Nursing 316 Exam 2 Chapter 20 Electroconvulsive Therapy

Tonic phase

The tonic phase of the seizure usually lasts 10 to 15 seconds and may be identified by a rigid plantar extension of the feet.

ECT notes

-The induction of a grand mal (generalized) seizure through the application of electrical current to the brain. -One of the most recent debates stems from the FDA's (2015) proposed rule that categorizes ECT machines as low-risk, a downgrade from their long-held high-risk classification. Critics of the procedure take offense to this proposal, with some even threatening to sue the FDA. -Despite its controversial image, ECT has been used continuously for more than 50 years, longer than any other physical treatment for mental illness. It has achieved this longevity because when administered properly, for the right illness, it can help as much as or more than any other treatment. -With ECT, seizure is induced by administering a dose of electrical current through electrodes placed either bilaterally (in the bifrontal or bifrontotemporal area) or unilaterally on the right side of the frontotemporal area. -Right unilateral ECT is associated with fewer cognitive side effects, and its efficacy can be ensured with adequate dosing strategies. -While unilateral treatments were once conducted on the hemisphere of the non-dominant hand, Sadock and associates note that the right hemisphere is involved in sustaining depressed mood regardless of handedness. -The dose of electrical current is carefully controlled through the use of an ECT machine. -The dose of electrical stimulation must be strong enough to reach the patient's seizure threshold, but this threshold is highly variable among individuals. Observing the patient for seizure activity is not always the best indicator. -The tonic phase of the seizure usually lasts 10 to 15 seconds and may be identified by a rigid plantar extension of the feet. -The clonic phase follows and is usually characterized by rhythmic movements of the muscles that decrease in frequency and finally disappear. Because of the muscle relaxant, movements may be observed merely as a rhythmic twitching of the toes. -Monitoring EEG activity during the treatment provides evidence of grand mal seizure activity.

Insulin Coma Therapy

Insulin coma therapy was used for clients with schizophrenia. The insulin injection treatments induced a hypoglycemiccoma, which Sakel claimed was effective in alleviating schizophrenic symptoms. This therapy required vigorous medical and nursing intervention through the stages of induced coma. Some fatalities occurred when clients failed to respond to efforts directed at termination of the coma. The efficacy of insulin coma therapy has been questioned, and its use has been discontinued in the treatment of mental illness.

pharmacoconvulsive therapy

Pharmacoconvulsive therapy induced convulsions with intramuscular injections of camphor in oil in clients with schizophrenia. He based his treatment on clinical observation and theorized the existence of a biological antagonism between schizophrenia and epilepsy. Thus, by inducing seizures he hoped to reduce schizophrenic symptoms. Some successes were reported in terms of reduction of psychotic symptoms, and until the advent of ECT in 1938, pentylenetetrazol was the most frequently-used method used to produce seizures in psychotic clients. Pharmacoconvulsivetherapy is no longer used in psychiatry.

Clonic phase

The clonic phase follows and is usually characterized by rhythmic movements of the muscles that decrease in frequency and finally disappear. Because of the muscle relaxant, movements may be observed merely as a rhythmic twitching of the toes.

1. The nurse is assessing a client for side effects of electroconvulsive therapy (ECT). Which side effects are common and to be expected? a)Temporary disorientation b)Enduring memory loss c)Residual seizure disorders d)Cardiovascular complications

a)Temporary disorientation Temporary memory loss and confusion are common side effects of ECT.

2. A client is preparing to undergo ECT. Which nursing intervention is appropriate? a)Keep the client NPO 24 hours before the procedure. b)Verify that informed consent has been granted. c)Ascertain that client has dentures securely in place. d)Place side rails down for easy access to the restroom.

b)Verify that informed consent has been granted. Informed consent must be obtained prior to ECT.

3. In the posttreatment period of electroconvulsive therapy (ECT), which is an appropriate nursing intervention? a)Monitor vital signs every 30 minutes during the first hour. b)Place client on back to facilitate comfort. c)Orient client to time and place. d)Ambulate immediately to promote adequate circulation.

c)Orient client to time and place. Orienting to time and place assists with overcoming the temporary confusion and disorientation that often follow the ECT treatments.

Role of the nurse (during the treatment)

§A blood pressure cuff may be placed on the lower leg and inflated above systolic pressure prior to the injection of the succinylcholine. §An airway/bite block is used to facilitate the client's airway patency. §Electrodes are placed on the temples to deliver the electrical stimulation. §The nurse assists the psychiatrist and the anesthesiologist as required, and provides support to the client, both physically and emotionally. --> A blood pressure cuff may be placed on the lower leg and inflated above systolic pressure prior to the injection of the succinylcholine. This is to ensure that the seizure activity can be observed in one limb that is unaffected by the muscle relaxant. Nursing interventions during the treatment include: •Ensuring patency of airway. Provide suctioning if needed. •Assisting anesthesiologist with oxygenation as required. •Observing readouts on machines monitoring vital signs and cardiac functioning. •Providing support to the client's arms and legs during the seizure. •Observing and recording the type and amount of movement induced by the seizure.

Role of the Nurse (After the treatment)

§After the treatment, anesthesiologist continues to oxygenate client with pure oxygen until spontaneous respirations return. §Most clients awaken within 10 or 15 minutes of the treatment and are confused and disoriented. §Some clients will sleep for 1 to 2 hours following the treatment. §All clients require close observation in this immediate posttreatment period. Nursing interventions in the post-treatment period include: •Monitoring pulse, respirations, and blood pressure every 15 minutes for the first hour, during which time the client should remain in bed. •Positioning the client on side to prevent aspiration. •Orienting the client to time and place. •Describing what has occurred. •Providing reassurance that confusion and memory loss will subside and memories should return following the course of ECT therapy. •Allowing the client to verbalize fears and anxieties related to receiving ECT. •Staying with the client until he or she is fully awake, oriented, and able to perform self-care activities without assistance. •Providing the client with a highly-structured schedule of routine activities in order to minimize confusion.

ECT Defined

§Electroconvulsive therapy (ECT) is the induction of a grand mal (generalized) seizure through the application of electrical current to the brain. §ECT has long had a negative reputation. §One of the most controversial treatments for psychological disorders §Despite its controversial image, ECT has been used continuously for more than 50 years. §With ECT, seizure is induced by administering a dose of electrical current through electrodes placed either bilaterally or unilaterally. •Right unilateral ECT is associated with fewer cognitive side effects. •The dose of electrical current is carefully controlled through the use of an ECT machine. •Amount of electrical stimulus applied is controversial •A patient's seizure threshold may increase 25 to 200 percent during the course of ECT treatments. •ECT itself acts as an anticonvulsant, because the seizure threshold increases as treatment progresses. •Movements are minimal because of the administration of a muscle relaxant before treatment. ‒Tonic phase ‒Clonic phase •Most require 6-12 treatments; some require up to 20. •Treatments administered every other day—3 times per week.

Role of the Nurse (Evaluation)

§Evaluation of the effectiveness of nursing interventions is based on the achievement of the projected outcomes. Evaluation of the effectiveness of nursing interventions is based on the achievement of the projected outcomes. Reassessment may be based on answers to the following questions: •Was the client's anxiety maintained at a manageable level? •Was the client/family teaching completed satisfactorily? •Did the client/family verbalize understanding of the procedure, its side effects, and risks involved? •Did the client undergo treatment without experiencing injury or aspiration? •Has the client maintained adequate tissue perfusion during and following treatment? Have vital signs remained stable? •With consideration to the individual client's condition and response to treatment, is the client reoriented to time, place, and situation? •Have all of the client's self-care needs been fulfilled? •Is the client participating in therapeutic activities to his or her maximum potential? •What is the client's level of social interaction?

Historical Perspectives

§First treatment performed in 1938 in Rome §Other types of somatic therapies tried •Insulin coma therapy ‒Introduced by German psychiatrist Manfred Sakel in 1933 •Pharmacoconvulsive therapy Introduced in Budapest in 1934 by Ladislas Meduna §ECT was widely accepted from around 1940 to 1960. §This was followed by a 20-year span when ECT was considered objectionable by the psychiatric profession and the public. §The second wave of acceptance began around 1980 and has been increasing to the present. §An estimated 100,000 people in the United States and about 2 million worldwide receive ECT treatments yearly.

ECT Mechanism of Action

§The exact mechanism of action by which ECT effects a therapeutic response is unknown. §Many parts of the central nervous system are affected by ECT. •Hormones, neuropeptides, neurotrophic factors, and nearly every neurotransmitter •Affected neurotransmitters include serotonin, norepinephrine, and dopamine, the same biogenic amines that are affected by antidepressant drugs --> The results of studies relating to the mechanism underlying the effectiveness of ECT are still ongoing and continue to bear mixed results. It may be a complex dynamic of several effects interacting with one another.

ECT Side Effects

§The most common side effects are temporary memory loss and confusion. §Proponents insist they are temporary and reversible. --> In one recent study that looked at long term outcomes of ECT in patients with bipolar I disorder the evidence supported that two years following ECT, cognitive skills and short-term memory were not impaired, while mood symptom recurrence had improved regardless of the level of mania.

ECT Contraindications

§There are no absolute contraindications for ECT. §Some patients may be at higher risk for adverse events that require attention and closer monitoring. --> Clients with cardiovascular problems are placed at risk because of the body's response to the seizure itself.

ECT Indications (Other conditions in which it has reported useful)

‒In episodic psychosis, atypical psychosis, obsessive-compulsive disorder, and delirium ‒In medical conditions such as neuroleptic malignant syndrome, hypopituitarism, intractable seizure disorders, and Parkinson's disease ‒For pregnant women and elderly individuals who are unable to take medication, ECT may be a safer alternative --> ECT has been reported as useful in episodic psychosis, atypical psychosis, obsessive-compulsive disorder, delirium, and medical conditions such as neuroleptic malignant syndrome, hypopituitarism, intractable seizure disorders, and Parkinson's disease, particularly when there's comorbid depression. Oztav and others (2015) reported that although the literature on safety of ECT in pregnancy is scarce, their research supported others' findings that it can be used safely. They also note that 40 percent of pregnant patients treated with ECT in their study demonstrated full recovery.

ECT Indications (other conditions where ECT is not effective)

‒In somatization disorders (unless there is comorbid depression) ‒Personality disorders ‒Anxiety disorders --> ECT has been reported as useful in episodic psychosis, atypical psychosis, obsessive-compulsive disorder, delirium, and medical conditions such as neuroleptic malignant syndrome, hypopituitarism, intractable seizure disorders, and Parkinson's disease, particularly when there's comorbid depression. Oztav and others reported that although the literature on safety of ECT in pregnancy is scarce, their research supported others' findings that it can be used safely. They also note that 40 percent of pregnant patients treated with ECT in their study demonstrated full recovery.

Role of the Nurse (In the treatment room)

•Client is placed on the table in a supine position. •Anesthesiologist intravenously administers a short-acting anesthetic. §A muscle relaxant is given intravenously to prevent severe muscle contractions during the seizure, thereby reducing the possibility of fractured or dislocated bones. --> The two most commonly-used anesthetic agents for ECT in the United States are methohexital and propofol. A muscle relaxant, usually succinylcholine chloride, is given intravenously to prevent severe muscle contractions during the seizure, thereby reducing the possibility of fractured or dislocated bones. Because succinylcholine paralyzes respiratory muscles as well, the client is oxygenated with pure oxygen during and after the treatment, except for the brief interval of electrical stimulation, until spontaneous respirations return.

ECT Indications (Schizophrenia)

•ECT can induce a remission in some clients who present with acute schizophrenia. ‒Particularly those who have marked positive, catatonic, or affective (depression or mania) symptomatology •It does not appear to be of value to individuals with chronic schizophrenic illness. --> ECT can induce a remission in some clients who present with acute schizophrenia, particularly those who have marked positive, catatonic, or affective (depression or mania) symptomatology. It does not appear to be of value to individuals with chronic schizophrenic illness.

ECT Indications (Major Depression)

•ECT has been shown to be effective in the treatment of severe depression. •ECT is typically considered only after a trial of therapy with antidepressant medication has proved ineffective. •May be considered the treatment of choice ‒When need for treatment response is urgent §Patients who are extremely suicidal or refusing food and nutritionally compromised --> ECT has been shown to be effective in the treatment of severe depression, particularly among depressed clients who are also experiencing psychotic symptoms, catatonia, psychomotor retardation, and neurovegetative changes, such as disturbances in sleep, appetite, and energy.

ECT Indications (Mania)

•ECT is indicated in the treatment of acute manic episodes and is at least as effective as lithium. •ECT is also indicated in the treatment of of bipolar disorders with mixed states. •It has been shown to be effective in treating manic clients who are refractory to antimanic drug therapy. •It is still only used when patient has failed to respond to medication. --> ECT is indicated in the treatment of acute manic episodes and is at least as effective as lithium. At present, it is rarely used for this purpose because lithium and other pharmocotherapies are so effective in the short and long-term. However, ECT has been shown to be effective in the treatment of manic clients who do not tolerate or fail to respond to lithium or other drug treatment, or when life is threatened by dangerous behavior or exhaustion. ECT should not be used while a patient is receiving lithium since lithium lowers the seizure threshold and may cause prolonged seizures when combined with ECT. Recent evidence has supported the use of ECT in the treatment of bipolar disorders with mixed states (concurrent depressive and manic features). This is especially beneficial since this type of bipolar disorder is often more severe, with lower interepisode remission, and higher risk for suicide.

Risks Associated with ECT (Mortality rate from ECT)

•Less than that of childbirth •About 0.002 percent per treatment and 0.01 percent for each patient •Although death is rare, it is usually related to cardiovascular complications. ‒Usually individuals with previously compromised cardiac status --> Assessment and management of cardiovascular disease prior to treatment is vital in the reduction of morbidity and mortality rates associated with ECT.

Risks Associated with ECT (memory loss)

•Memory impairment almost always occurs to some degree during ECT treatments. ‒Studies indicate most patients return to their cognitive baselines after 6 months. •Some clients report persistent memory impairment and in most cases. ‒Among patients who showed little improvement with ECT •All clients receiving ECT should be informed of the possibility for some degree of permanent memory loss. --> The extent of the amnesia was directly related to the number of ECT treatments received. The researchers also found that stimulation produced by sine wave (continuous) current resulted in greater short- and long-term deficits than that produced by short-pulse wave (intermittent) current.

Individuals at high risk with ECT

•Myocardial infarction or cerebrovascular accident within preceding 3-6 months, aortic or cerebral aneurysm, severe underlying hypertension, congestive heart failure •Patients with intracranial lesions may be at risk for edema or brain herniation after ECT. •Patients with increased intracranial pressure are at increased risk related to increased cerebral blood flow during seizures. •Severe osteoporosis, acute and chronic pulmonary disorders, and high-risk or complicated pregnancy. --> Patients with intracranial lesions may be at risk for edema or brain herniation after ECT, but these risks can be decreased by pretreatment with dexamethasone in cases where the lesion is small. Patients with intracranial lesions may be at risk for edema or brain herniation after ECT, but these risks can be decreased by pretreatment with dexamethasone in cases where the lesion is small. Patients with increased intracranial pressure are at increased risk related to increased cerebral blood flow during seizures, but Sadock and associates note that risk can be lessened by controlling the patient's blood pressure during the treatment. Other factors that place clients at risk during ECT include severe osteoporosis, acute and chronic pulmonary disorders, and high-risk or complicated pregnancy

Role of the nurse (planning/implementation

•Nursing interventions before the treatment •Ensuring physician and anesthesiologist have obtained informed consent and signed permission form is on chart •Ensuring most recent laboratory reports and results of ECG and x-ray examination are available •1 hour before treatment, taking and recording vitals •Have client void and remove dentures, eyeglasses or contact lenses, jewelry, and hairpins. •Following institutional requirements, client changes clothing •Client to remain in bed •30 minutes before treatment, administering pretreatment medication prescribed by physician •Staying with the client to help allay fears and anxiety •Maintain a positive attitude about the procedure, and encourage the client to verbalize feelings --> ECT treatments are usually performed in the morning. The client is given nothing by mouth (NPO) for 6 to 8 hours before the treatment. Some institutional policies require that the client be placed on NPO status at midnight prior to the treatment day. The treatment team routinely consists of the psychiatrist, anesthesiologist, and two or more nurses. --> The usual order is for atropine sulfate or glycopyrrolate (Robinul) given intramuscularly. Either of these medications may be ordered to decrease secretions (to prevent aspiration) and counteract the effects of vagal stimulation (bradycardia) induced by the ECT.

Role of the nurse (diagnosis/outcome identification)

•Selection of appropriate nursing diagnoses for the client undergoing ECT is based on continual assessment before, during, and after treatment.

Nurses may also be required to assess:

•The client's mood and level of interaction with others •Evidence of suicidal ideation, plan, and means •Level of anxiety and fears associated with receiving ECT •Thought and communication patterns •Baseline memory for short- and long-term events •Client and family knowledge of indications for, side effects of, and potential risks associated with ECT •Current and past use of medications •Baseline vital signs and history of allergies •The client's ability to carry out activities of daily living

Role of the Nurse ECT (Assessment)

•The nursing process is the method of delivery of care for the client receiving ECT. •The client must receive a thorough physical examination before initiation of therapy. •This examination should include assessment of cardiovascular and pulmonary status, as well as laboratory blood and urine studies. •A skeletal history and x-ray assessment should also be considered. •The nurse must ensure that informed consent has been granted. •The nurse must also assess mood, level of anxiety, thought and communication patterns, and vital signs. •Appropriate nursing diagnoses are formulated based on assessment data.

Risks Associated with ECT (brain damage)

•The subject has been studied using a variety of brain imaging modalities, and virtually all conclude there is no evidence of brain damage caused by ECT treatments. --> The question of brain damage secondary to ECT treatments has been advanced as a concern by critics of the procedure. The subject has been studied using a variety of brain imaging modalities and virtually all conclude there is no evidence of brain damage caused by ECT treatments. Previously-cited studies on the neurorestorative effects of ECT have argued that this, too, is evidence in contradiction to ideas about brain-damaging effects of ECT.