P



P



4091


Pacemaker Management: Permanent


Definition: Care of the patient receiving permanent support of cardiac pumping though the insertion and use of a pacemaker


Activities:



• Provide information to patient and family related to pacemaker implantation (e.g., indications, functions, universal programming codes, potential complications)


• Provide concrete objective information related to the effects of pacemaker therapy to reduce patient uncertainty, fear, and anxiety about treatment-related symptoms


• Document pertinent data in patient permanent record for initial insertion of pacemaker (e.g., manufacturer, model number, serial number, implant date, mode of operation, programmed parameters, upper and lower rate limits for rate-responsive devices, type of lead fixation, unipolar or bipolar lead system, capability for pacing and/or shock delivery, delivery system for shocks)


• Assure confirmation of pacemaker placement post-implantation in initial insertion with baseline chest x-ray


• Monitor for signs of improved cardiac output at specified intervals after initiation of pacing (e.g., improved urine output, warm and dry skin, freedom from chest pain, stable vital signs, absence of JVD and crackles, improved level of consciousness), per facility protocol


• Palpate peripheral pulses at specified intervals per facility protocol to ensure adequate perfusion with paced beats


• Monitor for potential complications associated with pacemaker insertion (e.g., pneumothorax, hemothorax, myocardial perforation, cardiac tamponade, hematoma, PVCs, infections, hiccups, muscle twitches)


• Monitor for failure to pace and determine cause (e.g., lead dislodgement, fracture, or migration), as appropriate


• Monitor for failure to capture and determine cause (e.g., lead dislodgement or malposition, pacing at voltage below capture threshold, faulty connections, lead fracture, ventricular perforation), as appropriate


• Monitor for failure to sense and determine cause (e.g., sensitivity set too high, malposition of catheter lead, lead fracture, lead insulation break), as appropriate


• Obtain chest x-ray immediately in the event of suspected lead fracture, patch crinkling, lead dislodgement, or lead migration


• Monitor for symptoms of arrhythmias, ischemia, or heart failure (e.g., dizziness, syncope, palpitations, chest pain, shortness of breath), particularly with each outpatient contact


• Monitor for pacemaker problems that have occurred between scheduled checkup visits


• Monitor for arm swelling or increased warmth on side ipsilateral to implanted endovascular leads


• Monitor for redness or swelling at the device site


• Perform a comprehensive appraisal of peripheral circulation (i.e., check peripheral pulses, edema, capillary refill, skin temperature, and diaphoresis) in any initial assessment of pacemaker patients and before initiating corrective actions


• Determine type and mode of pacemaker, including universal pacemaker code information for the five positions, before initiating corrective actions


• Gather additional data, if possible, from patient’s permanent record (e.g., date of implantation, frequency of use, programming changes and parameters) before initiating corrective actions


• Ensure ongoing monitoring of bedside EKG by qualified individuals


• Note frequency and duration of dysrhythmias


• Monitor hemodynamic response to dysrhythmias


• Facilitate acquisition of a 12-lead EKG, as appropriate


• Monitor sensorium and cognitive abilities


• Monitor blood pressure at specified intervals and with changes in patient condition


• Monitor heart rate and rhythm at specified intervals and with changes in patient condition


• Monitor drug and electrolyte levels for patients receiving concurrent antiarrhythmic medications


• Monitor for metabolic conditions with adverse effects on pacemakers (acid-base disturbances, myocardial ischemia, hyperkalemia, severe hyperglycemia [greater than 600 mg/dl], renal failure, hypothyroidism)


• Instruct patient related to the potential hazards for electromagnetic interference from outside sources (i.e., keep at least 6 inches away from sources of interference, do not leave cell phones in the “on” mode in a shirt pocket over the pacemaker)


• Instruct patient related to sources of highest electromagnetic interference (e.g., arc welding equipment, electronic muscle stimulators, radio transmitters, concert speakers, large motor-generator systems, electric drills, hand-held metal detectors, magnetic resonance imaging, radiation treatments)


• Instruct patient to check manufacturer warnings when in doubt about household appliances


• Instruct patient related to potential hazards from environmental interactions (e.g., inappropriate pacing or rhythm sensing, shortened generator life, cardiac arrhythmias, cardiac arrest)


• Instruct patient related to the potential hazards from metabolic disruptions (e.g., potential to increase pacer or capture thresholds)


• Instruct patient on the need for regular checkups with primary cardiologist


• Instruct patient to consult primary cardiologist for all changes in medications


• Instruct patient with new pacemaker to refrain from operating motor vehicles until permitted per primary cardiologist (usually 3 months minimally)


• Instruct patient in the need for regular monitoring of pacemaker sensing and capture thresholds


• Instruct patient in the need for regular interrogation of pacemaker by cardiologist for evidence of electromagnetic interference


• Instruct patient in the need to obtain chest x-ray minimally annually for continued pacemaker placement confirmation


• Instruct patient of the signs and symptoms of dysfunctional pacemaker (e.g., bradycardia <30 beats per minute, dizziness, weakness, fatigue, chest discomfort, angina, shortness of breath, orthopnea, pedal edema, paroxysmal nocturnal dyspnea, dyspnea on exertion, hypotension, near-syncope, frank syncope, cardiac arrest)


• Instruct patient to carry manufacturer identification card at all times


• Instruct patient to wear a medical alert bracelet or necklace that identifies patient as a pacemaker patient


• Instruct patient on the special considerations at government security gates or the airport (e.g., always inform security guard of implantable pacemaker, walk through security gates, DO NOT allow hand-held metal detectors near the device site, always walk quickly through metal detection devices or ask to be searched by hand, do not lean on or stand near detection devices for long periods)


• Instruct patient that hand-held metal detectors contain magnets that can reset the pacemaker and cause malfunction


• Instruct patient’s family that no harm comes to a person touching a patient who is receiving a pacemaker discharge


5th edition 2008




4092


Pacemaker Management: Temporary


Definition: Temporary support of cardiac pumping though the insertion and use of a temporary pacemaker


Activities:



• Determine indications for temporary pacing and duration of intended pacing support


• Determine intended mechanics of pacing (e.g., internal or external, unipolar or bipolar, transthoracic, epicardial, or central venous catheter) including appropriateness of type of pulse generator selected


• Perform a comprehensive appraisal of peripheral circulation (i.e., check peripheral pulses, edema, capillary refill), skin temperature and diaphoresis


• Ensure ongoing monitoring of bedside EKG by qualified individuals


• Note frequency and duration of dysrhythmias


• Monitor hemodynamic response to dysrhythmias


• Facilitate acquisition of a 12-lead EKG, as appropriate


• Monitor sensorium and cognitive abilities


• Monitor blood pressure at specified intervals and with changes in patient condition


• Monitor heart rate and rhythm at specified intervals and with changes in patient condition


• Instruct patient related to the chosen pacemaker (e.g., purpose, indications, mechanics, duration)


• Ensure externally paced patients are aware of possibility of discomfort and availability of sedation for comfort and/or relaxation


• Obtain informed consent for insertion of the selected temporary pacemaker


• Prepare skin on chest and back by washing with soap and water and trim body hair with scissors, not razor, as necessary


• Prepare the chosen pacemaker for use, per facility protocol (i.e., ensure battery is fresh, identify atrial and ventricular wire sets, identify positive and negative leads for each pair of wires, identification labels as indicated/preferred)


• Assist with insertion or placement of selected device, as appropriate


• Apply external transcutaneous pacemaker electrodes to clean, dry skin on the left anterior chest and to the posterior chest, as appropriate


• Provide sedation and analgesia for patients with external transcutaneous pacemaker, as indicated


• Set rate according to patient need, as directed by physician (general guidelines 90 to 110 beats per minute surgical patients, 70 to 90 beats per minute medical patients, 80 beats per minute cardiac arrest patients)


• Set the milliamperage (mA) according to patient (general adult guidelines: nonurgent 10 mA, emergent 15 to 20 mA) and increase mA until capture is present


• Monitor patient response to mA setting at regular intervals in anticipation of fluctuations resulting from endothelial sheath formation around electrode tips


• Set the sensitivity (general adult guidelines: 2 to 5 millivolt, if failure to sense occurs, turn millivolt DOWN; if sensing beats not actually present, turn millivolt UP)


• Initiate pacing by slowly increasing mA level delivered until consistent capture (capture threshold) occurs (general guidelines of mA output at 1.5 to 3 times higher than threshold, and minimally 15 to 20 mA in emergent conditions)


• Obtain chest x-ray examination after insertion of invasive temporary pacemaker


• Monitor for presence of paced rhythm or resolution of initiating dysrhythmia


• Monitor for signs of improved cardiac output at specified intervals after initiation of pacing (e.g., improved urine output, warm and dry skin, freedom from chest pain, stable vital signs, absence of JVD and crackles, improved level of consciousness) per facility protocol


• Palpate peripheral pulses at specified intervals per facility protocol to ensure adequate perfusion with paced beats


• Inspect skin frequently to prevent potential burns for patients with external transcutaneous pacemaker


• Monitor for potential complications associated with pacemaker insertion (e.g., pneumothorax, hemothorax, myocardial perforation, cardiac tamponade, hematoma, PVCs, infections, hiccups, muscle twitches)


• Observe for changes in cardiac or hemodynamic status that indicate a need for modifications in pacemaker status


• Monitor for failure to pace and determine cause (e.g., battery failure, lead dislodgement, wire fracture, disconnected wire or cable), as appropriate


• Monitor for failure to capture and determine cause (e.g., lead dislodgement or malposition, battery failure, pacing at voltage below capture threshold, faulty connections, lead fracture, ventricular perforation), as appropriate


• Monitor for failure to sense and determine cause (e.g., sensitivity set too high, battery failure, malposition of catheter lead, lead fracture, pulse generator failure, lead insulation break), as appropriate


• Monitor for conditions that potentially influence capture and sensing (e.g., fluid status changes, pericardial effusion, electrolyte or metabolic abnormalities, certain medications, tissue inflammation, tissue fibrosis, tissue necrosis)


• Perform capture and sensitivity threshold testing every 24 to 48 hours with newly inserted pacers to determine best generator settings (contraindicated in patients paced 90% or more of the time)


• Perform threshold testing separately for atrial and ventricular chambers


• Provide appropriate incisional care for pacemakers with insertion sites (e.g., dressing change, antimicrobial and sterile occlusive dressing), per facility protocol


• Ensure that all equipment is grounded, in good working order, and carefully located (e.g., in a location where it will not be dropped on the floor)


• Ensure that wires are of a length to deter inadvertent dislodging of electrodes


• Wear gloves when adjusting electrodes


• Insulate electrode wires when not in use (e.g., cover unused thoracic wires with the fingertip of a disposable glove)


• Instruct patient and family member(s) regarding symptoms to report (e.g., dizziness, fainting, prolonged weakness, nausea, palpitations, chest pain, difficulty breathing, discomfort at insertion or external electrode site, electrical shocks)


• Teach patient and family member(s) precautions and restrictions required while temporary pacemaker is in place (e.g., limitation of movement, avoid handling the pacemaker)


4th edition 2004; revised 2008




1400


Pain Management


Definition: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient


Activities:



• Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors


• Observe for nonverbal cues of discomfort, especially in those unable to communicate effectively


• Assure patient attentive analgesic care


• Use therapeutic communication strategies to acknowledge the pain experience and convey acceptance of the patient’s response to pain


• Explore patient’s knowledge and beliefs about pain


• Consider cultural influences on pain response


• Determine the impact of the pain experience on quality of life (e.g., sleep, appetite, activity, cognition, mood, relationships, performance of job, and role responsibilities)


• Explore with patient the factors that improve/worsen pain


• Evaluate past experiences with pain to include individual or family history of chronic pain or resulting disability, as appropriate


• Evaluate, with the patient and the health care team, the effectiveness of past pain control measures that have been used


• Assist patient and family to seek and provide support


• Utilize a developmentally appropriate assessment method that allows for monitoring of change in pain and that will assist in identifying actual and potential precipitating factors (e.g., flow chart, daily diary)


• Determine the needed frequency of making an assessment of patient comfort and implement monitoring plan


• Provide information about the pain, such as causes of the pain, how long it will last, and anticipated discomforts from procedures


• Control environmental factors that may influence the patient’s response to discomfort (e.g., room temperature, lighting, noise)


• Reduce or eliminate factors that precipitate or increase the pain experience (e.g., fear, fatigue, monotony, and lack of knowledge)


• Consider the patient’s willingness to participate, ability to participate, preference, support of significant others for method, and contraindications when selecting a pain relief strategy


• Select and implement a variety of measures (e.g., pharmacological, nonpharmacological, interpersonal) to facilitate pain relief, as appropriate


• Teach principles of pain management


• Consider type and source of pain when selecting pain relief strategy


• Encourage patient to monitor own pain and to intervene appropriately


• Teach the use of nonpharmacological techniques (e.g., biofeedback, TENS, hypnosis, relaxation, guided imagery, music therapy, distraction, play therapy, activity therapy, acupressure, hot/cold application, and massage) before, after, and, if possible, during painful activities; before pain occurs or increases; and along with other pain relief measures


• Explore patient’s current use of pharmacological methods of pain relief


• Teach about pharmacological methods of pain relief


• Encourage patient to use adequate pain medication


• Collaborate with the patient, significant other, and other health professionals to select and implement nonpharmacological pain relief measures, as appropriate


• Provide the person optimal pain relief with prescribed analgesics


• Implement the use of patient-controlled analgesia (PCA), if appropriate


• Use pain control measures before pain becomes severe


• Medicate prior to an activity to increase participation, but evaluate the hazard of sedation


• Assure pretreatment analgesia and/or nonpharmacologic strategies prior to painful procedures


• Verify level of discomfort with patient, note changes in the medical record, inform other health professionals working with the patient


• Evaluate the effectiveness of the pain control measures used through ongoing assessment of the pain experience


• Institute and modify pain control measures on the basis of the patient’s response


• Promote adequate rest/sleep to facilitate pain relief


• Encourage patient to discuss his/her pain experience, as appropriate


• Notify physician if measures are unsuccessful or if current complaint is a significant change from patient’s past experience of pain


• Inform other health care professionals/family members of nonpharmacologic strategies being used by the patient to encourage preventive approaches to pain management


• Utilize a multidisciplinary approach to pain management, when appropriate


• Consider referrals for patient, family, and significant others to support groups, and other resources, as appropriate


• Provide accurate information to promote family’s knowledge of and response to the pain experience


• Incorporate the family in the pain relief modality, if possible


• Monitor patient satisfaction with pain management at specified intervals


1st edition 1992; revised 1996, 2004




5562


Parent Education: Adolescent


Definition: Assisting parents to understand and help their adolescent children


Activities:



• Ask parents to describe the characteristics of their adolescent child


• Discuss parent-child relationship during earlier, school-aged years


• Understand the relationship between the parent’s behavior and child’s age-appropriate goals


• Identify personal factors that impact on the success of the educational program (e.g., cultural values, presence of any negative experiences with social service providers, language barriers, time commitment, scheduling issues, travel, and general lack of interest)


• Identify the presence of family stressors (e.g., parental depression, drug addiction, alcoholism, low literacy, limited education, domestic violence, marital conflict, blending of families after divorce, and excessive punishment of children)


• Discuss disciplining of parents themselves when they were adolescents


• Instruct parent on normal physiological, emotional, and cognitive characteristics of adolescents


• Identify developmental tasks or goals of the adolescent period of life


• Identify defense mechanisms used most commonly by adolescents, such as denial and intellectualization


• Address the effects of adolescent cognitive development on information processing


• Address the effects of adolescent cognitive development on decision making


• Have parents describe methods of discipline used before adolescent years and their feelings of success with these measures


• Provide online resources, books, and literature designed to teach parents about teen parenting


• Describe the importance of power and control issues for both parents and adolescents during adolescent years


• Instruct parents about essential communication skills that will increase their ability to empathize with their adolescent and assist their adolescent to problem solve


• Instruct parents about methods of communicating their love to adolescents


• Explore parallels between school-aged dependency on parents and adolescent dependency on peer group


• Reinforce normalcy of adolescent vacillation between desire for independence and regression to dependence


• Discuss effects of adolescent separation from parents on spousal relationships


• Share strategies for managing adolescent’s perception of parental rejection


• Facilitate expression of parental feelings


• Assist parents to identify reasons for their responses to adolescents


• Identify avenues to assist adolescent to manage anger


• Instruct parents how to use conflict for mutual understanding and family growth


• Role play strategies for managing family conflict


• Discuss with parents issues over which they will accept compromise and issues over which they cannot compromise


• Discuss necessity and legitimacy of limit setting for adolescents


• Address strategies for limit setting for adolescents


• Instruct parents to use reality and consequences to manage adolescent behavior


• Refer parents to support group or parenting classes, as appropriate


1st edition 1992; revised 2013




5566


Parent Education: Childrearing Family


Definition: Assisting parents to understand and promote the physical, psychological, and social growth and development of their toddler, preschool, or school-aged child


Activities:



• Ask parent to describe the behaviors of the child


• Understand the relationship between the parent’s behavior and child’s age-appropriate goals


• Design an education program that builds on the family’s strengths


• Involve parents in the design and content of the education program


• Identify personal factors that impact on the success of the education program (e.g., cultural values, presence of any negative experiences with social service providers, language barriers, time commitment, scheduling issues, travel, and general lack of interest)


• Identify the presence of family stressors (e.g., parental depression, drug addiction, alcoholism, low literacy, limited education, domestic violence, marital conflict, blending of families after divorce, and excessive punishment of children)


• Identify appropriate developmental tasks or goals for the child


• Identify defense mechanisms used most by age group


• Facilitate parents’ discussion of methods of discipline available, selection, and results obtained


• Instruct parent on normal physiological, emotional, and behavioral characteristics of child


• Provide online resources, books, and literature designed to teach parents about parenting


• Provide parents with readings and other materials that will be helpful in performing parenting role


• Instruct parents on the importance of a balanced diet, three meals a day, and nutritious snacks


• Review nutritional requirements for specific age groups


• Review dental hygiene facts with parents


• Review grooming facts with parents


• Review safety issues with parents (e.g., children meeting strangers, water safety, bicycle safety)


• Discuss avenues parents can use to assist children in managing anger


• Discuss approaches parents can use to assist children to express feelings positively


• Help parents identify evaluation criteria for day care and school settings


• Inform parents of community resources


• Identify and instruct parents on how to use a variety of strategies in managing child’s behavior


• Encourage parents to try different childrearing strategies, as appropriate


• Encourage parents to observe other parents interacting with children


• Role play childrearing techniques and communication skills


• Refer parents to support group or parenting classes, as appropriate


1st edition 1992; revised 2013



5568


Parent Education: Infant


Definition: Instruction on nurturing and physical care needed during the first year of life


Activities:



• Determine parent(s)’ knowledge and readiness and ability to learn about infant care


• Monitor learning needs of the family


• Provide anticipatory guidance about developmental changes during the first year of life


• Assist parent(s) in articulating ways to integrate infant into family system


• Teach parent(s) skills to care for newborn


• Instruct parent(s) on formula preparation and selection


• Give parent(s) information about pacifiers


• Give information about adding solid foods to diet during the first year


• Instruct parent(s) on appropriate fluoride supplementation


• Give information about developing dentition and oral hygiene during the first year


• Discuss alternatives to a bedtime bottle to prevent nursing bottle caries


• Provide anticipatory guidance about changing elimination patterns during the first year


• Instruct parent(s) on how to treat and prevent diaper rash


• Provide anticipatory guidance about changing sleep patterns during the first year


• Demonstrate ways in which parent(s) can stimulate infant’s development


• Encourage parent(s) to hold, cuddle, massage, and touch infant


• Encourage parent(s) to talk and read to infant


• Encourage parent(s) to provide pleasurable auditory and visual stimulation


• Encourage parent(s) to play with infant


• Give examples of safe toys or available things in home that can be used as toys


• Encourage parent(s) to attend parenting classes


• Provide parent(s) with written materials appropriate to identified knowledge needs


• Reinforce parent(s)’ ability to apply teaching to child care skills


• Provide parent(s) with support when learning infant caretaking skills


• Assist parent(s) in interpreting infant cues, nonverbal cues, crying, and vocalizations


• Provide anticipatory guidance about changing sleep patterns during the first year


• Provide information on newborn behavioral characteristics


• Demonstrate reflexes to parent(s) and explain their significance to infant care


• Discuss infant’s capabilities for interaction


• Assist parent(s) to identify behavioral characteristics of infant


• Demonstrate infant’s abilities and strengths to parent(s)


• Explain and demonstrate infant states


• Demonstrate quieting techniques


• Monitor parent skill in recognizing the infant’s physiological needs


• Reinforce caregiver role behaviors


• Reinforce skills parent does well in caring for infant to promote confidence


• Provide parent(s) with information about making home environment safe for infant


• Provide information about safety needs of infant while in a motor vehicle


• Instruct parent(s) on how to reach health professionals


• Place follow-up telephone call 1-2 weeks after encounter


• Provide information about community resources


3rd edition 2000

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