MANDATORY
Area of Practice: / Cardiac Care
Module and Status: / Care of the Cardiac Surgery Patient
Level: / 3
Author/date of origin: / Carolyn Kenny 2001
Author/date of review: / Chrissie Spiers – April 2006
Time estimate:
Knowledge required related to skill (should know):
· indications for temporary pacing via epicardial wires following cardiac surgery
· discuss factors which may affect the intrinsic conduction system in the post-operative patient
· demonstrate a clear understanding of the components of a temporary pacing system including pacemaker units for single chamber and dual chamber pacing
· discuss the rationale for selecting atrial, ventricular or AV sequential pacing and recognise each of these on a rhythm strip
· describe the pacing modes most commonly used following cardiac surgery and explain the pacemaker codes employed for identification. Should know at least: AOO, AAI, VOO, VVI, DOO, DDD
· explain when fixed rate ventricular pacing is inappropriate and why
· discuss in detail the terms: uniplolar, bipolar, threshold, output, demand rate, fixed rate, sequential, sensing, inhibiting, R wave, capture, sensitivity in relation to temporary pacing / · recall the procedure/protocol for checking the threshold and suggest factors which may increase or decrease the energy required for capture
· outline the practitioners responsibilities for the care of a patient with epicardial wires
i. immediately after surgery
ii. as the patient recovers
· discuss the possible complications associated with temporary epicardial pacing and how these may be:
i. minimised
ii. recognised
iii. managed
· recall how to check the batteries and change them if required
· describe in detail the steps to take should pacing fail in a pacing-dependent patient and demonstrate familiarity with the emergency equipment required
· how to clearly explain temporary pacemaker therapy to a patient and evaluate his/her understanding
Practice descriptor, i.e. can demonstrate skill used stating knowledge base and act appropriately at this level:
On patient’s return from surgery
· establishes haemodynamic monitoring and sets appropriate alarm limits
· correctly identifies position of pacing wires and secures them according to unit procedure/protocol to ensure patient safety
· correctly recognises the pacing mode and documents both mode and rate
· records a base line rhythm strip
· checks the threshold if required according to unit policy and procedure/protocol
· documents intrinsic rhythm
· if appropriate, explains temporary pacing therapy to the patient and reassures at all times / · can initiate the appropriate actions/emergency response in the event of the pacing unit failing
· regularly checks the pacing unit and records observations reporting any haemodynamic changes, rhythm changes, ectopic beats or other complications of epicardial pacing
Continuing Care:
· monitors patient for signs of local and systemic infection
· ensures all exposed metal connections are insulated and electrical safety is maintained, e.g. awareness of static electricity
· liaises with medical staff with regard to removal of epicardial pacing wires
· reassures patient and significant others at all times
Practice descriptor, i.e. can demonstrate skill used stating knowledge base and act appropriately at this level:
Removal of epicardial wires:
· checks INR and liaises with medical staff if elevated
· explains procedure to the patient and ensures pacing unit is off
· supports the patient’s skin and gently, but firmly, withdraws each wire slowly until completely removed, whilst observing the monitor for ectopic beats / · checks wire to ensure complete removal
· if indicated, send tip of wire to microbiology laboratory
· cover site with occlusive dressing according to unit policy and procedure/protocol
· monitors the patient for possible complications and documents the procedure in the integrated clinical pathway record
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