Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

SKILL 16-8

Using an External (Transcutaneous)

Pacemaker (Continued)

Comments

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 V 2 to V 5 position, cen-
    tered 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.

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