RN/Thomson AHC Home Study Program CE CENTER

CE credit is no longer available for this article. (Expired July 2008)

Originally posted July 2006

By Marianna K. Sunderlin, RN, MSN

MARIANNA SUNDERLIN is a telemetry staff nurse at INOVA Fair Oaks Hospital in Fairfax, VA. The author has no financial relationships to disclose.

Every day, patients' lives are extended by pacemakers and other implantable cardiac devices that enable faltering hearts to soldier on. This review will help you to maximize your care for the increasing number of patients whose future depends on them.

The number of patients with implantable cardiac devices is rising sharply. In 2000, 152,000 hospitalized patients received pacemakers, compared to 197,000 in 2003.^1,2 During that same period, the number of hospitalized patients who received implantable cardioverter defibrillators nearly doubled, increasing from 34,000 to 64,000.^1,2 And these statistics don't include the countless others who received these devices in outpatient settings.²

Thanks to advances in technology, the quality of life for patients with these devices is better than ever before. Both pacemakers, which use low-energy electrical signals to correct less serious dysrhythmias, and implantable cardioverter defibrillators (ICDs), which prevent sudden cardiac death by delivering a high-energy electrical pulse to interrupt a potentially life-threatening dysrhythmia, have become smaller, lighter, and easier to live with.

In addition, a relatively new device, the biventricular pacemaker, can pace both ventricles to improve the efficiency of a weakened heart. And the FDA may soon approve an implantable hemodynamic monitor that allows clinicians to more closely follow the status of heart failure patients.

Because the indications for implantable cardiac devices are expanding, chances are good that if you haven't yet cared for a patient who's going to receive one, you soon will. When that happens, you'll want to know how pacemakers and ICDs work, which patients are candidates for which devices, and what care the patient requires.

Pacemakers nudge the heart back on track

Most pacemakers are implanted to treat bradycardia.³ Bradycardia can be caused by conduction disorders such as heart block or by sinoatrial (SA) node dysfunction.

Located in the upper right atrium, the SA node is the heart's natural pacemaker. In some people, age, heart disease, or medication causes the SA node to function too slowly or fail, causing sinus pause, sinus arrest, or sick sinus syndrome—episodes of tachycardia that alternate with bradycardia. For these patients and certain others with varying degrees of heart block or hypertrophic obstructive cardiomyopathy, an implanted pacemaker can provide electrical signals that tell the heart to beat at the proper rate.^3,4 Most patients do not feel the pacemaker's electrical signals.

Compared to earlier devices, today's pacemaker is smaller (about the size of the face of a wristwatch), lighter (20 – 30 gm), and shaped to be less obtrusive.⁴ Made of titanium, it consists of computer circuits that control the pacing system, one or more leads that are placed into the heart, and a lithium battery.⁴

Many pacemakers have optional features, such as electrocardiogram storage, which records events so you can compare them to the patient's history of symptoms. Almost all devices feature rate responsiveness, which allows the device to pace the heart at a faster-than-normal rate while the patient is exercising.^3,4

Pacemakers are classified based on how they pace the heart, which chambers of the heart they pace, what they do when they sense a dysrhythmia, how many leads they use, and where those leads are placed. Most are demand pacemakers, which means they provide electrical signals only when they sense that the heartbeat has dropped below a preset rate.⁵ Single-chamber devices have one lead that paces the right atrium or right ventricle; dual-chamber devices have separate leads that connect to both the right atrium and ventricle.⁶

A biventricular pacemaker has three leads: one for each ventricle and one for the right atrium. In a process called cardiac resynchronization therapy, this type of device restores the normal simultaneous contraction of the ventricles, thus limiting septal wall motion.⁷

Studies show that biventricular pacing significantly improves left ventricular ejection fraction, exercise tolerance, and quality of life.^8,9 It also reduces the frequency of hospitalization and the need for IV medication for worsening heart failure.⁸ Biventricular pacing is indicated for patients who have all of the following:⁷

• New York Heart Association (NYHA) class III or IV heart failure,
• symptomatic heart failure despite optimal medical treatment,
• ejection fraction of 35% or lower, and
• QRS interval of 130 milliseconds or longer.

ICDs deliver shocks to combat potentially fatal dysrhythmias

An ICD is an implanted device that can deliver high-energy electrical pulses (shocks) to restore the heart's normal rhythm when a patient is having a sustained, potentially life-threatening dysrhythmia.¹⁰ Most patients perceive an ICD shock as painful or extremely uncomfortable.¹⁰

ICDs are implanted in patients who've had or are at high risk for ventricular tachycardia or ventricular fibrillation, and for certain highly symptomatic patients with atrial fibrillation.¹⁰ ICDs effectively prevent sudden cardiac death more than 90% of the time.¹¹

An ICD is about the size of a pager. Like a pacemaker, it uses leads to monitor the heart's rhythm and deliver electrical pulses as needed. Most ICDs can record episodes of dysrhythmia for later evaluation, and some can be programmed to serve as pacemakers, sparing the patient the shock from an ICD.¹¹

Although not yet FDA-approved, an implantable hemodynamic monitor (IHM) called the Chronicle (Medtronic, Minneapolis, MN) uses a lead placed in the right ventricle to continuously measure intracardiac pressure, body temperature, physical activity, and heart rate.¹² The IHM stores these measurements, and a patient uses a remote monitor to intermittently transmit the data over a phone line to a secure Web site that the physician can access.¹² This investigational device has been used in patients with NYHA class III and IV heart failure.

Using an IHM may allow clinicians to monitor patients more closely and intervene before a patient develops symptoms of worsening heart failure. In one study, 274 CHF patients who received an IHM were randomly assigned to one of two groups. For the first six months after implantation, the control group received optimal medical care, but their physicians did not have access to the data the IHM captured. The "treatment" group received optimal medical care that was guided by IHM data. Compared to those in the control group, patients in the treatment group had a significantly lower number of hospitalizations.¹³ The IHM was particularly effective for those with class III heart failure.¹³

What to watch for during and after implantation surgery

The surgery and postop care are similar for all patients regardless of which type of implantable cardiac device they receive. Typically, patients undergo same-day surgery or are admitted for an overnight stay.⁷ They usually receive local anesthesia and undergo moderate sedation.⁷

Through a small incision, the surgeon places the device under the skin in the upper chest beneath the collarbone or, less frequently, beneath the abdominal muscles.^4,10 Each lead is threaded through the subclavian or cephalic vein and passed into the intended chamber of the heart, where it's anchored with a soft prong or a tiny screw.^4,10 The surgery usually takes one or two hours, or possibly longer for a biventricular pacemaker, for which three leads must be placed.^3,7

The rate of complications during or soon after device implantation is 1% – 5%.^3,4 During implantation and lead placement, there's a risk for dysrhythmias, tamponade, or perforation of the myocardium, and pneumothorax or hemothorax.^4,7,12 Other complications include hematoma and infection.⁴ Antibiotics may be ordered as prophylaxis, and patients will receive pain medication as needed.¹²

After surgery, patients are usually kept on bed rest for six hours.⁷ In addition to monitoring your patient's vital signs and pain, you'll observe his cardiac rhythm via 12-lead EKG or telemetry.⁷

Teaching patients about living with an implanted device

Ideally, patient teaching should start preoperatively and include the patient's family and caregivers.⁷ To reinforce your teaching, give your patient a copy of the information sheet.

While recovery from these procedures is generally uncomplicated, patients need to learn beforehand how to avoid putting tension or stress on the leads so that they stay in place. Tell your patient to keep the arm on the side of the device in a sling for the first day postop, even while he sleeps, to completely immobilize it. For four to six weeks after the surgery, he shouldn't raise the affected arm over his head, lift anything with it, or do any activity that requires abrupt, forceful arm movements.^3,4,12

Teach your patient about potential complications. Tell him to seek care immediately if he experiences chest pain or shortness of breath. He should call his physician if he develops swelling of the hands, arms, legs, ankles, or feet, or sudden weight gain, such as three pounds overnight or five pounds over two or three days. These signs and symptoms could indicate, among other things, worsening heart failure, which could mean that the device is not functioning properly.⁷

You'll need to explain how to spot signs of infection. Tell the patient to call his physician if the surgical site becomes red, warm, or has drainage, or if he develops a fever.⁷

Make sure your patient receives an ID card, which is usually supplied by the device manufacturer, and instruct him to always carry it. Patients can show this card to security personnel at airports and anywhere where they might have to go through a metal detector, and to healthcare professionals before routine exams and during emergency care.

The card contains information about the type of device and leads implanted. Pacemaker ID cards contain a five-digit letter code that indicates which heart chambers are paced and sensed, how the device responds to sensing, and whether it has rate modulation or multisite pacing. ICD cards have a similar code. More information, including the meaning of each letter code, is available from the Heart Rhythm Society at www.hrsonline.org/ep-history/topics_in_depth/topics/modecodehistory2.asp.

Be sure to clear up patient misconceptions

Many patients mistakenly believe that having a pacemaker or ICD will severely restrict their activities.³ Explain that for most patients, the impact on lifestyle and activities is minimal, and by reducing symptoms during activities, a pacemaker improves the quality of life. Reassure him that he'll gradually be able to resume his normal activities, as tolerated, with the exception of contact sports.^10,12

One activity that tends to be top of mind for patients is whether they can drive. Initially, a patient with an ICD will likely be restricted from driving because of the risk of injury—to himself and others—if he loses consciousness.¹⁰ Such restrictions may vary with state law, and patients may be allowed to resume driving if they go for a prolonged period—six months or one year—without receiving a shock, or without fainting when they are shocked.¹⁰

Another concern: Patients worry about how certain electrical equipment and devices will affect their pacemaker or ICD. Reassure your patient that most devices have features that prevent interference from household appliances, including microwaves and office or shop equipment.¹⁴ It is also safe to pass through metal detectors at airports and electronic anti-theft devices used by department stores.^3,14 While safe to use, cell phones shouldn't be carried in a chest pocket directly over an implanted device due to the possibility of interference from some high-powered digital cell phones.³ However, machinery that contains large magnets or strong electromagnetic fields, such as high-voltage electrical transformers, arc welding equipment, and high-current industrial equipment, should be avoided.^3,14

Certain medical procedures and equipment can also interfere with an implanted cardiac device, so it is important to tell your patient that he should always notify his healthcare providers that he has such a device.¹⁴ X-rays, electroconvulsive therapy, and radiofrequency ablation appear to be safe for most patients, while procedures such as transcutaneous electrical nerve stimulation (TENS) and extracorporeal shock-wave lithotripsy can adversely affect pacemakers and ICDs.^10,15 The good news is that some implantable cardiac devices can be temporarily disabled with a special magnet while a patient undergoes procedures that include electrocautery, and then reprogrammed after the procedure is completed.¹⁵

MRIs are generally contraindicated for a patient with a pacemaker or ICD. However, several small studies suggest that MRI might be safe for patients with certain pacemakers and ICDs, and at least one manufacturer is designing future devices to be MRI-safe.¹⁶

For patients with ICDs, the possibility of receiving a shock can cause anxiety or depression, which can negatively impact their quality of life.¹⁷ In fact, up to 38% of ICD patients experience significant anxiety.¹⁷ Be sure to remind your patient that although shocks can be frightening and painful, their presence indicates that the ICD is working—protecting him from life-threatening dysrhythmias.¹⁷ Teach the patient coping strategies, such as deep breathing and positive thinking. You should also encourage him to continue engaging in activities that give him pleasure (rather than avoiding them for fear of triggering a shock).¹⁷

Finally, regardless of which type of device your patient has, emphasize the importance of taking all medications as prescribed. Explain that antiarrhythmics and other drugs work in conjunction with pacemakers and ICDs to help control the heart's rhythm.^3,10 Remind patients that those with pacemakers need to follow-up with their cardiologist once or twice each year, while those with ICDs may need to do so once every three to six months. At these visits, the physician will check the device's settings, collect information stored in its memory, and adjust its programming if necessary.

With more and more patients receiving pacemakers, ICDs, and combination devices, it's essential that nurses in all areas of the hospital have a basic understanding of this technology. And educating your patient so he better understands his implanted device will increase his adherence to the follow-up treatment—and that may ultimately prolong his life.

REFERENCES

Patient Information: Living with an implantable cardiac device

Tens of thousands of people have a battery-powered device surgically placed in their chest to help their heart beat normally. Many of them have a pacemaker, which uses low-energy electrical signals to keep the heart from beating too slowly. Others have an implantable cardioverter defibrillator (ICD), which provides a high-energy electrical pulse when needed to interrupt a dangerously fast heartbeat. If you're going to receive a pacemaker or ICD, there are some things you need to know.

The surgery

To implant the device, your surgeon will make a small incision, most likely just below your collarbone, and connect the device's wires to certain parts of your heart. Many patients need only local anesthesia and are able to go home the same day as the procedure or after staying overnight.

Right after surgery, you'll need to avoid moving the arm on the side of the device, even while you sleep. Be sure to call your doctor right away if you have chest pain, shortness of breath, fever, sudden weight gain, or swelling of the hands, arms, legs, ankles, or feet, or if your incision becomes red, warm, or has drainage.

Living with the device

You can resume your normal activities as soon as your doctor says so, but avoid putting pressure directly over the device, and don't participate in contact sports. Ask your doctor about when it's safe to drive.

Most electrical equipment, including household appliances such as microwave ovens and office and shop equipment, won't affect your device. It's also safe to pass through metal detectors at airports and other security checkpoints. You, will, however, have to avoid things that contain large magnets or strong electromagnetic fields, such as high-voltage electrical transformers, arc welding equipment, and heavy-duty industrial motors and equipment. You will also need to keep cell phones at least six inches away from your device.

Remember to always carry the ID card your doctor gave you and to tell your healthcare providers—including your dentist—that you have a pacemaker or ICD. Also, be sure to take all medications as prescribed, follow your doctor's instructions about diet and exercise, and keep all scheduled medical appointments.

Replacing the battery

Depending upon which device you have, the battery will last at least five years. Even though changing the battery requires replacing the pacemaker or ICD, this procedure is usually quicker and simpler than the initial surgery.

Sources: 1. Wood, M. A., & Ellenbogen, K. A. (2002). Cardiology patient pages. Cardiac pacemakers from the patient's perspective. Circulation, 105(18), 2136. 2. American Heart Association. "Managing your pacemaker." 2006. www.americanheart.org/presenter.jhtml?identifier=32 (17 Apr. 2006). 3. Woodruff, J., & Prudente, L. A. (2005). Update on implantable pacemakers. J Cardiovasc Nurs, 20(4), 261.

Participate in RN's July Web Poll!

To take the test, return to the top of the page and click the "Take the Test Now" button.

Originally posted July 2006

By Marianna K. Sunderlin, RN, MSN

MARIANNA SUNDERLIN is a telemetry staff nurse at INOVA Fair Oaks Hospital in Fairfax, VA. The author has no financial relationships to disclose.

Every day, patients' lives are extended by pacemakers and other implantable cardiac devices that enable faltering hearts to soldier on. This review will help you to maximize your care for the increasing number of patients whose future depends on them.

The number of patients with implantable cardiac devices is rising sharply. In 2000, 152,000 hospitalized patients received pacemakers, compared to 197,000 in 2003.^1,2 During that same period, the number of hospitalized patients who received implantable cardioverter defibrillators nearly doubled, increasing from 34,000 to 64,000.^1,2 And these statistics don't include the countless others who received these devices in outpatient settings.²

Thanks to advances in technology, the quality of life for patients with these devices is better than ever before. Both pacemakers, which use low-energy electrical signals to correct less serious dysrhythmias, and implantable cardioverter defibrillators (ICDs), which prevent sudden cardiac death by delivering a high-energy electrical pulse to interrupt a potentially life-threatening dysrhythmia, have become smaller, lighter, and easier to live with.

In addition, a relatively new device, the biventricular pacemaker, can pace both ventricles to improve the efficiency of a weakened heart. And the FDA may soon approve an implantable hemodynamic monitor that allows clinicians to more closely follow the status of heart failure patients.

Because the indications for implantable cardiac devices are expanding, chances are good that if you haven't yet cared for a patient who's going to receive one, you soon will. When that happens, you'll want to know how pacemakers and ICDs work, which patients are candidates for which devices, and what care the patient requires.

Pacemakers nudge the heart back on track

Most pacemakers are implanted to treat bradycardia.³ Bradycardia can be caused by conduction disorders such as heart block or by sinoatrial (SA) node dysfunction.

Located in the upper right atrium, the SA node is the heart's natural pacemaker. In some people, age, heart disease, or medication causes the SA node to function too slowly or fail, causing sinus pause, sinus arrest, or sick sinus syndrome—episodes of tachycardia that alternate with bradycardia. For these patients and certain others with varying degrees of heart block or hypertrophic obstructive cardiomyopathy, an implanted pacemaker can provide electrical signals that tell the heart to beat at the proper rate.^3,4 Most patients do not feel the pacemaker's electrical signals.

Compared to earlier devices, today's pacemaker is smaller (about the size of the face of a wristwatch), lighter (20 – 30 gm), and shaped to be less obtrusive.⁴ Made of titanium, it consists of computer circuits that control the pacing system, one or more leads that are placed into the heart, and a lithium battery.⁴

Many pacemakers have optional features, such as electrocardiogram storage, which records events so you can compare them to the patient's history of symptoms. Almost all devices feature rate responsiveness, which allows the device to pace the heart at a faster-than-normal rate while the patient is exercising.^3,4

Pacemakers are classified based on how they pace the heart, which chambers of the heart they pace, what they do when they sense a dysrhythmia, how many leads they use, and where those leads are placed. Most are demand pacemakers, which means they provide electrical signals only when they sense that the heartbeat has dropped below a preset rate.⁵ Single-chamber devices have one lead that paces the right atrium or right ventricle; dual-chamber devices have separate leads that connect to both the right atrium and ventricle.⁶

A biventricular pacemaker has three leads: one for each ventricle and one for the right atrium. In a process called cardiac resynchronization therapy, this type of device restores the normal simultaneous contraction of the ventricles, thus limiting septal wall motion.⁷

Studies show that biventricular pacing significantly improves left ventricular ejection fraction, exercise tolerance, and quality of life.^8,9 It also reduces the frequency of hospitalization and the need for IV medication for worsening heart failure.⁸ Biventricular pacing is indicated for patients who have all of the following:⁷

• New York Heart Association (NYHA) class III or IV heart failure,
• symptomatic heart failure despite optimal medical treatment,
• ejection fraction of 35% or lower, and
• QRS interval of 130 milliseconds or longer.

ICDs deliver shocks to combat potentially fatal dysrhythmias

An ICD is an implanted device that can deliver high-energy electrical pulses (shocks) to restore the heart's normal rhythm when a patient is having a sustained, potentially life-threatening dysrhythmia.¹⁰ Most patients perceive an ICD shock as painful or extremely uncomfortable.¹⁰

ICDs are implanted in patients who've had or are at high risk for ventricular tachycardia or ventricular fibrillation, and for certain highly symptomatic patients with atrial fibrillation.¹⁰ ICDs effectively prevent sudden cardiac death more than 90% of the time.¹¹

An ICD is about the size of a pager. Like a pacemaker, it uses leads to monitor the heart's rhythm and deliver electrical pulses as needed. Most ICDs can record episodes of dysrhythmia for later evaluation, and some can be programmed to serve as pacemakers, sparing the patient the shock from an ICD.¹¹

Although not yet FDA-approved, an implantable hemodynamic monitor (IHM) called the Chronicle (Medtronic, Minneapolis, MN) uses a lead placed in the right ventricle to continuously measure intracardiac pressure, body temperature, physical activity, and heart rate.¹² The IHM stores these measurements, and a patient uses a remote monitor to intermittently transmit the data over a phone line to a secure Web site that the physician can access.¹² This investigational device has been used in patients with NYHA class III and IV heart failure.

Using an IHM may allow clinicians to monitor patients more closely and intervene before a patient develops symptoms of worsening heart failure. In one study, 274 CHF patients who received an IHM were randomly assigned to one of two groups. For the first six months after implantation, the control group received optimal medical care, but their physicians did not have access to the data the IHM captured. The "treatment" group received optimal medical care that was guided by IHM data. Compared to those in the control group, patients in the treatment group had a significantly lower number of hospitalizations.¹³ The IHM was particularly effective for those with class III heart failure.¹³

What to watch for during and after implantation surgery

The surgery and postop care are similar for all patients regardless of which type of implantable cardiac device they receive. Typically, patients undergo same-day surgery or are admitted for an overnight stay.⁷ They usually receive local anesthesia and undergo moderate sedation.⁷

Through a small incision, the surgeon places the device under the skin in the upper chest beneath the collarbone or, less frequently, beneath the abdominal muscles.^4,10 Each lead is threaded through the subclavian or cephalic vein and passed into the intended chamber of the heart, where it's anchored with a soft prong or a tiny screw.^4,10 The surgery usually takes one or two hours, or possibly longer for a biventricular pacemaker, for which three leads must be placed.^3,7

The rate of complications during or soon after device implantation is 1% – 5%.^3,4 During implantation and lead placement, there's a risk for dysrhythmias, tamponade, or perforation of the myocardium, and pneumothorax or hemothorax.^4,7,12 Other complications include hematoma and infection.⁴ Antibiotics may be ordered as prophylaxis, and patients will receive pain medication as needed.¹²

After surgery, patients are usually kept on bed rest for six hours.⁷ In addition to monitoring your patient's vital signs and pain, you'll observe his cardiac rhythm via 12-lead EKG or telemetry.⁷

Teaching patients about living with an implanted device

Ideally, patient teaching should start preoperatively and include the patient's family and caregivers.⁷ To reinforce your teaching, give your patient a copy of the information sheet.

While recovery from these procedures is generally uncomplicated, patients need to learn beforehand how to avoid putting tension or stress on the leads so that they stay in place. Tell your patient to keep the arm on the side of the device in a sling for the first day postop, even while he sleeps, to completely immobilize it. For four to six weeks after the surgery, he shouldn't raise the affected arm over his head, lift anything with it, or do any activity that requires abrupt, forceful arm movements.^3,4,12

Teach your patient about potential complications. Tell him to seek care immediately if he experiences chest pain or shortness of breath. He should call his physician if he develops swelling of the hands, arms, legs, ankles, or feet, or sudden weight gain, such as three pounds overnight or five pounds over two or three days. These signs and symptoms could indicate, among other things, worsening heart failure, which could mean that the device is not functioning properly.⁷

You'll need to explain how to spot signs of infection. Tell the patient to call his physician if the surgical site becomes red, warm, or has drainage, or if he develops a fever.⁷

Make sure your patient receives an ID card, which is usually supplied by the device manufacturer, and instruct him to always carry it. Patients can show this card to security personnel at airports and anywhere where they might have to go through a metal detector, and to healthcare professionals before routine exams and during emergency care.

The card contains information about the type of device and leads implanted. Pacemaker ID cards contain a five-digit letter code that indicates which heart chambers are paced and sensed, how the device responds to sensing, and whether it has rate modulation or multisite pacing. ICD cards have a similar code. More information, including the meaning of each letter code, is available from the Heart Rhythm Society at www.hrsonline.org/ep-history/topics_in_depth/topics/modecodehistory2.asp.

Be sure to clear up patient misconceptions

Many patients mistakenly believe that having a pacemaker or ICD will severely restrict their activities.³ Explain that for most patients, the impact on lifestyle and activities is minimal, and by reducing symptoms during activities, a pacemaker improves the quality of life. Reassure him that he'll gradually be able to resume his normal activities, as tolerated, with the exception of contact sports.^10,12

One activity that tends to be top of mind for patients is whether they can drive. Initially, a patient with an ICD will likely be restricted from driving because of the risk of injury—to himself and others—if he loses consciousness.¹⁰ Such restrictions may vary with state law, and patients may be allowed to resume driving if they go for a prolonged period—six months or one year—without receiving a shock, or without fainting when they are shocked.¹⁰

Another concern: Patients worry about how certain electrical equipment and devices will affect their pacemaker or ICD. Reassure your patient that most devices have features that prevent interference from household appliances, including microwaves and office or shop equipment.¹⁴ It is also safe to pass through metal detectors at airports and electronic anti-theft devices used by department stores.^3,14 While safe to use, cell phones shouldn't be carried in a chest pocket directly over an implanted device due to the possibility of interference from some high-powered digital cell phones.³ However, machinery that contains large magnets or strong electromagnetic fields, such as high-voltage electrical transformers, arc welding equipment, and high-current industrial equipment, should be avoided.^3,14

Certain medical procedures and equipment can also interfere with an implanted cardiac device, so it is important to tell your patient that he should always notify his healthcare providers that he has such a device.¹⁴ X-rays, electroconvulsive therapy, and radiofrequency ablation appear to be safe for most patients, while procedures such as transcutaneous electrical nerve stimulation (TENS) and extracorporeal shock-wave lithotripsy can adversely affect pacemakers and ICDs.^10,15 The good news is that some implantable cardiac devices can be temporarily disabled with a special magnet while a patient undergoes procedures that include electrocautery, and then reprogrammed after the procedure is completed.¹⁵

MRIs are generally contraindicated for a patient with a pacemaker or ICD. However, several small studies suggest that MRI might be safe for patients with certain pacemakers and ICDs, and at least one manufacturer is designing future devices to be MRI-safe.¹⁶

For patients with ICDs, the possibility of receiving a shock can cause anxiety or depression, which can negatively impact their quality of life.¹⁷ In fact, up to 38% of ICD patients experience significant anxiety.¹⁷ Be sure to remind your patient that although shocks can be frightening and painful, their presence indicates that the ICD is working—protecting him from life-threatening dysrhythmias.¹⁷ Teach the patient coping strategies, such as deep breathing and positive thinking. You should also encourage him to continue engaging in activities that give him pleasure (rather than avoiding them for fear of triggering a shock).¹⁷

Finally, regardless of which type of device your patient has, emphasize the importance of taking all medications as prescribed. Explain that antiarrhythmics and other drugs work in conjunction with pacemakers and ICDs to help control the heart's rhythm.^3,10 Remind patients that those with pacemakers need to follow-up with their cardiologist once or twice each year, while those with ICDs may need to do so once every three to six months. At these visits, the physician will check the device's settings, collect information stored in its memory, and adjust its programming if necessary.

With more and more patients receiving pacemakers, ICDs, and combination devices, it's essential that nurses in all areas of the hospital have a basic understanding of this technology. And educating your patient so he better understands his implanted device will increase his adherence to the follow-up treatment—and that may ultimately prolong his life.

REFERENCES

Patient Information: Living with an implantable cardiac device

Tens of thousands of people have a battery-powered device surgically placed in their chest to help their heart beat normally. Many of them have a pacemaker, which uses low-energy electrical signals to keep the heart from beating too slowly. Others have an implantable cardioverter defibrillator (ICD), which provides a high-energy electrical pulse when needed to interrupt a dangerously fast heartbeat. If you're going to receive a pacemaker or ICD, there are some things you need to know.

The surgery

To implant the device, your surgeon will make a small incision, most likely just below your collarbone, and connect the device's wires to certain parts of your heart. Many patients need only local anesthesia and are able to go home the same day as the procedure or after staying overnight.

Right after surgery, you'll need to avoid moving the arm on the side of the device, even while you sleep. Be sure to call your doctor right away if you have chest pain, shortness of breath, fever, sudden weight gain, or swelling of the hands, arms, legs, ankles, or feet, or if your incision becomes red, warm, or has drainage.

Living with the device

You can resume your normal activities as soon as your doctor says so, but avoid putting pressure directly over the device, and don't participate in contact sports. Ask your doctor about when it's safe to drive.

Most electrical equipment, including household appliances such as microwave ovens and office and shop equipment, won't affect your device. It's also safe to pass through metal detectors at airports and other security checkpoints. You, will, however, have to avoid things that contain large magnets or strong electromagnetic fields, such as high-voltage electrical transformers, arc welding equipment, and heavy-duty industrial motors and equipment. You will also need to keep cell phones at least six inches away from your device.

Remember to always carry the ID card your doctor gave you and to tell your healthcare providers—including your dentist—that you have a pacemaker or ICD. Also, be sure to take all medications as prescribed, follow your doctor's instructions about diet and exercise, and keep all scheduled medical appointments.

Replacing the battery

Depending upon which device you have, the battery will last at least five years. Even though changing the battery requires replacing the pacemaker or ICD, this procedure is usually quicker and simpler than the initial surgery.

Sources: 1. Wood, M. A., & Ellenbogen, K. A. (2002). Cardiology patient pages. Cardiac pacemakers from the patient's perspective. Circulation, 105(18), 2136. 2. American Heart Association. "Managing your pacemaker." 2006. www.americanheart.org/presenter.jhtml?identifier=32 (17 Apr. 2006). 3. Woodruff, J., & Prudente, L. A. (2005). Update on implantable pacemakers. J Cardiovasc Nurs, 20(4), 261.

Participate in RN's July Web Poll!

To take the test, return to the top of the page and click the "Take the Test Now" button.