PACEMAKER, CARE OF PERMANENT
A pacemaker is implanted when the heart’s natural pacemaker fails to work properly. It provides electrical impulses to the cardiac muscle as a means to stimulate contraction and support cardiac output.
Many types of pacemakers are available for use; the majority can be programmed to perform various functions. When caring for a patient with a pacemaker, it’s important to know the type of pacemaker, its rate, and how it works. This information will help the nurse ensure that the pacemaker is functioning properly and detect complications more quickly. The patient should have a manufacturer’s card with pacemaker information; his medical records may also contain this information. The nurse can obtain this information from the patient or the patient’s family.
Essential Documentation
Chart the date of insertion, type of pacemaker (demand or fixed rate), rate of pacing, chambers paced, chambers sensed, how the pulse generator responds, and whether it is rate-responsive. If the patient knows the three- or four-letter pacemaker code, record it. Document the patient’s apical pulse rate, noting whether it is regular or irregular. If the patient is on a cardiac monitor, place a rhythm strip in the chart. Electronic health records may automatically demonstrate patient’s rhythm. Note the presence of pacemaker spikes, P waves, and QRS complexes and their relationship to each other. Ask the patient about and record symptoms of pacemaker malfunction, such as dizziness, fainting, weakness, fatigue, chest pain, and
prolonged hiccups. Check the pacemaker insertion site and describe its condition. Assess and document the patient’s understanding of the pacemaker.
PACEMAKER, CARE OF TRANSCUTANEOUS
Completely noninvasive and easily applied, a transcutaneous pacemaker proves especially useful in an emergency. Large skin electrodes are placed on the patient’s anterior and posterior chest; then they are connected to a pulse generator to initiate pacing.
Nursing care of the patient receiving temporary transcutaneous pacing includes proper lead placement and attachment, assessment of the patient’s response and cardiac rhythm, and monitoring for possible pacemaker malfunction. Because external pacing may be uncomfortable for the conscious patient, a sedative should be given.
Essential Documentation
Chart the patient’s heart rate and rhythm. Note the pacemaker rate and the output, in milliamperes (mA), at which capture occurs. Describe whether or not all QRS complexes are captured; record as a percentage (such as 100% capture). Place a rhythm strip showing pacemaker function in the chart, if available. Electronic health records may automatically demonstrate patient’s rhythm. Describe the condition of the
skin at the electrode sites and any skin care performed. Record the assessment of the patient, including skin color and temperature, mental status, and urine output. Document measures to reduce anxiety and provide comfort as well as the patient’s response to these measures. Record patient teaching and emotional support given.
PACEMAKER, CARE OF TRANSVENOUS
Transvenous pacing is accomplished by threading a pacing wire through a vein, such as the subclavian, antecubital, femoral, or jugular vein, to the right atrium (for atrial pacing), right ventricle (for ventricular pacing), or both (for dual-chamber pacing). Some pulmonary artery catheters also have a lumen for a transvenous pacing electrode. The pacing wire is then connected to a pulse generator outside the body.
If the patient has a transvenous pacemaker, the nurse should monitor the patient for complications such as pneumothorax, hemothorax, cardiac perforation and tamponade, diaphragmatic stimulation, pulmonary embolism, thrombophlebitis, and infection. Sometimes a patient may begin to hiccup from irritation of the diaphragm and phrenic nerve due to dislocation of the lead.
Also, if the health care provider threads the electrode through the antecubital or femoral vein, venous spasm, thrombophlebitis, or lead displacement may occur. Nursing interventions also focus on protecting the patient from microshock, preventing and detecting pacemaker malfunction, and providing patient education.
Pacemaker malfunction often begins with the patient experiencing bradycardia and signs of decreased cardiac output. Often the first symptoms may include diaphoresis, syncope, or postural hypotension. The occurrence of symptoms depends on how dependent the patient is on the pacemaker and on the degree that the pacemaker is actually malfunctioning.
Essential Documentation
Chart the pacemaker’s settings. Document the patient’s vital signs and include a rhythm strip in the note. Place a rhythm strip in the chart whenever pacemaker settings are changed or when the patient is treated for a complication caused by the pacemaker. Electronic health records may automatically demonstrate patient’s rhythm. Document interventions to prevent shock and pacemaker malfunction. Chart the assessment of the pacemaker insertion site, noting drainage, redness, and edema. Describe site care and document dressing changes. Include signs and symptoms of other complications, the name of the health care provider notified, the time of notification, orders given, nursing interventions, and the patient’s response. Record patient and family education and emotional support rendered.
PACEMAKER, INITIATION OF TRANSCUTANEOUS
A temporary pacemaker is usually inserted in an emergency. In a life-threatening situation, when time is critical, a transcutaneous pacemaker is the best choice. This device sends an electrical impulse from the pulse generator to the patient’s heart by way of two electrodes, which are placed on the front and back of the patient’s chest. Transcutaneous pacing is quick and effective, but it is only a temporary measure.
Essential Documentation
The nurse should chart the date and time transcutaneous pacing is initiated. Record the reason for transcutaneous pacing and the location of the electrodes. Chart the pacemaker settings. Note the patient’s response to the procedure along with complications and interventions. If possible, obtain rhythm strips before, during, and after pacemaker use; whenever settings are changed; and when the patient is treated for a pacemaker-related complication. Electronic health records may automatically demonstrate patient’s rhythm. Describe the frequency of paced or captured beats. During patient monitoring, record the patient’s response to temporary pacing and note changes in the patient’s condition. Record patient and family teaching, emotional support, and comfort measures provided.
PACEMAKER, INSERTION OF PERMANENT
A permanent pacemaker is a self-contained unit designed to operate for 3 to 20 years. In an operating room or cardiac catheterization laboratory, a surgeon implants the device in a pocket under the patient’s skin in the pectoral region within the chest wall. A permanent pacemaker allows the patient’s heart to beat on its own but prevents pacing from falling below a preset rate. Pacing electrodes can be placed in the atria, the ventricles, or both. Pacemakers may pace at a rate that varies in response to intrinsic conditions such as skeletal muscle activity and may also have antitachycardia and shock functions.
Candidates for permanent pacemakers include patients with myocardial infarction and persistent bradyarrhythmia and patients with complete heart block or slow ventricular rates stemming from congenital or degenerative heart disease or cardiac surgery. Patients who experience Stokes-Adams attacks, sick sinus syndrome, and those with Wolff-Parkinson-White syndrome may also benefit from a permanent pacemaker.
Essential Documentation
Record the time that the patient returned to the unit after insertion of the pacemaker. Document the type of pacemaker used, pacing rate, and health care provider’s name. Record the pacemaker three-letter code. Verify that the chart contains information on the pacemaker’s serial number, three-letter code, and its manufacturer’s name. Note whether the pacemaker reduces or eliminates the arrhythmia and include other pertinent observations, such as the condition of the incision site and the percentage of paced or captured beats. Chart the patient’s vital signs and level of consciousness every 15 minutes for the first hour, every hour for the next 4 hours, every 4 hours for the next 48 hours, and then once every shift, or according to facility policy or health care provider’s order. Record these frequent assessments on a critical care or frequent vital signs flow sheet. Assess for and record signs and symptoms of complications, such as infection, lead displacement, perforated ventricle, cardiac tamponade, or lead fracture and disconnection. Record the name of the health care provider notified, the time of notification, interventions, and the patient’s response. Document the patient and family teaching. This may be recorded on a patient-teaching flow sheet.
PACEMAKER, INSERTION OF TRANSVENOUS
A transvenous pacemaker is usually inserted in an emergency or during cardiac surgery by threading an electrode catheter through a vein, such as the brachial, femoral, subclavian, or jugular vein, and then into the patient’s right atrium, right ventricle, or both. The electrodes are then attached to an external battery-powered pulse generator. Some pulmonary artery catheters have transvenous pacing electrodes.
Essential Documentation
The nurse should record the date and time that the pacemaker was inserted, the reason for pacing, and the location of the insertion site. Chart the pacemaker settings and the frequency of paced or captured beats. Document the patient’s level of consciousness and cardiopulmonary assessment, including vital signs. Note the patient’s response to the procedure, complications, and interventions. Include a rhythm strip in the note or the electronic health record will
automatically record rhythm in chart. Document the assessment of the insertion site and the neurovascular assessment of the involved limb, if appropriate. Record the patient and family teaching and the support provided.
PACEMAKER MALFUNCTION
Occasionally, a pacemaker fails to function properly. To determine whether the patient’s pacemaker is malfunctioning, the nurse must know its mode of function and its settings. If a malfunction occurs, the nurse should notify the health care provider immediately, obtain a 12-lead ECG, call for a stat chest x-ray, begin continuous ECG monitoring, and prepare for temporary pacing.
Essential Documentation
The nurse should record the date and time of the malfunction. Record the patient’s signs and symptoms, such as dizziness, syncope, irregular pulse, pale skin, dyspnea, chest pain, hypotension, heart rate below
the pacemaker’s set rate, palpitations, hiccups, and chest or abdominal muscle twitching. Place a cardiac rhythm strip in the chart, if possible, noting the percentage of captured beats or malfunctioning of the pacemaker, such as firing without capturing or the electronic health record will demonstrate patient heart rhythm. Note the name of the health care provider notified, the time of notification, and the orders given, such as obtaining a stat ECG, placing a magnet over a permanent pacemaker, and preparing for temporary pacing. If a temporary pacemaker malfunctions, chart the troubleshooting actions, such as repositioning the patient and checking connections and battery settings; the results of these efforts; and the patient’s response. Be sure to include patient and family education and emotional support provided.
PAIN MANAGEMENT
A person who feels pain typically seeks medical help not only because of a desire for relief, but also because the person believes the pain signals a serious problem. This perception produces anxiety, which in turn may increase the patient’s perception of pain. The nurse’s primary goal is to eliminate or minimize the patient’s pain. The nurse can use a number of tools to assess pain. Always document the results of assessments. (See
Assessing and documenting pain, pages 283 and 284.)
Interventions to manage pain include administering analgesics, providing emotional support and comfort measures, and using cognitive techniques to distract the patient. Patients with severe pain usually require an opioid analgesic. Invasive measures, such as epidural or patient-controlled analgesia, may also be required.
Essential Documentation
When charting pain levels and characteristics, the nurse should describe the location of the pain and note if it is internal, external, localized, or diffuse. Record whether the pain interferes with the patient’s sleep or activities of daily living. In the chart, describe what the pain feels like in the patient’s own words. Chart the patient’s description of how long the pain lasts and how often it occurs. Record the patient’s ranking of his pain using a pain rating scale.
Describe the patient’s body language and behaviors associated with pain, such as wincing, grimacing, or restlessness. Note sympathetic responses commonly associated with mild to moderate pain, such as pallor, elevated blood pressure, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, and diaphoresis. Record parasympathetic responses commonly associated with severe, deep pain, including pallor, decreased blood pressure, bradycardia, nausea and vomiting, dizziness, and loss of consciousness.
Chart situations that worsen the pain as well as interventions that relieve or decrease the pain, including heat, cold, massage, or drugs.
Document interventions taken to alleviate the patient’s pain and the patient’s responses to these interventions. Also, note patient teaching and emotional support provided.
PARACENTESIS
Paracentesis is a bedside procedure in which fluid from the peritoneal space is aspirated through a needle, trocar, or cannula inserted in the abdominal wall. Paracentesis is used to diagnose and treat massive ascites when other therapies have failed. Additionally, it is used as a prelude to other procedures, including radiography, peritoneal dialysis, and surgery. It is also used to detect intra-abdominal bleeding after traumatic injury and to obtain a peritoneal fluid specimen for laboratory analysis.
Essential Documentation
The nurse should document that the procedure and its risks have been explained to the patient and that a consent form has been signed. Chart
patient teaching about the procedure. The facility may require documentation of patient education on a patient-teaching flow sheet. Record baseline vital signs, weight, and abdominal girth. Indicate that the abdominal area measured was marked with a felt-tipped marking pen.
The nurse should record the date and time of the procedure. Describe the puncture site and record the amount, color, viscosity, and odor of the aspirated fluid. Also, record the amount of fluid aspirated in the fluid intake and output record. Record the number of specimens sent to the laboratory. Note whether the wound was sutured and the type of dressing that was applied.
Record the patient’s tolerance of the procedure, vital signs, and signs and symptoms of complications (such as shock and perforation of abdominal organs) that occur during the procedure. If peritoneal fluid leakage occurs, document that the notification of the health care provider, any orders given, nursing actions, and the patient’s response.
The nurse should keep a record of the patient’s vital signs and nursing activities related to drainage and dressing changes. Document drainage checks and the patient’s response to the procedure every 15 minutes for the first hour, every 30 minutes for the next 2 hours, every hour for the next 4 hours, and then every 4 hours for the next 24 hours (or according to the facility’s policy). This is best recorded on a flow sheet. Continue to document drainage characteristics, including color, amount, odor, and viscosity. Document daily patient weight and abdominal girth measurements after the procedure.
PARENTERAL NUTRITION ADMINISTRATION, LIPIDS
Lipid emulsions provide a source of calories and essential fatty acids. A deficiency in essential fatty acids can hinder wound healing, adversely affect the production of red blood cells and hormones, and impair prostaglandin synthesis. Typically given as separate solutions in conjunction with parenteral nutrition, lipid emulsions may also be given alone. They can be administered through a peripheral or central venous line.
Essential Documentation
Note the type of lipid solution, its volume, and the infusion rate. Document whether the lipids are being given peripherally or centrally, and note the location of the line. Record vital signs before starting the infusion, at regular intervals during the infusion (according to the facility’s policy), and following the infusion. This is best recorded on a flow sheet. In the intake and output record, chart the amount of lipids infused. Document site care and describe the condition of the insertion site, cleaning the site, and the type of dressing applied. Also, record tubing and lipid solution changes. Monitor the patient for adverse reactions, and document observations, interventions, and the patient’s response. Record patient teaching about lipids.
PARENTERAL NUTRITION ADMINISTRATION, TOTAL
Total parenteral nutrition (TPN) is the administration of a solution of dextrose, proteins, electrolytes, vitamins, trace elements, and (frequently) insulin in amounts that exceed the patient’s energy expenditure, thereby achieving anabolism. Because this solution has about six times the solute concentration of blood, it requires dilution by
delivery into a high-flow central vein to avoid injury to the peripheral vasculature. Typically, the solution is delivered to the superior vena cava through an indwelling subclavian vein catheter. Generally, TPN is prescribed for any patient who cannot absorb nutrients through the GI tract for more than 10 days.
Because TPN solution supports bacterial growth and the central venous (CV) line gives systemic access, contamination and sepsis are always a risk. Strict surgical asepsis is required during solution, dressing, tubing, and filter changes. Site care and dressing changes should be performed according to the facility’s policy and whenever the dressing becomes wet, soiled, or nonocclusive. Tubing and filter changes should be performed every 24 hours or according to the facility’s policy. Most facilities require that two nurses verify the contents of the TPN solution and the prescribed administration rate against the health care provider’s order before hanging the solution.
Essential Documentation
Document the type and location of the CV line and the volume and rate of the solution infused. Record the amount of TPN infused on the intake and output record. Document site care, describing the condition of the insertion site, cleaning of the site, and the type of dressing applied. Many facilities document all of this information on an IV flow sheet. (See
“IV flow sheet,” page 227.) Monitor a patient receiving TPN for adverse reactions, such as hyperglycemia, hypoglycemia, air embolism, extravasation, phlebitis, pneumothorax, hydrothorax, septicemia, and thrombosis, and document observations, interventions, and the patient’s response to them. Record patient teaching about TPN. When discontinuing a CV or peripheral IV line for TPN, record the date and time and the type of dressing applied. Also, describe the appearance of the infusion site.
PATIENT-CONTROLLED ANALGESIA
Some patients receive opioids by way of a patient-controlled analgesia (PCA) infusion pump that allows patients to self-administer boluses of an opioid analgesic IV, subcutaneously, or epidurally within limits prescribed by the health care provider. To avoid overmedication, an adjustable lockout interval inhibits premature delivery of additional boluses. PCA increases the patient’s sense of control, reduces anxiety, reduces drug use over the postoperative course, and gives enhanced pain control. Indicated for patients who need parenteral analgesia, PCA therapy is typically given to patients postoperatively, terminal cancer patients, and others with chronic diseases.
Essential Documentation
The nurse should document the name of the opioid used, lockout interval, maintenance dose, amount the patient receives when activating the device, and amount of opioid used during the shift. Record the patient’s assessment of pain and pain relief and patient teaching performed. Document the patient’s vital signs and level of consciousness according to facility policy. Record observations of the insertion site. See
PCA Flow Sheet, page 288, for an example of documentation.
PATIENT REQUESTING ACCESS TO MEDICAL RECORDS
According to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the patient has the right to view and obtain copies of his or her medical records. Many states have since enacted laws allowing patients access to such records, and health care providers are required to honor such requests. HIPAA guarantees patients the right to obtain their medical records. The nurse should follow facility policy for provision of medical records to a patient.
PATIENT SELF-DOCUMENTATION OF CARE
Self-documentation can be effective for patients who must perform considerable self-care (those with diabetes, for example) or for those trying to discover what precipitates a problem such as chronic headaches.
By using self-documentation, a patient with diabetes may record information about his or her diet, insulin dose, self-tested blood glucose
levels, and activity level. This information can help the patient avoid insulin reactions and delay, prevent, or even reverse complications of hyperglycemia or hypoglycemia. Self-documentation may provide valuable information for the health care provider or nurse, as well.
A patient with chronic headaches may be asked to record when a headache occurred, what warning signs were noticed, and what pain-relief measures were tried and their effect. Analyzing this information may help prevent headaches.
The patient can document entries on preprinted forms or in a journal. Such records can be used in both inpatient and outpatient care
settings. Depending on facility policy, these entries may or may not become a permanent part of the medical record. (See
Keeping a record of monitored activities, page 290.)
Essential Documentation
The nurse should record the date and time of patient teaching about self-documentation. In the note, describe the instructions provided to the patient regarding measuring or timing or the symptoms to record and how frequently this should be done. Record the patient’s response to this teaching. Describe the type of record keeping the patient is using. Document that the patient is able to verbalize understanding or give a return demonstration. Include any written materials given to the patient. Record that the patient knows who to call with questions or for emergency services.
PATIENT SELF-GLUCOSE TESTING
Patients with an established diagnosis of diabetes may prefer to use their own glucose meter to test his daily glucose levels. Per policy, the facility will require a health care provider’s order stating that the patient may use his or her own glucose meter.
If the patient is permitted to use his or her own FDA approved glucose meter, the nurse must verify the patient’s competency by having the patient demonstrate the procedure to ensure that the patient is
performing it correctly and using the meter properly. Advise the patient to perform quality control testing on the meter each day. If the patient is using the meter for the first time during this admission, correlate the first glucose result from the meter with a fasting blood glucose level drawn by the facility’s laboratory.
The nurse should confirm with the patient how to record his or her blood glucose levels and stress the importance of bringing results to all follow-up appointments. (See
Keeping a record of blood glucose levels below) Review blood glucose levels that should be reported immediately. Frequency of testing is determined by whether the patient has type 1 or type 2 diabetes as well as the health care provider’s instructions.
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