Acknowledgement Electro convulsive therapy is used as a first - line treatment for patient who need rapid resolution of life

threatening symptoms or who have poor response to other treatment. Today, ECT has had a resurgence of popularity. The procedure has been greatly modified since the early days of its use. Modern techniques have reduced morbidity and mortality from ECT allowing the procedure to gain a role as a respected and legitimate method of treatment for selected patents. I extremely delighted to prepare this protocol for those nurses who are directly and indirectly involved in giving ECT. This is a beginning effort. We extremely grateful to Madam G.S. Reddy, Vice Principal who inspire us to prepare protocol in particular theme as well as giving valuable input. I also appreciate to Madam Usha Ukande, Principal who always been an adrenaline

to take up this challenge to prepare this protocol. I also very much thankful to Madam. Achamma Varghese for her encouragement and support.
Mrs. Jyoti Srivastava Mr. Shailendra Ghosh MSN. ( Previous )

UNIT I

Electro Convulsive Therapy

History :
Convulsive therapy was first used by a Hungarian Dr. Von Meduna in 1935, who injected camphor in oil IM into schizophrenia patient on the assumption of an infrequent association between epilepsy and schizophrenia. This assumption was later proved to be false. In 1937 two Italian doctor Uogocerletti and Lucio Bini introduced electro convulsive therapy as a physical method of treatment for some mental illness. The first patient to be so treated, who had been found wondering around a train station in Rome, recovered from his psychotic episode after 11 treatments and was discharge within a few months.

Types :
1. 2. 3. 4. Bilateral Unilateral Direct Modified

What is Electro Convulsive Therapy????

Electro-convulsive therapy (ECT) involves the passage of an electrical current through the brain of a patient to produce a grand mal seizure. E.C.T. involves passing an electric current through a person's brain while they are under a general anesthetic and have been given a muscle relaxant. This produces a convulsion (muscular contractions) modified by the anesthetic.

Techniques:
Direct ECT

ECT can be given by a direct and indirect method. The patient is administered atropine sulphate subcutaneous .6 mgm to 1.0 mgm, half an before the treatment or IV just before the treatment. A grand mal seizure is induced in the patient by passing an electric current through the temporal lobe. Immediate after ECT treatment appropriate resuscitative and other emergency Management equipment and supplies are to be kept ready. ECT gave by this technique cause a lot of anxiety to the patient.

Modified ECT
In this type ECT give with the use of anesthesia, muscles relaxation and oxygenation. The anesthesia is necessary to allay anxiety and achieve the maximum effect. It used to modify the force of convulsion and to avoid complications like bone fractures.

Note: Modified ECT also used for the patients who are recovering from heart condition.

Indications:
The indication depends upon the availability or non-availability of psychotropic drugs.\ The common conditions are : State of severe depression. Involutional Melancholia Schizophrenia - Catatonic - Paranoid Mania Unipolar , bipolar depression Psychotic Depressions Post partum Depression Confusional state in Organic psychosis Others : - Premorbid personality - Anorexia

Early morning insomnia Weight loss Lack of concentration Ides of guilt and worthlessness. Suicidal thoughts and suicidal attempts.

Contraindications:
Confusion is likely to be much exaggerated by the use of treatment. Neurotic Illness History Organic Brain Damage Psychotic reactions due to senile brain damage or areterio sclerosis in such cases all ready existing of cardio vascular diseases eg. Recent M.I. Active tuberculosis Severe respiratory diseases. Active Bone diseases. Patient below 16 year of age. 1st trimester of pregnancy.

Other Contra indications:

1. 2. 3. 4. 5. Raised intra cranial pressure. Cerebral artery Aneurysm. Artificial Pacemaker. If patient is taking MAO and Lithium. Severe Hypertension

Number and Frequency of treatment:

The most patient need 4 to 12 ECTs Some evidence that Elderly require elderly, require more treatment. If there is no improvement in patients symptoms after 6 123 ECTs stop the course. Treatment should be given 2 3 times a week

Electrode Position
Five different electrode positions are described consistently in the literature, of which three are in relatively regular use. ECT Electrode Positions

Bilateral (Bitemporal)

One electrode is placed on each side of the head at a point (3) four centimeters perpendicular to the middle of a line connecting the external ear canal with the angle of the eye.

Unilateral d'Elia
Right handed people are usually left brain dominant - hence unilateral stimulation of the right side can spare some side effects that relate to language (which is a left brain job). Half of all left handed people are also left dominant. Hence unilateral ECT uses the temporal position detailed with 'bilateral ECT on the right (3), with the second electrode one inch ipsilateral to the vertex of the scalp.

Bifrontal
Using two electrodes, one above each eye (4), is considered by some to reduce the likelihood for cognitive side effects.

LART
The Left Anterior Right Temporal is a hybrid of Bitemporal and Bifrontal ((3) and (4) on opposite sides of the head). There is relatively little evidence for this position devised by Swartz as yet- but intuitively it does spare the left temporal (speech) area.

Amount of Current:
The nature and range of stimulus intensity setting varies from device to device. 70 to 120 volts (varies from patient to patient) for .2 to .6 second will, produce a convulsive effect. The actual amount of the current passing during treatment was found to range from 200 to 1600 milliamphers.

Complications:

Compression fracture of the dorsal vertebrae. Dislocation of jaw and shoulder. Fracture of the upper end of the humorous and femur. Memory disturbance especially in elderly patients. Temporary confusion and clouding of consciousness. Small risk of developing epilepsy. Tongue bites injury to teeth or lips. Headache Death

UNIT II

Nursing Care Issue:

Nurse are in critical position to improve and evaluate patients understanding of ECT, to be advocates for a patients rights to full information and choice of treatment, and to educate patients family members and friend about ECT.

Nurses Role A. Preliminary Phase

1. Preparation of patients by:

Consent signature with relatives either prior to admission or any time before procedure. Fasting for at least 5 hours before the treatment is essentials. Check Psychiatrist order. Check the thoroughly physical examination done by the doctor( Ecg, Lugs, bone, blood for Hb, Urine for sugar, , X-ray etc ) Encourage the patient empty his bladder before going to treatment room. Administer injection Atropine sulphate 1 : 1000 gm I.M. 30 minutes before E.C.T. Loosen the clothing. Hair clips, pin jewelry and false teeth, bangles, watch, ring etc. must be removed. Remove lipstick, nail polish or any other makeup.

2. Preparation of Equipments:

Electro therapy machine Electrodes usually moistened in saline or some jelly. Bowl of saline solution. Oxygen apparatus. Injection tray with Tourniquet Cotton spirit swab. Airway Mouth gage Suction apparatus. Drugs : Coramine, Neostagmin, Escoline etc ( to be used in emergency Prepare bed in which patient to be kept after ECT.

B. Intraprocedure Phase: Management of convulsion

Patient lies on the back with a small pillow between the dorsal vertebrae. Holding of the patient :

- One attendant holds feet closely together. - Another puts pressure on pelvis. - Two more, one on each side holding shoulder and wrist. - The fifth attendant controls the head putting mouth or towel and pressing chin firmly. - The psychiatrist or psychiatrist nurse applies electrodes on the temporal region after cleaning the area and moistening electrodes in 30 % saline or jelly.

When the patient is ready, the shock is administered by the psychiatrist 40 120 volts of alternative current for .3 - .7 seconds.

Tonic Phase:
There will be violent clinching of the jaw and body muscles contract slightly.

Clonic Phase:

Patient goes into clonic stage of convulsion. Fits last for 2 minutes. Patient does no0t breath during this phase. When the fit is subsided patient is turned to one side. Usually patient starts breathing at this time. If not and show cyanosis oxygen inhalation is given , some times artificial breathing is also given.

C. After Care:

Assess and record the vital sign . Transfer the patient in bed. Keep him on side lying position, wipe and secretion. Till he regains conscious. During the period of unconsciousness, patient should be watched closely for skin color, respiratory difficulty or cyanosis of such happen informs doctor immediately. Patient is confused and unable to stand or walk for sometime. So, somebody should look after him. The patient should be allowed to rest for an hour or two after the treatment. Headache is common after the treatment. Patient should not be allowed to drive car at least 24 hours. Make note any injury or complaint of pains. Make observation of any change.

D. Teaching Points:
Nurse has to give some of the teaching pints about ECT for patients and their family about: The patient should take nothing by mouth after midnight before ECT, unless medication is prescribed.

Patient should wear loose, comfortable, nonrestrictive clothing to facilitate donning a hospital gown before the procedure. The patient should expect electrode paste at the temple where the electrode is positioned. The patient can expect confusion immediately after a seizure, since ECT produces a temporary disorientation. Outpatients must be supervised after ECT. Outpatients should not drive, since they may be unable to find the parking lot or the way of home. Patient should continue to take prescribed medication as suggested.

Modified ECT Nurses Responsibilities: 1. Preparation of Equipment :

ECT Machine, extension cord, oxygen and suction machine, are checked to see that they are in good working condition. Resuscitation equipment is thoroughly checked.

2. Prepare tray with:

Spirit swab, kidney basin, forceps, syringes 2 ml or 5 ml sterile towel, needles 23 or 24 number etc. Keep emergency drug like adrenaline, digoxin, neostagmine, etc which to be used in emergency. Other required articles as tourniquet, lubricants, B.P., apparatus, stethoscope, resuscitation equipments .

3. Preparation of patient:

Have thoroughly physical examination of the patient ( ECG, vital Sign, respiratory status etc ) Help and supervisor patient in bath. Remove jewelry and hair clips if female patient. Remove denture if there. Remove hearing aid, glass and valuable are also taken care of.. Support and reassurance are utmost importance, especially on the day of treatment and during the waiting period beforehand. This reduce the fear and anxiety that the patient probably be feeling.

3.

Assist with procedure :

The patient will be clothed in garments that make possible the availability of the exposure of the chest and the feet and arms. The first sign of the modified convulsion is observed in these areas well as eyes. Screen the bed area, place the patient on a non-sagging mattress, prepared with mackintosh and draw sheet.

It is the nurse responsibility to have functioning equipment ready before the ECT begins. First the nurse and than the anesthetic check that the oxygen and suction apparatus are in working order. Psychiatrist who is administering the ECT checks that the ECT machine is in working condition and that the voltage is correctly set.

Bibliography :
1. Burgess Ann Wilbert , (1997 ), Psychiatry nursing : Promoting Mental Health, 1 ST edition , London : Prentice Hall International ( UK), pp. 344 346 2. Bimla Kapoor, (2002 ), Text Book of Psychiatry Nursing, 1st Edition, N.Delhi : Kumar Publishing House, pp. 118 128 3. Bhatia M.S.( 2006 ), essential of Psychiatry, 5th Edition, New Delhi : CBS Publishers & Distributors ; pp. 30.11 30.18. 4. Internet Resourcess

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UNIT III Check List (Electro Convulsive Therapy )

Name of Student Year of Training Task Situation Date Equipments .. .. .. .. Sphygmomanometer, Stethoscope, Spirit Swab in a container, Clients chart, Pen, Paper bag, Resuscitation set, suction apparatus. ECT machine, extension cord, oxygen Electrodes usually moistened in saline or some jelly, Bowl of saline solution, Oxygen apparatus, Tourniquet Cotton spirit swab, Airway, Mouth gag, Drugs : Coramine, Neostagmin, Escoline etc ( to be used in emergency etc.

Direction to assessor: Tick the column that best describes the behaviour observed. Critical Task marked with *: All to be done, essential tasks marked with #:

CRITICAL / ESSENTIAL ELEMENTS A. Preparation of patients by :

YES

NO

Consent signature with relatives either prior to admission or any time before procedure was taken. Patient was kept Fasting for at least 5 hours before the treatment. Psychiatrist order was checked. Checked for the thoroughly physical examination done by the doctor( Ecg, Lugs, bone, blood for Hb, Urine for sugar, , X-ray etc ) Patient emptied his urinary bladder. Administered injection Atropine sulphate 1 : 1000 gm I.M. 30 minutes before E.C.T.

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Loosen the clothing. Hair clips, pin jewelry and false teeth, bangles, watch, ring etc. were removed. Lipstick, nail polish or any other makeups were removed.

B. Preparation of Equipments
Checked that Electro therapy machine is working condition. Electrodes moistened in saline or some jelly. Bowl of saline solution. Oxygen apparatus. Injection tray with o Tourniquet o Cotton spirit swab. Airway Mouth gage Suction apparatus. Drugs : Coramine, Neostagmin, Escoline etc ( to be used in emergency ) Prepared bed in which patient to be kept after ECT.

C. Management of Convulsion
Patient was kept on the back with a small pillow between the dorsal vertebrae. Holding of the patient: - One attendant holds feet closely together. - Another puts pressure on pelvis. - Two more, one on each side holding shoulder and wrist. - The fifth attendant controls the head putting mouth or towel and pressing chin firmly. - The psychiatrist or psychiatrist nurse applies electrodes on the temporal region after cleaning the area and moistening electrodes in 30 % saline or jelly.

D. After Care :

Vital sign was taken and recorded. Patient was transferred in bed gently. Keep him on side lying position, wipe and secretion. Till he regains conscious. Patient was allowed to rest for an hours Assessed for any kind pain or headache. Patient was instructed for not be allowed to drive car at least 24 hours. Made note of any injury or complaint of pains . Reported any significant change in patient. 12

Comments: . Signature of Observer Signature of Student

UNIT IV Appendix

(Picture showing various placements of electrodes)

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(Placement of unilateral electrode)

(Placement of Bilateral Electrode)

CHOITHRAM COLLEGE OF NURSING

Protocol

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Developed By Mrs. Jyoti Srivastava

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