# Situation: A 45-year-old man with hypertrophic cardiomyopathy (HCM) is admitted to the coronary care unit after fainting at home. Echocardiography shows a thickened septum with left ventricular outflow tract obstruction. He has vomited repeatedly for 2 days. Before discharge he receives an implantable cardioverter-defibrillator. Which instruction should the nurse include in his teaching?

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> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 45-year-old man with hypertrophic cardiomyopathy (HCM) is admitted to the coronary care unit after fainting at home. Echocardiography shows a thickened septum with left ventricular outflow tract obstruction. He has vomited repeatedly for 2 days.

Before discharge he receives an implantable cardioverter-defibrillator. Which instruction should the nurse include in his teaching?

## 보기

1. Go to the emergency department after any single shock
2. Undergo magnetic resonance imaging freely once healed
3. Keep a mobile phone 15 cm or more from the device **✔ 정답**
4. Stay clear of microwave ovens while they are running

**정답: 3**

## 해설

Clients with an implanted cardiac device keep mobile phones about 15 cm from the device, carry the device card, and avoid strong magnets. Magnetic resonance imaging is done only if the device is labeled MRI-conditional and per protocol, and emergency services are called if the device shocks more than once or the client feels unwell.

## 심화 해설

Understanding the question

A patient with hypertrophic cardiomyopathy (HCM) and left ventricular outflow tract obstruction has received an implantable cardioverter-defibrillator (ICD). Before discharge, the nurse must teach safety precautions. The key distinction is between everyday household items that are safe with reasonable precautions versus those that require strict avoidance or emergency response.

Why option 3 is correct

The instruction to keep a mobile phone 15 cm (about 6 inches) or more from the device is a standard, evidence-based recommendation for all patients with cardiac implantable electronic devices (CIEDs), including ICDs. Modern smartphones contain magnets and generate electromagnetic fields. When a phone is held directly over the device pocket, the magnetic field can exceed 10 gauss (G), which is the threshold at which a CIED activates its magnet response [1]. This magnet mode can temporarily suspend tachyarrhythmia detection or alter pacing behavior, potentially causing discomfort or, in vulnerable patients, serious arrhythmias [1].

The 15 cm rule is a practical, universal precaution that minimizes the risk of unintended magnet activation without requiring the patient to avoid normal phone use entirely. The patient may still use the phone normally; the instruction is simply to avoid placing it in a shirt pocket over the device or resting it directly on the chest.

Why the other options are incorrect

Watch out! Option 1 is too aggressive. A single ICD shock does not automatically require an emergency department visit. The standard teaching is that the patient should call emergency services or seek urgent evaluation if the device delivers more than one shock in a short period, if the patient feels unwell after a shock, or if the shock is accompanied by syncope, chest pain, or persistent palpitations. A single shock in an otherwise asymptomatic patient warrants a call to the device clinic, not necessarily an ED visit.

Watch out! Option 2 is dangerous. MRI is generally contraindicated in patients with CIEDs unless the device is specifically labeled MRI-conditional and the scan follows a strict institutional protocol. Older devices or those without this labeling must not be exposed to MRI. The patient cannot undergo MRI "freely" after healing.

Watch out! Option 4 reflects outdated teaching. Modern microwave ovens are well shielded and do not interfere with ICDs. Patients may use microwave ovens normally. The concern about staying clear of running microwaves applied to much older pacemaker models and is no longer a standard restriction.

The magnet response and why distance matters

The underlying mechanism is the reed switch or Hall-effect sensor inside the ICD. When an external magnet is brought close to the device, the switch closes and triggers the magnet response. For ICDs, this typically means suspension of tachyarrhythmia detection and therapy, meaning the device will not deliver a shock even if the patient develops ventricular tachycardia or fibrillation while the magnet is in place [1]. This is intentional during surgery or device interrogation, but accidental activation from a phone or tablet magnet is dangerous because it leaves the patient temporarily unprotected.

The study by Kamitani et al. specifically investigated tablets, laptops, and smartphones and found that these devices can generate magnetic flux densities at or above 10 G at close range, particularly for subcutaneous ICDs and extravascular ICDs, which may be more susceptible because of their implantation depth and orientation [1]. The 15 cm separation is therefore not arbitrary; it is the distance at which the magnetic field from common consumer electronics reliably falls below the activation threshold.

Clinical teaching priorities for ICD patients

The nurse should organize discharge teaching around three categories: what to avoid, what to use with precautions, and what to do in an emergency. The table below summarizes the key points relevant to this question.

| Item or situation | Recommendation | Rationale |
| --- | --- | --- |
| Mobile phone | Keep 15 cm from device; use ear on opposite side | Prevents magnet response activation [1] |
| Microwave oven | Safe to use normally | Modern ovens are adequately shielded |
| MRI | Only if device is MRI-conditional and per protocol | Strong magnetic fields can damage device or lead |
| Single ICD shock | Call device clinic; observe for symptoms | One shock alone is not an emergency |
| Multiple shocks or feeling unwell | Call emergency services immediately | May indicate electrical storm or device malfunction |

Key point! The 15 cm rule applies to all handheld electronic devices with magnets, not just phones. Tablets and laptops should also be kept away from the device pocket [1]. The patient should also carry a device identification card at all times and inform all healthcare providers, including dentists and radiologists, about the ICD before any procedure.

The emphasis on remote monitoring in current guidelines  and the demonstrated benefits of structured follow-up  reinforce that discharge teaching should include clear instructions on how to transmit device data and when to contact the clinic. However, the immediate safety instruction that addresses the most common daily exposure risk is the mobile phone distance rule, making option 3 the correct answer.References (research sources)

- [1]Impact of magnetic fields from tablets, laptops, smartphones, and household/leisure magnets on cardiac implantable electronic devices.Research articleKamitani N, Miyazaki A, Tomida S, Shimizu K, Ohira N, Kondo K, Miura H, Koyama D, Tominaga S, Henmi R, Sugiura R, Masui H. (2025) · DOI: 10.1002/joa3.70106

## 임상 시나리오

ICD Discharge Teaching: Daily SafetyPractical precautions for patients with an implantable cardioverter-defibrillator
Keep a mobile phone at least 15 cm from the device pocket. Avoid placing the phone in a shirt pocket over the ICD or resting it directly on the chest during calls.

Carry the device identification card at all times. This card provides essential information about the device model, leads, and manufacturer for emergency or medical personnel.

Avoid strong magnets and industrial electromagnetic sources. Household items such as microwave ovens are generally safe when used normally and do not require staying clear while running.

CautionCall emergency services if the device delivers more than one shock or if the patient feels unwell after any shock. A single shock with full recovery does not require an emergency visit. MRI is permitted only if the device is labeled MRI-conditional and performed per protocol.

## 핵심 개념

- **ICD (Implantable Cardioverter-Defibrillator)** — A cardiac device that detects and treats life-threatening tachyarrhythmias via pacing or shock therapy.
- **Electromagnetic interference (EMI)** — Disruption of device function caused by external magnetic or electrical fields, potentially altering pacing or detection.
- **Magnet mode** — A CIED response triggered by a magnet field above ~10 gauss, which can suspend tachyarrhythmia detection or change pacing.
- **MRI-conditional** — Device labeling indicating safe MRI scanning only under specific manufacturer and institutional protocol conditions.
- **Hypertrophic cardiomyopathy (HCM)** — A genetic myocardial disorder with thickened ventricular walls, often causing left ventricular outflow tract obstruction and arrhythmia risk.

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