Med-Surg - Cardiovascular System, part 7: Cardioversion, Pacemakers
This article continues our discussion of the cardiovascular system and focuses on cardioversion and pacemakers.
The Med-Surg Nursing video series follows along with our Medical-Surgical Nursing Flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
Types of cardioversion
Cardioversion is an intervention used to help restore a patient’s normal cardiac rhythm when they have a dysrhythmia (an irregular beating of the heart).
There are two types of cardioversion — electrical cardioversion and chemical cardioversion.
Electrical cardioversion uses external electric shocks to help restore normal heart rhythm. Defibrillation, for example, is the use of electrical cardioversion in an emergency, such as ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT).
Chemical cardioversion employs medications to help restore a patient’s cardiac rhythm.
Note that when administering adenosine, there is a brief period of asystole (aka flatlining) that occurs after administration that is normal and expected with this medication.
Nursing care for patients undergoing cardioversion
Ensure patient is on anticoagulation medication
For a scheduled cardioversion, ensure the patient has been on anticoagulation medication for 4 – 6 weeks prior to procedure. This is because cardioversions can cause blood clots.
Stand clear when delivering a shock
For an electrical cardioversion, make sure that all the staff is standing clear when a shock is delivered. Oxygen should be cleared as well.
Monitor the patient after cardioversion
After a cardioversion, maintain the patient’s airway.
Monitor their vital signs, including their EKG.
For more on the various classes of antidysrhythmic medications, see our Pharmacology Second Edition Flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
What is a pacemaker?
A pacemaker is a device that provides electrical stimulation of the heart when the SA node (sinoatrial node), the natural pacemaker in the heart, doesn't maintain proper cardiac rhythm.
What are the types of pacing?
Pacemakers can provide different types of pacing: atrial pacing, ventricular pacing, and AV pacing.
A pacemaker can provide atrial pacing when a patient experiences SA node failure. SA node failure may result in the patient developing a consistently slow heartbeat (sinus bradycardia), or the patient’s normal pacemaker activity may stop entirely (sinus arrest).
A pacemaker can provide ventricular pacing when the patient has a complete AV block, that is the electrical signal that controls the heartbeat is partially or completely blocked.
Sometimes the pacemaker must provide both atrial and ventricular pacing — AV pacing. This is required when a patient has both SA node failure and a complete AV block.
What are pacemaker modes?
A pacemaker can be set to one of two modes, asynchronous and synchronous.
A pacemaker set to to asynchronous mode will fire at a consistent, constant rate regardless of the heart’s electrical activity.
A pacemaker set to synchronous mode will fire only when the heart’s intrinsic rate falls below a preset number. Another name for this is a demand pacemaker.
For more on the natural pacemaker of the heart, as well as EKG interpretation for dysrhythmias, you can check out our EKG Interpretation - Nursing Flashcards.
Post-op nursing care for a patient with a pacemaker
Nursing care for a patient in a sling
Usually, a patient’s arm is put in a sling when they are in PACU (the post-anesthesia care unit) after having had a pacemaker inserted. The patient should be instructed to minimize all shoulder movement. They should especially avoid lifting their arm above the shoulder so they don’t displace the leads that were just placed during surgery.
Additionally, check the insertion site for bleeding and for any signs of infection.
Assess for hiccups
Assess the patient for hiccups. If the patient has consistent hiccups, that is indicative that the pacemaker is pacing the patient’s diaphragm and not their heart. In this situation, surgical intervention may be required.
If hiccups are observed in the patient, alert the provider.
Patient teaching for a patient with a pacemaker
The following care should be taught to patients after they have a pacemaker inserted:
- The patient should always carry their pacemaker ID wherever they go. This will have the details of the make and model of the patient’s specific brand and type of pacemaker.
- Patients should take their pulse daily to gauge their heart rate. This allows them to determine if the pacemaker is working effectively.
- Patients should avoid contact sports and heavy lifting for 2 months after having their pacemaker inserted.
- A pacemaker will set off airport security detectors. The patient should alert airport officials when they need to pass through an airport security detector.
- MRIs are contraindicated — patients with pacemakers should not have an MRI.
- It is okay for a person with a pacemaker to use a garage door opener and their microwave.
Hi, I'm Cathy with Level Up RN. In this video, I am going to talk about cardioversion as well as pacemakers. Be sure to stay till the end of the video because I'll be giving you guys a little quiz to test your understanding of some of the key facts I'll be covering in this video. Also, if you have our medical surgical nursing flashcards available at leveluprn.com, be sure to pull those out so you can follow along with me.
First up, we have a cardioversion, which is an intervention that is used to help restore a patient's normal cardiac rhythm when they have a dysrhythmia. And we have electrical cardioversion and chemical cardioversion.
So with electrical cardioversion, we are using external electric shocks to help restore that rhythm. So defibrillation is the use of electrical cardioversion in an emergency. And just as a reminder, we would defibrillate v fib as well as pulseless v tach.
Then we have a chemical cardioversion, which is the use of medications to help restore that patient's cardiac rhythm.
Examples of these medications include adenosine as well as procainamide. And as a side note, with adenosine, when you administer that, there is a brief period of asystole that occurs after administration that is normal and expected with this medication.
In terms of nursing care for a cardioversion, we want to make sure the patient has been on anticoagulation for several weeks before a scheduled cardioversion, as cardioversions can cause a blood clot. Also, for electrical cardioversion, we want to make sure that all the staff is standing clear when a shock is delivered. And then after the cardioversion, we want to make sure we are maintaining our patient's airway. So that's priority number one. We're going to be monitoring their vital signs, monitoring their EKG, and then we also need to monitor them for signs and symptoms of a dislodged clot, which can cause a stroke, an MI or a PE, which are all very serious complications.
Now let's talk about pacemakers. So a pacemaker is a device that provides electrical stimulation of the heart when the heart's natural pacemaker cannot maintain proper cardiac rhythm.
So a pacemaker can provide atrial pacing, which would be used when the patient has S-A node failure.
A pacemaker can provide ventricular pacing when the patient has a complete AV block. Or the pacemaker can provide both.
So AV pacing when the patient has S-A node failure and a complete AV block.
The pacemaker can be set to one of two modes. So it can be set to asynchronous mode, which means that it will fire at a consistent, constant rate regardless of the heart's electrical activity, or it can be set to synchronous mode. Another name for this is a demand pacemaker. So in this mode, the pacemaker will fire only when the heart's intrinsic rate falls below a preset number.
In terms of post-op nursing care, when your patient returns from their operation, from getting a pacemaker inserted, they will likely have their arm in a sling. Usually, they put the arm in a sling when the patient's in PACU. It's going to be important to tell your patient that they need to avoid lifting their arm above the shoulder so that we don't displace the leads that were literally just placed in surgery. Also, you want to check the insertion site for bleeding and for any signs of infection.
And then you also want to assess your patient for hiccups, which I know sounds like a random thing. But if the patient has consistent hiccups, then that is indicative of the pacemaker pacing the patient's diaphragm as opposed to their heart and surgical intervention may be required. So definitely alert the provider if you see hiccups in your patient.
In terms of patient teaching, we want to advise our patient to carry their pacemaker I.D. wherever they go, they need to take their pulse daily, and then after surgery, they need to avoid contact sports and heavy lifting for several months. We want to alert the patient that the pacemaker will set off airport security devices, so they need to be aware of that. However, it's totally okay for them to use their garage door opener or their microwave. Also, MRIs are contraindicated for patients who have a pacemaker.
All right. Time for a quiz. I have three questions for you. First question. What type of medication does the patient need to be on for several weeks prior to a cardioversion? The answer is an anticoagulant, because a cardioversion carries a risk for dislodging a clot. Question number two, a pacemaker in asynchronous mode will only fire when the heart's intrinsic rate falls below a certain rate. True or false? The answer is false. So a pacemaker in synchronous mode will only fire when the heart rate falls below a certain rate. A pacemaker in asynchronous mode will fire regardless of the heart's intrinsic rate. Question number three, a patient will need to wear a sling and minimize shoulder movements following insertion of a pacemaker. True or false? The answer is true.
Okay, I hope this video has been helpful. Hope you're enjoying these little quiz questions. If you found this information helpful, be sure to like this video and leave me a comment because I love to hear from nursing students and nurses who watch my videos. Take care and good luck studying.
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