ELECTRO

ELECTRO

CONVULSIVE

CONVULSIVE

THERAPY

GUIDED BY –

Mr. M. Lakshmanan Sir

PRESENTED BY –

1. Ms. Kadam Tejashri

2. Ms. Kanadi Tejashri

3. Ms. Khaire Kanchan

4. Ms. Khedekar Rupali

5. Ms. Khopade Shital

6. Ms. Kolekar Rohini

7. Ms. Kshirsagar Mangal

8. Ms. Landge Deepika

9. Ms. More Shital

10.Ms. Jadhav Sampada

11.Ms. Karkada Yavalin

12. Ms. Mandavkar Vidya

Introduction

History

Description

Techniques

Mechanism of Action

Indications

Contraindications

Placement of Current

Articles with Purpose

Observation

Number and Frequency of ECT treatment

Complications

Role of Nurse

A) Pre – Care of Patient

B) Intra – Care of Patient

C) Post – Care of Patient

ELECTRO CONVULSIVE THERAPY

Aim –

To study the electroconvulsive therapy in details equipments, scientific

Principles related and role of nurse in Electro convulsive therapy.

Objective –

At the end of this project the students are able to

1. Understand the definition of electroconvulsive therapy.

2. List down the indications and contraindications.

3. Understand the pre, intra and post procedure care.

4. Understand the mechanism of action.

5. Understand the pre, intra and post procedure care.

ELECTRO CONVULSIVE THERAPY

Introduction –

A number of heroic therapies were introduced in the 1900-1930’s to treat a mental illness.

History –

1) In 1934 Dr. Ladislace Van Meduna a Hungarian psychiatrist.

2) Cereleti and Bini are first neuropsychiatrist who used electro convulsive therapy in 1937.

Description –

1) It is painless form of electric therapy.

2) It is used for patient with depression & schizophrenic disorder.

3) It is prepared by barbiturate anesthesia and an injection of chemical relaxant.

4) An electric shock applied for a fraction of a second through electrodes placed on the temporal region.

ELECTRO-CONVULSIVE THERAPY

TECHNIQUES

The techniques used for convulsive therapy administration are of two types.

1) Direct Electroconvulsive therapy –Here is given the absence of muscular relaxation and

general anesthesia.2) Modified Electroconvulsive therapy –

By drug induced muscular relaxation and general anesthesia given by an anesthetist.

Administration of atropine sulphate subcutaneously 0.6 mgm – 1.0 mgm.

Electroconvulsive therapy usually administered in the morning after an Overnight fast. It given at any other time during the day the patient

should be empty stomach for at least 4 hours no any oral medications should

be gives.

MECHANISM OF ACTION –Despite much research the precise mechanism of action of

Electroconvulsive therapy is still not known. Most theories about the mode

of action of electroconvulsive therapy focus on its efficacy with depressed

patient and including the following.

NEUROTRANSMITTER THEORY –Suggests that electroconvulsive therapy release hypothalamic or pituitary

hormones or both which results in it antidepressant effects. Electroconvulsive therapy release prolactin thyroid stimulating

hormone, adenocorticotropic hormone, but the specific hormone, responsible for

the therapeutic effect are not known.

ANTICONVULSANT THEORY –Suggest that electroconvulsive therapy treatment exerts a profound anticonvulsant effect on the brain that results in an antidepressant effect. Some support for this theory is based on the fact that a person seizure threshold rises over the course of electroconvulsive therapy and that some patient with epilepsy have fewer seizure after receiving electroconvulsive therapy.

CARDIOVASCULAR EFFECT – Transient cardiovascular changes are expected in electroconvulsive therapy. Routine electrocardiograph should performed to rule out baseline pathology with further work-up as indicated.

SYSTEMIC EFFECT –Headache, nausea, muscle soreness, drowsiness may occur after electro convulsive therapy, but they usually respond to supportive management and nursing intervention.

COGNITIVE EFFECT – Electroconvulsive therapy is associated with a range of cognitive side effects including a period of confusion immediately after the seizure, memory disturbance during the treatment course. Although a few patient report persistent deficits. The onset of cognitive side effects varies considerably among patient.

INDICATIONS –1) Indications in depression -

Severe depression with suicidal risk Depressive stuporDepression with marked retardation Severe purpural depressionDepressive illness with nihilistic or paranoid delusion.Failure to respond to an adequate course of antidepressant. Inability to tolerate side effects of antidepressant.

2) Schizophrenia -Excitement (Secondary to catatonia or delusion) Stupor (Catatonic)Schizophrenic episodeIntolerable or resistant to drugs.Puerperal schizophreniaschizophrenic episode in the presence of chronic physical

illness when drugs are contraindicated.Schizophrenia episode in first trimester of pregnancy.

3) Mania -Excited or uncooperative behaviors Bipolar mood disorder with mixed features.

Bipolar mood disorder rapid cyclers.Other mania in First trimester of pregnancy puerpural mania schizophrenia.Post partum psychosisSchizoaffective disorderOther conditions

6) Other Conditions -Organic delusions disorderOrganic mood disorderPsychotic disorder – not otherwise specified Obsessive compulsive disorderDysarythmia

7) Condition not specified in DSM IVParkinson’s diseaseNeuroleptic malignant syndromeSecondary catatonia Lithal CatatoniaDrug dependenceHypochondriasLack of concentrationHysteriaAnorexiaEarly morning sicknessWeight loss Ideas of quiltSuicide

CONTRAINDICATIONS –

1) Increase intracranial pressure 2) Acute myocardial infarction3) Hypertension4) Cardiac disease5) Aneurysm6) Thrombophlebitis7) Bleeding disorder 8) Haematoma9) Sub-archnoid Hemorrhage

PLACEMENT OF ELECTRODES –

The electrodes are moistened with saline or 25% bicarbonate solution and

are applied on head according to the position of application of electrodes.

Two types of electro convulsive therapy.

1) Bilateral electro convulsive Therapy - This is standard from of electro convulsive therapy used

most commonly. Each electrode is placed 2.5 – 40 cm above the midpoint on a line joining the tragus of the ear and the lateral can thus of the eye.

BILATERAL ELECTRO CONVULSIVE THERAPY –

This is standard from of electro convulsive therapy used most commonly. Each electrode is placed 2.5 – 40 cm above the midpoint on a line joining the tragus of the ear and the lateral canthus of the eye.

2) Unilateral electro convulsive Therapy - Here the electrodes are placed only on one side of head,

usually the non dominant side, In the right handed. There

are various position.

ARTICLES ARTICLES PURPOSE PURPOSE

1) Electrode paste and gel alcohol, 1) Electrode paste and gel alcohol, preps, saline. preps, saline.

1) Concentrated saline is a good 1) Concentrated saline is a good conductor of electricity, there by it conductor of electricity, there by it facilitates in producing convulsion.facilitates in producing convulsion.

2) Electroencephalogram. 2) Electroencephalogram. 2) Recording of electrical activity of 2) Recording of electrical activity of brain through surface electrodes.brain through surface electrodes.

3) Blood pressure cuff (two) peripheral 3) Blood pressure cuff (two) peripheral nerve stimulator and pulse oxymeter. nerve stimulator and pulse oxymeter.

3) To monitor vital parameter.3) To monitor vital parameter.

4) Stethoscope.4) Stethoscope. 4) To check the heart beats. 4) To check the heart beats.

5) Reflex hammer. 5) Reflex hammer. 5) To check the muscle tone. 5) To check the muscle tone.

6) Intravenous and venipuncture 6) Intravenous and venipuncture supplies.supplies.

6) To introduce the anesthetic drug and 6) To introduce the anesthetic drug and Intravenous fluid.Intravenous fluid.

ARTICLES ARTICLES PURPOSE PURPOSE

7) Mouth gag or tongue depressor. 7) Mouth gag or tongue depressor. 7) To prevent biting of tongue or injury 7) To prevent biting of tongue or injury to lips.to lips.

8) Stretcher with firm matters and side 8) Stretcher with firm matters and side rails. rails.

8) To prevent injury. 8) To prevent injury.

9) Suction device. 9) Suction device. 9) To prevent the patient from 9) To prevent the patient from aspiration pneumonia. aspiration pneumonia.

10) Ventilation equipments including 10) Ventilation equipments including tubing, masks, ambu bag, oral airways, tubing, masks, ambu bag, oral airways, and intubations equipment with an and intubations equipment with an oxygen delivery system capable of oxygen delivery system capable of providing positive pressure oxygen. providing positive pressure oxygen.

10) To prevent the patient from 10) To prevent the patient from respiratory and cardiac complication. respiratory and cardiac complication.

11) Emergency and other medications 11) Emergency and other medications as recommended as recommended by as recommended as recommended by anesthesia staff.anesthesia staff.

11) To handle the emergency situation 11) To handle the emergency situation during electro convulsive therapy.during electro convulsive therapy.

OBSERVATION –

The production of grand mal seizure is necessary for direct and modified electro

convulsive therapy. The Tonic phase – It is muscle contractions last for 10 seconds

approximately. The clonic phase – It is movement for convulsion lasts for 25 to 30 seconds approximately. Then the patient goes in to the relaxation phase. The physician can see changes in Electroencephalograph also.With the use of anesthesia in modified electro convulsive therapy, mild

grimace or blepharo spasm (A tonic spasm of the eyelid muscles) is observed when

the current is applied. There is a slow planter flexion (reverse babinski) during

the tonic phase and there are fine movements of the toes during the clonic

phase.

Number and frequency of ECT treatment – Amount – 70 to 130 volts for 1 to 1 second. 200 to 1600 milliamp here

Number and frequency –There is no clinical justification for fixed number of treatments.

Depression – 5 – 10 treatments for bipolar disorder, manic type, schizoaffective

disorder.

Catatonic schizophrenia given three times a week.

COMPLICATIONS –

1) Impairment of memory – Impairment of memory may vary from mild tendency to forget

names to a severe confusion.

2) Fractures and dislocations – Most frequently the fracture and dislocation are caused by

muscular contraction due to electro – convulsive therapy.Compression fracture of vertebra of dorsal area between the

second and eight – usually third, forth and fifth vertebra is common.Dislocation of law is the most frequent in complication of the

tonic phase. It can be totally prevented by supporting the law or applying pressure on the chin upward.

3) Apnea –Apnea is a physiological phenomenon in any epileptic seizure.

4) Fear – Due to an unpleasant experience an waking up after the

treatment.

OTHER COMPLICATIONS –

1) Headache 2) Backache 3) Painful mastication 4) Injury to mouth and tongue 5) Brain damage 6) Nausea 7) Vomiting 8) Prolong Seizures

If the duration of seizure is longer than 120 seconds on EEG is defined as

Prolong Seizures.

NURSING INTERVENTION BEFORE GIVING ECT NURSING INTERVENTION BEFORE GIVING ECT

RATIONAL RATIONAL

1) Check that a through physical examination chart 1) Check that a through physical examination chart including ECG, lung, bone, blood for Hemoglobin, Urine including ECG, lung, bone, blood for Hemoglobin, Urine for sugar and other tests and albumin and x-rays is for sugar and other tests and albumin and x-rays is completed. completed.

1) To select the patient for 1) To select the patient for ECT therapy. ECT therapy.

22) Written consent or declaration for the treatment from the ) Written consent or declaration for the treatment from the nearest relative after explaining the method of treatment nearest relative after explaining the method of treatment and risks. Do not tell the patient that ECT will be given. The and risks. Do not tell the patient that ECT will be given. The word current may cause fear in the patient. He may be told word current may cause fear in the patient. He may be told that “injection” will be given unless he is aware of the that “injection” will be given unless he is aware of the treatment relatives should be explained in detail. treatment relatives should be explained in detail.

2) For legal protection 2) For legal protection

Explanation to the relatives Explanation to the relatives will avoid them from shock will avoid them from shock and fear of therapy. and fear of therapy.

3) The patient should be given nothing orally before 3) The patient should be given nothing orally before treatment. If he is to be treated in an emergency it treatment. If he is to be treated in an emergency it should be Nursing intervention before giving ECT.should be Nursing intervention before giving ECT.

3) To prevent vomiting and 3) To prevent vomiting and aspiration after the aspiration after the treatment rational. treatment rational.

Two to Three hours after breakfast or meals. Two to Three hours after breakfast or meals.

NURSING INTERVENTION BEFORE NURSING INTERVENTION BEFORE GIVING ECT GIVING ECT

RATIONAL RATIONAL

Remove metallic articles from his or her Remove metallic articles from his or her body for example watch bangles ring. body for example watch bangles ring.

To prevent the electrical To prevent the electrical current passing on unwanted current passing on unwanted areas. Metal is a good conduct areas. Metal is a good conduct of electricity.of electricity.

Remove artificial dentures. Remove artificial dentures. To prevent if from dislodging To prevent if from dislodging and blocking the respiratory and blocking the respiratory passage. passage.

Remove lipstick, nail polish or any other Remove lipstick, nail polish or any other make up. make up.

To check for cyanosis. These To check for cyanosis. These colors will mask the change in colors will mask the change in the patient.the patient.

Loosen the tight clothes like necktie in men Loosen the tight clothes like necktie in men and blouse or other tight garments in and blouse or other tight garments in women, preferably give hospital clothes.women, preferably give hospital clothes.

To help in facilitating To help in facilitating respiration and meet any respiration and meet any emergency. emergency.

Replace the long acting sedative with Replace the long acting sedative with hypnotics. hypnotics.

To enhance the effectiveness To enhance the effectiveness of ECT. of ECT.

Encourage the patient to empty his bladder Encourage the patient to empty his bladder & bowels. He/she should void immediately & bowels. He/she should void immediately before the treatment. before the treatment.

To reduce his/her To reduce his/her embarrassment after the embarrassment after the treatment. If the bladder is full treatment. If the bladder is full he may spoil the bed due to a he may spoil the bed due to a relaant effect of the drug. relaant effect of the drug.

NURSING INTERVENTION BEFORE GIVING ECT NURSING INTERVENTION BEFORE GIVING ECT

RATIONAL RATIONAL

Encourage the patient to maintain his personal Encourage the patient to maintain his personal hygiene. Remove oil from hair. hygiene. Remove oil from hair.

To help patient to To help patient to develop a feeling that he develop a feeling that he is going for treatment oil is going for treatment oil is a bad conductor of is a bad conductor of electricity.electricity.

Give pre-medication to the patient Injection Give pre-medication to the patient Injection Atropine and calmpose. Atropine and calmpose.

To reduce anxiety of the To reduce anxiety of the patient and achieve patient and achieve effectiveness. effectiveness.

Take the patient on a stretcher to the waiting Take the patient on a stretcher to the waiting room. room.

Prepare him or her Prepare him or her psychologically that he psychologically that he or she is producing for or she is producing for treatment.treatment.

The patient is transferred on a trolley from the The patient is transferred on a trolley from the waiting room to the ECT room on a well padded waiting room to the ECT room on a well padded bed and placed in a comfortable dorsal position. A bed and placed in a comfortable dorsal position. A small pillow is placed under the lumbar curve. small pillow is placed under the lumbar curve.

To prevent injury of well To prevent injury of well padded bed is given ECT padded bed is given ECT treatment is given in a treatment is given in a dorsal position or supine dorsal position or supine position. position.

Give a short acting anesthetic agent. Thiopental Give a short acting anesthetic agent. Thiopental 25 gm to 5 gms. I/V and scoline (Succinylcholine) 25 gm to 5 gms. I/V and scoline (Succinylcholine) 30 to 50 mgm. (check prescriptions) the dose of 30 to 50 mgm. (check prescriptions) the dose of drugs may vary from patient to patient. drugs may vary from patient to patient.

To help the patient to To help the patient to anaesthetized quickly, to anaesthetized quickly, to reduce his anxiety and reduce his anxiety and cause less vigorous cause less vigorous convulsions, thereby convulsions, thereby prevent complications. prevent complications.

NURSING INTERVENTION DURING ECT NURSING INTERVENTION DURING ECT RATIONAL RATIONAL

Well padded mouth gag or tongue depressor is Well padded mouth gag or tongue depressor is placed in between the teeth.placed in between the teeth.

To prevent biting of To prevent biting of tongue or injury to lips. tongue or injury to lips.

Support the shoulder and arms lightly, restraint Support the shoulder and arms lightly, restraint the thigh with the help of a sheet. the thigh with the help of a sheet.

To prevent fracture tight To prevent fracture tight pressure on any of these pressure on any of these areas may lead to areas may lead to fracture of numerous or fracture of numerous or femur. femur.

Hyper extension of the head with support to the Hyper extension of the head with support to the chin by nurse. chin by nurse.

To prevent jaw To prevent jaw dislocation or fracture dislocation or fracture and for patient air-way. and for patient air-way.

Give a few breaths of oxygen to the patient. Give a few breaths of oxygen to the patient. To help the patient to To help the patient to overcome a phase of overcome a phase of apnea faster after apnea faster after convulsions.convulsions.

Provide electrodes dipped in saline water or jelly Provide electrodes dipped in saline water or jelly for placing on the temporal region.for placing on the temporal region.

Concentrated saline is a Concentrated saline is a good conductor of good conductor of electricity thereby if electricity thereby if facilitates in producing facilitates in producing convulsions. convulsions.

NURSING INTERVENTION DURING ECT NURSING INTERVENTION DURING ECT RATIONAL RATIONAL

Make an observation of grant mal seizures the Make an observation of grant mal seizures the presence of the initial tonic stage which lasts for presence of the initial tonic stage which lasts for 10-15 seconds followed by convulsions lasting for 10-15 seconds followed by convulsions lasting for 25 to 30 seconds. The, there is phase of muscular 25 to 30 seconds. The, there is phase of muscular relaxation with torturous respiration. relaxation with torturous respiration.

To ensure that there are To ensure that there are no stuns or sub shocks no stuns or sub shocks and the treatment is and the treatment is successful. successful.

Do suction immediately. Do suction immediately. To keep airway patient To keep airway patient and prevent the patient and prevent the patient from aspirations. from aspirations.

Restore respiration by giving 02 by mask, if Restore respiration by giving 02 by mask, if required. required.

To prevent the patient To prevent the patient from respiratory and from respiratory and cardiac complications. cardiac complications.

NURSING INTERVENTION POST ECTNURSING INTERVENTION POST ECT RATIONAL RATIONAL

Nursing Intervention. Nursing Intervention. Rational Rational

Observe the record the respiration pulse and Observe the record the respiration pulse and blood pressure of the patient. blood pressure of the patient.

To prevent any To prevent any respiratory or cardiac respiratory or cardiac complication. complication.

Put the railings and place the patient on a side Put the railings and place the patient on a side lying position, wipe the secretions. lying position, wipe the secretions.

To protect the patient To protect the patient from fall as he may from fall as he may become restless to avoid become restless to avoid aspiration of secretions. aspiration of secretions.

Transfer the patient to the recovery room only Transfer the patient to the recovery room only when she can answer a simple question i.e. “open when she can answer a simple question i.e. “open your mouth Shanti Devi”. your mouth Shanti Devi”.

To ensure that the To ensure that the patient has come out of patient has come out of the phase of the phase of unconsciousness. unconsciousness.

Record pulse, respiration blood vessels pressure Record pulse, respiration blood vessels pressure and the level of consciousness every is minutes and the level of consciousness every is minutes once these vital signs are stabilized, record after once these vital signs are stabilized, record after 30 minutes till the patient recovers completely.30 minutes till the patient recovers completely.

To make an early nursing To make an early nursing diagnosis of the patient diagnosis of the patient going into complication. going into complication.

Allow the patient to sleep for 30 minutes to one Allow the patient to sleep for 30 minutes to one hour if he/she wants to sleep.hour if he/she wants to sleep.

To help the patient to To help the patient to overcome physical overcome physical exhaustion. exhaustion.

NURSING INTERVENTION POST ECT NURSING INTERVENTION POST ECT RATIONAL RATIONAL

Make a note of any injuries or complaint of pains Make a note of any injuries or complaint of pains by the patient body pain or headache. by the patient body pain or headache.

To detect any type of To detect any type of complication, specially complication, specially fractures. fractures.

Encourage the patient to go for a shower bath and Encourage the patient to go for a shower bath and change his/her clothes. change his/her clothes.

To give the patient a To give the patient a sense of well being and sense of well being and freshness. freshness.

Allow the patient to take clear tea, followed by Allow the patient to take clear tea, followed by breakfast, if he/she does not vomit. breakfast, if he/she does not vomit.

To meet the nutritional To meet the nutritional needs of the patient as needs of the patient as he /she has not taken he /she has not taken any thing orally since any thing orally since morning.morning.

Help the patient to carry on his daily activity to Help the patient to carry on his daily activity to planned he should be allowed go to the day care planned he should be allowed go to the day care room. room.

To enable the patient To enable the patient

To resume his daily work To resume his daily work

To understand that ECT To understand that ECT is also a part of the is also a part of the treatment.treatment.

Make observation of any change. Make observation of any change. To note the significant To note the significant change in the behavior of change in the behavior of the patient. the patient.

1) GAIL W. STUART MICHELE T. LARAIA Principles and practice of Psychiatric Nursing 8th Edition. Dean and Professor College of Nursing Page No. – 352 – 355

2) MARY AND BOYD Psychiatric Nursing Contemporary practice Professor and Associate Dean Southern Illinois UniversityPage No. 123 – 164

3) KAPLAN & SADOCK’S Synopsis of PsychiatryBehavioral Sciences/Clinical Psychiatry Ninth Edition, professor of Psychiatry Page no. 1138 – 1144

4) S. NAMBI Psychiatry for NursesJaypee brothers Medical Publishers (P) Ltd. Page No. 183 – 186

5) BIMLA KAPOOR Text Book of Psychiatric Nursing Volume – II Kumar Publishing House 8th EditionPage No. – 125 - 129

6) LOUISE REBRACA SHIVES Basic Concepts of Psychiatric Mental Health Nursing 6th edition Page No. 220 – 225

7) M.S. BHATIA Essentials of Psychiatry Fourth Edition Satish Kumar Jain for CBS Publishers and Distributors Page No – 30.1 – 30.15

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