Case Study on permanent pacemaker Assignment PDF

Caring the pt who will need
permanent pacemaker

TABLE OF CONTENTS
INTRODUCTION..........................................................................................3
ESSAY ...........................................................................................................3
Reflections.................................................................................................7
REFERENCES.............................................................................................10

INTRODUCTION
The case was based on Mrs Jennette 85 years old who came to the
hospital with the dizziness and shortness of breath indicating the symptoms
of bradycardia. The case highlights the symptoms of slow Atrial Fibrillation
(AF) causing bradycardia. The report will cover about my understanding on
the case which will include about symptoms of bradycardia, normal heart
rate, in the form of case summary. The report will also present reflection
writing in which I will discuss my personal experience and learning which I
has gained by this case study as well as the research which I have performed
(Reflective writing, 2018).
ESSAY
An 83 years old lady, who will be referred as Mrs Jenette to protect
her identity came with shortness of breath, slow heart rate, dizziness etc.,
which are the symptoms of bradycardia. On admission vital signs taken as
it will be key for the initial evaluation. 12 lead ECG performed as its
important and most diagnostic value to analyses rhythm and identify
potential ischemic changes which in case of Mrs Jennette showed slow AF.
Physical examination also performed as it will help with the signs of
hypoperfusion such as cyanosis, diaphoresis, altered mentation, pallor and
weak pulses. Assessed heart sound and lungs for the signs of pulmonary
congestion. Blood investigations also taken including serum electrolyte
levels, Blood Urea Nitrogen (BUN) and creatine to assess the renal function
and kidney injury including creatine kinase, troponin, thyroid function test
and B -type natriuretic peptide (BNP) will help in assessing ischemia, heart
failure and myocardial injury (Murano & Stark, 2017). In addition, serum
drug levels for medications is also measured as Mrs Jennette was on
medication digoxin regularly, which the results showed all reports were
under normal levels. Cardiologist reviewed all her past medications and
including present. Chest radiograph performed to assess pulmonary vascular
congestion as in Mrs Jenette was normal. By analysis it was found that the
Mrs Jenette has a past history of AF and 2:1 Heart Block (HB). HB is a

disease of electrical conduction system of heart. It can occur any part of the
conduction system and can be transient or permanent (Olson, 2014). Mrs
Jennette has a history of Tricuspid Regurgitation (TR), Atrial Regurgitation
(AR), DVT and pericarditis. She also had a problem of right bundle branch
block which is resolved in 2018.
As Mrs Jennette came on admission with slow AF which is a sign of
bradycardia. A bradycardia is defined as slow heart rate which is less than
60 beats per minute (Murano & Stark, 2017). As a normal heart rate of a
person is between 60 and 100 per minute. While the heart rate which is
noted in Mrs Jenette was 35/44 beats per minute which is quite low than
normal heart rate. Therefore, in order to provide treatment to the patient she
was kept in observation and it was noted that the body temperature of Mrs
Jennette was 36.5, Pulse was about 35-44/min, and blood pressure recorded
is 140/85. However, AF is not alone is the sign of bradycardia, some other
symptoms such as dizziness and shortness of breath can be seen in patient
which indicates that it might be possible that she is suffering from
bradycardia (Bonikowske et.al., 2019).
Mrs Jenette showing symptoms of bardycardia with slow AF upon
monitoring. She was seen by the cardiologist and kept for observation. The
initial management for bradycardia is stabilization of ventricular rate by
both pharmacological and nonpharmacological intervention. She was
admitted in Coronary Care Unit (CCU) for cardiac monitoring, and kept in
CCU for 4 days by withholding her regular medications with a metoprolol
as being betablockers and digoxin is an inhibitor of ATPase enzyme which
both medications can decrease the heart rate (Cardiovascular Expert Group).
Joanne states (Discussion Group) by withholding or reducing those
medication can obtain increased heart rate (Olson, 2014). Barrett et al
(2012), states bradycardia is a sign of general conduction system disease or
iatrogenic due to the medication used for AF control. After observation of 4
days she was prepared for procedure permanent pacing insertion. The reason

that she is placed or recommended for permanent pacemaker is to maintain
an adequate heart rate. There are two reasons due to which pacemaker is
used first because natural pacemaker is not functioning properly or secondly
because of presence of block in heart's electrical conductive system (Dalia
& Amr 2019)
AF is an abnormal rhythm of the heart which affects the upper chamber of
the heart (atria) which do not function properly due to abnormal electrical
activity. People with AF can have slow heart rate which is called
tachycardia -bradycardia syndrome (Leonard,2019). Sodeck et al 2007
states, there are six categories for underlying the mechanism of bradycardia
primarily abnormality of cardiac automaticity and /or conduction and
second the side effects of cardio active drugs including blockers, digitalis
glycosides and calcium channel blockers, and third, during myocardial
infarction, then failure of implanted previous PPM including electrolyte
imbalance and the last toxicity of the medication. Vanessa stated
(Discussion Group) medication toxicity one of the causes for
bradyarrhythmias including slow AF (Goldberger et al, 2017). As Mrs
Jenette was taking Digoxin 62.5mcg regularly, upon blood investigation
digoxin serum results were within normal levels.
American Heart Association (AHA) 2005 states, initial treatment to patient
with bradycardia is to support airway and breathing with supplementary
oxygen, monitoring the patient with blood pressure, oxygen saturation and
establish intravenous access. Obtaining better ECG will help to define
rhythm, while initiating treatment and evaluating the hemodynamic status of
the patient with potential reversible causes. However, healthcare provider
must be able to identify the signs and symptoms of poor perfusion and
determine that those signs caused by bradycardia. If the symptoms are mild
and asymptomatic do not require immediate treatment but need to be
monitored sign of deterioration (Murano & Stark, 2017).

According to Australian Resuscitation Council (ARC) 2009, guidelines
suggest that if the patient is symptomatic bradycardia with hypotension
systolic blood pressure below 90mmhg and heart rate below 40/minute
needs immediate treatment. Atropine is first line treatment for bradycardia
from 0.5mg every 3 to 5 minutes to the maximum dose of 3mg can be
given intravenously to increase the ventricular rate, if the patient fails to
respond to atropine, adrenaline can be given as second line agent with rate
of 2-10mcg/minute as infusion or bolus to maintain mean arterial pressure
of 70mmHg. There are other medications can be given, if the patient is
unresponsive to atropine, isoprenaline, dopamine and glucagon, glucagon
can be given if the patient is overdosed with betablockers or calcium
channel blocker. The patients who fail to the pharmacotherapy and at the
risks of being asystole, emergency transcutaneous pacing can be provided
(AHA 2005). The pacing function usually set at the rate 70-80beats /minute
starting with 30MA increasing until electrical captures with good cardiac
output established (ARC 2009). Transcutaneous pacing is a temporary
method which can be used in case of emergency to stabilize that patient
until permanent means for pacing can be achieved (Mollerach and et.al.,
2019). In transcutaneous pacing a pulse of electric current is delivered
through the patient's chest. It is important to assess the mechanical and
electrical capture as the electrical capture can be seen in the ECG
monitoring and mechanical capture need to palpate the pulses at the carotid
and femoral artery (Murano & Stark, 2017). Transcutaneous pacing can be
very painful due to powerful skeletal muscle contraction. Therefore, patient
may require sedation prior to pacing. The two medicines or drugs such as
fentanyl and midazolam can be given (Moldaven, and Et. Al, 2015).
Fentanyl can be given as it will help in the treatment of severe pain and also
midazolam can be given as it will help in medication for anesthesia, it will
help in inducing sleepiness, decreasing anxiety.

Temporary Transcutaneous Pacing (TTP) as bridging therapy to transvenous
pacing, Cath lab needs to be arranged for transvenous pacing. Burri & Dayal
2018 states Temporary transvenous pacing can double the risks of PPM
infection as it associated with serious complications such as perforation and
tamponade. European Society of Cardiology (ESC) guidelines on pacing
states transvenous pacing should be used only as a last resort when
pharmacology therapy fails and in cases limited to such as High degree AV
block without the escape rhythm and life threatening brady arrhythmias
(Brignole et al, 2013). In transvenous pacing, pacing wires will be inserted
through the subclavian or jugular vein or femoral vein if venous access
limited. The Electrodes are positioned in right atria or ventricles or both
(dual chamber pacing) connecting cable leads attached to the pacing wires
to an external generator (Olson, 2014). Chest x-ray need to be performed to
confirm the catheter tip and will help in ruling out pneumothorax as one of
the complications (Murano & Stark, 2017).
As the part of nursing practice, it is highly required that patient
should be informed about the type of treatment which they are going to have
both previous and after the treatment including the pacemakers how they
work and the precautions to be taken after the implantation (Olshansky &
Hayes, 2016). I feel that the type of treatment which is provided to Mrs
Jenette is right and the cardiologist and medical team played an important
role including nurses in the treatment process.
Reflections
In the case I have observed the whole process from patient coming to
hospital to the stages of treatment from which Mrs Jennette went. Which
gives an understanding that how the patient suffering from bradycardia can
be treated and what medication should be provided. I have observed that
patient has been provided with pacemaker which is very much essential in
order to maintain the heart rate. I have also analyzed that the heart beat of
lady which was noted during the examination when she visited hospital for

treatment was 35/44 beats per minute which is considered to be as too low
as compared to normal heart beat. I have also noted that body temperature
of lady suffering from bradycardia. I have analyzed that transcutaneus
pacing is a best treatment which can be provided to patient while waiting for
ppm insertion. While waiting for ppm insertion it might be possible.
After the procedure of PPM insertion, she was monitored closely using
pacing function in order to identify pacing irregularities. Recommended to
take the bed rest of 6 hours (Olson, 2014). According to the patient she feels
better and feels less shortness of breath. After the PPM insertion,
recommenced all her regular medications Including apixaban 2.5 mg which
is used for lowering the risk of blood clots and treat the stroke if the patient
has atrial fibrillation and the second digoxin 62.5 mcg helps to slow the
electrical conduction from atria to the ventricles which helps to keep the
heart rate in normal range (leonard, 2017).
In the case it has been mentioned that nurse has prepared a transcutaneous
pacing for emergency purpose which clearly indicates that how important it
is for a person to have proper knowledge about the type of diseases and
treatment which should be provided to the patients.
The learning which I have gained will be off great importance to me
in future. As with the help of this case scenario I know have an
understanding of how to treat patients, how medication is provided to them,
what steps can be taken in the treatment of patient with bradycardia.
The study has also given me an understanding that why permanent
pacemaker is used. In future I will aim at developing at my problem-solving
skills and assertive skills in order to ensure that I manage my work properly.
I will also take suggestion from my seniors for the help and preparing the
strategies to deal with situation. From the case scenario I have analyzed that
having a theoretical knowledge is very important as before doing anything

practically in a professional career. it is highly required that a person should
have a proper theoretical knowledge about the field as it provides individual
a basis to its practical work. The research which has been performed by me
will help me in making clinical decisions in future. As all patients clinical
decisions are based on research evidence. Thus, this case has helped me to
gain the research skills as well as analytical skills.
CONCLUSION
The case study helps in understanding about bradycardia which is a
heart rate that is too slow. The bradycardia can be due to patients age or
physical condition. Elderly people such as Mrs Jenette is prone to
bradycardia as she had AF and conduction disturbances. If the patient is
symptomatic with the low heart rate should be provided with permanent
pacemaker but if in some case it might not be possible to provide this
treatment immediately or if the patient is under observation then
transcutaneous pacing can be used until TVP or PPM inserted. As a part of
nursing it is highly required that patient should be informed about the pre
procedures and post procedures of treatment. The study has been proved
immense importance to me and it has helped me to enhance my knowledge
in this field.

REFERENCES
Books and Journals
Bektas, F. and Soyuncu, S., 2016. The efficacy of transcutaneous cardiac
pacing in ED. The American journal of emergency
medicine, 34(11). pp.2090-2093.
Bektas, F., & Soyuncu, S. (2016). The efficacy of transcutaneous cardiac
pacing in ED. The American journal of emergency
medicine, 34(11). 2090-2093.
Bonikowske, A. R. and et.al., (2019). Frequency and characteristics of
exercise-induced second-degree atrioventricular block in patients
undergoing stress testing. Journal of electrocardiology, 54. 54-60.
Fadahunsi, O. O. and et.al., (2016). Incidence, predictors, and outcomes of
permanent pacemaker implantation following transcatheter aortic
valve replacement: analysis from the US Society of Thoracic
Surgeons/American College of Cardiology TVT Registry. JACC:
Cardiovascular Interventions, 9(21). 2189-2199.
Gladwell, P. W. and et.al., (2015). Direct and indirect benefits reported by
users of transcutaneous electrical nerve stimulation for chronic
musculoskeletal pain: qualitative exploration using patient
interviews. Physical therapy, 95(11). 1518-1528.
MOLDOVAN, A., and Et. Al, 2015. DEXMEDETOMIDINE USED IN
THE PREVENTION AND TREATMENT OF INTENSIVE CARE
UNIT DELIRIUM. Acta Medica Transilvanica, 20(2).
Mollerach, F. B. and et.al., (2019). Causes of fetal third-degree
atrioventricular block and use of hydroxychloroquine in pregnant
women with Ro/La antibodies. Clinical rheumatology, 1-7.
Nazif, T. M. and et.al., (2015). Predictors and clinical outcomes of
permanent pacemaker implantation after transcatheter aortic valve
replacement: the PARTNER (Placement of AoRtic TraNscathetER

Valves) trial and registry. JACC: Cardiovascular Interventions, 8(1
Part A). 60-69.
Online
Reflective writing. 2019. [Online] Available through
<https://grammar.yourdictionary.com/for-students-and-parents/wha
t-is-reflective-writing.html>
Permanent pacemaker. 2019. [Online] Available through
<https://emedicine.medscape.com/article/1839735-overview>