A pacemaker is an electronic device that provides electrical stimuli to the heart muscle. Pacemakers provide an electrical stimulus to depolarize the heart and cause a contraction to occur at a controlled rate. The function of the pacemaker (or pacer) is to maintain the heart rate when the patient’s own intrinsic system is unable to do so. The stimulus of the pacer is produced by a pulse generator and delivered via electrodes or leads that are implanted in the epicardium or endocardium. The electrodes may be unipolar or bipolar, and the proximal end attaches to a pulse generator that is placed in the chest or abdomen.
Nursing Care Plans
Nursing care for patients with pacemakers involves the monitoring and prevention of common complications, preventing dislodgement, and educating the patient on the proper use and maintenance of the pacemaker.
- Ineffective Tissue Perfusion
- Impaired Skin Integrity
- Risk for Injury
- Risk for Infection
- Impaired Physical Mobility
- Disturbed Body Image
Ineffective Tissue Perfusion
- Ineffective Tissue Perfusion: Cardiopulmonary, Cerebral
May be related to
- Cardiac dysrhythmias
- Heart blocks
- Decreased blood pressure
- Decreased cardiac output
- Pacemaker battery failure
Possibly evidenced by
- Decreased blood pressure
- Decreased heart rate
- Decreased cardiac output, stroke volume
- Increased peripheral vascular resistance
- Changes in the level of consciousness
- Mental changes
- Cold clammy skin
- Cardiopulmonary arrest
- Inappropriate pacing or sensing
- The client will be free of dysrhythmias with an adequate cardiac output to perfuse all body organs.
- The client will be free of dysrhythmias and be able to maintain cardiac output within normal limits.
- The client will be able to recall accurately all instructions given.
- The client will be able to adhere to all activity restrictions.
- The client’s permanent pacemaker will function without complications, with no lead dislodgement or competitive rhythms noted.
Nursing Assessment and Rationales
1. Monitor ECG for changes in rhythm, rate, and presence of dysrhythmias. Treat as indicated.
Observation for pacemaker malfunction promotes prompt treatment. Pacer electrodes may irritate the ventricle and promote ventricular ectopy.
2. Obtain and observe rhythm strip every 4 hours and prn. Notify the physician of abnormalities.
Identifies proper functioning of pacemakers, with appropriate capture and sensing.
3. Monitor vital signs every 15 minutes until stable; repeat every 2 hours or prn.
Assures adequate perfusion and cardiac output.
4. Monitor for signs of failure to sense the patient’s own rhythm, and correct the problem.
Potential causes are lead dislodgement, battery failure, low, sensitivity, wire fracture, or improper placement of the catheter.
5. Monitor for muscle twitching or hiccups.
This may indicate pacer lead had dislodged and migrated to the chest wall or diaphragm after perforation of the heart.
6. Monitor for sudden complaints of chest pain, and auscultate for pericardial friction rub or muffled heart tones. Observe for JVD and pulsus paradoxes.
This may indicate perforation of the pericardial sac and impending or present cardiac tamponade.
7. Monitor the patient for complaints of dizziness, weakness, fatigue, syncope, edema, chest pain, palpitations, pulsations in neck veins, or dyspnea.
During ventricular pacing, AV synchrony may cease and cause a sudden decrease in cardiac output. This may indicate “pacemaker syndrome” or failure of the pacer to function which results in decreased perfusion.
Nursing Interventions and Rationales
1. Ensure that all electrical equipment is grounded. Avoid touching equipment and the patient at the same time.
Prevents the potential for microshock and accidental electrocution. Electric current seeks the path of least resistance, and the potential for stray current to travel through the electrode into the patient’s heart may precipitate ventricular fibrillation.
2. Limit movement of extremity involved near the insertion site as ordered.
Prevents accidental disconnection and dislodgement of lead wires immediately after placement.
3. Check the patient for low blood sugar levels, and use glucocorticoids or sympathomimetics, mineralocorticoids, or anesthetics.
May impair the pacemaker stimulation threshold.
4. Protect patients from microwave ovens, radar, diathermies, etc.
Environmental electromagnetic interference may impair demand pacemaker function by disrupting the electrical stimulus.
5. If the patient arrests and requires defibrillation, attempt to avoid the pacemaker battery location as a site for defibrillation. If the patient is successfully resuscitated, prepare for potential reprogramming of the pacemaker.
Defibrillator Shock may result in pacemaker damage and potential diversion of electrical current. Pacemakers may be damaged, or settings may be altered by the application of electrical current required to resuscitate the patient.
7. Instruct the patient in checking pulse rate every day for 1 month, then every week, and notify the physician if the rate varies more than 5 beats/minute.
Provides the patient with some control over the situation. Assists in promoting a sense of security; allows prompt recognition of deviations from preset rate and potential pacemaker failure.
8. Instruct on limitations on activity: avoid excessive bending, stretching, lifting heavy, strenuous exercise, or contact sports.
A full range of motion can be recovered in approximately 2 months after fibrosis stabilizes the pacemaker lead. Excessive activity may cause lead to dislodgement.
9. Instruct to avoid shoulder-strap purses, suspenders, or firing rifles resting over the generator site.
May promote irritation over implanted generator site.
10. Instruct to wear a MedicAlert bracelet with information about the type of pacemaker and rate.
Provides, necessary information about the patient, condition, and ethical considerations on the pacemaker should the patient be incapacitated and unable to speak.
11. Instruct the patient to notify the physician if radiation therapy is needed, and to wear a lead shield if it’s required.
Radiation therapy can cause the failure of the silicone chip in the pacer with repeated radiation treatment.
12. Instruct patient/family regarding avoiding electromagnetic fields, magnetic resonance imaging, radio transmitters, and the like. If the patient notices dizziness or palpitations, the patient should try to move away from the area, and if symptoms persist, seek medical attention.
May affect the function of the pacemaker and alter the programmed settings.
Recommended nursing diagnosis and nursing care plan books and resources.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
The definitive guide to nursing diagnoses as reviewed and approved by the NANDA International. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of it’s evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions show how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis…. subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other nursing care plans for cardiovascular system disorders:
- Angina Pectoris (Coronary Artery Disease) | 4 Care Plans
- Cardiac Arrhythmia (Digitalis Toxicity) | 3 Care Plans
- Cardiac Catheterization | 4 Care Plans
- Cardiogenic Shock | 5 Care Plans
- Congenital Heart Disease | 5 Care Plans
- Heart Failure | 18 Care Plans
- Hypertension | 6 Care Plans
- Hypovolemic Shock | 4 Care Plans
- Myocardial Infarction | 7 Care Plans
- Pacemaker Therapy | 6 Care Plans