NR 324 Week 8 Pacemaker Discharge Summary Paper Example

Discharge Summary Paper: A 79-Year-Old Retired Dairy Farmer Whose Heartbeat Now Depends on a Pacemaker

Student Name

College of Nursing, Chamberlain University

NR 324: Adult Health I

Instructor Name

Month Day, Year

Discharge Summary Paper: A 79-Year-Old Retired Dairy Farmer Whose Heartbeat Now Depends on a Pacemaker

What Is Permanently Different

Mr. N. is 79, a retired dairy farmer who still helps his son with the calves most mornings. He goes home today after three days in hospital with a new dual-chamber permanent pacemaker in his upper left chest. Before this admission, his heart set its own rhythm. From now on, whenever the electrical signal between the upper and lower chambers fails, a device does that work, and the device needs checking, protecting and, in about ten years, replacing. That is the change this paper is about. The admission itself is summarized only as far as it explains that change.

Why He Came In and What Was Done, Briefly

He was brought in by his son after two episodes of nearly fainting in the barn. His heart rate on arrival was 34, and the electrocardiogram showed complete heart block, meaning the signal from the upper chambers was not reaching the lower chambers at all. He had been taking metoprolol for blood pressure. The team first stopped the metoprolol and watched him for 48 hours on the monitor, because medicines that slow conduction are a reversible cause that current guidance says should be considered before a permanent pacemaker (Kusumoto et al., 2019). The block did not resolve, and the pacemaker was placed on day 3 without complication.

Long-Term Conditions He Arrived With

High blood pressure: continues; managed now without metoprolol (see medicines).

Osteoarthritis of both knees: unchanged; affects how he gets up from a chair and how far he walks.

Mild hearing loss: uses no hearing aids; teaching was done face to face, slowly, with written copies.

Type 2 diabetes, diet-controlled: A1c 6.6% three months ago; no change in plan.

Medicines, Before Against After

Table 1 compares what he took before admission with what he takes now, with the reason for every difference.

Table 1

Medicines Before and After Admission

Note. Doses taken from the pharmacy record at admission and the discharge medication reconciliation.

What He Can Do Now, and What He Cannot Yet

Can do unaided: shows where the incision is, says it should stay dry for 5 days, and names three signs to call about: swelling at the site, redness spreading, or fluid leaking.

Can do unaided: keeps his left elbow below shoulder height when putting on a shirt, demonstrated twice, and says he will not lift anything heavier than a gallon of milk with his left arm for 4 weeks, which means no lifting calf bottles or feed buckets with that arm.

Can do unaided: shows his temporary device identification card and says he will show it at airport security and before any MRI.

Can do unaided: says he will keep his cell phone in the right-side pocket and at least six inches from the device.

Cannot yet do: set up the home remote monitor, which plugs in beside the bed and sends device readings to the clinic. He has no home internet; the monitor uses a cellular connection, and his son will set it up tonight with the leaflet. This is recorded as not yet done.

Cannot yet do reliably: say, without prompting, what to do if he feels dizzy or faint again. He said "sit down" but not "and call." His son was taught the answer: sit or lie down, and call 911 if he faints or has chest pain.

The First Month: What the Restrictions Are For

Each restriction in the teaching exists to protect something specific in the first weeks, and Mr. N. was told the reason alongside the rule, because a farmer who does not know why he should not lift a feed bucket is likely to lift it. The pacemaker leads are threaded through a vein into the heart and take several weeks to settle into the heart wall; raising the arm high or lifting heavy loads with it can pull a lead out of position, which would mean another procedure. The pocket under the skin can bleed, especially while he takes aspirin, which is why ibuprofen is stopped for two weeks and why swelling at the site is a reason to call. And the incision can become infected, which in a man who works around animals and soil is a real concern, so he was asked to keep the dressing covered and dry and to wear a clean shirt when helping in the barn.

His son was present for all of this teaching. On the farm, the son will be the person who notices if his father starts lifting with the left arm again, and he agreed to do the calf bottles himself for the month.

Monitoring at Home, With Owners

Remote monitor set up and first transmission sent: his son, tonight; the device clinic nurse confirms receipt by phone within 2 days.

Wound check: device clinic, in 7 to 10 days.

First full device check in person: device clinic, at 3 months; thereafter remote checks every 3 months and an in-person check once a year. An expert consensus statement from the Heart Rhythm Society recommends remote monitoring as part of standard follow-up for patients with implanted cardiac devices (Slotwiner et al., 2015).

Blood pressure on amlodipine: Mr. N. takes it at the pharmacy machine each Saturday and writes it on the card in his wallet; his primary care office reviews it at a visit in 3 weeks.

Left arm restriction ending at 4 weeks: Mr. N., confirmed by the device clinic at the wound check.

Closing

The admission lasted three days. Its effect lasts the rest of Mr. N.'s life: a device to protect, a clinic that watches it from a distance, a changed blood pressure medicine, and for the next month a working farmer who cannot lift with his left arm. The discharge plan is judged by whether he can manage those things at home, and the two gaps, the remote monitor and the dizziness answer, have named owners before he leaves.

References

Kusumoto, F. M., Schoenfeld, M. H., Barrett, C., Edgerton, J. R., Ellenbogen, K. A., Gold, M. R., Goldschlager, N. F., Hamilton, R. M., Joglar, J. A., Kim, R. J., Lee, R., Marine, J. E., McLeod, C. J., Oken, K. R., Patton, K. K., Pellegrini, C. N., Selzman, K. A., Thompson, A., & Varosy, P. D. (2019). 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation, 140(8), e382-e482. https://doi.org/10.1161/CIR.0000000000000628

Slotwiner, D., Varma, N., Akar, J. G., Annas, G., Beardsall, M., Fogel, R. I., Galizio, N. O., Glotzer, T. V., Leahy, R. A., Love, C. J., McLean, R. C., Mittal, S., Morichelli, L., Patton, K. K., Raitt, M. H., Pietro Ricci, R., Rickard, J., Schoenfeld, M. H., Serwer, G. A., . . . Yu, C.-M. (2015). HRS expert consensus statement on remote interrogation and monitoring for cardiovascular implantable electronic devices. Heart Rhythm, 12(7), e69-e100. https://doi.org/10.1016/j.hrthm.2015.05.008