedure, precautions and restrictions while the temporary pacemaker is in place, and when to notify the nurse.
Perform hand hygiene.
Check the patient's history for hypersensitivity to local anesthetics and latex. Then attach the cardiac monitor to the patient and obtain a baseline assessment, including the patient's vital signs, skin color, LOC, heart rate and rhythm, and emotional state.
Next, insert a peripheral I.V. line if the patient doesn't already have one. Begin an I.V. infusion of the specified I.V. fluid at a keep-vein-open rate.
Insert a new battery into the external pacemaker generator and test it to make sure it has a strong charge. Connect the bridging cable to the generator and align the positive and negative poles. This cable allows slack between the electrode catheter and the generator, reducing the risk of accidental catheter displacement.
Clean entry
Place the patient in the supine position. If necessary, clip the hair around the insertion site.
All personnel performing and assisting with the procedure should don masks, caps, goggles or face shields, sterile gowns, and gloves.
Next, open the supply tray while maintaining a sterile field. Using sterile technique, the physician will clean the insertion site with antimicrobial soap and then wipe the area with povidone-iodine solution. He'll cover the insertion site with a fenestrated drape. Because fluoroscopy may be used during the placement of leadwires, put on a protective apron.
Provide the physician with the local anesthetic to numb the insertion site.
After anesthetizing the insertion site, the physician will puncture the brachial, femoral, subclavian, or jugular vein. Then he'll insert a guide wire or an introducer and advance the electrode catheter.
Map to the heart
As the catheter advances, watch the cardiac monitor. When the electrode catheter reaches the right atrium, you'll notice large P waves and small QRS complexes. Then, as the catheter reaches the right ventricle, the P waves become smaller while the QRS complexes enlarge. When the catheter touches the right ventricular endocardium, expect to see elevated ST segments, premature ventricular contractions, or both.
When the electrode catheter is in the right ventricle, it will send an impulse to the myocardium, causing depolarization. If the patient needs atrial pacing, either alone or with ventricular pacing, the physician may place an electrode in the right atrium.
All fired up and ready to go
Meanwhile, continuously monitor the patient's cardiac status and treat any dysrhythmias, as appropriate.
When the electrode catheter is in place, attach the catheter leads to the bridging cable. Ensure that the positive and negative electrodes are connected to the respective positive and negative terminals.
Check the battery's charge by pressing the BATTERY TEST button.
Set the pacemaker as ordered. Pacing thresholds will be determined by each individual patient.
The physician will then suture the catheter to the insertion site. Afterward, put on sterile gloves and apply a sterile occlusive dressing to the site. Label the dressing with the date and time of application.
Take care to prevent microshock. This includes warning the patient to only use grounded electrical equipment, such as telephones, electric shavers, televisions, or lamps. (See Transvenous pacemaker complications.)
Other safety measures you'll want to take include placing a plastic cover supplied by the manufacturer over the pacemaker controls to avoid an accidental setting change. If the patient is disoriented or uncooperative, use restraints to prevent accidental removal of pacemaker wires. (See chapter 1, “Restraint application” section.) If the patient needs emergency defibrillation, make sure the pacemaker can withstand the procedure.
If the physician inserts the electrode through the brachial or femoral vein, immobilize the patient's arm or leg to avoid putting stress on the pacing wires.
Check these . . .
After insertion, assess the patient's vital signs, skin color, LOC, and peripheral pulses to determine the effectiveness of the paced rhythm. Perform a 12-lead ECG to serve as a baseline and then perform additional ECGs daily or with clinical changes. Also, if possible, obtain a rhythm strip before, during, and after pacemaker placement; any time that pacemaker settings are changed; and whenever the patient receives treatment because of a complication caused by the pacemaker.
. . . and monitor these
Continuously monitor the ECG reading, noting capture, sensing, rate, intrinsic beats, and competition of paced and intrinsic rhythms. If the pacemaker is sensing correctly, the sense indicator on the pulse generator should flash with each beat. (See When a temporary pacemaker malfunctions, and Documenting transvenous pacemaker insertion.)
Outline