03.04 Pacemakers

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Electrical Conduction of The Heart (Cheat Sheet)
EKG Electrical vs Mechanical Worksheet (Cheat Sheet)
Parts of EKG waveform (Image)
Implanted Pacemaker and Cardiac Pacemaker Leads (Image)

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Hey guys! Welcome to the lesson on pacemakers where we will explore what a pacemaker is, why a patient might need one, and what they do in the body.

Pacemakers are used to fix electrical issues in the heart. This picture shows a heart and the electrical nodes within that control the heart rate and rhythm. Pacemakers may be placed on the chest, or implanted under the skin in the chest. They might be temporary or permanent, depending on the patient’s condition. The patient must have an X-ray to ensure that the pacemaker is in the correct place. Next let’s explore the use of pacemakers in more detail.

Okay so first let's review the electrical signals of the heart.  The electrical signals of the heart make the heart beat by setting the pace for the rate and rhythm, and making sure that the ventricles contract to pump blood through the vessels of the body. Without the signals, the body would not be perfused with blood. This picture shows where each part of the electrical system is in the heart. The atria are located on the top,  and the ventricles below. The SA node is the natural pacemaker of the heart so first it will send the signal through the atria making the atria contract first. Next, the AV node signal is going to go through the bundle of his into the purkinje fibers. This allows the ventricles to contract after the atria.

So, a patient may have damage to the SA node of the heart. If the natural pacemaker of the heart is damaged, the signals are out of whack causing alternating slow and fast heart rates. A pacemaker may be implanted in any situation where there are poor electrical signals in the heart, irregular rhythms, heart rates that are too slow, or ineffective pumping like in heart failure.  

There are different types of pacemakers that the doctor may choose to implant in the patient’s chest depending on what the issue is with their heart.  The single chamber pacemaker has one wire and is placed in the patient that is having bradycardia, but the chambers are pumping as they should be. In this case the SA node is not providing the electrical impulses at the necessary rate to effectively perfuse the body. The dual-chamber has two wires, one is placed in the atrium and one in the ventricle to treat slow heart rates, heart block, or atrial fibrillation.  So in this case, the AV node is faulty as well and needs some help on providing signals to the ventricles. Biventricular pacemakers are used for patients with heart failure where the ventricles aren’t working together. It has three wires that are placed to help the ventricles pump at the same time. Now, some pacemakers respond based on the signals present in the heart and give signals as needed. These are called rate-responsive pacemakers.

So, when you’re taking care of a patient with a pacemaker, it’s important to ensure that it’s functioning properly. If your patient’s experiencing dizziness, syncope, confusion, shortness of breath, intolerance of exercise, or pain and swelling at the site, you should immediately notify the doctor. Interrogation of the pacemaker may be done by a professional using a device to check the settings.

The patient with a pacemaker is probably going to be monitored by EKG and telemetry per the doctor’s order when admitted to the hospital. You will notice pacer spikes on the rhythm strip. The location of the spike depends on where the pacemaker leads are located in the heart. A spike before the QRS is called ventricular pacing, and a spike before the p wave is called atrial pacing. Dual chamber pacing may show one or both. If your patient isn’t showing a spike at all, don’t worry as long as the rate and rhythm are appropriate. If you observe irregular rate and rhythms, the doctor should be notified because the pacemaker may need to be interrogated. Pacemaker syndrome may occur after placement where the atria and ventricles are contracting at the same time. This is very ineffective at pumping blood through the body, and needs to be addressed.

If your patient has a pacemaker, and their heart stops beating, you will use a defibrillator to shock the heart in attempt to restart it. It’s very important to avoid defibrillator patch placement over the pacemaker to avoid damage. When a patient is at the end of life, say they are going on hospice, they or their family may request to have the pacemaker deactivated to avoid prolonged life. If you are caring for a patient that is a DNR which means “do not resuscitate”, their pacemaker must be deactivated with a big magnet over their chest when they pass away to stop the electrical signals.

Patient education is crucial after the placement of a pacemaker to ensure that it isn’t damaged. The patient must avoid devices that interfere with the pacemaker device such as MRIs. After placement, the patient must keep the skin dry for two weeks. Provider notification ensures that inappropriate tests aren’t ordered that may damage the device. Any strange signs and symptoms such as syncope, dizziness, or shortness of breath should immediately be shared with the doctor. If the pacemaker needs interrogated, this will be done by a representative of the pacemaker company that makes them, not the doctor or nurse.  Batteries must be replaced about every 5-10 years depending on the device.

The nursing concepts for pacemakers include EKG rhythms, patient education, and perfusion.

Let’s review the key points to know about pacemakers. So, pacemakers are placed in patients with sick sinus syndrome where the SA node isn’t sending the heart the correct signal to contract, irregular rhythm, slow heart rates and heart failure. The purpose of the pacemaker is to provide the electrical signals to make the chambers contract in the right order and timing. Pacemakers make the heart beat to perfuse the body with blood. Make sure you are monitoring telemetry and EKG strips, and assessing for signs of pacemaker malfunction such as dizziness, syncope, or irregular rhythm. When caring for a dying patient with a pacemaker, you  should address need to deactivate it with the doctor, patient, and family. Patients must be educated on the importance of changing the batteries as instructed, getting the pacemaker interrogated as needed, and avoiding certain electronics and scans such as MRIs.

I hope you got a good grasp on what pacemakers are used for and what to consider with your patient’s that have them. Please check out the lessons titled Cardiac Anatomy and Electrical A&P of the Heart to help you better grasp how the heart works. Thanks for listening, now go out and be your best self today, and as always, happy nursing!


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