Purpose: To outline the care of patients with permanent or temporary pacemakers.
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1 University of Kentucky / UK HealthCare Policy and Procedure Policy # NR08-03 Title/Description: Care of Patients with Pacemakers Purpose: To outline the care of patients with permanent or temporary pacemakers. Policy Procedure Types of Pacemakers Locations for Care of Patients with Pacemakers Documentation, Orders, & Assessment of Pacemakers References Persons and Sites Affected Policies Replaced Effective Date Review/Revision Dates Policy Adult and pediatric patients with permanent pacemakers may be located in areas with or without cardiac monitoring based on the physician or advanced practice provider orders. Adult and pediatric patients receiving temporary pacing shall be located in designated areas with cardiac monitoring. Nursing staff caring for patients with temporary pacemakers shall have a documented competency for the current temporary pacemaker box the institution uses. The Central Monitoring Station (CMS) has trained Cardio-Pulmonary Technicians (CPTs) that analyze and interpret ECG rhythms in progressive & telemetry care areas. CPTs are responsible for interpreting and posting the interpretation of the patient s rhythm, but shall not have access to the pacemaker settings, function, or the patient s response to the pacemaker. CPTs are not licensed to complete nursing assessments. It is the responsibility of the RN caring for the patient (at the bedside in hard telemetry areas or the CMS RN for soft tele areas) to perform the cardiac assessment of the patient and assess if pacemaker system is functioning properly and effectively. Procedure Types of Pacemakers 1. Permanent pacemakers include implantable cardioverter defibrillators (ICDs) and the pulse generator and leadwire system is generally surgically implanted within the patient s body for long term use. Policy # NR08-03 Care of Patients with Pacemakers 1
2 2. Temporary pacemakers utilize a pulse generator outside the patient s body and the leadwire system varies depending on the type of temporary pacemaker. Temporary pacemaker systems include: a. Transcutaneous: The pulse generator is the Zoll monitor connected to the leadwire system which consists of two large electrode pads placed on the front and back of the patient s chest. b. Transvenous: The pulse generator is a pacemaker box outside of the patient s body connected to a leadwire system that is inserted through a large vein and placed in the patient s endocardium. c. Epicardial: The pulse generator is a pacemaker box outside of the patient s body connected to a leadwire system that has been surgically attached to the patient s epicardium. Locations for Care of Patients with Pacemakers 1. Adult and pediatric patients with permanent pacemakers may be located in areas with or without cardiac monitoring based on the physician or advanced practice provider orders. 2. Adult and pediatric patients receiving temporary pacing shall be located in designated areas with cardiac monitoring. 3. Transcutaneous pacemakers are located on all code carts via the Zoll monitors and electrode pads. Nurses must be certified in advanced cardiac life support (ACLS) and/or pediatric advanced life support (PALS) to use the pacing/cardioversion features on the Zoll monitor. 4. Patients with temporary transvenous pacing wires shall be placed in designated adult and pediatric ICUs. 5. Only balloon tipped temporary transvenous pacing wires may be placed at the bedside in critical care ICUs or the EDs; other types must be placed in the cardiac cath lab or the operating room. 6. Patients with epicardial wires shall be located in designated adult and pediatric ICUs and progressive care/telemetry units. a. Designated progressive care/telemetry areas shall accept patients with external epicardial pacemakers in place only if the patient is not 100% dependent upon the pacer or in a complete heart block. Documentation, Orders, & Assessment of Pacemakers 1. Permanent Pacemakers For all adult and pediatric critical care and progressive/telemetry care areas: a. Documentation must be entered into the patient s medical record by the nurse per unit protocol and include: i. Type ii. Mode (DDD, etc.) iii. Function (capturing, under-sensing, etc.) Policy # NR08-03 Care of Patients with Pacemakers 2
3 iv. Rhythm v. Rate b. RNs should consult with a physician or advanced practice provider if they feel an interrogation of the pacemaker is needed. No order is required for the pacemaker to be interrogated, however, once the pacemaker is interrogated, if its determined a change needs to be made to the pacemaker, an order should be placed in the electronic charting system by the physician or advanced practice provider. c. Posting ECG strips: i. For all adult and pediatric patients in the ICUs that have orders for cardiac monitoring, a strip must be posted at the beginning of the shift with the interpretation of the function of the pacemaker by the nurse, and with any changes in pacemaker function or patient response to the pacemaker. ii. For all adult and pediatric patients in progressive care/telemetry areas with orders for cardiac monitoring, the Cardio-Pulmonary Technicians in the Central Monitoring Station are responsible for interpreting and posting the interpretation of the patient s rhythm at the beginning of each shift and with rhythm changes. d. All adult and pediatric patients shall have at least 1 patent IV access maintained unless otherwise specified by physician/advanced practice provider order. e. A skin assessment must be done every shift for signs of infection for permanent pacemakers. f. Site care for the new permanent pacemaker shall be per physician/advanced practice provider orders. Notify physician/advanced practice provider and culture the permanent pacemaker site if infection is suspected. g. Pacemaker assessment and function must be communicated within SBAR handoff. 2. Temporary Pacemakers For designated adult and pediatric critical care and progressive/telemetry care areas: a. Documentation must be entered into the patient s medical record by the nurse per unit protocol and include: i. Type ii. Site iii. Mode (DDD, etc.) iv. Function (capturing, under-sensing, etc.) v. Rhythm Policy # NR08-03 Care of Patients with Pacemakers 3
4 vi. vii. viii. ix. Rate ma (milliamps) or mv (millivolts) for atrial and ventricular output mv (millivolts) for atrial and ventricular sensitivity Interventions b. Adult and pediatric ICU and progressive care/telemetry nurses competent with the temporary pacemaker box may initiate, change settings, and discontinue pacing for temporary pacemakers per physician/advanced practice provider orders. c. From a standing order, RNs may initiate emergency mode temporary pacing for symptomatic bradycardia and immediately notify physician/advanced practice provider. d. The battery and security of connections of temporary pacemakers shall be checked every shift and documented in the patient s medical record. e. The battery of the temporary pacer box shall be replaced with every new patient, every 3 days, or when the battery light indicator is flashing and documented in the patient s medical record. f. All adult and pediatric patients with external epicardial pacemakers in place must be on continuous ECG monitoring whether or not they are connected to a pacer box. g. All adult and pediatric patients shall have at least 1 patent IV access maintained unless otherwise specified by physician/advanced practice provider order. h. Temporary pacemaker wires shall not be placed, repositioned, or removed by nursing staff. i. All adult and pediatric patients with a temporary trans-venous pacemaker will be placed on bed rest unless otherwise ordered by the physician or advanced practice provider. j. All adult and pediatric patients with epicardial pacing wires in place which are not attached to the pacemaker generator shall have each set of terminal ends insulated with a glove, finger cots, or plastic caps and covered with a gauze dressing (4x4) to secure and to prevent micro-shock hazard to promote the safety of the patient and staff. k. Posting ECG strips: i. For all adult and pediatric patients in the designated ICUs with temporary pacemakers, a strip must be posted at the beginning of the shift with the interpretation of the function of the pacemaker by the nurse, with changes to pacemaker settings, and with any changes in pacemaker function or patient response to the pacemaker. ii. For all adult and pediatric patients in designated progressive care/telemetry areas with temporary epicardial pacemakers, the Cardio-Pulmonary Technicians in the Central Monitoring Station are responsible for interpreting and posting the interpretation of the patient s rhythm at the beginning of each shift and with rhythm changes. Policy # NR08-03 Care of Patients with Pacemakers 4
5 References l. Documentation also includes a skin assessment of patient s lead wire entry/exit sites every shift for signs of infection. m. The site care for temporary transvenous pacemakers shall be the same as any central venous catheter. n. The site care for epicardial wires shall be per the physician/advanced practice provider orders. o. Notify physician if infection is suspected and culture the areas surrounding the entry/exit sites of the temporary pacemaker. p. Removal of epicardial pacing wires is only to be done by physician or advanced practice providers: i. Keep patient on bed rest for a minimum of 1 hour. ii. Pediatric ICU nurses will have 1 unit of PRBCs at the bedside prior to removal. If not needed, the blood will be returned/discarded per the Blood Bank policy. iii. Upon removal of the wires, the nurse will monitor the patient every 15 minutes x 4, every 30 minutes x 2, and every 1 hour x 2, assessing the patient for cardiac tamponade (tachycardia, pulsus paradoxus, Beck Triad <hypotension, jugular venous distention, and muffled heart sounds>, altered level of consciousness, and cyanosis). q. Pacemaker assessment and function must be communicated within SBAR handoff. 1. Weigand DL, editor: AACN procedure manual for critical care, ed 6, Philadelphia, 2010, Saunders. 2. Resources for Medtronic Temporary Pacemaker include Medtronic Manuals and Medtronic 5388 Dual Chamber Temporary Pacemaker. 3. Verger, JT & Lebet, RM, editors: AACN Procedure Manual for Pediatric Acute and Critical Care, St. Louis: Elsevier/Saunders, OSCOR external pulse generator pacemakers. Policy # NR08-03 Care of Patients with Pacemakers 5
6 Persons and Sites Affected Enterprise Chandler Good Samaritan Kentucky Children s Ambulatory Department Nursing Policies Replaced Chandler HP Good Samaritan Kentucky Children s CH Ambulatory KC Other Effective Date: 7/24/2015 Review/Revision Dates: 5/1984; 7/2011; 7/24/2015 Approval by and date: Signature Date Name Richard Zerbee, Chair, Nursing Professional Practice Council, Review Team Leader Signature Date Name Robyn Cheung, Director, Nursing Professional Practice and Innovation Signature Name Colleen Swartz, Chief Nurse Executive Date Policy # NR08-03 Care of Patients with Pacemakers 6
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