Mr. Carmel Tabone, age 58, is scheduled for permanent pacemaker insertion as treatment for a tachyarrhythmia that does not respond to medication therapy. He is scheduled for an insertion of a permanent pacemaker.
- Tabone’s pacemaker is set at 72 bpm. His heart rate is 76 bpm. Is this expected? Explain the rationale for your answer.
- Following insertion, which potential complications should the nurse monitor for, and how do these complications arise as a result of the procedure?
- What common initial postoperative complication will the nurse monitor for after Mr. Tabone has an insertion of a permanent pacemaker?
- What will the nurse document about Mr. Tabone’s pacemaker?
- 4Which nursing interventions and expected patient outcomes will be used to meet the outcomes of patient care?
Part 4: Permanent Pacemaker.
a) Pacemaker Set at 72 bpm, HR = 76 bpm – Is This Expected?
Yes, this is expected.
- Rationale: Pacemakers are usually set to maintain a minimum heart rate (in this case, 72 bpm). If the patient’s intrinsic heart rate (76 bpm) is above the set rate, the pacemaker remains inactive or on standby. It only activates when the heart rate drops below the programmed threshold. This is a demand mode pacemaker—a normal and intended function.
b) Post-Insertion Complications and How They Arise.
The nurse should monitor for the following potential complications (Carrión-Camacho et al., 2019):
- Pneumothorax
- May occur from accidental puncture of the pleura during lead insertion.
- Monitor for chest pain, dyspnea, decreased breath sounds.
- Lead dislodgement
- Caused by movement of the arm or improper anchoring.
- Can result in loss of pacemaker capture → bradycardia or asystole.
- Bleeding or hematoma at the insertion site
- Due to vascular trauma or anticoagulation.
- Infection
- Entry point or pocket infection if aseptic technique is not maintained
- Cardiac perforation (rare).
- May cause tamponade, hypotension, or pericardial effusion.
c) Common Initial Postoperative Complication
Lead displacement is the most common initial complication post-insertion. Signs: Failure to sense or pace properly, changes in ECG, dizziness, or bradycardia (Carrión-Camacho et al., 2019). To prevent this :
- Restrict arm movement on the affected side.
- Avoid raising the arm above shoulder level for several days.
d) Nurse Documentation Post-Pacemaker Insertion.
The nurse should document (Palmer, 2014):
- Type of pacemaker (single, dual-chamber, biventricular).
- Pacing mode and settings (e.g., set rate: 72 bpm).
- Pacing function/capture confirmed on ECG.
- Vital signs and heart rhythm pre- and post-procedure.
- Site condition (dry, intact, bruising, bleeding).
- Patient’s response (pain, dizziness, etc.).
- Patient teaching provided about restrictions and follow-up.
e) Nursing Interventions and Expected Outcomes.
Nursing Interventions:
- Monitor cardiac rhythm for pacemaker function and arrhythmias (Assis et al., 2007).
- Assess the insertion site for bleeding, infection, or swelling.
- Restrict movement of the affected arm for 24–48 hours.
- Administer analgesics for pain management.
- Educate the patient on.
- Avoiding magnetic fields and strong electrical interference.
- Using an ID card or medical bracelet.
- Reporting symptoms like dizziness, palpitations, or fatigue.
Expected Outcomes:
- The patient remains hemodynamically stable with a normal heart rate.
- No signs of infection or bleeding at the insertion site.
- The pacemaker shows appropriate sensing and pacing on ECG.
- Patient verbalizes understanding of post-procedure care.
- No signs of lead displacement or pacemaker malfunction.
