What nursing care is required for pacemaker placement?

Nursing Care for Pacemaker Placement

Continuous ECG monitoring for 12-24 hours after pacemaker implantation is essential to detect early complications such as lead dislodgement, failure to capture, or sensing issues. 1

Pre-Procedure Nursing Care

• Identify patients with implanted devices before surgery and obtain appropriate records from the device clinic monitoring the patient's device 1
• Determine the original indication for device placement and whether the patient is pacemaker-dependent (having an unstable or absent spontaneous rhythm with hemodynamic instability in the absence of pacing) 1
• Evaluate the device within 3-6 months before significant surgical procedures, especially those involving major abdominal or thoracic surgery with large amounts of electrocautery 1
• Document device type, whether the patient is pacemaker-dependent, programmed settings, and battery status 1

Intra-Procedure Nursing Care

• For pacemaker-dependent patients, ensure the device is reprogrammed to an asynchronous mode (VOO or DOO) or a magnet is placed over the device during surgery 1
• For patients with implantable cardioverter defibrillators (ICDs), ensure tachyarrhythmia treatment algorithms are programmed off before surgery to prevent unwanted shocks 1
• Maintain continuous ECG monitoring and pulse monitoring during surgery, as electrocautery may interfere with ECG monitoring 1
• Assist in minimizing electromagnetic interference by:
  • Using bipolar electrocautery systems when possible 1
  • Using short, intermittent bursts of electrocautery at the lowest possible energy levels 1
  • Maximizing distance between electrocautery and the device 1
  • Ensuring proper placement of the ground patch to minimize current flow through the pacemaker 1

Post-Procedure Nursing Care

• Provide continuous ECG monitoring for 12-24 hours after implantation to detect potential complications 1
• Monitor for lead dislodgement, which is a well-known early complication after insertion of pacemakers 1
• Watch for sudden increases in pacing threshold or failure to sense, which can be identified with ECG monitoring and corrected with non-invasive reprogramming 1
• Evaluate the wound and generator pocket for signs of infection or hematoma 1
• Obtain 12-lead ECGs and chest radiographs (postero-anterior and lateral) to confirm proper lead placement 1
• Ensure appropriate programming of primary pacing and sensing parameters 1

Documentation Requirements

• Document all symptomatic tachy- or bradyarrhythmias and all rhythms requiring immediate treatment in the patient's permanent record 1
• Record significant changes in rhythm, particularly the onset/offset of tachycardias, as diagnostic clues to arrhythmia mechanism often become evident at these times 1
• Maintain proper documentation of the patient's pacing system in a database for monitoring performance and reliability 1

Patient Education

• Provide education and psychological support to the paced patient 1, 2
• Teach patients how to observe the function of their pacemaker and emphasize the importance of following doctor's orders 2
• Instruct patients on the importance of regular follow-up visits to the outpatient cardiac pacemaker control department 1, 2

Long-Term Follow-Up Planning

• For the simplest single-chamber pacemakers, schedule first follow-up after 4-6 months, second after a similar interval, then annually until signs of battery depletion appear 1
• For more complex dual-chamber pacemakers, follow the same initial schedule but continue examinations on a 6-monthly basis thereafter 1
• Ensure the patient understands the schedule for long-term follow-up, which depends on the initial indication for pacing, overall clinical condition, type of pacemaker, and any associated complications 1

Special Considerations

• For emergency cardioversion, ensure paddles are placed as far from the implanted device as possible and in an orientation perpendicular to the device leads (anterior-posterior paddle position is preferred) 1
• After surgery involving electrocautery, assess the function of the implanted device to ensure proper operation 1
• For patients with temporary pacemakers, provide more intensive monitoring as they have a higher risk of loss of capture than permanent pacemakers 1

By following these guidelines, nurses can provide comprehensive care for patients undergoing pacemaker placement, minimizing complications and ensuring optimal device function.