CH 20 Electroconvulsive Therapy

Mechanism of Action

- The exact mechanism by which ECT effects a therapeutic response is unknown. Several theories exist, but the one to which the most credibility has been given is the biochemical theory. - electric stimulation results in significant increases in the circulating levels of several neurotransmitters - include serotonin, norepinephrine, and dopamine, the same biogenic amines that are affected by antidepressant drugs. - may also result in increases in glutamate and gamma-aminobutyric acid - therapeutic response from ECT may be related to the modulation of white matter microstructure in pathways connecting frontal and limbic areas, which are altered in major depression - controversial

Nursing Process - ECT - • Planning/Implementation:

o Approximately 30 min before treatment, administer the pretreatment medication as prescribed by the physician. The usual order is for atropine sulfate or glycopyrrolate (Robinul) given IM; either of these meds may be ordered to decrease secretions (to prevent aspiration) and counteract the effects of vagal stimulation (bradycardia) induced by ECT o A muscle relaxant, usually succinylcholine chloride, is given IV to prevent severe muscle contractions during the seizure, thereby reducing the possibility of fractured or dislocated bones. o 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. o Monitor Pulse, respirations, and BP Q15minutes for the first hour, during which time the client should remain in bed o MAINTAIN AIRWAY

2. Which of the following best describes the average number of ECT treatments given and the timing of administration? a. One treatment per month for 6 months b. One treatment every other day for a total of 6 to 12 treatments c. One treatment three times per week for a total of 20 to 30 treatments d. One treatment every day for a total of 10 to 15 treatments

b. One treatment every other day for a total of 6 to 12 treatments

9. Atropine sulfate is administered to a client receiving ECT for what purpose? a. To alleviate anxiety b. To decrease secretions c. To relax muscles d. As a short-acting anesthetic

b. To decrease secretions

7. Sam, who has been hospitalized for ECT treatments, says to the nurse on admission, "I don't want to end up like McMurphy in One Flew Over the Cuckoo's Nest! I'm scared!" Which of the following statements would be most appropriate by the nurse in response to Sam's expression of concern? a. "I guarantee you won't end up like McMurphy, Sam." b. "The doctor knows what he is doing. There's nothing to worry about." c. "I know you are scared, Sam, and we're going to talk about what you can expect from the therapy." d. "I'm going to stay with you as long as you are scared."

c. "I know you are scared, Sam, and we're going to talk about what you can expect from the therapy."

4. Electroconvulsive therapy is thought to effect a therapeutic response by: a. Stimulation of the CNS b. Decreasing the levels of acetylcholine and monoamine oxidase c. Increasing the levels of serotonin, norepinephrine, and dopamine d. Altering sodium metabolism within nerve and muscle cells

c. Increasing the levels of serotonin, norepinephrine, and dopamine

1. Electroconvulsive therapy is most commonly prescribed for: a. Bipolar disorder, manic b. Paranoid schizophrenia c. Major depression d. Obsessive-compulsive disorder

c. Major depression

10. Succinylcholine is administered to a client receiving ECT for what purpose? a. To alleviate anxiety b. To decrease secretions c. To relax muscles d. As a short-acting anesthetic

c. To relax muscles

8. The priority nursing intervention before starting ECT therapy is to: a. Take vital signs and record. b. Have the patient void. c. Administer succinylcholine. d. Ensure that the consent form has been signed.

d. Ensure that the consent form has been signed.

5. The most common side effects of ECT are: a. Permanent memory loss and brain damage b. Fractured and dislocated bones c. Myocardial infarction and cardiac arrest d. Temporary memory loss and confusion

d. Temporary memory loss and confusion

Nursing Process - ECT - • Assessment:

o A complete physical examination must be completed o Assessment of the cardiovascular and pulmonary status as well as lab blood and urine studies; a skeletal history and x-ray should also be considered o Consent must be obtained o ECT is voluntary and that consent may be withdrawn at any time

Risks associated with ECT:

o Mortality: although occurrence is rare, the major cause of death with ECT is from cardiovascular complications o Permanent memory loss: most individuals report no problems with their memory, aside from the time immediately surrounding the ECT treatments; however, some clients have reported retrograde amnesia extending back to months o Brain damage: there is no evidence to substantiate that ECT produces any permanent changes in brain structure or functioning

NURSING DIAGNOSIS: Decreased cardiac output related to vagal stimulation occurring during the ECT

OUTCOME CRITERIA: Client demonstrates adequate tissue perfusion during and after treatment (absence of cyanosis or severe change in mental status).

NURSING DIAGNOSIS: Risk for aspiration related to altered level of consciousness immediately following treatment

OUTCOME CRITERIA: Client experiences no aspiration during ECT.

NURSING DIAGNOSIS: Risk for activity intolerance related to post-ECT confusion and memory loss

OUTCOME CRITERIA: Client gradually increases participation in therapeutic activities to the highest level of personal capability.

NURSING DIAGNOSIS: Impaired memory/acute confusion related to side effects of ECT

OUTCOME CRITERIA: Client maintains reality orientation following ECT treatment

NURSING DIAGNOSIS: Risk for injury related to risks associated with ECT

OUTCOME CRITERIA: Client undergoes treatment without sustaining injury.

Nursing Diagnosis: Anxiety (moderate to severe) related to impending therapy

OUTCOME CRITERIA: Client verbalizes a decrease in anxiety following explanation of procedure and expression of fears.

NURSING DIAGNOSIS: Deficient knowledge related to necessity for and side effects or risks of ECT

OUTCOME CRITERIA: Client verbalizes understanding of need for and side effects/risks of ECT following explanation.

NURSING DIAGNOSIS: Self-care deficit related to incapacitation during postictal stage

OUTCOME CRITERIA: Client's self-care needs are fulfilled at all times.

6. Sam has a diagnosis of major depression. After an unsuccessful trial of antidepressant medication, Sam's physician has hospitalized Sam for a course of ECT treatments. Sam says to the nurse on admission, "I don't want to end up like McMurphy in One Flew Over the Cuckoo's Nest! I'm scared!" Sam's priority nursing diagnosis at this time would be: a. Anxiety related to deficient knowledge about ECT b. Risk for injury related to risks associated with ECT c. Deficient knowledge related to negative media presentation of ECT d. Acute confusion related to side effects of ECT

a. Anxiety related to deficient knowledge about ECT

3. Which of the following conditions is considered to be the only absolute contraindication for ECT? a. Increased intracranial pressure b. Recent myocardial infarction c. Severe underlying hypertension d. Congestive heart failure

a. Increased intracranial pressure

Nurses may be required to assess:

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