What action is appropriate for the nurse to implement when monitoring the ECG of a patient with a transvenous ventricular demand pacemaker? The ECG strip shows QRS complexes without pacer spikes
1. Plan for immediate removal of pacer lead wires.
2. Continue to observe the patient and the ECG rhythm.
3. Call the health care provider and explain that capture has been lost.
4. Call a code for ventricular fibrillation.
2
Rationale 1: "Transvenous" means that the battery is external and the lead wires are passed through the vein into the heart muscle. There is no need to remove or displace the lead wires because it only comes on when the patient's heart rate drops below the programmed set point. "On demand" means it only comes on sometimes.
Rationale 2: The demand pacemaker only fires when the patient's heart rate drops below the preset rate. The patient's own rhythm will continue to dominate if it stays above a predetermined rate. The patient's QRS complexes will not have a spike. QRS complexes that have a spike indicate that QRS complex is pacemaker generated, not an intrinsic beat.
Rationale 3: If one spike is noted with a QRS following it when the rate is below the set point, then the capture has not been lost. One would see a spike without a QRS if the lead wire was misplaced or capture had been lost.
Rationale 4: The risk of ventricular fibrillation is not present under these conditions.
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