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

22. Monitor the patient’s heart rate and rhythm to assess ven-
    tricular 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.

ExcellentSatisfactoryNeeds Practice