Goal: The equipment is applied correctly without adverse effect to the patient; and the patient regains signs of circulation, including the capture of at least the minimal set heart rate.
1. Bring necessary equipment to the bedside stand or overbed table.
2. Perform hand hygiene and put on PPE, if indicated.
3. Identify the patient.
4. If the patient is responsive, explain the procedure to the patient. Explain that it involves some discomfort and that you will administer medication to keep him or her comfortable and help him or her to relax. Administer analgesia and sedation, as ordered, if not an emergency situation.
5. Close curtains around bed and close the door to the room, if possible.
6. If necessary, clip the hair over the areas of electrode placement. Do not shave the area.
7. Attach cardiac monitoring electrodes to the patient in the lead I, II, and III positions. Do this even if the patient is already on telemetry monitoring. If you select the lead II position, adjust the LL (left leg) electrode placement to accommodate the anterior pacing electrode and the patient’s anatomy.
8. Attach the patient monitoring electrodes to the ECG cable and into the ECG input connection on the front of the pacing generator. Set the selector switch to the ‘Monitor on’ position.
9. Note the ECG waveform on the monitor. Adjust the R-wave beeper volume to a suitable level and activate the alarm by pressing the ‘Alarm on’ button. Set the alarm for 10 to 20 beats lower and 20 to 30 beats higher than the intrinsic rate.
10. Press the ‘Start/Stop’ button for a printout of the waveform.
11. Apply the two pacing electrodes. Make sure the patient’s skin is clean and dry to ensure good skin contact. Pull the protective strip from the posterior electrode (marked ‘Back’) and apply the electrode on the left side of the thoracic spinal column, just below the scapula.
12. Apply the anterior pacing electrode (marked ‘Front’), which has two protective strips—one covering the gelled area and one covering the outer rim. Expose the gelled area and apply it to the skin in the anterior position, to the left side of the sternum in the usual V2 to V5 position, centered close to the point of maximal cardiac impulse. Move this electrode around to get the best waveform. Then expose the electrode’s outer rim and firmly press it to the skin.
13. Prepare to pace the heart. After making sure the energy output in milliamperes (mA) is on 0, connect the electrode cable to the monitor output cable.
14. Check the waveform, looking for a tall QRS complex in lead II.
15. Check the selector switch to ‘Pacer on.’ Select synchronous (demand) or asynchronous (fixed-rate or nondemand) mode, per medical orders. Tell the patient he or she may feel a thumping or twitching sensation. Reassure the patient you will provide medication if the discomfort is intolerable.
16. Set the pacing rate dial to 10 to 20 beats higher than the intrinsic rhythm. Look for pacer artifact or spikes, which will appear as you increase the rate. If the patient does not have an intrinsic rhythm, set the rate at 80 beats/minute (Craig, 2005).
17. Set the pacing current output (in milliamperes [mA]). For patients with bradycardia, start with the minimal setting and slowly increase the amount of energy delivered to the heart by adjusting the ‘Output’ mA dial. Do this until electrical capture is achieved: you will see a pacer spike followed by a widened QRS complex and a tall broad T wave that resembles a premature ventricular contraction.
18. Increase output by 2 mA or 10%. Do not go higher because of the increased risk of discomfort to the patient.
19. Assess for mechanical capture: Presence of a pulse and signs of improved cardiac output (increased blood pressure, improved level of consciousness, improved body
temperature).
20. For patients with asystole, start with the full output. If capture occurs, slowly decrease the output until capture is lost, then add 2 mA or 10% more.
21. Secure the pacing leads and cable to the patient’s body.
22. Monitor the patient’s heart rate and rhythm to assess ventricular response to pacing. Assess the patient’s vital signs, skin color, level of consciousness, and peripheral pulses. Take blood pressure in both arms.
23. Assess the patient’s pain and administer analgesia/sedation, as ordered, to ease the discomfort of chest wall muscle contractions (Craig, 2005).
24. Perform a 12-lead ECG and additional ECG daily or with clinical changes.
25. Continually monitor the ECG readings, noting capture, sensing, rate, intrinsic beats, and competition of paced and intrinsic rhythms. If the pacemaker is sensing correctly, the sense indicator on the pulse generator should flash with each beat.
26. Remove PPE, if used. Perform hand hygiene.
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