6 Pacemaker Therapy Nursing Care Plans

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.

Here are six (6) pacemaker therapy nursing care plans:

1. Ineffective Tissue Perfusion

Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level.

Nursing Diagnosis

- Ineffective Tissue Perfusion: Cardiopulmonary, Cerebral

May be related to

- Cardiac dysrhythmias
- Heart blocks
- Tachydysrhythmias
- 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 level of consciousness
- Mental changes
- Cold clammy skin
- Cardiopulmonary arrest
- Inappropriate pacing or sensing

Desired Outcomes

- Patient will be free of dysrhythmias with an adequate cardiac output to perfuse all body organs.
- Patient will be free of dysrhythmias and be able to maintain cardiac output within normal limits.
- Patient will be able to recall accurately all instructions given.
- Patient will be able to adhere to all activity restrictions.
- Permanent pacemaker function will be without complications, with no lead dislodgement or competitive rhythms noted.

Nursing Interventions	Rationale
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 ventricle and promote ventricular ectopy.
Obtain and observe rhythm strip every 4 hours and prn. Notify physician of abnormalities.	Identifies proper functioning of pacemakers, with appropriate capture and sensing.
Monitor vital signs every 15 minutes until stable, repeat every 2 hours or prn.	Assures adequate perfusion and cardiac output.
Monitor for signs of failure to sense patient’s own rhythm, and correct problem.	Potential causes are lead dislodgement, battery failure, low, sensitivity, wire fracture, or improper placement of the catheter.
Ensure that all electrical equipment are grounded. Avoid touching equipment and patient at the same time.	Prevents 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.
Monitor for muscle twitching or hiccups.	May indicate pacer lead had dislodged and migrated to chest wall or diaphragm after perforation of the heart.
Monitor for sudden complains of chest pain, and auscultate for pericardial friction rub or muffled heart tones. Observe for JVD and pulsus paradoxus.	May indicate perforation of the pericardial sac, and impending or present cardiac tamponade.
Monitor patient for complains 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.
Limit movement of extremity involved near insertion site as ordered.	Prevents accidental disconnection and dislodgement of lead wires immediately after placement.
Monitor patient for low blood-sugar levels, use glucocorticoids or sympathomimetics, mineralocorticoids, or anesthetics.	May impair the pacemaker stimulation threshold.
Protect patient from microwave ovens, radar, diathermies, and etc.	Environmental electromagnetic interference may impair demand pacemaker function by disrupting the electrical stimulus.
If patient arrests, and requires defibrillation, attempt to avoid pacemaker battery location as site for defibrillation. If patient is successfully resuscitated, prepare for potential reprogramming of pacemaker.	Defibrillatory shock may result in pacemaker damage and potential diversion of electrical current. Pacemakers may be damaged or settings may be altered by application of electrical current required to resuscitate patient.
Instruction patient on need for pacemaker, procedures involved, expected outcomes, and etc.	Provides knowledge, decreases fear and anxiety, and provides baseline for further instruction.
Instruction patient in checking pulse rate every day for 1 month, then every week, and to notify physician if rate varies more than 5 beats/minute.	Provides patient with some control over situation. Assists in promoting a sense of security; allows prompt recognition of deviations from preset rate and potential pacemaker failure.
Instruct on limitations on activity: avoid excessive bending, stretching, lifting heavy, strenuous exercise, or contact sports.	Full range of motion can be recovered in approximately 2 months after fibrosis stabilizes pacemaker lead. Excessive activity may cause lead dislodgement.
Instruct to avoid shoulder-strap purses, suspenders, or firing rifle resting over generator site.	May promote irritation over implanted generator site.
Instruct to wear a medicalert bracelet with information about type of pacemaker and rate.	Provides, necessary information about the patient, condition, and pacemaker should patient be incapacitated and unable to speak for self.
Instruct patient to notify physician if radiation therapy is needed, and to wear lead shield if it’s required.	Radiation therapy can cause failure of the silicone chip in the pacer with repeated radiation treatment.
Instruct patient/family regarding avoiding electromagnetic fields, magnetic resonance imaging, radio transmitters, and the like. If patient notices dizziness or palpitations, patient should try to move away from the area, and if symptoms persists, seek medical attention.	May affect the function of the pacemaker and alter the programmed settings.

2. Impaired Skin Integrity

Impaired Skin Integrity: Altered epidermis and/or dermis [The integumentary system is the largest multifunctional organ of the body.]

May be related to

- Insertion of pacemaker
- Alteration in activity
- Changes in mobility
- Loss of elasticity of the skin
- Aging

Possibly evidenced by

- Disruption of skin tissue
- Insertion site
- Skin layer destruction

Desired Outcomes

- Patient will have healed wound sites without signs or symptoms of infection.
- Patient will have well-healed incision with no signs or symptoms of infection.
- Patient will be able to recall instructions given.
- Patient will be able to demonstrate appropriate wound care prior to discharge.

Nursing Interventions	Rationale
Inspect pacemaker insertion site for redness, edema, warmth, drainage, or tenderness.	Prompt detection of problems helps promote prompt treatment or nursing intervention.
Change dressing daily, or per hospital protocol, using sterile technique.	Allows for observation of the site and detection of inflammation or infection. Sterile technique is recommended because of the close proximity of the portal or opening to the heart, increasing potential for systemic infection.
Instruct on wound care to pacer site and to avoid taking showers for 2 weeks post insertion.	Promotes compliance with care to decrease potential for infection. Moisture can promote bacterial growth.
Instruct patient and/or family to observe for signs of redness, drainage, fever, pain, or tenderness and swelling at site. Have them report to primary care provider immediately.	Prompt recognition of complications and facilitates timely treatment.
Instruct patient to avoid wearing constrictive clothing until site has healed completely.	May cause discomfort at incision site from pressure and rubbing against skin.
Instruct patient/family regarding pacemaker use, need for removal or replacement, and signs and symptoms to report to physician.	Pulse generators may require removal for battery replacement, fracture of lead wires, pacemaker failure, and so forth. Knowledge of potential problems can help facilitate timely identification, notification of physician and appropriate care.

3. Risk for Injury

Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.

May be related to

- Pacemaker failure
- Puncture of perforation of heart tissues
- Lead migration
- Skin erosion

Possibly evidenced by

- Decreased cardiac output
- Decreased stroke volume
- Increased peripheral vascular resistance
- Increased systemic vascular resistance
- Hemorrhage
- Diaphoresis
- Hypotension
- Chest pain
- Muscle twitching
- Pneumothorax
- Decreased breath sounds

Desired Outcomes

- Patient will be free of life-threatening complications that may be associated with pacemaker insertion.

Nursing Interventions	Rationale
Monitor patient for bleeding at pacemaker site.	Bleeding at incision site may occur based on the patient’s coagulation status. Pressure dressings or manual pressure may be required to control bleeding.
Monitor for presence of pulses at site distal to pacer insertion.	Hemorrhage may promote tissue edema and compression to arterial blood flow resulting in diminished or absent pulses.
Monitor vital signs; observe for diaphoresis, dyspnea, and restlessness.	Hypotension and these other signs may indicate puncture of subclavian vasculature and potential hemothorax.
Monitor for dyspnea, chest pain, pallor, cyanosis, absent or diminished breath sounds, tracheal deviation, and patient’s feeling of impending doom.	May indicate puncture of the lung and presence of pneumothorax, requiring immediate treatment.
Monitor patient for presence of muscle twitching and hiccups.	May indicate perforation of the heart with pacing to the chest wall or diaphragm.
Observe for signs and symptoms of cardiac tamponade.	May indicate perforation of the pericardial sac and impending cardiac tamponade which requires immediate medical attention.
Instruct patient in signs and symptoms, such as restlessness, syncope, chest pain, or dyspnea of which to notify nurse.	Provides prompt identification of potential complication and allows for timely treatment May indicate malposition of lead irritating heart muscle tissue, which can then be promptly treated.
Instruct patient and/or family to notify physician for redness, swelling, or drainage at site of pacemaker battery insertion.	Provides for potential identification of infection and allows for prompt treatment with antimicrobials to reduce possibility of sepsis.

4. Risk for Infection

Risk for Infection: At increased risk for being invaded by pathogenic organisms.

May be related to

- Invasive procedure
- Pacemaker insertion

Possibly evidenced by

- Redness and heart at site of insertion
- Pain and swelling

Desired Outcomes

- Patient will exhibit no signs of infection at site of catheter or permanent battery.
- Patient will be able to accurately demonstrate wound care.

Nursing Interventions	Rationale
Assess presence of hematoma, redness, and swelling at site, temperature elevation, and/or skin erosion.	Indicates presence of infection or potential for skin breakdown.
Administer antibiotics as ordered.	Prevents or treats wound infection.
Empty drainage device, if present.	Promotes wound drainage and healing.
Apply sterile dressing until wound heals. Avoid dislodging of catheter during site care.	Maintains sterility of wound.
Instruct patient of signs to observe indicating infection and to notify physician.	Provides for measures to take and information to report for prompt treatment.
Instruct patient in method to take temperature.	Monitors for potential elevation associated with infection.
Instruct patient in technique to change dressing.	Sterility can be maintained if proper technique is used.

5. Impaired Physical Mobility

Impaired Physical Mobility: Limitation in independent, purposeful physical movement of the body or of one or more extremities.

May be related to

- Pain
- Limb immobilization

Possibly evidenced by

- Inability to move as desired
- Imposed restrictions on activity
- Decreased muscle strength
- Decreased muscle coordination
- Pain
- Limited range of motion

Desired Outcomes

- Patient will regain optimal mobility within limitations of disease process and will have increased strength and function of limbs.

Nursing Interventions	Rationale
Evaluate patient’s perception of his degree of immobility.	Psychological and physical immobility are interrelated. Psychological immobility is used as a defence mechanism when the patient has no control over his body, and this can lead to disproportionate fear and concern. If pacemaker insertion was an emergent procedure, patient may have misperceptions regarding movement and may be afraid that any movement may result in his demise. Changes in body image promotes psychological immobility and may result in emotional handicaps, rather than actual physical ones.
Maintain bed rest following pacemaker insertion for 24-48 hours or depending on protocol.	Provides time for stabilization of leads and decreases potential for dislodgement.
Immobilize extremity proximal to pacer insertion site with arm board, sling, and so forth.	Prevents potential for dislodgement of lead caused by movement.
Resume range of motion exercises one week after permanent pacemaker insertion to affected extremity. Provide ROM to unaffected extremity immediately after pacer insertion, as warranted.	Promotes gradual increase in activity. Stretching should be avoided until lead wire has been secured in the heart. ROM prevents stiffness of shoulders and joint immobility.
Instruct on extension-dorsiflexion exercises of feet every 1-2 hours.	Promotes venous return, prevents venous stasis, and decreased potential for thrombophlebitis.
Monitor patient for progression and improvement in stiffness or pain.	Physical therapy may be required if immobility results are severe.
Apply trapeze bar to bed.	Allows for easier movement; allows patient to assist with movement in bed with unaffected extremity.
Reposition every 2 hours and prn.	Prevents potential for immobility hazards, such as pressure areas and atelectasis.
Instruct patient regarding deep breathing exercises to be done every 1-2 hours, and to avoid forceful coughing.	Facilitates lung expansion and decreases potential for atelectasis. Coughing may dislodge pacemaker lead.
Instruct patient and/or family regarding need for immobilization of arm immediately post-pacemaker insertion, and how long immobility is to be expected.	Provides knowledge, and decreases fear that patient may be immobilized for long periods of time.

6. Disturbed Body Image

Disturbed Body Image: Confusion in mental picture of one’s physical self.

May be related to

- Presence of pulse generator and battery
- Loss of control of heart function
- Diseases process

Possibly evidenced by

- Fear of rejection
- Fear of reaction from others
- Negative feelings about body
- Refusal to participate inc are
- Refusal to look at wound
- Withdrawal from social contracts
- Withdrawal from family

Desired Outcomes

- Patient will recognize physical change in body image and deal appropriately.
- Patient will be able to effectively deal with body image disturbances in the current situation.
- Patient will be able to talk with family, therapist, or others about emotional or psychological problems.

Nursing Interventions	Rationale
Evaluate level of patient’s knowledge about disease process, treatment, and anxiety level.	May identify extent of problem and interventions that will be required.
Evaluate the extent of loss to the patient or family, and what it means to them.	Depending on the time frame for patient teaching prior to the insertion of the pacemaker, the patient may not have received adequate information, and may have difficulty dealing with changes in his body appearance, as well as generalized health condition and loss of control.
Assess patient’s stage of grieving.	Provides recognition of appropriate versus inappropriate behavior. Prolonged grief may require further care.
Observe for withdrawal, manipulation, noninvolvement with care, or increased dependency. Set limits on dysfunctional behaviors and help patient to seek positive behaviors that will assist with recovery.	May suggest problems with adjustment to health condition, grief response to the loss of function, or worry about others accepting patient’s new body status. Patients may deal with crises in the same manner as previously and may need redirection in behaviors to facilitate recovery and acceptance.
Provide positive reinforcement during care and with instruction and setting goals. Do not give false reassurance.	Promotes trust and establishes rapport with patient as well as an opportunity to plan for the future based on reality of the situation.
Provide opportunity for patient to take active role in wound care.	Promotes self-esteem and facilitates feelings of control of body and health.
Provide reassurance that pacemaker will not alter sexual activity.	Promotes knowledge and decreases fear.
Discuss potential for mood changes, anger, grief, and so forth, after discharge, and to seek help if persisting for lengthy time.	Facilitates identification that feelings are not unusual and must be recognized in order to deal with them effectively.
Identify support groups for patient and/or family to contact.	Provides ongoing support for patient and family and allows for ventilation of feelings.
Consult counselor or therapist, if needed.	May be required for further interventions to resolve emotional or psychological issues.

References and Sources : nurseslabs.com

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