|1. Check that
patient has a patent IV, and that the
defibrillator, emergency cart and appropriate
medications are available.
||1. This is an
emergent procedure. Venous access, emergent
equipment and drugs have a high probability of
patient and family and allow for ventilation and
questions; obtain consent (time permitting).
||2. Time is needed
for coping; relieves anxiety; promotes
|3. Wash and dry
insertion site; clip hair if necessary.
||3. Prepare site
|4. Obtain vital
signs and ECG rhythm strip prior to insertion.
Connect to 12 lead EKG and continuously monitor
before, during and after.
baseline parameters. This will assist in
monitoring for changes and complications.
according to central line insertion checklist.
||5. IAW Infection
|6. Prep selected
site IAW central line insertion checklist.
||6. Reduce risk of
the area locally.
||7.. Reduce pain
|8. Prepare the
external temporary generator:
the mA to 6.
rate control to ten beats above the
sensitivity dial fully clockwise.
|8. The rate set
above the patients a rate will suppress the
patients natural pacemaker.
|9. Connect the
alligator clamp, one end to the V1 EKG lead and
the other to the distal or negative electrode
wire of the pacemaker catheter.
||9. This electrode
serves as an exploratory intracavitary lead and
resulting EKG waveform helps to ascertain
patient while physician inserts pacing electrode.
||10. The EKG
pattern is distinctive when the pacing electrode
is in the vena cava, right atrium and right
EKG findings indicate electrode position:
QRS with rabbit ears
|Lead II, III,
or neg QRS
Axis/ pattern of injury (elevated ST)
Chest X-ray is required to confirm placement.
Insertion of a pacemaker during a cardiac arrest (asystole)
requires connecting the pacing wire to the generator and
setting the stimulation threshold to maximum or 20 mA,
and an arbitrary rate of 70 bpm. The electrode is then
advanced blindly while one scans the EKG for evidence of
|1. After contact
between pacing electrode and the right
ventricular endocardium is established, assist
the physician in connecting to pacemaker
generator. Set according to physicians
Obtain a 12 Lead
all Methods of Temporary Pacing
Determine the stimulation threshold:
pacing rate above patients
decrease output (mA) from 20 mA until
capture is lost.
increase output (mA) until capture is
established. This is the stimulation
output (mA) at least 1.5 to 2 times
higher than the stimulation threshold.
This output setting is sometimes referred
to as the maintenance threshold.
Determine the sensitivity threshold:
rate at least 10 beats per minute below
patients intrinsic heart rate.
sensitivity control to most sensitive
setting (fully demand or lowest numerical
setting). Sensing indicator light should
flash with each intrinsic R wave.
the pacemaker rate, output (mA), and sensitivity
(demand or asynchronous), as prescribed or as
determined by threshold testing.
Assess rhythm for appropriate pacemaker function:
is there a QRS complex for every
ventricular pacing artifact?
is the rate at or above the pacemaker
rate if in the demand mode?
does the sensitivity light indicate that
every QRS complex is sensed?
|1. The physician
sets the parameters; must generate a written
order for its use.
output dial regulates the amount of electric
current (mA) that is delivered to the myocardium
to initiate depolarization. Ventricular pacing (stimulation
threshold) should be established at less than 1
mA output whenever possible. The maintenance
threshold is set at 1.5 to 2 times above the
stimulation threshold to allow for increases in
stimulation threshold without loss of ventricular
threshold is the level at which intrinsic
ventricular activity is recognized by sensing
electrodes. For demand pacing, the sensitivity
must be measure and set.
threshold is set at maximum and is lowered only
if pacer is sensing inappropriately. If set
too high, it will result in sensing P or T as
an R wave; if set too low, it results in
asynchronous pacing (nonsensing).
by patients response. A-V interval (similar
to intrinsic PR interval) should be set for
optimal ventricular filling, usually between 150
to 250 ms.
tracing should reflect appropriate response to
pacemaker settings if pacemaker is functioning
|2. Ensure the
pacing wire is secured as it exists the
introducer; check all connections as well as
battery and control settings at least q.4 hrs and
migration of wires; these connects are easily
disconnected and may result in cardiac arrest.
Protects setting from being inadvertently being
|3. Maintain site
care per Infection Control Manual SOP on central
||3. This is a
central line with potential for sepsis.
|4. Keep the pulse
generator dry and the controls protected from
||4. Moisture will
cause pacemaker malfunction; improperly set
controls can cause cardiac irritability resulting
in dysrhythmias and cardiac arrest.
|5. Protect the
patient from electromicroshock and
electromagnetic interference (EMI):
exposed wires with gloves or tape.
pulse generator in rubber glove.
rubber gloves when handling exposed wires.
any nurse-patient contact with electrical
for ungrounded electrical equipment.
dressing over wires dry and intact when
not in use.
Electromicroshock and EMI can cause the pulse
generator to fail.
patient for complications. Restrict patient
mobility depending on insertion site.
||6. All invasive
procedures have a percentage of complications
that can be prevented by an astute nurse.
location, type of pacing, pacing mode, stimulus
threshold, sensitivity setting, pacing rate and
intervals, intrinsic rhythm, and percent of
pacing. Post sample tracings.
documentation assists in the care of the patient
and early recognition and prevention of
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This page last updated 07/25/10