NURSING PROCESS: THE PATIENT WITH A PACEMAKER
After a temporary or a permanent pacemaker is inserted, the pa-tient’s heart rate and rhythm are monitored by ECG. The pace-maker’s settings are noted and compared with the ECG recordings to assess pacemaker function. Pacemaker malfunction is detected by examining the pacemaker spike and its relationship to the surrounding ECG complexes (Fig. 27-28). In addition, cardiac output and hemodynamic stability are assessed to identify the pa-tient’s response to pacing and the adequacy of pacing. The appearance or increasing frequency of dysrhythmia is observed and reported to the physician.
The incision site where the pulse generator was implanted (or the entry site for the pacing electrode, if the pacemaker is a tempo-rary transvenous pacemaker) is observed for bleeding, hematoma formation, or infection, which may be evidenced by swelling, un-usual tenderness, unusual drainage, and increased heat. The patient may complain of continuous throbbing or pain. These symptoms are reported to the physician.
The patient with a temporary pacemaker is also assessed for electrical interference and the development of microshock. The nurse observes for potential sources of electrical hazards. All elec-trical equipment used in the vicinity of the patient should be grounded. Improperly grounded equipment can generate leakage of current capable of producing ventricular fibrillation. Exposed wires must be carefully covered with nonconductive material to prevent accidental ventricular fibrillation from stray currents. The nurse, working with a biomedical engineer or electrician, should make certain that the patient is in an electrically safe environment.
Patients, especially those receiving a permanent pacemaker, should be assessed for anxiety. In addition, for those receiving permanent pacemakers, the level of knowledge and learning needs of the patient and the family and the history of adherence to the therapeutic regimen should be identified.
Based on assessment data, major nursing diagnoses of the patient may include the following:
· Risk for infection related to pacemaker lead or generator in-sertion
· Risk for ineffective coping
· Deficient knowledge regarding self-care program
Based on the assessment findings, potential complications that may develop include decreased cardiac output related to pace-maker malfunction.
The major goals for the patient may include absence of infection, adherence to a self-care program, effective coping, and mainte-nance of pacemaker function.
The nurse changes the dressing regularly and inspects the insertion site for redness, swelling, soreness, or any unusual drainage. An in-crease in temperature should be reported to the physician. Changes in wound appearance are also reported to the physician.
The patient treated with a pacemaker experiences not only lifestyle and physical changes but also emotional changes. At different times during the healing process, the patient may feel angry, depressed, fearful, anxious, or a combination of these emotions. Although each patient uses individual coping strategies (eg, humor, prayer, communication with a significant other) to manage emotional dis-tress, some strategies may work better than others. Signs that may indicate ineffective coping include social isolation, increased or prolonged irritability or depression, and difficulty in relationships.
To promote effective coping strategies, the nurse must recog-nize the patient’s emotional state and assist the patient to explore his or her feelings. The nurse may help the patient to identify perceived changes (eg, loss of ability to participate in contact sports), the emotional response to the change (eg, anger), and how the pa-tient responded to that emotion (eg, quickly became angry when talking with spouse). The nurse reassures the patient that the re-sponses are normal, then assists the patient to identify realistic goals (eg, develop interest in another activity) and to develop a plan to attain those goals. The nurse may also teach the patient easy-to-use stress reduction techniques (eg, deep-breathing exer-cises) to facilitate coping. Education (Chart 27-3) may assist a pa-tient to cope with changes that occur with pacemaker treatment.
After pacemaker insertion, the patient’s hospital stay may be less than 1 day, and follow-up in an outpatient clinic or office is com-mon. The patient’s anxiety and feelings of vulnerability may in-terfere with the ability to learn information provided. Nurses often need to include home caregivers in the teaching and pro-vide printed materials for use by the patient and caregiver. Prior-ities for learning are established with the patient and caregiver. Teaching may include the importance of periodic pacemaker monitoring, promoting safety, avoiding infection, and sources of electromagnetic interference (see Chart 27-3).
Expected patient outcomes may include:
1) Remains free of infection
a) Has normal temperature
b) Has white blood cell count within normal range (5,000 to 10,000/mm3)
c) Exhibits no redness or swelling of pacemaker insertion site
2) Adheres to a self-care program
a) Responds appropriately when queried about the signs and symptoms of infection
b) Identifies when to seek medical attention (as demon-strated in responses to signs and symptoms)
c) Adheres to monitoring schedule
d) Describes appropriate methods to avoid electromag-netic interference
3) Maintains pacemaker function (see Chart 27-3)
a) Measures and records pulse rate at regular intervals
b) Experiences no abrupt changes in pulse rate or rhythm