Electroconvulsive Therapy
for them to talk and DO NOT
1.
2. Exact mechanism by which ECT
effects a therapeutic response is
unknown.
3. The only absolute contraindication
for ECT is increase in ICP.
a. Other conditions that are
high risk include
cardiovascular disorders,
aortic or cerebral
aneurysm, severe HPN,
severe osteoporosis, and
pregnancy.
4. ECT involves application of
electrodes on the head of the
client to deliver an electrical
impulse to the brain. This causes a
seizure.
a. It is believed that the shock
stimulates brain chemistry
to correct chemical
imbalance of depression.
b. With 70-110 volts lasting
for 1-1 second.
5. Clients are usually given a series of
6-15 treatments scheduled 3 times
a week.
6. Generally, a minimum 6 treatments
is needed to sustain improvement
in depressive symptoms.
a. Maximum benefit is
achieved in 12-15
treatments.
7. Common side effects: anterograde
amnesia, headache
Note: it is a somatic (Soma=Body)
treatment and indicated for severely
depressed clients-that are not coping up
with the medications (anti-depressant)
and to those patient who has an
hampered ADLs (Manic-Catatonic)
● For those client who are
Depressed they often have a very
slow movement and manner of
talking so as a nurse we must wait
FINISH their sentence
Preparation of Client for ECT
1) Consent form
2) NPO after midnight (6-8 hours)
3) Remove any nail polish on
fingernail
4) Void just prior to the procedure
a) Done before introduction of
pre-op medication
5) IV is started for the administration
of medication
a) Atropine Sulfate-to lessen
secretions/bundle of
bubbles in the mouth and
should be given an hour
before procedure starts
b) Succinylcholine- muscle
relaxants, however some
doctors says daw that they
must get rid of this
because it can cause
respiratory depression
Note: this is an invasive procedure
therefore it needs Consent for 18 and
above
During ECT
1) Initially, the client receives a short-
acting anesthesia so he or she is
not awake during the procedure.
2) Next, he or she receives a muscle
relaxant - usually Succinylcholine -
that relaxes all muscles to reduce
greatly the outward signs of the
seizure (e.g. clonic, tonic muscle
contractions)
3) Electrodes are placed on the
client’s head: one on either side
(bilateral) or both on one side of
the head (unilateral).
4) Electrical stimulation is delivered
which causes seizure activity in the
brain that is monitored by the EEG.
 5) The client receives oxygen and is
assisted to breathe with an ambu
bag. He or she generally begins to
waken after a few minutes.
a) Vital signs are monitored
and the client is assessed
for the return of a gag
reflex.
After ECT
1) The client may be mildly confused
or disoriented briefly. He or she is
very tired and often has a
headache.
a) The symptoms are just like
those of anyone who has
had a grand mal seizure.
2) In addition, the client will have
some short-term memory
impairment.
3) Following a treatment, the client
may eat as soon as he or she is
hungry and usually will sleep for a
period. Headaches are treated
symptomatically.
Note: It is a very invasive procedure that
allows delivery of electrical impulses to
the brain (70-110 volts)-usually the
“microphone like a like thingy” is placed
both right and left temporal portion of the
head/brain
● This can cause a tingling sensation
within the brain and cause a petit-
mal to grand-mal seizure to
troubleshoot the brain
● Because they believe that changes
in the electrical impulses of the
client’s brain can change the
behavior of the client,
Note: During in the previous years Pre-
medication is not provided and was
considered inhuman especially in “The
medical City” But now within the OPD
setting they use the very light anesthetic
(Lidocaine) (Indications)
● Catatonic Type of Schizophrenia
● Paranoid and Manic Type of
Schizophrenia
● Major depressive disorder for
those who are unresponsive to
medication.
● Bipolar Disorder
Note: Side-effects: Retrograde Memory
loss/Amnesia, Headache and Muscle
ache.
● Introducing a Petit-mal to grand-
mal seizure that should last for 30
sec-60 sec.
Note: it is contraindicated to the 1st and
last trimester of pregnancy (NLE)
● Happy Hormones- Serotonin and
Norepinephrine
● For Schizophrenia- Serotonin,
Dopamine and Norepinephrine are
all involved in the disease
Note: Clients are usually given a series of
6-12 treatment (NLE) scheduled every
other day or 3 times a week
● Acute- usually one treatment is
enough
● Chronic- usually 2-3 or 5 treatment
is enough
To generate a seizure with a right
unilateral treatment
● One electrode is placed on the
crown of the head and the other on
the right temple.
● Those receiving the right unilateral
treatments may respond
somewhat more slowly than those
who receive bilateral treatments.
○ This difference is usually
no greater than 1-2
treatments.
● Right unilateral is usually
associated with less memory side
effects.
● Patients who do not respond to
right unilateral treatments may
 require a switch to bilateral
placement.
Note: Antero=Before but for NLE is
Retrograde.
Note: for unilateral it is said that it can
decrease the amount of amnesia but if the
unilateral is not effective we resort to
bilateral.
Bilateral Treatment
● Involves placing the electrodes on
both temples.
● This may be associated with more
acute memory side effects than
right unilateral treatments.
● Indicated for severe mental
illnesses including depression with
psychosis, manic episodes of
bipolar disorder, psychosis related
to schizophrenia, and catatonia.
Note: Even though vital signs monitoring
is important, the first and foremost
assessment that we must do as a nurse is
to check for temporary amnesia and you
have to ORIENT or RE-ORIENT the client.
● Then ASSESS FOR GAG REFLEX
(because usually right after the
therapy the patient are so thirty)
○ So as a Golden Rule We
assess for Gag Reflex
before introducing Liquids
○ Then if gag reflex is
present give them water
with straw
Note: The placement of Mouth
piece/clothing- to prevent the teeth and
tongue injury because of seizure.
● For moving teeth- always refer to
the dentist/inform the physician.
Note: Like any other seizure patient
always get tired after so they would want
to sleep and as a nurse you must allow
them to sleep and always turn them to
their side
MILIEU THERAPY
● Provides a safe community in
milieu treatment programming, the
environment stressors will be kept
to a minimum and efforts will be
made to eliminate those
conditions that can trigger
negative reactions from the
individual.
● This removal of threats to the
client creates the ideal therapeutic
environment/
SAFETY
● A safe, structured environment
● MT programs emphasize routines,
boundaries, and open
communication to build trust
between the people in the
program. To help accomplish
these goals, therapists use
predictable, reliable responses
when communicating with
participants.
● Dispose of all needles safely out of
reach of client
● Do not allow smoking (sometimes
permitted up to 5 sticks and nurse
must light the patient’s cigarette
because they can’t keep a
lighter/match)
● Restrict the use of matches and
lighters (the nurse should be the
one to light the cigarette for pt.)
● Identify potential weapons
● Be aware of items that are harmful
if ingested
● No caffeine/alcoholic beverages
(Milo, Nestea, Tea, coffee and etc.)
● No religious item
BALANCE
● Note: independent (OCD patient
must be assisted) vs. dependence-
(Catatonic patient and Depressive
patient )
 ● Modern milieu therapy directs
hands-on experiences aimed at
developing key life skills that will
better prepare for greater
responsibility, independence and
adulthood.
● PERSONAL HYGIENE - integrates
hygiene into the patients’ daily
routines as a basic expectation to
help them establish a consistent
practice of physical care
● ORGANIZATION SKILLS - executive
functioning skills, such as
planning, organizing and
scheduling are essential for living
an independent and productive life.
● HEALTHY BOUNDARIES - Part of
getting along well with others, both
authority figures and peers, is
establishing healthy and adaptive
interpersonal boundaries.
● LIFE SKILLS DEVELOPMENT - As
mental health challenges diminish,
there is a corresponding increase
placed upon to resume
responsibility to learn and practice
life skills.
NORMS
● In milieu therapy, you take on
increasing responsibility for your
care as your mental condition
improves. If you're in a hospital or
day hospital program, staff
members expect you to take you to
become more responsible as you
progress through these four levels:
1. You do some behavior that is self-
destructive, hurts someone else, or
damages your environment in
some way. You're disoriented,
unable to participate in group
therapy and don't take care of your
hygiene.
2. You're not destructive. You're
oriented as to time, place, and
person. You go to at least one
therapy session per day. You try to
take care of your hygiene.
3. You go to all your scheduled
therapy sessions and begin to take
charge of meeting your own goals.
4. You're actively engaged in helping
other patients progress through the
first three levels.
Principles of Milieu Theory
● To promote a fundamental respect
for individuals (both clients and
staff).
● To use opportunities for
communication between client and
staff for maximum therapeutic
benefit.
● To encourage clients to act at a
level equal to their ability and to
enhance their self esteem
(autonomy is reinforced).
● To promote socialization.
● To provide opportunities for clients
to be part of unit management.
● Individuals are held responsible for
their own actions.
● Peer pressure is utilized to
reinforce rules and regulations.
● Team approach is used.
● Group discussions and temporary
seclusions are favoured
approaches for acting out
behaviour.
● The nurses function is to act in
ways that consistently promote
these goals.
What is Milieu Therapy?
● Milieu therapy is a method for
treating mental health conditions
using a person’s surroundings to
encourage healthier ways of
thinking and behaving.
● In milieu therapy, you spend a
significant amount of time in a
home-like environment, interacting
 with other people as you conduct
ordinary activities throughout the
day. You may attend group or
individual therapy sessions as part
of your schedule.
STRUCTURE
● According to the milieu therapy
approach, clients are kept in their
usual environment, for example, a
day treatment center or halfway
house, and continue most of their
routine activities while receiving
treatment.
Crisis Stabilization
The crisis stabilization unit is in effect an
emergency department for psychiatry,
frequently dealing with suicidal, violent, or
otherwise critical individuals.
Open Units
Open units are psychiatric units that are
not secure as crisis stabilization units.
They are not used for acutely suicidal
persons, instead, the focus in these units
is to make life as normal as possible for
patients while continuing treatment to the
point where they can be discharged.
Medium Term
Another type of psychiatric hospital in
medium term, which provides care lasting
several weeks.
Juvenile Wards
Juvenile wards are sections of psychiatric
hospitals or psychiatric wards set aside
for children or adolescents with mental
illness.
Halfway Houses
One type of institution for the mentally ill
is a community-based halfway house.
Their facilities provide assisted living for
an extended period of time for patients
with mental illnesses, and they often aid in
the transition to self-sufficiency.
LIMIT SETTINGS
● Limits are powerful tools for
teaching appropriate behaviour.
Their purpose is not to initiate a
power struggle, but to give the
individuals in your care guidance,
respect, and a feeling of security.
● Clear, effective limit setting is a
part of the therapeutic relationship
that all staff should develop with
consumers in their care. Limit
setting allows the boundaries of
the therapeutic relationship to be
established and provides the
consumer with a clear
understanding of what is and isn’t
acceptable behaviour and what the
consequences of their actions will
be. It also allows for consistency
across staff interactions with the
consumer aiding in reducing
agitation and confusion.
● Limit setting can provide choices
to the consumer who is upset and
is a useful tool in assisting to
reduce anxiety. Those choices
should be clear either, or’ choices
as too many options can become
confusing, increasing distress and
agitation and potentially escalating
their behaviour to a more
aggressive level.
● The choices offered need to be
accessible within the environment
you are in, for example, if you don’t
have access to provision of a
portable music option then
offering to let the consumer listen
to music may not be a viable
choice to be offering.
Note: especially for manipulative patients,
wants to dominate the group therapy e.g.
won’t share mic during videoke session
UNIT MODIFICATION
 ● Patients are separated by their
conditions into wards, keeping the
more volatile and likely dangerous
from the lesser harmful. They may
have a room to themselves or may
have to share a room with other
patients. Rooms are sparse with
little furniture (lowers the chances
of suicide), and will be checked
every 15-20 minutes by tech or
nurse to ensure that patients are
okay. These checks occur all day
and night, even while patients are
asleep.
Note: check if patient is still breathing
during the night -- 24/7 checks
Placement of manic patients farthest from
the nursing station to reduce stimulus.
The nursing station is a busy area that
could be a stimulus to trigger a manic
episode. Placement of depressed patients
nearest to the nurses station because of
the potential attempt to suicide.
● Patient rooms should be painted in
colors which inspire calm and
serenity, and are not too heavy on
the senses, evoking familiarity.
● Another example that attests to
the significance of color choice at
healthcare centers is anorexia and
obesity units, which should be in
different colors because while blue
suppresses the appetite, lowering
blood pressure and is therefore fit
for use at obesity units or centers,
orange increases the appetite,
stimulates the brain, and triggers
socialization urges, making it fit for
use ar anorexic units.
Note: Socialization is needed for anorexic
pt. Comorbidity of anorexia is depression
● While cool colors can be used in
rooms or areas intended for edgy,
twitchy and anxious patients, red
and orange can be considered for
patients suffering from
depression.
Note: Yellow-green for anxious
patients
● Highly saturated colors should
NOT be used in autism and
schizophrenia wards, people with
epilepsy or other neurological
disorders should not be exposed
to colors that are too red or too
stimulating as it may trigger
seizures.
Note: glaring light triggers as well
● Overly bright colors with distinct
contrasts should NOT be used in
areas where psychotic patients
stay. Such patients are susceptible
to negative influences from such
colors not when they wear them,
but rather when they find
themselves in an environment
painted in such colors. It may leave
a tiring, intimidating, and
frightening impression. Calming
neutral colors with soft, warm
tones may instead be used.
Note: To be safe just go with ‘cool’ colors
--------------------------------------------------------------------
Milieu Therapy
● Provides a safe community.
● In milieu treatment programming,
the environment stressors will be
kept to a minimum and efforts will
be made to eliminate those
conditions that can trigger
negative reactions from the
individual.
● This removal of threats to the
client creates the ideal therapeutic
environment.
Notes: Milieu "middle" in greek. Something
to do with the environment. A milieu
environment is not just done, it is created.
A nurse acts as a creator of the milieu
environment or a milieu therapist or a
member of a milieu.
Nurse as a milieu therapist- client feels
safe and comfortable.
Form a circle, do not cross legs.
Ideal therapy group number- 8-10 people
● Safety
○ Disposing of all needles
safely out of reach of client ● Balance- between dependent and
○ Do not allow smoking
■ Some nursing
homes allow
smoking to
smokers utmost 5
sticks a day
■ Nurses light the
patient's cigarette
because they
cannot give them
the lighter or match
○ Restrict the use of matches
and lighters
○ Identify potential weapons
○ Be aware of items that are
harmful if ingested
■ Breakables
■ Drinks with caffeine
● Tea, sodas,,
energy
drinks,
coffee
■ Alcohol
■ Juices with tea
content (Nestea)
■ No plastic straw
(metal pwede), not
bottled
■ Usually no religious
articles allowed
■ Check client's
shorts for presence
of strings or garter
or tali
○ MT programs emphasize
routines, boundaries, and
open communication to
build trust between the
people in the program.
○ To help accomplish these
goals, therapists use
predictable, reliable
responses when
communicating with
participants.
independent functions that the
client should be doing.
○ Modern milieu therapy
directs hands-on
experiences aimed at
developing key life skills
that will better prepare for
greater responsibility,
independence, and
adulthood.
○ Personal hygiene-
integrates hygiene into the
patients' daily routines as a
basic expectation to help
them establish a consistent
practice of physical care.
■ Manic patients lagi
naliligo. Must
assist.
○ Organizational skills-
executive functioning skills,
such as planning,
organizing, and scheduling
are essential for living and
independent and
productive life
■ Plan with the
officers of the
patients'
government/leaders
○ Healthy boundaries- part of
getting along well with
others, both authority,
figures, and peers, is
establishing healthy and
adaptive interpersonal
boundaries
 ■ Students should not
serve food to
patients to allow
patients to establish
interpersonal skills
by lining-up and
saying thank you
when the meal is
given, 'excuse me'
○ Life skills development- as
mental health challenges
diminish, there is a
corresponding increase
placed upon to resume
responsibility to learn and
practice life skills
■ Occupational
therapy- basket
weaving, eat
sandwich, compute
etc
■ For business
● Norms
○ In milieu therapy, you take
on increasing responsibility
for your care as mental
condition improves. If
you're in a hospital or day
hospital program, staff
members expect you to
take you to become more
responsible as you
progress through these
four levels
○ You do some behavior that
is self-destructive, hurts
someone else, or damages
your environment in some
way. You're disoriented,
unable to participate in
group therapy and dont
take care of your hygiene.
○ You're not destructive.
You're oriented as to time,
place, and person. You go
to at least one therapy
session per day. You try to
take care of your hygiene.
○ You go to all your
scheduled therapy
sessions and begin to take
charge of meeting your
own goals.
○ You're actively engaged in
helping other patients
progress through the first
three levels.
Principles of Milieu Theory
● To promote a fundamental respect
for individuals (both client and
staff)
● To use opportunities for
communication between client and
staff for maximum therapeutic
benefit.
○ The patients' government
relies to the nurses and
staff about the necessary
things they lack
● To encourage clients to act at a
level equal to their ability and to
enhance their self-esteem
(autonomy is reinforced)
● To promote socialization
○ Talking, eating together,
fellowship
● To provide opportunities for clients
to be part of unit management
● Group discussion and temporary
seclusions are favoured
approaches for acting out behavior
○ During role plays and
premotivation technique
● The nurses' function is to act in
ways that consistently promote
these goals.