Mapua Institute of Technology San Lorenzo School of Health Sciences Makati City A Case Study in NCM 364L – BN01 Submitted to The Philippine Heart Center Quezon City In Partial Fulfilment of the Requirements for NCM364L Curative and Rehabilitative Nursing Care Management 2 – Part A (RLE) Submitted by Cantong, Rinolucy Dela Cruz, Katrina Paola Dela Peňa, Marco Fadrigo, Kevin Haidar, Nahida Leonardo, Roddy Levin Lim, Carmina Bianca Nicolas, Katherine Anne Sison, Francis Tan, Joan Rae Tomines, Guthrie
Transcript
Mapua Institute of TechnologySan Lorenzo School of Health Sciences
Makati City
A Case Study in NCM 364L – BN01Submitted to
The Philippine Heart CenterQuezon City
In Partial Fulfilmentof the Requirements
for NCM364LCurative and Rehabilitative Nursing Care Management 2 – Part A (RLE)
Submitted byCantong, Rinolucy
Dela Cruz, Katrina PaolaDela Peňa, Marco
Fadrigo, KevinHaidar, Nahida
Leonardo, Roddy LevinLim, Carmina Bianca
Nicolas, Katherine AnneSison, FrancisTan, Joan Rae
Tomines, GuthrieVillaos, Donna Pia
September 7, 2007
TABLE OF CONTENTS
I. Overview of the Study 1
II. Profile of the Patient 2
III. Nursing Care Assessment
5
IV. Physical Assessment 7
V. Significant Laboratory & Diagnostic Findings
9
VI. Electrical Conduction of the Heart 13
VII. Pathophysiology of Complete Heart Block
15
VIII. Treatment and Management
16
IX. Drug Interpretation and Study
21
X. Nursing Care Plan
33
XI. Discharge Planning 42
XII. Supporting Background Re: Amphetamine Use in CHB
46
I. OVERVIEW OF THE STUDY
Heart block, also called atrioventricular block or A-V block, is an abnormality of the spread or flow of electrical activity from the upper heart chambers, the atria, to the lower heart chambers, the ventricles.
Heart block results in an abnormality or disturbance in the rate or rhythm of the heartbeat.
Heart block occurs in three levels of severity. First-degree block is a delay of the signal that stimulates the ventricles to contract, and second-degree block is a partial or intermittent interruption of the signal that stimulates the ventricles to contract. Third-degree block is a complete interruption of the signal that stimulates the heart to contract.
Heart block is a disorder of impulse conduction, meaning that an electrical impulse is impaired from traveling along its normal pathway. Heart block is also called atrioventricular block, because it often occurs in the atrioventricular, or A-V, node, which transmits electrical signals from the atria (the upper chambers of the heart) to the ventricles (the lower chambers of the heart). Depending on its severity, A-V block may be an abnormal delay, a partial interruption, or a complete interruption of the impulse. Delays often have no symptoms, but can cause the heart rate to fall so far below normal that it causes dizziness or fainting. Certain forms of intermittent block may occur in normal people during sleep and cause heart rates of 40 beats per minute and even lower.
Third-degree heart block: Also called complete heart block, each sinus node impulse is completely interrupted in the A-V node or beyond, and the ventricles must generate their own impulse to contract. Depending on its cause, third-degree block may be transient (temporary) or permanent.
II. PROFILE OF THE PATIENT
Patient Profile:
Name: Villareal, Margarita Gelacio Ward: MW/WW, Bed L
Registration #: 1P087363Age: 29 years old Sex: Women Date of Birth: 08-07-1978 Place of Birth: Quezon City Civil Status: Single Religion: Mormon (LDS)Ethnicity: AsianHome Address: #21 Lakandula st. Parang, Marikina City, 1800Educational Attainment: College undergraduateOccupation: Government employee
Client Complaint:
Dizziness, DOB, near syncopal attack
Admitting Diagnosis:
Complete Heart Block with ventricular asystole S/P “e” TPI
Final Diagnosis
Complete heart block S/P PPI
Patient History:
History of Present Illness:
Patient is non-hypertensive, non-diabetic, non-asthmatic, smoker (2-10 sticks per day), and an alcoholic drinker for 10 years. She had a history of amphetamine use and last intake was a month ago.
Patient is apparently well until 10 years prior to admission when she had her second pregnancy. She experienced episodes of dizziness and near syncopal attack. Also, she had a syncopal attack twice when she was still a child. The first incident was when she was 8 years old and the other was when she was 12 years old. The doctor advised her to consult a cardiologist but she did not comply. 8 years prior to admission, she had another episode of syncopal attack. She sought for medical help and it was found out that her heart rate is slow. According to her 2D-echo was done but the result was unrecalled. She was given Bricanyl as a maintenance medication. 3 years prior to admission, the patient had frequent episodes of dizziness, near syncopal attack and easy fatigability. No consultation was done. She just continued her maintenance medication. 6 hours prior to admission, patient had continuous episodes of dizziness, DOB, and near syncopal attack thus she was immediately brought to PHC-ER.
At the ER, patient is drowsy and confused. BP then was 90/60, cardiac rate 30, clear breath sounds. Atropine was given and BP went up but after 10 minutes patient had another episode of syncope. Thus, emergency TPI was done. Patient was then admitted to the ward.
On admission, patient is conscious, coherent, afebrile, not in distress with BP 140/90, CR 60 (paced rhythm), RR 18. Pink palpebral sclera, adynamic precordium, normal rate regular rhythm, no murmurs, flabby abdomen, soft and non-tender, NABS, no edema in the extremities, and weak pulses on all extremities.
I. Pertinent Family Medical History:
(-) Tuberculosis (+) Cancer (-) Asthma (+) Hypertension(-) Diabetes Mellitus
II. Social History:(+) heavy smoker (+) heavy alcoholic drinker(+) amphetamine user for 10 years
The patient has no family background on cancer from her uncle and hypertension from her mother. She is a heavy alcohol drinker and cigarette smoker. For the past 10 years, she has used amphetamine occasionally.
Narrative Summary:
The patient is Margarita Gelacio Villareal. 29 years old, born on August 07, 1978 at Quezon City. A Mormon (LDS), a single mother living with her mom and 3 daughters at 21 Lakandula Street parang Marikina City.
The patient has a negative family background on Tuberculosis, Asthma, and Diabetes Mellitus. However, hypertension and Cancer runs in the family. The patient was a heavy smoker, heavy alcoholic drinker, and an occasional amphetamine user for almost 10 years.
Patient is apparently well until 10 years prior to admission when she had her second pregnancy. She experienced episodes of dizziness and near syncopal attack. The doctor advised her to consult a cardiologist but she did not comply. 8 years prior to admission, she had another episode of syncopal attack. She sought for medical help and it was found out that her heart rate is slow. According to her 2D-echo was done but the result was unrecalled. She was given Bricanyl as a maintenance medication. 3 years prior to admission, the patient had frequent episodes of dizziness, near syncopal attack and easy fatigability. No consultation was done. She just continued her maintenance medication. 6 hours prior to admission, patient had continuous episodes of dizziness, DOB, and near syncopal attack thus she was immediately brought to PHC-ER.
18 of August 2007, Margarita Gelacio Villareal, were admitted at Philippine Heart Center. Upon admission the patient was temporarily ordered nothing per orem (NPO). She underwent Chest X-ray, Electrocardiogram (ECG), and 2D echo with Doppler. Medicine (Atropine) was also administered 1 mg, IV, for 3 doses. After the proper evaluation of her case, the cardiologist confirmed that Margarita Gelacio Villareal needs a Permanent Pacemaker Insertion (PPI).
However, due to the unavailability of PPI; an emergency Temporary Pacemaker Insertion (TPI) was done to temporarily normalize her heart rhythm and cardiac rate. It was on September 3, 2007 that she finally had her PPI.
III. NURSING CARE ASSESSMENT
Health-Perception/Health Management PatternsThe client thinks that she’s healthy enough to consult a doctor. She manages her health through self care. She doesn’t believe in faith healers/albularyos. Too much happiness and anger causes her chest pain which she actually ignores.
Nutritional/ Metabolic PatternThe client usually eats 3 times a day. She drinks 5 glasses of water a day. She prefers to eat fatty foods. She takes “Centrum” as her daily supplement. She is now on low salt low fat diet. Her skin is warm. No various interruptions in skin integrity are found. She has pasta on her right molar.
Elimination patternThe client has normal urinary output but abnormal bowel movement (twice a week). She urinates without discomfort.
Activity/Exercise PatternThe client has a sufficient energy for completing her desired required activities. She has the ability to do full self-care She doesn’t have any musculoskeletal problems.
Sleep/ Rest PatternThe client has an adequate amount of sleep every night. She doesn’t experience any disturbances and nightmares in her sleep.
Cognition/ Perception PatternThe client has a normal eye vision. She noticed that there are changes in her memory lately. She has no hearing difficulty.
Self perception/ Self control patternThe client describes herself as God-fearing and naughty. She’s currently happy cause God gave her a second life. She became emotional during the times when her past was being tackled.
Role/ Relationship patternThe client lives with her mother, uncle and children. She’s a single parent and she has 3 children. She’s close to her friends and family. She’s working as a government employee.
Sexuality/ Reproductive PatternMenarche at 13 years of age. Her menstruation is on regular intervals with 1 week duration, consuming 2 pads a day, mildly soaked. Three years ago, client and her husband used condom as a contraceptive.
Coping/ Stress PatternThe most helpful in talking things over is her mother and God. Before, she used to depend on her friends. She cope up with her problems through prayers and she’s a fan of the saying “Laughter is the best medicine”. She
has a history of drug abuse, Amphetamines specifically and she loves to drink alcoholic beverages. She did this, because of peer pressure and family-related problems.
Value-belief PatternThe patient is a mormon (LDS) and handles things by talking to God. She believes in the wonders of herbal medicine. She is not against blood transfusion. She’s looking forward to go home.
IV. PHYSICAL EXAMINATION
General InformationClient is female,29 years old,currently residing at 21 Lakandula St. Marikina City. She is presently confined in Female ward at Bed “L”.
Vital Signs (current)Client’s temperature is 36.5 per axilla; afebrile. Respiratory rate is 17 breaths/min; regular. Blood pressure is 110/90; taken on the right arm while lying. Client’s cardiac rate is 60 bpm; at radial pulse.
General SurveyClient is conscious, coherent and not in distress. Client is oriented to person, time and place. Client’s body is mesomorph and well-developed. Her looks is appropriate to her age. She’s is well nourished. She is calm and happy so far.
SkinClient’s skin is pallor and smooth with good skin turgor. The client’s skin is warm to touch. Edema or lesions are not present.
HeadClient’s head is normocephalic. Closed fontanelles were noted. Hair is evenly distributed. Scalp is clean and intact.
EyesClient’s eyelids are symmetrical. Conjunctiva is pale. Client’s sclera is anicteric. Her cornea is smooth and clear. Pupil size is equal (R=3mm; L= 3mm). Client’s visual acuity is normal.
EarsClient has 2 ear piercings (1 Right and 1 Left). External pinnae are normoset and symmetrical. External canal is clean. Tympanic membrane is intact. Gross hearing is symmetrical
NoseNasolabial fold is symmetrical. External nose is not tender and there’s no presence of lesions. There is no discharge or nasal flaring. Air moves freely as the client breathes through the nares. Mucosa is pinkish with clear, water discharge. There are no lesions. Nasal septum is intact and in midline. The maxillary and frontal sinuses are not tender. Client’s gross smell is symmetrical
MouthClient’s outer lips are pale and dry. Client’s gums are pale and with a moist and firm texture. The tongue is on central position. It moves freely and there is no presence of tenderness. It is smooth with no palpable nodules. Client’s speech is intact.
Pharynx
The uvula is positioned in midline of soft palate. Client’s mucosa is pale. Tonsils are not inflamed.
NeckClient’s neck is head centered. Lymph nodes are not palpable. Trachea is placed in midline of the neck.
Chest and LungsClient’s inspiration/ expiration ratio is 1:1. Chest expansion is symmetrical. The anterior-posterior- lateral ratio diameter is 2:1.
HeartHeart sounds are distinct. She has an adynamic precordium, normal rate regular rhythm, no murmurs.
Breast and AxillaeClient’s breast is equal. Skin is uniform in color and intact. There is no tenderness. Masses and nodules are not present. The nipples are round, everted and equal in size.
AbdomenClient’s abdomen is uniform in color. Abdomen is symmetrical.Umbilicus is sunken. Bowel sounds are audible.
Genito-urinary SystemNot Performed.
Back and ExtremitiesPeripheral pulses are weak and irregular. Nails and nail beds are pink. There is decreased ROM at her lower extremities due to temporary pacemaker insertion. Muscle tone normal. Spine is located midline and is vertically aligned. Costovertebral angle tenderness is not noted.
V. SIGNIFICANT LABORATORY AND DIAGNOSTIC FINDINGS
Complete Blood Count with Differential (August 23,2007)Test Test Results Normal ValuesRed Blood Cell (RBC) 4.55x10 /L 4.00 – 4.50x10 /L Mean Corpuscular Hemoglobin Concentration (MCHC)
331 L g/L 334 – 335 g/L
White Blood Cell Count and Differential White Blood Cells (WBC) 10.40H 5.00 – 10.00Neutrophils 44 L % 55 – 65 L %Lymphocytes 48 H % 25 – 35 H %Monocytes 7 % 2 – 6 %Eosinophils 1 L % 2 – 4 %
Complete Blood Count with Differential (September 3,2007)Test Test Result Normal valuesRed Blood Cell (RBC) 4.30x10/L 4.00-4.50x10/LMean Corpuscular Hemoglobin Concentration (MCHC)
333L g/L 334 – 335 g/L
White Blood Cell Count and DifferentialWhite Blood Cells (WBC) 16.70H 5.00 – 10.00Neutrophils 91 55 – 65 L %Lymphocytes 6 25 – 35 H %Monocytes 3 2 – 6 %
Interpretation:
Red Blood Cells – principal means of delivering oxygen to the blood. In the case of our client, there is a slight increase in the number of the red blood cells on August 23, 2007 but it is still considered within normal range.
MCHC – is a measure of the average concentration or the percentage of hemoglobin within a single RBC. A great decrease in MCHC could stimulate hypochromic anemia but since there is only a 4% decrease it could still be considered normal.
White Blood Cells – major function is to fight infection and react against foreign bodies or tissues. The test shows a 10% increase in the WBC. This could result from the insertion of the temporary pacemaker. The procedure is invasive and it could stimulate increase production of antibodies to prevent infection.
Neutrophils – primary function is phagocytosis. In the case of Mrs. Margarita Villareal, the Neutrophils decrease at 11% on the August 23, 2007. This decrease may result from dietary deficiency.
On the September 3, 2007 WBC result, the neutrophils show an elevation to the count. The client might have experienced physical and emotional stress which can cause the elevation.
Lymphocytes – main function is to fight chronic bacterial infection and acute viral infection. The White Blood Count shows a slight elevation of the lymphocytes. The elevation could be cause by the insertion of the temporary pace marker. It triggered the body mechanism to production antibodies.
Monocytes – have similar functions to neutrophils. There were an increase number of the monocytes in the test result. This could result to the temporary insertion of a pacemaker which is the case of our client.
Eosinophils – are involved in allergic reaction. Decreased in counts are due to the increased adrenosteriod production.
Other laboratory results such as electroyte serum levels does not show any significant findings which may be correlated to the occurrence of the complete heart block.
Interpretation: Third degree atrioventricular block Septal fibrosisNon-specific St T-wave changes
*The ECG in the case of Ms. Margarita Villareal the rhythm of the Atrial and Ventricular are usually regular. The Atrial rate is 86 beats per minute while the ventricular rate is 53 beats per minute. The Atrial conduction produced normal P waves but occur more frequently than the QRS complex. The P-R intervals are inconsistent to each other. The QRS complex produced are normal with a 0.10 per seconds. Since there is a complete dissociation between the SA and the AV node, the ventricular depolarization is slowed because the ventricles use its intrinsic ability to contract without the aid of impulse conduction.
Normal ECG:
P wave – represent the normal electrical impulse starting in the sinus node and spreading through the atria. It is normally 2.5 mm or less in height and 0.11 sec in duration.
QRS wave – represents ventricular depolarization. It is normally less than 0.12 seconds in duration.
T wave – represents ventricular repolarization. It follows the QRS wave but sometimes it cannot be since at the ECG because it occurs at the time as the QRS wave. PR interval – measures from the start of the P wave to the beginning of the QRS complex and represent the time needed for sinus node stimulation, atrial depolarization and conduction through the AV node before ventricular depolarization. Normal ranges from 0.12 to 0.20 seconds.
ECG Post Temporary Pacemaker as of August 24, 2007
With the aid of a temporary pacemaker, the patient’s heart rhythm is stabilized thereby depending on the impulse conducted by the pulse generator.
Pacemaker uses the heart’s remaining capabilities and stimulates the normal electrophysiological functioning of the heart as closely as possible to produce the best cardiac output.
VI. ELECTRICAL CONDUCTION SYSTEM OF THE HEART
The heart’s electrical system controls all the events that occur when your heart pumps blood. The electrical system also is called the cardiac conduction system. The EKG/ECG (electrocardiogram), is a graphical picture of the electrical activity of the heart.
The heart’s electrical system is made up of three main parts: The sinoatrial (SA) node located in the right atrium of your heart The atrioventricular (AV) node located on the interatrial septum close
to the tricuspid valve The His-Purkinje system located along the walls of your heart’s
ventricles
A heartbeat is a complicated series of events that take place in your heart. A heartbeat is a single cycle in which your heart’s chambers relax and contract to pump blood. This cycle includes the opening and closing of the two inlet and outlet valves of the right and left ventricles of the heart.
Each heartbeat has two basic parts: diastole, and atrial and ventricular systole. During diastole, the atria and ventricles of the heart relax and begin to fill with blood. At the end of diastole, the heart’s atria contract (atrial systole), pumping blood into the ventricles, and then begin to relax. The heart’s ventricles then contract (ventricular systole), pumping blood out of your heart.
Each beat of the heart is set in motion by an electrical signal from within your heart muscle. In a normal, healthy heart, each beat begins with a signal from the SA node. This is why the SA node is sometimes called the heart’s natural pacemaker. The pulse, or heart rate, is the number of signals the SA node produces per minute.The signal is generated as the two vena cava fill your heart’s right atrium with blood from other parts of the body. The signal spreads across the cells of the heart’s right and left atria. This signal causes the atria to contract. This action pushes blood through the open valves from the atria into both ventricles.
The signal arrives at the AV node near the ventricles, where it slows for an instant to allow the heart’s right and left ventricles to fill with blood. The signal is released and moves to the His bundle located in the walls of the heart’s ventricles.
From the His bundle, the signal fibers divide into left and right bundle branches through the Purkinje fibers that connect directly to the cells in the walls of the heart’s left and right ventricles. As the signal spreads across the cells of the heart’s ventricle walls, both ventricles contract, but not at exactly the same moment. The left ventricle contracts an instant before the right ventricle. This pushes blood through the pulmonary valve (for the right ventricle) to your lungs, and through the aortic valve (for the left ventricle) to the rest of the body.
As the signal passes, the walls of the ventricles relax and await the next signal. This process continues over and over as the atria refill with blood and other electrical signals come from the SA node.
PHYSIOLOGY OF THE ELECTRICAL CONDUCTION SYSTEM
Coronary Arteries supply blood to the myocardium
Sino-Atrial Nodes sends electrical stimulus through the intranodal pathways
Internodal Pathways relay the electrical stimulus throughout the Atrial Myocardium
Atrial Contraction occurs and stimulus is further sent towards the Atrio-Ventricular Nodes
Electrical stimulus reaches the Atrio-Ventricular Node
Atrial Node Delay
Bundle of His separates into the
Left Bundle Branch Right Bundle Branch
Anterior fasciclePosterior fascicle
Stimulus Reaches the Pukinje Fibers all throughout the ventricular myocardium
Ventricular Myocardium Contraction Occurs
Ventricular Repolarization
Legend:•••••• Mechanism•••••• P wave (atrial depolarization)•••••• PR interval•••••• QRS complex (ventricular depolarization)•••••• T wave (ventricular repolarization)
VII. PATHOPHYSIOLOGY OF COMPLETE HEART BLOCK
Decreased pumping action of the heart
Occasional methamphetamine user for
10 years
Heavy alcoholic drinker & cigarette smoker
Increased catecholamine activity of the PNS
Contributes to
Over stimulation of the vagus nerve
Exacerbation
Deterioration of cardiac nodal
fibers
Decreased rate at SA node
Decrease excitability of AV junction fibers
Progresses to a conduction block at the
level of AV
Absence of impulse conduction
Ventricles contract at their own intrinsic rate (20-40 bpm)
Continuous monitoring with the use of an electrocardiogram
The ECG is generally used to evaluate and monitor anesthesia, angina pectoris, anxiety, dysrhythmias, bradycardia, carbon monoxide posisoning, chest pain.
In relation to the patient’s condition, the use of ECG was helpful in the diagnosis of a 3rd Degree AV Block (Complete Heart Block) and the evaluation of the paced rhythm coming from the transvenous pacemaker & permanent pacemaker.
Medical Intervention/sIntervention Rationale
Administration of Atropine 1mg every 3-5 mins. for 3 doses
The administration of Atropine sulfate is indicated to the patient’s case to be used as a treatment of bradycardia (an extremely low heart rate), asystole and pulseless electrical activity (PEA) in cardiac arrest.
This works because the main action of the vagus nerve of the parasympathetic system on the heart is to slow it down. Atropine blocks that action and therefore may speed up the heart rate.
Surgical Intervention/sIntervention Rationale
“E” Temporary Pacemaker Insertion via femoral vein (transvenous)
Temporary pacing may be used in emergency or elective situations that require limited, short-term pacing. In this form of pacing, the pulse generator is external.
Transvenous pacing is used in the patient for the pacing the heart since it is an emergency situation. The pacing electrode is inserted via the femoral vein which threads the
electrode in the right atrium/ventricle so that it will be in direct contact with the endocardium.
Permanent Pacemaker Insertion via subclavian vein
Permanent pacing with an implantable pacemaker involves placement of one or more pacing wires within the chambers of the heart. One end of each wire is attached to the muscle of the heart. The other end is screwed into the pacemaker generator. The pacemaker generator is a hermetically sealed device containing a power source and the computer logic for the pacemaker.
In the patient’s case the generator is placed below the subcutaneous fat of the chest wall, above the muscles and bones of the chest.
The outer casing of pacemakers is so designed that it will rarely be rejected by the body's immune system. It is usually made of titanium, which is very inert in the body.
PACEMAKERS
The heart has an electrical system that controls how fast or slow it beats. The natural pacemaker sends electrical impulses from the top of the heart (the atria), towards the bottom of the heart (the ventricles). When electrical signals reach these chambers, the heart contracts and then relaxes. The heart pumps blood to all parts of the body. This pumping makes waves of pressure that are felt as our pulse.
When the electrical signal is intermittent or slow, you may need an artificial pacemaker. You may have had one of the following symptoms:
Dizziness – when the heart rate drops, even for a few seconds, you may feel dizzy or faint. You may fall down;
Blackouts or fainting spells;
Blurred vision;
Shortness of breath; and
Chest pain
The heartbeat is usually 50 to 110 beats per minute. However, it may be as low as 30 to 40 beats per minute if you have a condition called “heart block”. There are different types of heart block.
Complete heart block – your natural pacemaker cannot send impulses between the atria and ventricles.
Intermittent heart block – your natural pacemaker works some of the time.
Sick sinus syndrome – sometimes the natural pacemaker is too slow or races uncontrollably and dizziness or fainting may result.
Types of Pacing
Temporary Pacing - Temporary pacing may be used in emergment or elective situations that require limited, short-term pacing. In this form of pacing, the pulse generator is external.
Transvenous pacing – this provides the most common means for pacing the heart in emergency situations. The surgeon inserts the pacing electrode via the transvenous route (either antecubital, femoral, jugular, or subclavian veins) and threads the electrode into the right atrium or right ventricle so that it comes into direct contact with the endocardium.
Permanent Pacing - is indicated in individuals who are experiencing irreversible bradychardia due to advanced AV block, sick sinus syndrome, or tachyarryhthmias refractory to pharmacologic intervention. The surgeon inserts electrode via the transvenous rate or by direct application to the epicardial surface during thoracotomy. The surgeon then places the permanent pulse generator into the small tunnel burrowed within the subcutaneous tissue below the right clavicle or, less often the left clavicle.
Artificial Cardiac Pacemaker – an electronic apparatus, initiates the heart beat when the heart’s intrinsic conduction system fails or is unreliable. Problems with the conduction system develop when (a) the SA node is damaged and unable to promote a reliable rhythm or (b) impulses from the SA node and atria are not adequately transmitted through the AV junction to the ventricles.
Artificial Pacemaker Design – Every pacemaker must consist of a pulse generator and a lead-electrode system. The pulse generator is essentially the pacemaker’s power source. The output circuit controls the current pulse delivery rate, pulse duration, and refractory period. The sensing circuit is responsible for identifying and analyzing any spontaneous intrinsic electrical activity and responding appropriately. The lead-electrode system delivers the electrical impulse from the pulse generator to the myocardium.
Electrical Current Flow – An electrical circuit is completed when electricity (electrons) flows from a negative pole to a positive pole via a conducting material. Voltage refers to the driving force that pushes the electrons to the circuit. Current is the number of electrons moving through the circuit. And the stimulation threshold refers to the smallest intrinsic electrical signal to activate the pacemaker’s sensing circuit.
Classification of Pacemakers –The classification uses a three-letter code: first letter denotes the cardiac chamber to be paced; the second letter reflects the chamber to be sensed; and the third letter indicates the type of response to occur.
1st letter 2nd letter 3rd letter
Chamber is paced Chamber is sensedMode (how pacemaker
respond to intrinsic heart pulses)
V = VentricleA = AtriumD = Dual
V = VentricleA = AtriumD = Dual
O = no sensing
I = inhibited responseT = trigger responseD = dual response
R = reverseO = no response to
sensed impulses
Modes of Pacing
1. Fixed Rate Pacing – this mode delivers an electrical impulse to the heart at a pre-set fixed rate regardless of cardiac activity.
2. Demand Pacing – the pacemaker fires only on demand or when needed to stimulate atrial or ventricular contraction.
3. Synchronous Pacing – operates in a manner similar to demand pacing. In syncrhronous pacing, the sensing electrode is placed in the atrium and the pacing electrode is placed in the ventricle.
4. Bifocal Pacing – Both atrial and ventricular pacing occur, depending on the appearance of QRS.
PACEMAKER THERAPY
Electronic Pacemakers
An electronic pacemaker is made up of two parts.
Pulse Generator – contains the circuitry and battery that generate the electrical signal. The battery can last from 6 to 15 years, depending on the type of pacemaker and how much you use it.
Leads – the wires that carry the electrical signal from the pulse generator to the heart. An electrode is located at the end of the lead.
Through this, the pacemaker monitors (senses) the heart’s electrical activity and sends out electrical impulses (paces) only when needed.
Preparation for the Procedure
1. Explain procedure to patient and relatives2. Patient NPO for four to six hours prior to surgery3. Get informed consent about the procedure4. Check patient for dentures, nail polish, jewelries, contact lens, etc. 5. A chest x-ray, electrocardiogram (ECG) and blood work may be
obtained. 6. An intravenous (IV) line will be inserted through which fluids and
medicines can be given. 7. An antibiotic (e.g. Cefuroxime) will be given through the IV to reduce
the possibility of infection.
Procedure
The procedure is a same day admission. It is performed under sterile conditions in the catheterization laboratory or operating suite. The patient will be asked to lie flat on a cushioned table under a large, C-shaped x-ray machine. The patient will be attached to a blood pressure cuff and heart monitor. The pacemaker is usually placed on the left or right upper chest (depending on whether you are left or right handed, so as not to interfere with activity). This area is shaved (if applicable), cleaned with antiseptic and covered with a sterile drape. It is then numbed with local anesthesia after
Leads
Pulse Generator
which a small 1-1.5 inch incision is made. The arm vein is then carefully entered using a needle so that the leads (wires) can be threaded down to the desired location in your heart (atrium or ventricle or both). The pulse generator is then attached and the incision is closed with stitches or staples. The patient will be exposed to intermittent low doses of x-rays during the procedure. X-rays are necessary to ensure the best placement of leads. An uncomplicated pacemaker procedure usually takes about 1 hour. The patient will be kept relaxed and sedated throughout the entire procedure.
After the Procedure
(See Discharge Planning)
IX. DRUG STUDY INTERPRETATION
DRUGS TAKEN IMPLICATIONATROPINE In the ER, the patient was given
atropine with a dose of 1 mg IV for 3 doses in order to increase her cardiac rate by inhibiting the vagal stimulation with the help of the parasympathetic nervous system.
MEFENAMIC ACID After the surgical procedure was made the patient experiences pain on the site of the operation so as her post-operative medication the patient was given this drug with a dosage of 500 mg/cap every 6 hours.
NUBAIN This is a pre-op medication given to the patient as an opiate analgesic to relieve pain with the dosage of 5 mg via IM administration.
DIPHENHYDRAMINE HYDROCHLORIDE
An anti-histamine and is a pre-op medication that is used to sedate and prevent allergic reactions. The dose given was 25 mg via IM administration.
CEFUROXIME This is an antibiotic given to the patient prior to surgery to prevent occurrence of infection. The dosage was 1.5 gm via IV.
DIAZEPAM Another pre-op medication given as an anti-anxiety drug with the dose of 10 mg/IV.
(See comprehensive table of drugs)
IX. DRUG STUDY (continuation)
GENERIC NAME
BRAND NAME/CHEMICAL NAME/
AVAILABILITY
MECHANISM OF ACTION INDICATION CONTRAINDICATION
ADVERSE EFFECTS
NURSING CONSIDERATIONS
NUBAIN
Dose: 5mg IM
GN: NALBUPHINE HDROCHLORIDE
AVAILABILITY: 10 mg/mL, 10 mL multiple dose vials (box of 1) IM, SQ
An opiate analgesic with both narcotic agonist and antagonist actions. Analgesic potency is about equal to that of morphine, and antagonist potency is about 1/ 25 that of naloxone. May cause sphincter of Oddi spasm. Does not increase pulmonary artery pressure, systemic vascular resistance, or myocardial work load.
Management of moderate-to-severe pain; preoperative and postoperative analgesia; supplement to balanced anesthesia; obstetrical analgesia during labor and delivery.
Patients with a history of hypersensitivity to any ingredients of the drug
Advise patient or caregiver that medication will usually be prepared and administered by a health care provider in a health care setting.
Caution patient or caregiver that medication may be habit forming and, if used at home, to use exactly as prescribed and not to change the dose or discontinue therapy unless advised by health care provider. Advise patient or caregiver to notify health care provider if medication does not adequately control pain.
Advise patient or caregiver that if medication needs to be discontinued after prolonged use that it will usually slowly be withdrawn unless safety concerns (eg, rash)
Respiratory: Depression, dyspnea, asthma.
Dermatologic: Itching, burning, urticaria.
require a more rapid withdrawal.
Advise patient or caregiver to notify health care provider if any of the following occur: excessive sedation or drowsiness; slow or shallow breathing; low BP; slow heart rate; severe constipation.
Instruct patient to get up slowly from lying or sitting position and to avoid sudden position changes to prevent postural hypotension.
Advise patient to report dizziness with position changes to health care provider.
Caution patient that hot tubs and hot showers or baths may make dizziness worse.
Caution patient that drug may cause dizziness or drowsiness and to
use caution while driving or performing other tasks requiring mental alertness or coordination until tolerance is determined.
BENADRYL
Dose: 25 mg Im
GN: DIPHENHYDRAMINE
AVAILABILITY:ADULT: 25 to 50 mg three or four times daily.10 to 50 mg intravenously or deep intramuscularly, 100 mg if required; maximum daily dosage is 400 mg.CHILDREN: 12.5 to 25 mg three to four times dailyOne to two teaspoonfuls three to four times daily. Maximum daily dosage not to exceed 300 mg.
Symptomatic relief of perennial and seasonal allergic rhinitis, vasomotor rhinitis and allergic conjunctivitis; temporary relief of runny nose and sneezing caused by common cold; dermatographism; treatment of urticaria and angioedema; amelioration of allergic reactions to blood or plasma; adjunct to epinephrine and other standard measures in anaphylaxis; relief of uncomplicated
Hypersensitivity to antihistamines; asthmatic attack; MAO inhibitor therapy; history of sleep apnea; use in newborn or premature infants and in nursing women; use as a local anesthetic.
GI: Nausea, diarrhea, dyspepsia and upper abdominal pain.
Others: Edema, dizziness, hypertension, headache, fatigue and increases in liver enzymes.
Advise patient that if allergy symptoms are not controlled not to increase the dose of medication or frequency of use but to inform their health care provider. Caution patient that larger doses or more frequent dosing does not increase effectiveness and may cause excessive drowsiness or other side effects.
Instruct patient to stop taking drug and immediately report any of these symptoms to health care provider: persistent dizziness; excessive drowsiness; severe dry mouth, nose, or throat; flushing; unexplained shortness of breath or difficulty breathing; unusual tiredness or
allergic conditions of immediate type when oral therapy is impossible or contraindicated (parenteral form); treatment and prophylactic treatment of motion sickness (injection only); nighttime sleep aid; management of parkinsonism (including drug-induced) in elderly who are intolerant of more potent agents, in mild cases in other age groups and in combination with centrally acting anticholinergics; control of cough from colds or allergy (syrup formulations).
weakness; sore throat, fever, or other signs of infection; bleeding or unusual bruising; fast or irregular heartbeat; excitability, confusion, or changes in thinking or behavior; chest tightness.
Advise patient that medication may cause drowsiness or dizziness and not to drive or perform other activities requiring mental alertness until tolerance is determined.
Advise patient to take sips of water, suck on ice chips or sugarless hard candy, or chew sugarless gum if dry mouth occurs.
Caution patient that alcohol and other CNS depressants (eg, sedatives) will have additional sedative effects if taken with diphenhydramine.
ATROPINE GN: Atropine Inhibits action of Administration Documented Dryness of Advise patient that
Sulfate
AVAILABILITY:ADULT: 0.5 mg rapid IV push,mg can be administered; maximal IV dose is 0.04 mg/kgPEDIATRIC: 0.02 mg/kg IV push, 1 mg maximal total IV dose is 0.04 mg/kg
acetylcholine or other cholinergic stimuli at postganglionic cholinergic receptors, including smooth muscles, secretory glands, and CNS sites.
Enhances sinus node automaticity. In addition, blocks effects of acetylcholine at AV node, thereby decreasing the refractory time and speeding conduction through AV node.
prior to anesthesia to reduce or prevent secretions of respiratory tract; to control rhinorrhea; treatment of parkinsonism; restoration of cardiac rate and arterial pressure in some situations; treatment of peptic ulcers; management of hypersecretion, irritation, or inflammation of stomach, intestines, or pancreas; treatment of diarrhea; relief of infant colic; management of spasms of bile tract; treatment of hypertonicity of small intestine and uterus; management of
hypersensitivity to atropine or belladonna alkaloids or related products; concomitant acute myocardial infarction/ischemia; thyrotoxicosis; narrow-angle glaucoma; congestive heart failure; tachycardia
the mouthblurred vision,photophobia tachycardia commonly occur with chronic administration of therapeutic dosespalpitation,dilated pupils,difficulty in swallowing hot dry skin, thirst, dizziness, restlessness, tremor, fatigue and ataxia. palpitation, restlessness and excitement, hallucinations, deliriumDepression and circulatory blood
medication, with exception of auto-injector, will be prepared and administered by a health care provider in a medical setting.
Review the patient information leaflet and instruction guide with potential user of auto-injector. Ensure that potential user of the auto-injector understands the indications for and use of the auto-injector, including symptoms of poisoning and preparation and use of the auto-injector.
Emphasize to potential user of auto-injector that medical attention must be sought immediately after use of the auto-injector.
hypermotility of colon; prevention of spasm of pylorus, biliary tree, ureters, and bronchi; treatment of frequent urination and bed-wetting; therapy for certain bradycardias and heart blocks; treatment of closed head injury with acetylcholine release; reduction of laughing and crying associated with brain lesions; treatment of alcohol withdrawal symptoms; relief of motion sickness. Antidote for CV collapse in certain
pressure declines death due to respiratory failure
overdoses or poisonings (eg, organophosphorous nerve agents having cholinesterase activity, organophosphorous or carbamate insecticides, muscarinic symptoms of insecticide or nerve agent poisonings). Short-term treatment and prevention of bronchospasm associated with chronic bronchial asthma, bronchitis, and COPD
PONSTEL GN: MEFENAMIC ACID
AVAILABILITY: 250 mg blue-banded, ivory capsules, imprinted with " FHPC 400" and "PONSTEL®".
Decreases inflammation, pain, and fever, probably through inhibition of cyclooxygenase activity and prostaglandin synthesis.
Relief of moderate pain lasting less than 1 week
Patients in whom aspirin, iodides, or any NSAID has caused allergic-type reactions; preexisting renal disease; active ulceration or chronic inflammation of GI tract.
medication if rash develops and to contact health care provider.
Instruct patient to report the following symptoms to health care provider: rash, visual problems, dark stools, decreased urinary output, persistent headache or stomach pain and unusual bruising or bleeding.
Advise patient to avoid intake of alcoholic beverages.
Instruct patient that drug may cause drowsiness and to use caution while driving or performing other activities requiring mental alertness.
Caution patient to avoid prolonged exposure to sunlight and to use sunscreen or wear protective clothing to avoid photosensitivity
GABA-mediated presynaptic inhibition at the spinal level as well as in the brain stem reticular formation.
symptoms; relief of preoperative apprehension and anxiety and reduction of memory recall; treatment of muscle spasms, convulsive disorders (used adjunctively), and status epilepticus.
children younger than 6 mo of age; lactation.
Impaired motor function, Depression, Anterograde amnesia (especially pronounced in higher doses), Reflex tachycardia
Determine any depression or drug abuse. Avoid simultaneous use of CNS depressants.
Reduce Drug gradually to avoid withdrawal symptoms such ad anxiety, tremors, anorexia, insomnia, weakness, headache and N&V.
The antidote for diazepam overdose is Flumazenil.
Tell the patient that the drug may cause dizziness, and drowsiness. Avoid activities that require mental alertness until drug effects realized.
Instruct the patient avoid alcohol and any other CNS depressants.
increase drug metabolism; thus requiring higher dose than the nonsmoker. Do not stop drug abruptly.
Inform the patient to report any adverse side effects or lack of response.
CEFUROXIME
Dose1.5 mg/IV
GN: Cefuroxime Injection
AVAILABILTY:
Inhibits mucopeptide synthesis in bacterial cell wall
Treatment of infections of lower respiratory tract, urinary tract, skin and skin structures, bone and joint; preoperative prophylaxis; treatment of septicemia, gonorrhea, and meningitis caused by susceptible strains of specific microorganisms.
Hypersensitivity to cephalosporins. GI: Nausea;
vomiting; diarrhea; anorexia; abdominal pain or cramps; flatulence; colitis, including pseudomembranous colitis.
Instruct patient to report these symptoms to health care provider: nausea, vomiting, diarrhea, skin rash, sore throat, bruising, hives, muscle or joint pain.
Instruct patient to report signs of superinfection: black “furry” tongue, white patches in mouth, foul-smelling stools, vaginal itching or discharge.
Warn patient that diarrhea that contains blood or pus may be a sign
of serious disorders. Tell patient to seek medical care and not to treat at home.
Instruct patient to seek emergency care immediately if wheezing or difficulty breathing occurs.
fever); phlebitis, thrombophlebitis, and pain at injection site.
X. NURSING CARE PLAN
Nursing problem #1: Immobility
Focus Assessment Criteria Clinical Significance1. ROM of affected extremity (left arm)2. Pain at the incision site
Pain and activity restrictions may serve as signals to client to immobilize the affected extremity.
3. Understanding activity restrictions, fears regarding movement
Fear of lead displacement may magnify the significance of these signals to such a degree that the client inappropriately immobilizes the arms.
Cues Nursing Diagnosis Goal/s EvaluationSubjective: The patient verbalized, “Hindi ako ganon ka-kumportable dahil hindi ko pwedeng gamitin ang kaliwang kamay sa ngayon dahil sariwa pa ang pagkakakabit ng panibagong pacemaker ko. Kumikirot lang ang tahi ko tuwing nabubunggo lang.”
Objective:
Guarding and restricted movement
Facial mask of pain when the area of surrounding the incision is touched
Self-focusing
Impaired physical mobility related to incisional site pain, activity restrictions, and fear of lead displacement
Inference:Placement of Permanent
Pacemaker
Incisional site painRestricted activity
Fear of lead displacement
Impaired physical mobility
Goal:
After 1 day of nurse-patient interaction, the client will demonstrate the ability to perform ADLs by:
- Demonstrating the ability to maintain arm restriction limitations
- Verbalizing prescribed restrictions
Nursing Interventions:
Independent Interventions
Rationale
Explain the need to remain on bed rest for up to 24 hours post procedure (or as prescribed)
Bed rest is prescribed to allow fibrosis to occur around the pacemaker and electrodes; this helps to prevent dislodgement
Medicate with prescribed analgesics before client engages in any activity
Judicious use of pain medication keeps pain signals from discouraging use of
The client is able to perform ADLs and express prescribed restrictions to be beneficial for her recovery.
affected armExplain that incision and subcutaneous pocket should feel sore for 3 to 4 weeks but discomfort eventually disappears
Understanding that discomfort is temporary encourages client to accept the pacemaker and participate in activity
Explain that affected arm and shoulder should not be moved in an overzealous manner (i.e., over the head) for 48 hours or as prescribed. Encourage client to perform active ROM (except for overzealous movements) in affected arm following physician’s instructions
Overzealous arm movements may potentially cause lead dislodgement, but regular active ROM exercises maintains joint function and prevents muscle contractures
Encourage early and complete participation in ADLs
Self-care increases independence and a sense of well-being
Reinforce physician-prescribed post-operative activity restrictions; these may include no driving, no lifting, no golfing, no bowling, etc., for 4 to 6 weeks after surgery
Activity restrictions allow continued fibrosis around pacemaker and electrodes to provide increased stabilization
Provide written information on activity instructions and restrictions
Written materials can serve as a valuable resource for postdischarge care at home
Nursing Problem #2: Expression of changes in one’s self
Focus Assessment Criteria Clinical Significance1. Accuracy of client’s perceptions regarding pacemaker The implantation of a pacemaker may implicate a sense of
loss, which can negatively affect the client’s self concept.2. Client’s self concept before pacemaker insertion Acceptance of pacemaker can be affected by many factors;
however, a person’s ability depends on his/her own personal strengths still present, compensate for what is lost, and view himself/herself as a unique person.
3. Availability of support system A strong support system can greatly help in the patient’s adjustment.
Cues Nursing Diagnosis Goal/s EvaluationSubjective: The patient verbalized, “Nag-aalala ako kasi baka magkaroon ng pagbabago sa aking mga gawain ang pagkakaroon ko ng pacemaker.”
Disturbed self-concept related to perceived changes associated with the presence of a pacemaker
InferencePPI
Dependence on impulse conduction
Use of Permanent Pacemaker
Perceived changes
Goal:
Throughout the course of treatment, the client will participate in self care through:
- Verbalizing an intent to follow the prescribed medical regimen
- Verbalizing recognition that despite the physical loss, he or she remains much the same person
Nursing Interventions:
Independent Interventions
Rationale
Identify and correct any misinformation client may have regarding pacemakers
Incorrect assumptions can cause doubt and uncertainty and contribute to poor self concept. Many times client and family have
The client participates in self care and expresses that dependence on the pacemaker is helpful in her day to day living as a uniqueperson.
Express concern in one’s self information related to old pacemakers. Today’s pacemakers can be well-adjusting (versus fixed rate) and require less frequent battery changes (e.g. 10yrs)
Encourage client to share feelings and concerns about living with a pacemaker
Sharing gives nurse the opportunity to identify and clarify misconceptions and address areas of concern
Expose client to other people who is currently dependent to pacemaker
To provide assurance that the pacemaker will not affect his/her day to day living
Assist client in distinguishing areas of life in which he or she is not dependent on others
This measure emphasizes areas for control and self-determination in learning toaccept the pacemaker andaltered body image
Help client to identify personal strengths that might aid coping
Discussing strengths encourages client tode-emphasize the disability
Nursing Problem #3: Risk for Ineffective Adherence
Focus Assessment Criteria Clinical Significance
1. Readiness and ability to learn and retain information A client or family failing to achieve learning goals requires a referral for assistance post discharge.
Cues Nursing Diagnosis Goal/s EvaluationRisk for Ineffective Therapeutic Regimen Management related to Insufficient Knowledge of Activity Restrictions, Precautions, Signs and Symptoms of Complications and Follow-up Care
InferencePPI
Post-PPI teachings not yet done
Risk for Ineffective Therapeutic Regimen
Goal:
Before hospital discharge, the client will be able to:- Understand the importance of the adhering to
the therapeutic regimen and acknowledge possible consequences of regimen mismanagement
- Demonstrate compliance to post-operative teaching and plans for discharge
Nursing Interventions:
Independent Interventions
Rationale
Review post procedural routine as needed
Reviewing enables nurse to evaluate whether or not client needs additional teaching
Instruct on incisional care including the following:
a. wound cleansingb. suture removal if
present (usually after 7days)
c. Expected swelling for 2 to 4 weeks
d. Recognizing signs and symptoms of infection
e. For a woman,
Proper incision care helps to prevent infection and other complications.
The client verbalizes the value of compliance to the therapeutic management and complies to the discharge instructions given by the health care provider.
wearing brassiere for support with gauze pad over the pulse generator to decrease rubbing over the suture line
Instruct client on home care measures.
a. Keep affected arm immobile for 24 to 48 hours postprocedure.
Understanding home care enables client to comply with the regimen.a. Arm movement
could cause traction on the lead and possible lead displacement.
Teach client and family to watch for and promptly report the following:
a. Redness, swelling, warmth, drainage, or pain at the surgical wound or temperature greater than 101°F
b. Joint stiffness, pain and muscle weakness in affected arm
c. Light headedness, fainting, dizzy
Early detection enables prompt treatment to prevent serious complications.a. These signs and
symptoms point to wound infection.
b. Joint stiffness, pain and muscle weakness may indicate neurovascular compression.
c. Light-headedness, fainting, dizzy
spells or chronic fatigue
d. Very rapid or slow pulse
e. Chronic hiccups or chest muscle twitching
f. Swollen ankles of hands
spelss, or chronic fatigue may result from cerebral hypoxia owing to insufficient cardiac output secondary to pacemaker malfunction.
d. Pulse changes may indicate pacemaker failure.
e. Chronic hiccups or chest muscle twitching may indicate lead displacement and electrical stimulation of diaphragm or intercostals muscles.
f. Swelling ankles or hands may indicate congestive heart failure related to insufficient cardiac output
Reassure that pacemaker should not interfere with sexual activity
Specifically discussing sexual activity can reduce fears and let client share
Instruct client to carry a pacemaker identification card at all times. Encourage client to apply for a Medic-Alert bracelet
Pacemaker identification card and Medic-Alert bracelet provide important information to caregivers in
emergency situations.Instruct client to notify physicians, nurses, and dentist about his or her pacemaker so that prophylactic antibiotics may be given before invasive procedures if needed
Because the pulse generator increases tissues susceptibility to infection, prophylactic therapy is indicated before many invasive procedures.
Instruct client to avoid strong electromagnetic fields including magnetic resonance imaging equipment are welding equipment, high-intensity power lines, dental ultrasonic cleaners, drills, internal combustion engines and poorly shielded microwave ovens.
a. Instruct client to avoid learning over open hood of a running car engine.
Electromagnetic fields can interfere with pacemaker function. A client with any anxiety about using a microwave open should stand about 6 feet away from oven when it is operating.
a. Anything that revolves at high revolutions can cause an electromagnetic field; therefore, this could lead to pacemaker malfunction
Warn that pacemaker triggers magnetic detection alarms such as those found at airport. Instruct client to carry
Anything that revolves at high revolutions can cause an electromagnetic field; therefore, this could
pacemaker identification card to verify pacemaker placement with airport security personnel.
lead to pacemaker malfunction
Emphasize the necessity of long-term follow-up care; reinforce physician’s instructions.
Regular follow-up care is essential for ongoing evaluation.
Explain that the battery is not lifelong and replacement might be necessary (average battery life is 5 to 10 years).
Understanding the need for battery replacement assists with coping should replacement be needed.
Teach pulse taking if appropriate and instruct client to notify physician if pulse rate falls below pacemaker set rate.
Pulse taking may help to enhance client’s sense of control over the situation.
Explain transtelephonic follow-up care, a system in which a client uses a transmitter at home to check the pacemaker over the phone.
Knowing what to expect after discharge may decrease client’s anxiety. Transtelephone monitoring provides reassurance to the patient that the pacemaker is working properly & can determine the need for battery replacement. It does not preclude the need for physician follow-up visits.
Explain the importance of Further evaluation may
seeking medical care or advice (phone) if shock function occurs.
be needed.
Provide written instructional materials at discharge.
Written information reinforces teaching and serves as a resource at home.
Provide client with names and phone numbers of persons to call should questions or an emergency arise (day or night).
This can help to reassure client that directs access for assistance is always available.
XI. PATIENT DISCHARGE PLAN/INSTRUCTIONS
MEDICATIONSMefenamic Acid
One (1) tablet 500mg to be taken orally/by mouth To be taken every six (6) hrs. a day For the management of pain due to post surgical procedure. Take mefenamic acid as exactly as it was prescribed by the doctor. Should be taken together with food or milk as mefenamic would
probably cause an upset stomach. Instruct the patient to take the missed dose as soon as you
remember. If it is almost time for the next dose, skip the missed dose and take the medicine at the next regularly scheduled time. He/she should not take extra medicine to make up the missed dose.
The patient may experience side effects while taking mefenamic acid such as upset stomach, mild heartburn or stomach pain, diarrhea, constipation; bloating, gas, dizziness, headache, nervousness; skin itching or rash, dry mouth ,increased sweating, runny nose and blurred vision.
EXERCISE AND REHABILITATION May return to doing normal activities within six (6) weeks after
the surgery. Any exercise is fine after 4-5 weeks No heavy lifting (usually five pounds[5lbs.] or more) or strenuous
arm exercise for about 2 to 3 weeks.
May still be able to drive or at least travel unless the physician has instructed you not to do so.
May still go to work unless the physician has instructed you not to do so.
May still do almost all the household activities. May still participate in sports and other recreational activities
except contact sports that may increase the chance of receiving a blow on the chest or the pacemaker device.
TREATMENT
A. Wound Care Proper hand washing should be carried and observe
cleanliness at all times. Observe wound daily, instruct patient to report any signs of
inflammation to your doctor. Clean the wound daily using prescribed antiseptic solution
(Betadine). Avoid wearing constrictive clothing like tight bra straps which
puts excessive pressure in the wound and the pulse generator.
Advise the patient to avoid getting the incision wet until the sutures have been removed (1 week). If on a shower, cover the incision with plastic wrap.
If the patient sees a suture sticking out of his/her incision, have the doctor remove it.
B. Pacemaker Management Regularly ensure that the pacemaker is properly placed by:
i. Taking the pulse daily either radial or carotid. The pulse can be found on the side of the lower neck, on the inside of the elbow, or at the wrist.); notify the doctor if pulse is slower than the set rate. Also, report for excessive palpations, vertigo or fainting.
How to check the pulse:
Using the first and second fingertips, press firmly but gently on the arteries until you feel a pulse.
Begin counting the pulse when the clock's second hand is on the 12
Count your pulse for 60 seconds (or for 15 seconds and then multiply by four to calculate beats per minute).
When counting, do not watch the clock continuously, but concentrate on the beats of the pulse.
If unsure about your results, ask another person to count for you.
ii. Check your "pacing lead" (the lead which sends information from the heart to the pacemaker) with an electrocardiogram (ECG) at your physician's office. In addition, you may participate in a telephonic check up for your pacemaker on a periodic basis. Your physician will provide special instructions.
iii. The table below lists various electrical and magnetic sources that are safe and sources that you should avoid.
Electrical or magnetic sources that are SAFE to be used by people with pacemakers and ICDs
Electrical or magnetic sources that should be AVOIDED by people with pacemakers and ICDs
Televisions, video cassette recorders (VCRs), and their remote controls
AM/FM radios Kitchen appliances
(toasters, blenders, electric can openers, refrigerators)
Personal computers, fax machines, copying machines, printers, electric typewriters
Garage door openers Automobiles (unless
your doctor has restricted your driving)
Lawn and garden equipment (mowers, leaf blowers)
Electric tools (drills, table saws)
Most medical tests (X-ray, CT scan, mammogram)
Dental procedures
(drills, screwdrivers) Cellular phones
Avoid completely:
Large magnets MRI machines CB or ham radios Radio transmitters
(including those used in toys)
High-voltage power lines [keep at least 25 ft away]
iv. Ensure the patient to carry a pacemaker identity card at all times because equipment used by doctors and dentists can affect the pacemaker.
v. Airport security systems will not affect the pacemaker, but the pacemaker may set off the alarm. Inform the patient to tell the guard regarding the use of a pacemaker.
HYGIENE
Maintain cleanliness at all times by doing the followingi. Take a bath daily (the incision line should be tightly
covered with a plastic)ii. Practice good oral hygiene by regularly brushing your
teethiii. Keep finger/toe nails properly trimmediv. Make sure that the perineal area is cleaned daily.
Wear clean and comfortable clothing and footwear. Wear supportive bra and place a gauze pad over the pulse
generator to decrease rubbing over the suture line.
OUT PATIENT FOLLOW UP
Before leaving the hospital, the patient will usually have a full evaluation, including a chest X-ray, electrocardiography (EKG, ECG), and a pacemaker check. One week to 10 days after discharge, the incision will be checked.
In 6 to 8 weeks after placement of the pacemaker, a full evaluation, including an EKG, and a pacemaker will be checked.
About every 1 to 3 months, the patient will be asked to have the pacemaker checked over the phone.
In 3 to 6 months after placement, the patient should either visit the doctor or clinic in person or have the pacemaker checked over the phone. Information can be sent directly over the phone to a computer on the other end of the line. This computer prints the information, and it can be reviewed by your doctor.
Once or twice per year, the patient will be asked to visit his/her doctor to have a full evaluation of the pacemaker.
If the battery life is low, the battery will need to be replaced his involves a surgical procedure similar to the initial implantation, except that the battery change is often a more simple procedure since the leads are already in place.
Cholesterol rich foods (chicharon, lechon, sisig.)Alcoholic and caffeinated beveragesJunk foodsAvoid using salty condiments(patis, toyo and bagoong)
Always be conscious of the food labeling and read its contents.
SEXUALITY / SOCIAL / SPIRITUAL
May continue sexual activity after 6 weeks of surgery. May join support groups concerning patients also with pacemakers. You must practice healthy habits like:
i. Take enough rest and sleep (at least 7-8hrs.)ii. Drinking plenty of water (at least 8 glasses of water.)iii. Avoiding vices such as alcohol drinking and cigarette smoking.
Pacemakers have very reliable technology, and the patient can have confidence that it will work to improve his/her heart rhythm. He/she should be able to return to a full and active lifestyle. If there are any questions or concerns, seek consultation from the the doctor, nurse or rehabilitation team.
XII. SUPPORTING BACKGROUND REGARDING SIGNIFICANCE OF AMPHETAMINE USE IN COMPLETE HEART BLOCK
CARDIOTOXICITY ASSOCIATED WITH METHAMPHETAMINE USEAND SIGNS OF CARDIOVASCULAR PATHOLOGY AMONG METHAMPHETAMINE USERS
TECHNICAL REPORT NO 238Sharlene Kaye and Rebecca McKetin
BACKGROUND The use of methamphetamine is widespread and, in many countries, is a major drug of abuse. As such, it is important to identify and understand the adverse health effects associated with methamphetamine use and consider the risk of such consequences for users. Although methamphetamine has effects on multiple organ systems, this report will focus on the cardiovascular effects of methamphetamine. Specifically, the aim of this report is to review the evidence for methamphetamine-related cardiovascular pathology and discuss the implications for methamphetamine users.
Methamphetamine cardiotoxicity Methamphetamine increases catecholamine activity in the branch of the peripheral nervous system responsible for modulating heart rate and blood pressure. Excessive catecholamine activity is thought to be the primary mechanism underlying the cardiotoxic effects of methamphetamine. High catecholamine levels are known to be cardiotoxic, causing narrowing and spasm of the blood vessels, rapid heart rate (tachycardia), high blood pressure (hypertension), and possible death of the heart muscle. Other features of catecholamine toxicity include the formation of fibrous tissue and an increase in the size of heart muscle cells.
Evidence of cardiotoxicity among methamphetamine users The most widely reported adverse cardiovascular effects of methamphetamine use are chest pain, tachycardia and other cardiac arrhythmias, shortness of breath and high blood pressure. The less frequently observed, but more severe, acute cardiovascular complications of methamphetamine use are acute myocardial infarction, acute aortic dissection, and sudden cardiac death. The medical literature contained several single case reports and case series reports of acute myocardial infarction. Acute myocardial infarction often occurred in the absence of identifiable coronary artery disease. The forms of chronic cardiovascular disease that are most commonly associated with methamphetamine use are coronary
artery disease and cardiomyopathy. Studies of methamphetamine-related fatalities have suggested that methamphetamine users are at risk of the premature and accelerated development of coronary artery disease. Clinical and experimental evidence alike suggest that the use of methamphetamine, particularly long-term use, can induce cardiomyopathy. As with acute myocardial infarction, cardiomyopathy has been associated with various routes of methamphetamine administration (e.g. oral, smoking and intravenous).
Factors influencing the cardiovascular effects of methamphetamine The necessary and sufficient dose to produce serious cardiovascular complications or death - that is, the “toxic” dose - is unclear, as the response to a specific dose varies due to individual differences in responsiveness and variations in degree of tolerance. The literature indicates that cardiovascular complications associated with methamphetamine use can occur with all of the major routes of administration: that is, intranasal, oral, smoking, and injecting. While there is no evidence to suggest that any one route of methamphetamine administration should be more strongly associated with cardiotoxicity than another, the risk of complications may be higher with patterns of use that are associated with frequent use and taking higher doses, such as injecting and smoking crystalline methamphetamine. Previous research also suggests that the risk of cardiovascular problems among methamphetamine users is increased when the drug is combined with alcohol, cocaine or opiates. Of particular concern is the concomitant use of methamphetamine and other psychostimulant drugs, such as cocaine, due to their potential synergistic effect on catecholamine activity.
Conclusions and recommendations Low level use of methamphetamine - for example, sporadic, low dosage use - does not appear to be associated with major acute complications, such as myocardial infarction, or chronic cardiovascular disease, in an otherwise healthy user. Methamphetamine may, however, exacerbate pre-existing underlying cardiac pathology, such as coronary atherosclerosis or cardiomyopathy, thereby increasing the risk of an acute event such as myocardial infarction or even sudden cardiac death. Long-term methamphetamine users appear to be most at risk of cardiovascular damage, such as premature, accelerated coronary artery disease. As such, methamphetamine toxicity is more likely to have a fatal outcome with chronic use. Given their high levels of polydrug use, methamphetamine users should also be made aware of the increased risk of adverse cardiovascular effects when methamphetamine is used with other drugs, particularly other psychostimulant drugs. Because of the
individual variation in sensitivity to methamphetamine’s cardiotoxic properties, treating methamphetamine toxicity should be based on the symptom presentation rather than the reported dose administered.
Further research is needed to establish the risk of serious cardiac events among methamphetamine users, whether there is evidence of a dose-response relationship between methamphetamine use and cardio toxicity in humans, and also the relative contribution of methamphetamine over other concurrent risk factors, such as tobacco smoking, alcohol and other drug use, obesity, and pre-existing cardiac pathology.
