PSYCHIATRY Nursing

SEMINAR
Risks associated with ECT
Pre, Intra Post ECT care
Risk associated with ECT
 Cardiovascular problems

 Rare
 Seizure-Tachycardia, Arterial hypertension
 Pre existing cardiac problems
 MI, Asystole, Arrhythmia, Brady arrhythmia, Atrioventricular block
 Memory loss & cognitive problems
®Greatest concern
®Almost all patients will be back to their normal base level
®Some patients- Persistent memory difficulties
Events lead to hospitalization, ECT etc might be forgotten
Memory problems, mostly for those who have little improvement with
ECT
®In rare instances, more extensive amnesia has occurred
 Memory loss & cognitive problems…
®Mostly with bilateral electrode placement
®Proportional to the number of ECT treatments received
®Black and Andreasen (2011) suggested that all clients receiving ECT
should be informed of the possibility for some degree of memory loss
 Mortality
• About 2 per 100,000 treatments
• Occurrence is rare, the major cause of death with ECT is from
cardiovascular complications
• Eg: Acute myocardial infarction
• Usually in individuals with previously compromised cardiac status
 Brain damage
Critics -ECT always results in some degree of immediate brain damage
Evidence- No brain damage
 Other adverse effects
ⲳFractures
ⲳBack pain
ⲳMuscle soreness
ⲳMinimum side effects-
o Naussea
o Vomitting
o Headache ( Can induce migraneous headache)
 Pre ect evaluation
◊ Physical, neurological and preanesthesia examinations
◊ Laboratory examinations
Blood & urine chemistry
◊ Chest Xray
◊ ECG
◊ If required
Dental examination
Xray of spine
CT, MRI if seizure/ SOL
 Concomitant medications
Check ongoing medicines to see interaction with ECT/ Seizure
threshold.
TCA, Tetracyclics, MAOI, Antipsychotics acceptable
®Benzodiazepines (Anticonvulsant activity)
®Lithium (Postictal delirium, Prolong seizure)
®Clozapine & Buproprion (Late appearing seizure)
Lidocaine, Theophylline contraindicated
 ASSESSMENT
• Physical examination
• MSE
• Level of anxiety and fears associated with receiving ECT
• Baseline memory for short- and long-term events
• Client and family knowledge about 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
Premedications
 Muscarinic anticholinergic drugs-
 To minimize oral & respiratory secretions & to block bradycardia and
asystole
 Atropine (0.3-0.6 mg IM or SC or 0.4 to 1 mg IV)
Glycopyrolate (0.2 to 0.4 mg IM, IV or SC )
 Anesthetic drugs
General anesthesia
Methohexital (0.75 to 1 mg/kg IV bolus)
Thiopental (2 to 3 mg/kg IV )
Etomidate, Ketamine, Alfentanil, Propofol
 Muscle relaxants
After the onset of anesthetic action, usually within a min
Profound relaxation of muscle
Succinyl choline- 0.5-1 mg/ kg IV, ultrafast acting depolarizing
blocking agent
 Pre ect- role of nurse
Physical assessment
Ensure consent has been obtained
Most recent laboratory tests, ECG, X ray has been obtained
NPO 6hr before treatment
Assess vital signs 1 hr before $ record
IV line
 Pre ect- role of nurse
Have the client void and remove dentures, eyeglasses or contact
lenses, jewelry, and hairpins.
Premedications
Stay with the client to help allay fears and anxiety.
Maintain a positive attitude about the procedure
Encourage the client to verbalize feelings.
 Articles required for ECT
Suction apparatus
Face mask
Oxygen cylinder
Tongue depressor
Mouth gag
Resuscitation apparatus
Full set of emergency drugs, ECT drugs
Defibrillator
 Intraprocedure
Supine position
Anesthetic, Muscle relaxant
Emergency equipments
100% oxygen 5 l per min
A blood pressure cuff placed on the lower leg and inflated above
systolic pressure prior to the injection of the succinylcholine.
Bite block
 Parameters
Voltage - 70-120 volts
Current -200-1600mA
Placement of electrodes:
 Induced seizure
First behavioral sign of contraction is plantar flexion,
TONIC phase
Clonic phase-Rhythmic contractions that decrease in frequency and
finally disappear
Ensure safety of patient
Monitor seizures
Continue oxygen till spontaneous respiration returns
 Role of nurse- INTRA ect
Ensure patency of airway.
Provide suctioning if needed.
Assist anesthesiologist with oxygenation as required.
Observe readouts on machines monitoring vital signs and cardiac
functioning.
Provide support to the client’s arms and legs during the seizure.
Observe and monitor the seizure
 Post ECT
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.
Close observation needed
 Post treatment care
Monitor pulse, respirations, and blood pressure every 15 minutes for
the first hour, during which time the client should remain in bed.
Position the client on side to prevent aspiration
 Orient the client to time and place.
Describe what has occurred.
 Post treatment care
Provide the client with a highly structured scheduled of routine
activities in order to minimize confusion.
Provide reassurance that confusion and memory loss will subside, and
memories should return following the course of ECT therapy.
Allow the client to verbalize fears and anxieties related to receiving
ECT.
Support the client until he or she is fully awake, oriented, and able to
perform self-care activities without assistance.
Research evidence
Effectiveness of a training programme for
ECT nurses
Jo Munday, Cecil Deans
2003 November
Electroconvulsive therapy (ECT) is a highly technical procedure requiring a team
that consists of an anesthetist, a psychiatrist, a clinical nurse specialist, and
recovery nurses. Traditionally, nursing education and training in the context of
providing a safe and high standard of care has not been addressed. Ninety-two
nurses from 42 different health agencies participated in a training program focusing
on defibrillation, electrocardiogram (ECG) and electroencephalogram (EEG)
monitoring, intubation, stimulus dosing, setting up the ECT equipment, and caring
for the patient. A non-experimental, one-group, pretest-posttest research design was
used in this study to evaluate the effectiveness of the training program for nurses
working with ECT.
Effectiveness of a training programme for
ECT nurses…
Effective training for nurses was hypothesized to make a difference in the
standards of practice and clinical effectiveness for patients undergoing ECT.
Findings from this study indicated a major knowledge deficit in key
components of ECT among nurses who have responsibilities in this area of
nursing care. With effective training, nurses' confidence levels increased
related to setting up the equipment, administering a double dose, helping with
intubation, and using a defibrillator. If nurses are to effectively function as
team members in the ECT procedure, they must receive the training necessary
to prepare them for this important role. The results of this study support the
recommendation of the Royal Australian and New Zealand College of
Psychiatrists that ECT nurses should be appropriately trained in anaesthetic
and resuscitation techniques and modern ECT practice.
Cognitive side effects of ECT in elderly depressed
patients
Gro Stromnes,Lars Tanum etal.2014

Knowledge about cognitive side-effects induced by electroconvulsive

therapy (ECT) in depressed elderly patients is sparse. In this study we
investigated changes in the cognitive functioning of non-demented
elderly depressed patients receiving ECT (n = 62) compared with
healthy elderly people (n = 17). Neuropsychological tests were
administered at the start of treatment and again within 1 week after
treatment. We computed reliable change indices (RCIs) using simple
regression methods. RCIs are statistical methods for analyzing change
in individuals that have not yet been used in studies of the acute
cognitive side-effects of ECT.
Cognitive side effects of ECT in elderly
depressed patients…
At the group level, only letter fluency performance was found to be
significantly reduced in the ECT group compared with the controls,
whereas both groups demonstrated stable or improved performance on
all other measures. At the individual level, however, 11% of patients
showed retrograde amnesia for public facts post-ECT and 40% of the
patients showed a significant decline in neuropsychological functioning.
Decline on a measure of delayed verbal anterograde memory was most
common. Our findings indicate that there are mild neurocognitive
impairments in the acute phase for a substantial minority of elderly
patients receiving ECT. Analysis of reliable change facilitated the
illumination of cognitive side-effects in our sample.
Summary
ANY QUERIES ??
 Conclusion
The nurse assists with ECT using the steps of the nursing process
before, during, and after treatment.
Important nursing interventions include ensuring client safety,
managing client anxiety, and providing adequate client education.
Nursing input into the ongoing evaluation of client behavior is an
important factor in determining the therapeutic effectiveness of ECT.
 Reference
o Benjamin James Sadock, Virginia Alcott Sadock , Kaplan and Sadock’s
synopsis of psychiatry, Tenth edition, Wolters Kluwer
o [Link] Townsend, Psychiatric Mental health nursing, Eigth edition,
Jaypee publications