CASE STUDY ON

DEPRESSION

SUBMITTED
Mr. RAHUL SRIVASTAV
ASSOCIATE PROFESSOR, (HOD)
DEPARTMENT OF MENTAL HEALTH NURSING,
YASHRAJ COLLEGE OF NURSING

SUBMITTED BY
Mr. BOBY DWIVEDI
M.Sc. NURSING 2ND YEAR,
YASHRAJ COLLEGE OF NURSING

DATE OF SUBMISION____________
 Patient’s Profile

I. Identification data
Client name : Miss Kavita
Age : 13 years
Sex : Female
Father name : Mr. Dilawar
Address : Haripur,
Gonda
Education : 8th class
Occupation : Studying
Religion : Hindu
Date of admission : 19-03-2020
Provisional diagnosis : Depression disorder
Final diagnosis : Adjustment disorder with depression

II. Informant : Mother

III. Presenting Chief Complaints

According to Patient
o Anxious about the performance in school
o Worry about studies
o Feeling of inability to cope
o Fatigue
o Headache, backache
o Feelings of hopelessness
According to Informant
o Poor judgment
o Depressed mood
o Disability in the performance of daily routine
o Tearfulness
o Lack of sleep
o Attention and memory span impaired
 o Flight or ideas
o Inappropriately ager
o Fighting
o Socially withdrawn
o Refuses to interact with others

IV. Family History

(a) Family Characteristics
Age
S. Relationship Age &
Name of the Educational Health
No with the (yr.)/ Occupation mode
family members Status Status
. Patient Sex of
death
1 Mr. Dilawar Father 41/M 12th Shopkeeper Healthy -
2 Mrs. Janki Mother 35/F 10th Housewife Healthy -
3 Mr. Munna Brother 8/M 3rd std Student Healthy -

(b) Genogram: Key:-

- Male
41 yrs 35 yrs

- Female

- Patient
13yrs 8 yrs

There is no family history of hypertension/diabetes mellitus/psychiatric

illness/alcoholism and suicide.

V. Socio-economic history
Miss Kavita is a student. Her father is only the earning members in her family.
His monthly family income is 10000/ per month. She belongs to a lower middle class
family. She is living in her father’s rented house. Electricity and water facility is
available in house. Drainage is proper.

VI. History of Present Illness

Miss Kavita apparently normal before 4 months then she developed the
symptoms like anxiety about the performance in school, worry about studies, feeling
of inability to cope, fatigue, headache, backache, feelings of hopelessness,
depressed mood, disability in the performance of daily routine, tearfulness,
insomnia, attention and memory span impaired, flight or ideas, inappropriately ager,
fighting, socially withdrawn, refuses to interact with others. Miss Kavita did not go for
any psychiatric treatment before. At present she is receiving Tab. Alprazolam
0.5mg/day and Tab. Fluoxetine 5mg/day along with supportive psychotherapy and
coping skills training.

VII. Past Psychiatric History

No significant data found related to the psychiatric illness in past life.

VIII. Personal History

(a) Perinatal history
Miss Kavita’s mother had proper antenatal checkup and period was
eventful. Baby delivered as full term normal vaginal delivery. Child cried
immediately after birth and there was no postnatal complication like cyanosis,
convulsions and jaundice.
(b) Childhood history
Primary caregiver was mother. Weaning started at the age of six months
and all developmental milestones was achieved at appropriate age period.
There was no behavior and emotional problems like temper tantrums, head
banging, nail biting, thumb sucking and enuresis.
(c) Educational history
Education was started at the age of 5 years. She is normal in academic
performance and had normal relationships with teachers and peers. She
never dropout from school.
(d) Play history
She used to play with female sex peer group and had good relationship
with friends.
(e) Premorbid personality
i. Interpersonal relationships : Maintained good relationship
ii. Temperament : Short temperament
iii. Use of leisure time : Be in the room and watch TV
iv. Predominant mood : Depressed mood
 v. Attitude to self and others : Socially withdrawn and refuses to
interact with others.
vi. Attitude to school and responsibility : She is going to school regular but
attention and memory span
impaired.
vii. Religious beliefs and moral attitudes : Having faith on religious.

IX. Physical Examination:

During physical examination all the finding found normal.

X. Mental Status Examination

(a) General appearance and behavior
 Appearance : Looking more depressed and shy
 Level of grooming : Normal
 Level of cleanliness : Adequate
 Level of consciousness : Active
 Mode of entry : Persuaded by mother
 Cooperativeness : Less cooperative
 Eye-to-eye contact : Not Maintained
 Psychomotor activity : Decreased
 Rapport : Spontaneous
 Gesturing : Normal
 Posturing : Normal posture
 Other movements : Not abnormal movement present
 Other catatonic phenomena : Not present
 Conversion and dissociative signs : Not present
 Compulsive acts or rituals : Not present
 Hallucinatory behavior : Not present

(b) Speech
Student Nurse : What is your name?
Client : Kavita
 Initiation : Patient responded when talk
 Reaction time : Delayed
  Rate : Slow
 Productivity : Monosyllabic
 Volume : Decrease and low pitch
 Tone : Monotonous
 Relevance : Some time off target
 Stream : Normal
 Coherence : Fully coherent
 Others : No rhyming, punning, echolalia perseveration.
(c) Mood
 Subjective
Student nurse : How do you feel?
Patient : Ok.
 Objective : Depressed mood and mood swings.
(d) Thought
Student Nurse : What type of the ideas comes in your mind?
Client : I want to study more but I don’t feel comfort.
 Stream : Flight of ideas.
 Form : No thought disorder is present
 Content
Student nurse : How do you feel about your study?
Client : I can’t study nicely…………...
Remarks : Hoplessness.
(e) Perception
 Hallucinations
Student Nurse : Do you hear any sound or see someone
whenever you are alone?
Client : No. I don’t feel anything like that.
Remarks : No hallucinations present
(f) Cognitive Functions
 Consciousness
Student Nurse : Hello Kavita
Client : Yes sir
Remarks : Patient has obeyed by calling his name
 Orientation
i. Person
Student Nurse : Who is sitting nearby you?
Client : My mother
Remarks : Oriented to person
ii. Place
Student Nurse : Where are you now?
Client : I am in hospital
Remarks : Oriented to place
iii.Time
Student Nurse : What is the day today?
Client : Thursday
Remarks : Oriented to time
 Attention
Student Nurse : Repeat the digit backward 2, 4, 6, 8, 10.
Client : 10, 8…4..6..2.
Remarks : Attention aroused with difficulty
 Concentration
Student Nurse : Name the months in backward?
Client : December, November…September, October,
June, July …August, March ….January.
Remarks : Concentration sustained with difficulty
 Memory
i. Immediate
Student Nurse : Repeat the word what I say Table, Pen, Rose,
Bus and Tree.
Client : Table, Pen ……….
Remarks : Immediate memory disturb
ii. Recent
Student Nurse : What you had in breakfast?
Client : Fried rice
Remarks : Recent memory present

iii.Remote
 Student Nurse : When is your birthday?
Client : don’t remembers
Remarks : Remote memory absent
 Intelligence
Student Nurse : Who is the Prime Minister of India?
Client : No answer
Remarks : Intelligence poor
 Abstraction
Student Nurse : What is the similarity and dissimilarity between
Dog and Lion?
Client : Both are animal. Dog is the domestic animal and
Lion is the king of forest.

(g) Insight: (grade1 to 6)

Student Nurse : Why do you come here?
Client : With my mother for my studies.
Remarks : Grade 5 Insight is present

(h) Judgment:
Student Nurse : What you will do if you find “Close letter on the
road”?
Client : I don’t know.
Remarks : Judgment is poor

XI. Vital Signs:

S. No. Vital Sign Normal Value Patient’s Value
1. Temperature 98.60 F 98.80 F
2. Pulse 72-90 Beats/M. 76 Beats/M.
3. Respiration 14-20 Breath/M. 22 Breath/M.
4. Blood Pressure 80-120mmHg 80-120mmHg

XII. Investigations:
 S. Patient’s Normal
Investigations Interpretation
No Value Value
1 Blood
 Heamoglobin 14 gm/dl 13-15 Normal
 Red blood cell 5.47 milcmm 4.5-6.51 Normal
 PCV 39.9% 20-54 Normal
 Platelets 2.43 lacs 1.5-4.5 Normal
 Total WBC different 9400 cu/mm 5000-11000 Normal
count
29% 20-45 Normal
 Lymphocytes
06% 1-6 Normal
 Esinophills
 Monocytes 01% 1-6 Normal
 MCV 93fl 80-99 Normal
 MCH 28pg 27-33 Normal
 MCHC 33.7g/dl 32-37 Normal
 ESR 20mm/hr 0-20 Normal
Routine Investigation
 RBS Normal
140 mgs/dl < 150
 Blood urea Normal
19 mg/dl 20-45
 S. Creatinine Normal
1.1mgs/dl 0.7-1.2
 S. Sodium Normal
142 meq/l 135-145
 S. Potassium Normal
4.0 meq/l 3.5-4.5
LFT
 S. Bilirubin
 S. total protein 1.2 mgs/dl 1 Normal
 S. Albumin 8.1 gm/dl 6-8 Normal
 S. Globulin 4.7 gm/dl 3-5 Normal
 Alkaline phosphate 3.4 gm/dl 1.8-3.6 Normal
64 IU/l 80-120 Normal

Patient is clinically normal.

 XIII. Medication chart:
1. Tab. Alprazolam 0.5mg/day and
2. Tab. Fluoxetine 5mg/day

Nsg. Responsibility
Contra-Indications
Pharmacological
Trade Name

Side-effects
Frequency

Indication
Action
Doses

Group
Route
Name

S.
No.

1. Alpre Alpra 0.5 Oral OD Benzo It raise the threshold Adjustment Cross-tolerance Nausea,  Report promptly if occipital
x zola mg diazep for propognation of disorder, occurs with Vomiting, headache, nausea, vomiting
m ine seizure activity and Insomnia barbiturates, Weakness, chest pain these may be
prevent methaqualone and Epigastric pain, hypertensive crisis
generalization of ethyl alcohol. Diarrhea, Vertigo,  Caution the patient to change
focal or local activity Blurring of Vision, his position slowly
Impotence,
Sedation

2. Proz Fluox 5 Oral HS SSRI It block the serotonin Depression Liver dysfunction Sedation,  Administer with food to
ec etine mg reuptake channel Threshold minimize gastric irritation.
and increase seizures,  Advise the patient to take
serotonin level at decreased medication exactly as directed.
post-synaptic space conduction time, Abrupt withdrawal may cause
EKG changes, insomnia, irritability and
Jitteriness seizures.
syndrome, Dry  Explain about adverse effects
mouth, and advise to avoid activities
constipation that require attention.
 If IM administration is preferred
give deep IM.
XIV.Other therapeutic therapies:
Therapy Indication Nurses responsibility
Yoga therapy Almost all condition  Provide correct guidance
 Provide calm environment
 Help during the difficulties in yoga
Supportive Depression,  Brought patient in directly as and active
psychotherapy psychosis, anxiety, participant
phobia  Coordinate the process to attain
maximum benefit
 Educate regarding the condition and
coping mechanism
Individual Stress related  Deliberately establishes a professional
psychotherapy disorder, alcohol and relation
drug dependence,  Remove or modify existing symptoms
sexual disorder and  Promote positive personality growth and
marital disharmony development
Group therapy Homogenous group,  Use any transference situations to
personality disorders, develop insight into their problems
families where the  Provide positive reinforcement, this
system needs gives ego support and encourages
change future growth
Family Psychosis, reactive  Assessment of family, roles,
counseling depression, anxiety, boundaries, resources, communication
psychosomatic patterns and problem solving skills
disorder, substance  Teaching communication skills
abuse  Teaching problem solving skills
Stress Stress, Anxiety,  Help in developing the solution of
management Adjustment disorder, problem
training Crisis  Help in adjust in the situation
Coping skill Ineffective coping  Provide support to use appropriate
training coping methods
 Help in use coping skill
XV. Process Recording:
 Time : 30 Minutes
Date : 15-09-2020
Place : Interview room of child psychiatric ward
Objectives : To
- maintain rapport
- obtain psychiatrist history
- make the patient ventilate feelings
- improve communication skills

Person Conversation Inference

Student Nurse Hello, Kavita Responding
Client Hello minimum
Student Nurse How you are feeling? Anxious
Client I am not feeling comfort, I am not able to do my
study,
Student Nurse What you had in breakfast? Loss of appetite
Client Yes I had Utapam but I don’t feel to take
Student Nurse Did you have bath? Self care deficit
Client No, I don’t want to take.
Student Nurse Did you join exercise today with others? Loss of interest
Client No, I am tired, I am not able to do exercise
Student Nurse Why you are not interested to do exercise? Coping deficit
Client It will not resolve my problem.
Student Nurse Can you repeat it 2…..6…..9…4…..1…..7….8 Immediate
Client 2…..8…..9…6…..3……….8 memory disturb
Student Nurse Can you tell me your birthday Remote memory
Client 20th May intact
Student Nurse What you will do after going from here? Not able to take
Client I don’t know, I got fail in exam, decision.
Student Nurse But again you can work hard and get pass. Inferiority feeling
Client I don’t know I can’t say anything.
Student Nurse You should not be hopeless, you can get pass Hopelessness
Client No, there is no meaning for my life.
Student Nurse You have a better future if you work hard once Social isolation
Client Yes so I don’t talk to anyone.
Student Nurse No, you must talk to other for cheerfulness. Irritable
Client I don’t want to talk anymore
Student Nurse Ok. Kavita bye, take care Termination of
Client Bye process recording

Assessment techniques
 Observation
 Communication
 Interview

Summary
Miss Kavita is a case of Adjustment disorder with depression. She is
responding minimum, anxious, having loss of appetite, loss of interest, self care
deficit, hopelessness, coping deficit, and inferiority feeling. Her immediate and
remote memory is intact but she is not able to take decision, having social isolation
and irritable mood.

Literature Review
Introduction
An exceptionally stressful life event producing an acute stress reaction; or a
significant life change leading to continued unpleasant circumstances that result in
an adjustment disorder. The stressful event or the continuing unpleasantness of
circumstances is the primary and overriding causal factor, and the disorder would
not have occurred without its impact. Reactions to severe stress and adjustment
disorders in all age groups, including children and adolescents are included in this
category.
These disorders can thus be regarded as maladaptive responses to severe or
continued stress, in that they interfere with successful coping mechanisms and thus
lead to problems in social functioning.

Definition
“Individual predisposition or vulnerability plays a greater role in the risk of
occurrence and the shaping of the manifestations of adjustment disorders than it
does in the other conditions but it is nevertheless assumed that the condition would
not have arisen without the stressor.”

Book Pictures Patient Pictures

Etiology  One or more stressors  Presence of stressor

 Maladaptive response to  Maladaptive response to the
the stressful life events(s) stressful life events
 Separation experiences
 Presence or possibility of
serious physical illness
 Poor coping skills or
personality factors
Types  Adjustment disorder with  Adjustment disorder with
depressive reaction depressive reaction
 Prolonged depressive
reaction
 Mixed anxiety and
 depressive reaction
 With predominant
disturbance of other
emotions
 With predominant
disturbance of conduct
 With mixed disturbance of
emotions and conduct
Clinical Features  Depressed mood  Anxious about the
 Anxiety performance in school
 Worry  Worry about studies
 Feeling of inability to cope  Feeling of inability to cope
 Plan ahead  Fatigue
 Some degree of disability  Headache, backache
in the performance of  Feelings of hopelessness
daily routine  Poor judgment
 Dramatic behavior  Depressed Mood
 Outbursts of violence  Disability in the performance
 Aggressive or dissocial of daily routine
behavior  Tearfulness
 Return to bed wetting  Insomnia
 Babyish speech  Attention and memory span
 Thumb sucking impaired
 Inappropriately ager
 Fighting
 Refuses to interact with
others
Diagnostic Evaluation  History collection  History collection
 Clinical examination  Clinical examination
 Mental status  Mental status examination
examination
Treatment
Psychopharmacology  Benzodiazepine  Benzodiazepine
  SSRI  SSRI
Other therapies  Yoga therapy  Yoga therapy
 Supportive psychotherapy  Supportive psychotherapy
 Stress management  Stress management training
training  Coping skill training
 Coping skill training  Crisis intervention
 Crisis intervention  Individual psychotherapy
 Individual psychotherapy  Family counseling
 Family counseling

Nursing Process:
Day 1

S. Needs Problems
No.

Experience minimal distress Acute Confusion

1
related to confusion
Demonstrate acceptable social Insufficient or excessive quantity or
2 skills while interacting with staff or ineffective quality of social exchange
family member

Nursing Diagnosis:

 Acute Confusion related to transient changes and disturbances in attention,

cognition, psychomotor activity, level of consciousness, and/or sleep/wake
cycle.

 Impaired social Interaction related to insufficient or excessive quantity or

ineffective quality of social exchange.
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Acute Acute Confusion The client will:  Do not allow the client to assume  Did not allow the client to Established
Confusion related to  Establish or responsibility for decisions or assume responsibility for a routine for
transient follow a actions if she is unsafe decisions or actions activities of
changes and routine for  If limits on the client’s behavior or  Explained limits, daily living &
disturbances in activities of actions are necessary, explain consequences, and experienced
attention, daily living limits, consequences, and reasons clearly, within the minimal
cognition,  Experience reasons clearly, within the client’s client’s ability to distress
psychomotor minimal ability to understand. understand. related to
activity, level of distress  Involve the client in making plans  Involved the client in confusion.
consciousness, related to or decisions as much as she is making plans as much as
and/or confusion able to participate. she is able to participate.
sleep/wake  Verbally  Assess the client daily or more  Assessed the client daily
cycle. recognize often if needed for her level of level of functioning
symptoms or functioning  Allowed the client to make
validate  Allow the client to make decisions as much as she
perceptions decisions as much as she is able. is able.
with staff or  Assist the client to establish a  Assisted the client to
caregiver daily routine, including hygiene, establish a daily routine,
 before taking activities. including hygiene, activities
action  Teach the client about underlying  Taught the client about
cause(s) of confusion. underlying causes of
confusion.
Insufficient Impaired social The client will:  Identify the factors that aggravate  Identified the factors that Successfully
or Interaction  Successfully performance. aggravate performance. completing
related to
excessive complete  Provide an environment as free  Provided an environment tasks or
insufficient or
quantity or excessive tasks or from distractions as possible. free from distractions. assignments
ineffective quantity or assignments Gradually increase the amount of Gradually increased the with
ineffective
quality of with environmental stimuli. environmental stimuli. assistance
quality of social
social exchange. assistance  Engage the client’s attention  Engaged the attention at some
exchange  Demonstrate before giving instructions. before giving instructions. extent
acceptable  Give instructions slowly, using  Given instructions slowly,
social skills simple language and concrete using simple language and
while directions. concrete directions.
interacting  Ask the client to repeat  Asked the client to repeat
with staff or instructions before beginning instructions before
family tasks. beginning tasks.
member  Separate complex tasks into  Separated complex tasks
small steps. into small steps.
 Provide positive feedback for  Provided positive feedback
 completion of each step. for completion of each step.
 State expectations for task  Stated expectations for
completion clearly. task completion clearly.
 Initially, assist the client to  Initially, assisted the client
complete tasks. to complete tasks.
 Progress to prompting or  Progress to prompting the
reminding the client to perform client to perform tasks or
tasks or assignments. assignments.
 Give the client positive feedback  Given the positive feedback
for performing behaviors that for performing behaviors for
come close to task achievement. task achievement.
 Gradually decrease reminders.  Gradually decreased
reminders.
 Teach the client’s family or  Taught the client’s family or
caregivers to use the same caregivers to use the same
procedures for the client’s tasks procedures for the client’s
and interactions at home. tasks and interactions at
home.
 Day 2
S. Needs Problems
No.
1. Safety and security measures for Risk for injury
free from injury

2. Maintain the normal or more Family members has low confidence and
adaptive coping strategies for confusion regarding client’s disease
dealing with client. condition

Nursing Diagnosis:

 At risk of injury as a result of environmental conditions interacting with the

individual’s adaptive and defensive resources.

 Disabled family coping strategies related to difficulty coping with client’s

illness as evidenced by neglectful care of the client.

Nursing Care Plan:

Needs /
Nsg. Implementat Evaluati
Problem Goals Intervention
Diagnosis ion on
s
Risk for Risk of The client  Place the  Placed the Risk of
injury injury as a will: client in a client in a injury
result of
 Be safe and room where room where has
environmen
tal free from the staff can the staff can minimize
conditions injury observe the observe the d to
interacting
 Respond to client closely. client. some
with the
individual’s reality  Monitor the  Monitored extent.
adaptive orientation client’s sleep the client’s
and
 Demonstrat pattern. sleep
defensive
resources e decreased  Talk to the pattern.
as aggressive client in  Talked to
evidenced
 by or simple, direct, the client in
uncooperati threatening concrete simple,
ve behavior
behavior language. direct
and
aggressive  Assist the language.
behavior. client’s  Assisted the
parents or client’s
caregivers to parents or
make the caregivers
distinction to make the
between distinction
accidental and between
purposeful accidental
incidents. and
 Provide purposeful
supervision incidents.
for potentially  Supervised
dangerous for
situations. potentially
Limit the dangerous
client’s situations.
participation in Limited the
activities. participation
in activities
when safety
cannot be
ensured.
Family Disabled Maintain the  Identify level  Identified Family
member family normal or of family the family member
s has coping more functioning. member’s s
low strategies adaptive  Assess the lacks and maintain
confiden related to coping communicatio knowledge the more
ce and difficulty strategies for n pattern, level of the adaptive
confusio coping with dealing with interpersonal client’s coping
n client’s client. relationships disease methods
regardin illness as between condition. .
g client’s evidenced members, role  Adequate
disease by expectations, information
condition neglectful problem given to the
care of the solving skills family
client. and members
availability of regarding
outside disease
support condition
systems. and
 Provide prognosis.
information for  Assisted the
the family family
about the members to
client’s illness, respond
what will be adaptively
required in the in the face
treatment of what they
regimen and may
long term consider to
prognosis. be a crisis
situation.
Day 3
S. Needs Problems
No.
Establish clearly defined family Dysfunctional behavior
1 member’s role and equitable
responsibilities
Improve the knowledge regarding Poor knowledge regarding disease
2
disease condition and prognosis condition, treatment and prognosis

Nursing Diagnosis:
  Impaired family process related to dysfunctional behavior evidenced by
change in availability for emotional support.

 Knowledge deficit regarding disease condition and prognosis as evidenced by

lack of information, unfamiliarity with information resources.

Nursing Care Plan:

Needs / Nsg. Implementat
Goals Intervention Evaluation
Problems Diagnosis ion
Dysfunctio Impaired Establish  Meet the  Met the Established
nal family clearly family family clearly
behavior process defined members to members to defined
related to family establish establish family
dysfunctio member’s levels of levels of member’s
nal role and responsibilit responsibilit role and
behavior equitable y in the y in the equitable
evidenced responsibilit family family responsibilit
by change ies  Arrange  Arranged ies
in seating seating
availability adults in adults in
for family family
emotional meeting to meeting to
support reinforce reinforce
their their
function as function as
a decision a decision
making unit making unit
 Hold adults  Hold adults
accountable accountable
for their for their
behavior behavior
  Assist  Assisted
family to set family to set
limits on limits on
abusive abusive
behaviors behaviors
 Taught
 Teach family to
family to communicat
communicat e clearly
e clearly and
and honestly to
honestly to increase
increase their ability
their ability to express
to express thoughts
thoughts  Encouraged
 Encourage family
family members to
members to evaluate
evaluate communicat
communicat ion pattern
ion pattern periodically
periodically
Client’s Knowledg Improve the  Discuss the  Discussed Family
family e deficit family disease the client’s members
members regarding member’s condition condition knowledge
have poor disease knowledge with family and improved
knowledge condition regarding members. prognosis regarding
regarding and disease Provide with family disease
disease prognosis condition written members. condition
condition, as and handout  Explained and
treatment evidenced prognosis. and allow the client’s prognosis of
and by lack of time to ask abnormal the client at
prognosis. informatio questions behaviors some extent
n, and clarify why he/she
unfamiliarit it. has.
y with  Discuss the  Cautionally
informatio client’s explained
n abnormal about the
resources. behavior medications
and causes uses and
of its. side effects.
 Educate the  Small group
family activities
members arranged
on the use and
of outcome
medications was
and assessed.
response
anticipated.
 Arrange the
small group
activities
and allow
the family
members
exchange
their
feelings and
knowledge
regarding
client’s
condition
and
prognosis.
 Day 4
S. Needs Problems
No.
1 Client able to attempt the new Low self-esteem
activities without fear of failure.

2 Gain in knowledge about client Family members are unaware about

disease condition and prognosis. disease condition and treatments.

Nursing Diagnosis:

 Low self esteem related to feeling of abandonment and impaired cognition

functions as evidenced by not engaging in any activities.

 Knowledge deficit regarding disease condition and prognosis as evidenced by

lack of information, unfamiliarity with information resources.

Nursing Care Plan:

Needs /
Nsg. Implementati Evaluati
Problem Goals Intervention
Diagnosis on on
s
Client Low self Client  Be accepting of  Accepted Client
has low esteem able to client and spend the client self
self related to attempt time with him thoughts esteem
esteem feeling of the new even though and feelings improved
and abandonme activities pessimism and it makes at some
confidenc nt and without negativism. positive extent.
e impaired fear of contribution.
cognition failure.  Focus on  Talked
 functions as strength and about the
evidenced accomplishment client’s
by not s and minimize strengths
engaging in failures. and victory.
any  Provide
activities. opportunities for  Repeated
success; plan success
activities with improves
short time span the client’s
and appropriate self esteem.
ability level.  Engaged in
 Help the client new tasks
set realistic, promotes
concrete goals personal
and determine growth and
appropriate new skills.
actions to meet
these goals and
encourage
involvement of
new activities/
tasks.
Client’s Knowledge Improve  Discuss the  Discussed Family
family deficit the client disease the client’s members
members regarding family condition with condition knowledg
have disease member’ family members. and e
poor condition s Provide written prognosis of improved
knowledg and knowledg handout and the condition regarding
e prognosis e allow time to ask with family disease
regarding as regarding questions and members. condition
disease evidenced disease clarify the  Explained and
condition by lack of condition doubts. the client’s prognosi
and information, and  Discuss the abnormal s of the
treatment unfamiliarity prognosi client’s abnormal behaviors client.
, with s. behavior and why he/she
prognosis information causes of its. has.
. resources.  Educate the  Cautionally
family members explained
on the use of about the
medications and medications
response uses and
anticipated. side effects.
 Arrange the  Small group
small group activities
activities and arranged
allow the family and
members outcome
exchange their was
feelings and assessed.
knowledge
regarding client’s
condition and
prognosis.
 Theory Application

Roy’s adaptation model:

In this model the person is viewed as an adaptive system; nursing
intervention is needed when there is a deficit between the adaptation level and
environment demands. The major concepts are
 Regulator
 Cognator
 Adaptive.
Adaptation is the process of coping with external and internal stimuli. It is
determined by the effects of three classes of stimuli –
 Focal,
 Contextual and
 Residual.
 Roy’s Adaptation Framework

Regulator
- Anxious about the - Rest
performance in school - Food
- Fatigue
- Sleep - Helps to develop
- Headache, backache
- Feelings of
- Exercise
- Elimination positive self concept

Positive Adaptation
hopelessness
- Poor judgment - O2, Food and - Assessing the
- Depressed Mood and Electrolyte
coping
mood swings
Stimuli

- Disability in the - Positive feed back

performance of daily Adaptation Level - Orientation to reality
routine
- Tearfulness Cognator - Prevent injury
- Insomnia - Promote Sleep
- Attention and memory - Educate about coping methods, - personal
span impaired hygiene, - disease condition, - medications, - Perception of past
- Flight or ideas - follow up, - Safe environment, - Positive and present
- Inappropriately ager reinforcement, - Cognition assessment, -
- Fighting IPR, - reality orientation, - Coping
- Socially withdrawn according to the situation.
- Refuses to interact
with others
Health Education:
 Encourage social interaction.
 Improve the self care needs independently.
 Engage the client’s attention before giving instructions.
 Give instructions slowly, using simple language and concrete directions
 Ask the client to repeat instructions before beginning tasks.
 Separate complex tasks into small steps.
 Provide positive feedback for completion of each step.
 Progress to prompting or reminding the client to perform tasks or
assignments.
 Give the client positive feedback for performing behaviors that come close to
task achievement.
 Sleep and hygiene techniques.
 Taught about the positive coping methods.
 Family’s to use alternative coping methods.
 Educated the patient and family members regarding medication- dosage and
side effects of the medication.
 Advice the patient for regular checks up and follows up.

Summary:
Miss Kavita brought to the psychiatric ward on 19-08-2008 with the
complaints of Anxious about the performance in school, worry about studies, feeling
of inability to cope, fatigue, headache, backache, feelings of hopelessness, poor
judgment, depressed Mood and mood swings, disability in the performance of daily
routine, tearfulness, insomnia, attention and memory span impaired, flight or ideas,
inappropriately ager, fighting, socially withdrawn, refuses to interact with others.
Then she is diagnosed as a case of Adjustment disorder with depression. I have
taken this case for my case study and given four days care with counseling and
health education from 15/01/09 to 18/01/09.
:Bibliography

1. Townsend.M, (2007), “Psychiatric Mental Health Nursing”, Jaypee brothers,

New Delhi, India.
2. Doenges M.E. et al., (1995), “Psychiatric Care Plans Guidelines for Planning
and Documenting Client Care”, 2nd ed. F. A. Davis Company, Philadelphia,
PA.
3. Ahuja.N, (2006), “A Short Text Book of Psychiatry”, Jaypee brothers, New
Delhi, India.
4. Sreevani.R, (2008), “A Guide to Mental Health and Psychiatric Nursing”,
Jaypee Brothers, New Delhi, India.
 MENTAL HEALTH NURSING

CASE STUDY ON
ALCOHOL DEPENDENT
SYNDROME
SUBMITTED TO
Mr RAHUL SRIVASTAVA
ASSOCIATE PROFESSOR
HOD,
MENTAL HEALTH NURSING

SUBMITTED BY
Mr. BOBY Dwivedi
M.Sc. NURSING 2nd YEAR,
YASHRAJ COLLEGE OF NURSING

DATE OF SUBMISION____________
 Patient’s Profile
Identification data
Client name : Mr. Vinoth Kumar Shukla
Age : 48 years
Sex : Male
Father / Spouse name : Mr. Kannya Shukla
Address : Gonda
Education : 5th Standard
Occupation : daily wager
Income : Rs. 3500/ month.
Marital status : Married
Religion : Hindu
Date of admission : 20.09.2020.
Provisional diagnosis : Alcohol dependent syndrome
Final diagnosis : ADS with Korakosaf’s syndrome
XVI.Informant : Wife

XVII. Presenting Chief Complaints:

According to the patient:
1. Decreased sleep, appetite, tremors
2. Restlessness, irritation
3. Generalized body ache
4. Easily getting anxiety, palpitation
According to the Informant (Wife):
1. Daily use to take alcohol minimum two quarters
2. Tremors, palpitation, chillness, sweating
3. Not going to work
4. Easily fatigability and breathing difficulties
5. Decreased sleep and appetite pattern past 15 days
6. Memory loss, repeating the same answers
7. Disoriented forget the home and name and everything. Past 15days
XVIII. History of Present Illness:
Mr. Vinoth Kumar Shukla, 48 years old man came with the chief complaints of
disoriented, memory loss, not going to the work, decreased sleep, repeated the
same words, easily fatigability, drinking alcohol daily, tremors, loss the present
consciousness, breathing difficulties, generalized body ache for past 15 days.
Now he was admitted in deaddiction centre. Client was apparently normal
before 15days. On the admission period he has tremors and disoriented,
repeated the same words and answers. Now he was treated with
antidepressant and CNS stimulant with behavior therapy. Now the patient has
confabulation and the physician decided to use the multidisciplinary treatment
approaches like individual psychotherapy, cognitive behavior therapy and
psychopharmacological treatment like antidepressant, anticraving and
benzodiazepine anxilotyic and sedations. Now he shows some prognosis after
implementation of the multidisciplinary treatment modalities.
XIX. Treatment History:
Mr. Vinoth Kumar Shukla at present under goes multidisciplinary treatment
such as psychopharmacology, psychological therapy and family therapy. Now
he is treated with Tab. Fluoxetine 20mg, Tab,. Naltrexone 50mg, Tab. Librium
25mg, Tab. clonazepam past one month.
XX. Past Psychiatric History:
There is no significant past psychiatric history
XXI.Past Medical History:
There is no significant history of medical illness. Before five years he had
chicken box and taken treatment in local hospital.
XXII. Past surgical History:
There is no significant history of surgical history.
Alcohol history:
Mr. Vinoth Kumar Shukla has history of alcohol habits past 28 years. Initially
he was working in alcohol factory, so at the age of 17 he has taken Beer with his
friends, the initial amount of Beer was 750ml and after marriage he use to take the
hot drinks, initially he was taken one quarter/day, gradually it was increased two and
three for day. Past 5 years he uses to take alcohol morning and evening. If money is
available he use to take full day for 3 to 4 quarters. Before 15 days he didn’t taken
alcohol due to money problems and he didn’t go to work, so he had tremors,
memory loss and disoriented and confabulation. Along with alcohol he has history of
smoking habits past 25yrs, initially he stared with for joyfulness and it was continued
past 25yrs. For day he smokes 3 to 6 cigarettes.
 Initially stated with one to two Beers
 Gradually increased with hot drinks for two to three quarters/day
 At present he use to take after getup from the bed and evening (3 to 4
quarters at intermittent time)
XXIII. Family History:
(a) Family Characteristics:
Age
Name
Relations &
S. of the Educatio
hip with Age/ Occupati Health mod
No family nal
the Sex on Status e of
. membe Status
Patient deat
rs
h
Mr.
ADS with
Vinoth 48Yr/ th
1 client 5 Std Former Korakosafo -
Kumar M
’s syn.
Shukla
Mrs. 42Yr/ Housewif
2 Wife - Healthy -
Radha F e
Mr. 24Yr/ Daily
3 Elder son 6th Std Healthy
Shanu M wager
Mr. Younger 18Yr/ Daily
4. 9th Std Healthy -
Kumar son M wager

(a) Genogram:
Key:-

48yrs 42 yrs - Male

- Female

- Patient
24yrs 18yrs

There is no history of psychiatric illness present in the family. There is no

history of consiagunious marriage and communicable disease like diabetes, asthma,
tuberculosis and hypertension. His father and brother also have the same alcoholic
history. His father was expired and brother was living healthily. There is no history of
suicidal attempted and history if chronic illness.
Socio-economic history;
They are living in own house. House is kutcha and having all the facilities like
water facility and electrical and closed drainage system. The communication pattern
of the family is normal. The total family income is Rs. 3500/month. Client is the
leader of the family.
XXIV.Personal History:
(c) Perinatal history:
Perinatal history collected from patient’s wife. She doesn’t aware of his
childhood history. Client can’t able collect the past events what was
happened in childhood. So there is no significant history collected from
the patients. From the case sheet, client is second son of the family,
his father use to take alcohol but mother doesn’t have the habits but
she has habits of tobacco chewing while he was in womb. Delivery
conducted in PHC and normal veginal delivery, the birth weight was
normal and cried immediately. There is no history of postpartum
complications.
(d) Childhood history
Mr. Vinoth Kumar Shukla brought up by his biological parents. During
childhood history he is active and normal developmental milestone. He
had breast feeding and artificial feeding, the weaning food started after
6 month. During the childhood he was introvert personality character.
(e) Educational history:
He started the education at the age of 5yrs in govt. school. The client’s
academic function was average and good relationship with peer
groups and teachers. During the school period he wouldn’t go school
regularly and stopped the education due to the poverty. At the age of
11 years he went for daily wagers works.
(f) Play history
During childhood he use play with his peer groups.
(g) Emotional problems during adolescence:
 He started the smoking and other habits after made a friendship with
peer groups and he always been with them. While going to the alcohol
industry work he stated above habits. He has blunted emotional
behavior.
(h) Occupational history:
He starts to work at the age of 11yrs and he used to go for daily wager
up to 16yrs after that he got job in alcohol factory. He used to go
regularly and during the working period he was sincere and regular
person. Past 15 days he didn’t go to the work.
(i) Puberty
He attain the secondary sexual characteristic at the age of 14yrs
(j) Premorbid personality
viii.Interpersonal relationships:
He has good relationship with His family members and wife.
ix. Use of leisure time:
Spending time with his friends and taking alcohol with friends.
x. Predominant mood:
He always having anxious mood.
xi. Habits:
He had smoking, alcohol and sometimes tobacco chewing habits
past 28years. He uses to take mixed diet and regular diet pattern.
Some times after taken heavy drinking he used to sleep without
food.
Physical Examination:
(a) General assessment:
 Appearance: Later adulthood
 Body built: Emaciated built
 Looking: irritate and anxious
 Height: 142cm
 Weight: 48kgs
 Vision: he has vision problem. He couldn’t see the nearest objects
 Mouth: he has bad odor smell from his mouth
  Teeth: most of the teeth affected by dental caries and eroded
gums.
 Gastrointestinal system: he has pain in epigastric region, and
loss of appetite, nausea and vomiting sensation.
 Integumentary system: the lower and upper extremities skin was
dried and has nail scratching.
 Respiratory system: after walking some distance in corridor he
has breathing difficulties.
Mental Status Examination
(a) General appearance and behavior
 Appearance: Later adulthood
 Level of grooming: Average grooming
 Level of cleanliness: inadequate cleanliness
 Level of consciousness: disoriented
 Mode of entry: brought by family members.
 Cooperative: less than normal co-operative
 Eye-to-eye contact: Not maintained normal eye to eye contact
 Psychomotor activity: increased psychomotor activity (sometimes
he has retarded psychomotor activity)
 Rapport: Not established rapport
 Gesturing: Normal gesture
 Posturing: uncomfortable posture
 Other movements: Not present
 Other catatonic phenomena: echolalia and echoprxia present
 Conversion and dissociative signs: Not present
 Compulsive acts or rituals: sometimes present.
 Hallucinatory behavior: Not Present.
Speech
 Student nurse: why did you left your drinking habits of alcohol?
 Client: he doesn’t understand the question. Client blinking here
and there. What the student nurse said to him, he repeated the
same words.
 Initiation: Minimal
  Reaction time: shortened
 Rate: Rapid
 Productivity: Monosyllabic
 Volume: low volume
 Tone: monotonous
 Relevance: irrelevant talk
 Stream: there is no stream of speech present
 Coherence: incoherent
 confabulation of speech present
(b) Mood
 Subjective: anxiety with irritation mood
 Student nurse: how do you feel now?
 Client: he repeated the same sentence.
 client has anxious and irritable mood and restless activity
 Thought
 Student Nurse: why you have angry with your wife?
 Client: she is not allowing to drink more and started the
monosyllable words
 Stream: he has poverty of thoughts
 Form: Irregular thought present
 Content: He had bizarre of thought process.
(c) Perception
 Student Nurse: Are you hearing any external and internal voice?
Are you felt that this thought comes from or inserted by anyone.
 Client: Not answered.
There is no auditory hallucination and delusion behavior. There is no
inappropriate laughing, and speech.
(d) Cognitive Functions:
 Consciousness:
- Student Nurse: what is your name?
- Client: Mr. Vinoth Kumar Shukla and repeated his name
several times
- Client has cloudy consciousness
 Orientation:
iv.Person
- Student Nurse: what is your wife name?
- Client: He denoted his wife but he didn’t tell the name.
v. Place
- Student Nurse: can you say name of the hospital?
Client: he has confusion with answers and he said that it is his
house.
vi.Time
- Student Nurse: what is the time now?
- Client: He said night.
- Client was not orientation with place, person and time.
 Attention:
- Student Nurse: can you repeat the digit 23, 45, 66 and 58
- Client: he repeated few digits
- Client has poor attention span.
 Concentration:
- Student Nurse: can you tell the answer 91 – 8 =?
- Client: he couldn’t answer.
- he has poor concentration
- Student nurse: can you tell the name months backwards?
- Client: he didn’t responded
 Memory:
i. Immediate
- Student Nurse: can you backwards this digit 25,46,78,90.
- Client: he answered only one digit.
- he has poor immediate memory power
ii. Recent
- Student Nurse: what you had in the morning?
- Client: he said his name Mr. Vinoth Kumar Shukla.
- he has poor recent memory

iii. Remote
- Student Nurse: can you tell your marriage day date?
 - Client: he didn’t answer.
- he has poor remote memory
- client has memory impairment
 Intelligence:
- Student Nurse: who is prime minister of India?
- Client: he doesn’t the answer.
- Client has poor intelligence
 Abstraction:
- Student Nurse: can you tell what is different between the balls
and orange?
- Client: he can’t able to answer.
- he has poor abstract thinking
(e) Insight: (grade1 to 6)
- Student Nurse: do you agree you’ have some illness?
- Client: He never responded.
- Client has poor insight.
(f) Judgment:
- Student Nurse: In front of you someone picked other person
money purse that time what is your reaction?
- Client: Not answered he has restless activity he taken his
case sheet and roaming in the room.
- Client has poor judgment
XXV. Vital Signs
S. No. Vital Sign Normal Value Patient’s Value
1. Temperature 98.60 F 98.6F
2. Pulse 72-90 Beats/M. 88 beats/mint
3. Respiration 14-20 Breath/M. 17breath/mint
4. Blood Pressure 80 -120 90 -130 mmhg
XXVI.Investigation:
Sl.N Investigations Patient’s Value Normal Value
o

1 Blood -Heamoglobin 12.0gm/dl 14-16

3.92 milcmm 4.5-6.51
 Red blood cell
 PCV 34.5% 40-54

 Platelets 2.43 lacs 1.5-4.5

 Total WBC different count 15500 cu/mm 5000-11000
84% 40-75
 Neutrophil
 Lymphocytes 11% 20-45

 Esinophills 06% 1-6

 Monocytes 01% 1-6
 MCV 83fl 80-99
 MCH
28pg 27-33
 MCHC
33.7g/dl 32-37

XXVII. Medication chart:

1. Tab. Chlordiazepoxide – 20mg Q.I.D.
2. Tab. Carbamazepine – 600mg B.D.
3. Tab. Thiamin – 100mg O.D.
4. Tab. Fluxetine – 20mg B.D.
5. Tab. Haloperidol – 10mg B.D.
6. Olenzepine – 5mg B.D.
7. Tab. Zintac - 150mg BD
 Pharmacologica

Responsibility
Trade Name

Side-effects
Indications
Frequency

Indication

Contra-
l Name

Action
Doses
Group

Route
S.

Nsg.
N.

Libriu Chlordia Anxiol 20 Oral Q.I. It increases the Anxiety, Jaundice, Physical Check the physician’s
m zepoxid ytic mg D. activity of the phobias, myastheniaand order.
e inhibitory psychosomatic gravis, psycholog Medication given must
transmitter disorders. acute ical be charted on the
GABA in pulmonary dependen patient’s case sheet.
1. different parts insufficienc
ce, Check the five rights for
of CNS. Sine y and
withdrawa drug administration
muscle respiratory
l Always address the
relaxant and depression.
syndrome patient by name and
anticonvulsant , sedation make certain
activity. skin rash identification
Tegret Carbama Antico 600 Oral B.D. It reduces Epilepsy, Hypersensi Drowsines Do not leave the
ol zepine nvuls mg polysynaptic alcohol tivity, s, patient until the drug is
ant responses and withdrawal A.V.conduc lassitude, swallowed
blocks post syndrome, tion dry mouth, Do not allow the patient
titanic mania, painful abnormaliti blurred to carry drugs
2.
potentiating. diabetic es, vision, Do not force oral
Effective in neurooathies, porphyria muscle medication
partial and trigeminal weakness, Check drug daily
generalized neuralgia insomnia Observe for drug
convulsion. specific side-effects
Oliza Olanzapi Thien 5 Oral BD It is an atypical Schizophrenia Hypersensi Sedation Instruct the family
3. ne obenz mg antipsychotic , acute tivity and members when to
 odiaz drug. It mainly psychosis, Hypotensi contact psychiatrist
epine act on 5HT2 mania, on (rare)
and D4 delusional
receptors. disorder,
ADHD.
Thai Thiamin Vitami 100 I.V B.D. It prevent
n mg peripheral
neuropathy and
4. - - -
metabolize the
glucose in
neuron cells.
Prod Fluxetin SSRI 20 Oral B.D. It blocks the Depressive Severe constipatio
ep e and mg serotonin episode, renal n, urinary
anticra
ving
reuptake depression failure, retention,
channel and with psychotic hypersensi hypotensi
5. increase symptoms, tivity, on,
serotonin level dysthymia, concomita impotenc
at post- ADHD, panic nt MAOI’s e,
synaptic space. attack, PTSD priapism,
and ADS. sedation
Oper Haloperi Butyr 10 Oral B.D It antagonist at Acute mania, Closed Tardive
ex dol ophen mg . central and acute angle dyskinesi
one peripheral schizophrenia, glaucoma, a, EPS,
dopamine bipolar prostatic anxiety,
6. receptors and affective hypertroph postural
selective for disorder, y, coma hypertens
the D2 receptor severe resulting ion, anti
produces agitation in from CNS cholinergi
calmness elderly depression c effects
XXVIII. OTHER THERAPEUTIC THERAPIES:
Cognitive behavior therapy and individual psychotherapy and
Motivational intervention:
Behavior therapy is a form of treatment for problems in which a trained person
deliberately establishes a professional relationship. Behavior therapy involves
identifying maladaptive behaviors and seeking to correct these by applying the
principles of learning conditions.
Here Mr. Vinoth Kumar Shukla has disorientation; poor attention span,
confabulation speech and poor memory, cloudy of consciousness past 15 days.
The psychologist and psychiatrist planned to give the cognitive behavior
therapy and individual psychotherapy. Initially the client was oriented to the
environment and family members- like every time the family and other people
introduce themselves with name and relationship to the patient. The family
members instructed to tell previous event and make the client get the flashback
memory. During the individual psychotherapy client was educated about the
effects of the alcohol and complications of alcohol.
Motivational interviewing:
Initially the client was assessed by the chief psychologist and assessed the
self motivation and interest of the patient to leave this habit after explained
about the effects of alcohol in individual, family, financial, social and work
places. Client has some have interest to leave the habit but he is not sure to
leave the habit.
XXIX.Process Recording:

Time : 30 Minutes
Date : 20.09.2020
Place : Counseling room in Deaddition centre
Objectives :
To
 -gain the confidence of the patient
 -assess the condition of the patient
 -collect the psychiatric history
 -identify the patient problems
Purposes and uses:
Person Conversation Inference
Student Nurse Good morning Mr. Vinoth Kumar Shukla Difficulties to
Client After two or three times, he responded Good maintain the
morning sir rapport
Student Nurse How do feel now? He doesn’t have
Client He said irrelevant word insight.
Student Nurse What you had in the morning? Difficulties in
Client He never responded speech
Student Nurse What is your wife name? Confabulation of
Client He said his name speech present
Student Nurse How many years you’re having this drinking he has poor
habits? concentration
Client He has restless activity and roaming here and and have easy
there distractibility
Student Nurse For day how much you will take?
Client He doesn’t listen the question and his did own
activities.
Student Nurse How you started the habits and what type of Client doesn’t
pleasure you are getting after taking alcohol? aware of the
Client Client starting sometimes and started initially complication of
started with joyfulness but present I couldn’t the drinking.
leave this habits (in between client talked
irrelevant matter)
Student Nurse Have you have idea about to leave this habit? Client has
Client Client not responded minimum self
motivation related
to cut down the
habit.
Summary:
Mr. Vinoth Kumar Shukla has impaired memory and confabulation speech
and poor insight and judgment, disorientation to place, person and time, poor attain
span and easy distractibility anxiety with irritability and clouding of consciousness
due to abruptly stopped the alcohol due to the money problems. Now he has
diagnosed as alcohol dependent syndrome with Korsakoff’s syndrome in acute
stage. Now he treated with antipsychotics, anticraving and sedations with other
therapies.
Disease Condition
Introduction:
Drugs are a pervasive part of our society. Certain mood altering substances are
quite socially acceptable and are used moderately by many adult. They include
alcohol caffeine and nicotine. Society has even developed a relative indifference to
an occasional abuse of these substances, despite documentation of their negative
impact on health.
Definition
Substance abuse is described as a maladaptive pattern of substance use losing to
clinically significant impairment or distress, as manifested by one or more of the
following, occurring, within a 12 months period.
1. Recurrent substance use resulting in a failure to fulfill major role
obligations at work, school or home(e.g., repeated absence or
poor work performance related to substances use: substance
related absences, suspensions, or expulsions from school
neglect of children or household)
2. Recurrent substances use in situation in which it isphusically
hazardous(e.g. driving an automobile cooperating a machine
when impaired by substance use)
3. Recurrent substance related legal problems(e.g. arrests for
substance related disorderly conduct)
4. Continued substance use despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the
effects of the substance (e.g. arguments with spouse about
consequences f intoxication physical fights)

The diagnosis of alcoholism is often made using the DSM-IV criteria for alcohol
dependence which requires three or more of the following symptoms to occur within
the same 12-month period:
 1. tolerance, as defined by either of the following:
o a need for markedly increased amounts of the substance to achieve
intoxication or desired effect
o markedly diminished effect with continued use of the same amount of
substance
2. withdrawal, as manifested by either of the following:
o the characteristic withdrawal syndrome for the substance
o the same (or a closely related) substance is taken to relieve or avoid
withdrawal symptoms
3. the substance is often taken in larger amounts or over a longer period than
was intended
4. there is a persistent desire or unsuccessful efforts to cut down or control
substance use
5. a great deal of time is spent in activities to obtain the substance, use the
substance, or recover from its effects
6. important social, occupational or recreational activities are given up or
reduced because of substance use
7. the substance use is continued despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to have been caused
or exacerbated by the substance (e.g., continued drinking despite recognition
that an ulcer was made worse by alcohol consumption)

Etiology
Biological factors:
Children if alcoholics are three times more likely than other children to become
alcoholics. Monozygotic twins have higher rate for concordance of alcoholism than
dizygotic twins.
Biochemical factors:
A second biological hypothesis relates to the possibility that alcohol may produce
morphine –like substances in the brain that are responsible for alcohol addiction.
Psychological factors:
The psychodynamic approach to the etiology of substance abuse on a punitive
superego and fixation at the oral stage of psychosexual development.
Personality factors:
Certain personality traits have been associated with tendency toward addictive
behavior like low-self esteem frequent depression passivity, the inability to relax or to
defer gratification and the inability to communicate effectively are common in
individuals who abuse substances. Substances abuse has also been associated
with antisocial personality and depressive responses styles.
Socio cultural factors:
Social learning:
The effects of modeling, imitation and identification behavior can be observed from
early childhood.
Conditioning:
Another important learning factor is the effect of the substance itself. Many
substances create a pleasurable experience that encourages the user to repeat it.
That is the intrinsically reinforcing proprieties if adductive drugs that condition the
individual to seek out their use again and again.
Cultural and ethnic influences:
Incidence of alcohol dependence among Asians is relatively low. This may be are
result of possible genetic intolerance of the substance. Some Asians develop
unpleasant symptoms such as flushing headaches nausea, and palpitations when
they drink alcohol.
Neurochemistry
Chronic use of alcohol leads to changes in brain chemistry especially in the
GABAergic system. Various adaptions occur such as changes in gene expression
and down regulation of GABA receptors. During acute alcohol withdrawal changes
also occur such as up regulation of alpha4 containing GABA receptors and down
regulation of alpha1 and alpha 3 containing GABA receptors. Neurochemical
changes occurring during alcohol can be minimized with drugs which are used for
acute detoxification. With abstinence from alcohol and cross tolerant drugs these
changes in neurochemistry gradually return towards normal.
Epidemiology:
The incidence of alcohol dependence us 2%. In India 20 to 40% of subjects aged
above 15 years are current users of alcohol and nearly 10% of them are regular or
excessive users. Nearly 15 to 30% of patients are developing alcohol related
problems and seeking admission in psychiatric hospitals.
 Book Pictures Patient Pictures
Types Alcohol Alcohol dependent
Opioids syndrome
Cannabis
Cocaine
Sedative
Nicotine
Amphetamine
Clinical Features  Agitation Confusion
 Alcoholic hallucinosis Anorexia
 Anorexia Irritability
 Anxiety and panic Derealization
attacks Headache
 Catatonia Insomnia
 Confusion Palpitations
 Delirium tremens Restlessness
 Depression Tachycardia
 Derealization Tremors
 Diaphoresis weakness
 Diarrhea
 Euphoria
 Fear
 Gastrointestinal upset
 Hallucinations
 Headache
 Hypertension
 Insomnia
 Irritability
 Nausea and vomiting
 Palpitations
 Psychosis
 Rebound REM sleep
 Restlessness
  Seizures and death
 Sweating
 Tachycardia
 Tremors
 Weakness

Psychopathology Jellinek (1952) outlined four Client started initially with

phases through which the his friends for enjoyment
alcoholic’s pattern of drinking and gradually increased the
progresses. amount of drink and
Phase I: this phase is changed the drinking
characterized by the use of brands and amount of
alcohol to relieve the alcohol.
everyday stress and tensions Now the client was in phase
of life. The individual may IV.
have observed parents or
other adults drinking alcohol
and enjoying the effects.
Phase II:
This phase begins with
blackouts brief periods of
amnesia that occur during or
immediately following a
period of drinking. The
individual feels enormous
guilt and becomes very
defensive about his or her
drinking. Excessive use of
denial and rationalization is
evident.
Phase Iii:
In this phase the individual
has lost control and
physiological dependence is
 clearly evident. This loss of
control has been described
as the inability to choose
whether or not to drink.
Binge drinking lasting from a
few hours to several weeks
is common.
Phase IV;
This phase is characterized
by emotional and physical
disintegration. The individual
is usually intoxicated more
than he or she is sober.
Impairment in reality testing
may result in psychosis.
Diagnostic Evaluation Laboratory investigation S. Bilirubin – 1.2 mgs/dl
GGT (γ glutyl transferase is S. total protein -8.1 gm/dl
raised to about 40 IU/L in
S. Albumin -4.7 gm/dl
about 80% of alcohol
S. Globulin -3.4 gm/dl
dependent individuals. GGT
A/G ratio -1.4
returns to normal rapidly
(within 48 hrs) on abstinence SGOT -32 u/l
from alcohol. GGT of more SGPT -28 u/l
than 50% in an abstinent
Alkaline phosphate -64 IU/l
individual signifies a
The blood investigation
resumption of heavy
shows that client has acute
drinking.
stage of impaired liver
MCV us more than 92 fl
function.
(normal 80-90fl) in about
60% of alcohol dependent
individuals. MCV takes
several weeks to return to
normal values after
 abstinence
Other lab markers include
alkaline phosphates, AST,
ALT, uric acid, blood
triglycerides and CK
Complications Gastro intestinal system Alcohol psychosis
Fatty liver, cirrhosis of liver, (korsakoff’s syndrome).
hepatitis, liver failure, Financial problems,
gastritis, esophageal occupational problems,
varicose, peptic ulcer hepatitis, anorexia, and
Central nervous system peptic ulcer.
peripheral neuropathy The client has korsakoff’s
Delirium tremens rum fits, psychosis characterized by
alcoholic psychosis, gross memory disturbances
dementia, cerebellar with confabulation, insight is
degeneration often impairment.
Social complications
Accidents, marital
disharmony divorce
occupational problems
increased incidence of drug
dependence financial
difficulties.
Acute intoxication,
withdrawal syndrome.
Treatment Psychopharmacology Patient’s medication chart
Psychopharmacology The drugs of choice for Tab. Chlordiazepoxide –
detoxification are usually 20mg Q.I.D.
benzodiazepines. Tab. Carbamazepine –
Chlordiazepoxide 600mg B.D.
200mg/day, diazepam 40- Tab. Thiamin – 100mg O.D.
80mg/day. A typical dose of Tab. Fluxetine – 20mg B.D.
chlordiazepide in moderate Tab. Haloperidol – 10mg
 alcohol dependence is 20mg B.D.
QID – 6 days, clormethiazole Olenzepine – 5mg B.D.
(1-2 mg/day) and 15 days.
carbamazepine (600-
1600mg/day), in addition
vitamins should also be
administered (especially
nicotinic and thiamin
100mg/day)
Aversion therapy:
Disulfiram aversion therapy
Psychotherapy Behavior therapy Cognitive behavior and
individual and group therapy individual therapy.
Deterrent agents(Aversion Motivational intervening
therapy therapy
Disulfiram aversion therapy),
psychosocial rehabilitation.
ECT Not recommend -
Others specific - -
treatments

Nursing management:
 Place the client in a room near the nurse station or where the staff can
observe the client closely.
 Decrease environment stimuli
 Reorient the client to person, time, place and situation as needed.
 Talk to the client in simple and direct language
 Maintain the fluid and electrolyte balance, provide food or nourishing fluids as
soon as the client can tolerate eating and provide increased amount of protein
 Don’t allow patient to rationalize or blame others for behaviors associated
with substance use.
 Provide positive reinforcement when the client shows insight into his
behavior.
  Discuss the events that led to the incident with patient in a non judgmental
manner. Assist the patient to plan weekly or even daily schedules of
purposeful activities.
 Maintain frequent contact with the client, even if it is only by a brief telephone
call.

Nursing Process:
Day 1

S. Needs Problems
No.

1 Personal care to maintain the Patient has disorientation and not aware
personal hygiene of personal hygiene

2 Maintain the adequate nutritional Patient not taking feed properly

status

Nursing Diagnosis:

1. Self care deficit related to cognitive impairment as

evidenced by difficulty carrying out tasks
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Poor personal Self care deficit Maintain  Provide assistance with self care  Assisted the client’s Client not
hygiene, lack related to the normal needs as required (taking the personal needs (daily maintain
in daily cognitive personal client to bathroom, dressing) activities) the normal
activities due impairment as hygiene  Encourage client to perform  Allowed the client to do ADLs and
to evidenced by and make independently as many activities independent work (bathing, personal
disorientation difficulty carrying the patient as possible. grooming) hygiene.
out tasks to do  Use concrete communication to  Maintain the IPR with good He needed
independe show client what is expected. rapport(oriented the patient the
ntly  Creative approaches may need to present environment) assistant to
to be taken with the client who is  Family food allowed and help the all
not eating. changed the environment. ADLs.
 Toileting needs are not being met  Structured schedule
establish a structured schedule established a pattern so the
for the client. client can develop
independent habit (daily
menu given to the client)
Client has loss Impaired Maintain  Asses the client’s nutritional  Assessed the client’s food Client’s
of appetite nutritional status the normal pattern. What food he likes more pattern and taken list nutritional
and nausea. less than body and and dislike food and food taking regarding what he likes. status
requirements adequate pattern. (mixed diet pattern) improved
related to loss of nutritional  According to the client condition  Client has acute stage of at some
appetite, nausea, status. the diet restriction should be liver impairment so salt and extent.
as evidenced by made fat restriction diet was
weight loss,  Create the pleasurable advised
emaciated built. environment during meal time.  Provided a clean and
 Allow the client to take home stimulated environment.
foods.  Home food was allowed to
 Instruct the client to take small take occasionally.
and frequent diet sequentially.  Frequent and small food
 Administer the antacids and provided.
appetizers.  Tab. zintac 15omg
 If the client not taking food administered.
adequately started the  On the admission day 5%
intravenous infusion (enternal dextrose with 100gm
feeding) thiamine infusion was
administered.
 Day 2
S. Needs Problems
No.

1 Maintain normal sleeping pattern Patient has decreased sleep pattern

2 Maintain the normal verbal Impaired verbal communication, and

communication disoriented to present situation

Nursing Diagnosis:

1. Disturbed sleeping pattern related to withdrawal complications as evidenced by client has dizziness and weakness,
restlessness

2. Impaired verbal communication related to disorientated as evidenced by losses associational thoughts

 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Decreased Disturbed Maintain the To promote sleep: Before bed time allow the Maintain the
sleep pattern sleeping pattern normal i. Encourage activities that client to hear the soft normal sleeping
related to sleeping prepare one for sleep: soft music (radio given to pattern after
withdrawal pattern music, warm bath client) implementation
complications as ii. Control intake of caffeine Restricted the client to of the
evidenced by containing substances within take coffee and tea at intervention.
client has 4hr of bedtime evening time
dizziness and iii. Provide a high carbohydrate During night time allow the
weakness, snack before bedtime. client to take a glass of
restlessness iv. Discourage the daytime milk
napping. Increase the During the day time short
program of activities to keep term menu was given to
the client busy. the client (activities like
v. Make the client to go for drawing, working in
regular bed time. It may rehabilitation centre)
helps to maintain the regular Instruct the client to go
circadian rhythm. bed before 9’o clock.
Use short term sleep medications Tab. Librium 20mg given
Irrelevant talk, Impaired verbal Maintain the  Attempt to decode incomprehensible  Decoded the Client maintain
unrealistic communication normal and communication patterns (like repeated incomprehensible the appropriate
thinking, related to appropriate the same answers) communication. and
disorientation disorientated as communication  Facilitate trust and understanding by  Constantly seen the comprehensibly
evidenced by and oriented consistently assigning the person patient and maintain the with others at
losses the client to (positive approach toward to client) IPR (every day maintain some extent
associational present  Anticipate and fulfill the client’s the rapport)
thoughts environment needs(attempt the client ADLs)  Fulfilled the patient’s
 Orient client to reality as required by needs.
call the client name, give elaborate  Every time called the
past history patient by his name
 Instruct the family members to talk  Oriented the client to
recurrently previous incidence and present situation(taken
present situation the client to visit the
ward& hospital)
 Day 3
S. Needs Problems
No.

1 Maintain the normal coping and Client has low self esteem and coping
adaptive behavior strategies

2 Acceptance of the reality Denial his behaviors.

Nursing Diagnosis:

1. Ineffective coping strategies related to impaired cognitive functions as evidenced by severe anxiety, restlessness
2. Ineffective denial character related to weak ego as evidenced by his statements indicating no problem with alcohol.
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Patient has Ineffective Maintain the  Reassure the client of safety and  Reassured the client by Client
low self coping more security through your presence. making trustful relations. maintain the
esteem and strategies adaptive  Identify the severe stressors and  The stressful stimulus normal
coping related to ways of remove the stimuli. was removed (advise to coping
strategies impaired coping in  Help the client define more change the work place) methods at
cognitive present & adaptive coping strategies. Make  Taught the new coping some extent
functions as stressful suggestions of alternatives that strategies to the patient.
evidenced by environment might be tried. (problem solving
severe anxiety,  Provide positive reinforcement for technique)
uncontrolled client’s attempts to change.  Positive reinforcement
behaviors  Identify the community resources was given.
to which the individual may go for  Used the available
support if past maladaptive coping resources help to the
patterns return. client from
decompensating
Client denial Ineffective denial Clint  Develop trust convey an attitude of Unconditional acceptance Client
his behaviors character related demonstrate acceptance. Ensure that client promotes dignity and self accepted his
and reason for to weak ego as to accept understands it is not the person bit worth. maladaptive
taking alcohol/ evidenced by his the reality the behavior that is unacceptable. behavior and
client should statements  Correct any misconceptions such I Corrected the reality.
accept the indicating no don’t have a drinking problem misconceptions related to
reality problem with  Identify recent maladaptive alcohol.
alcohol. behavior or situation that have Advised the client to
occurred in the client’s life and change the works or
discuss how use of substances working place
may be a contributing factor.
 Do not allow the client to Elaborately explained
rationalize or blame others for about his maladaptive
behaviors associated with behavior and solved his
substance use. problem.
 Theory Application
Peplau’s Interpersonal theory:
The core of Peplau’s approach is interpersonal relations. The theory includes
the concept such as communication, roles and growth and development.
Communication us a problem solving process whereby the nurse and client
collaborate to meet the clients need. The nurse may assume the roles of counselor,
leader, resource, surrogate, and teacher. These roles are designed to lead to growth
and development.
Roy’s adaptation model:
In this model the person is viewed as an adaptive system; nursing
intervention is needed when there is a deficit between the adaptation level and
environment demands. The major concepts are
 Regulator
 Cognator
 Adaptive.
Adaptation is the process of coping with external and internal stimuli. It is
determined by the effects of three classes of stimuli –focal, contextual and residual.
Orems’s self care theory:
Self care is defined as the continuous contribution adults give to personal
health and well being. The major concepts are self care and nursing system. The
self care agency is aided by intellectual curiosity, instruction, supervision from
others, and experience performing self care measures.
King’s theory:
King’s theory of goal attainment encompasses three broad interlocking open
systems, the personal and interpersonal and social system. The personal system
and social system influence the quality of care and the major elements in the goal
attainment are contained in the interpersonal system. In these system two or more
persons come together under the guidance if health care organization to promote an
optimal state of health. The major concepts are interaction, perception,
communication, transaction, roles, stress, growth and development and time and
space.
Roy’s adaptation model:
In this model the person is viewed as an adaptive system; nursing
intervention is needed when there is a deficit between the adaptation level and
environment demands. The major concepts are
 Regulator
 Cognator
 Adaptive.
Adaptation is the process of coping with external and internal stimuli. It is
determined by the effects of three classes of stimuli: –
 Focal,
 Contextual and
 Residual.
 Roy’s Adaptation Framework

Regulator
- Rest - Helps to develop
- Food
- Sleep positive self concept
- Memory loss
- decreased sleep - Exercise - Assessing the
- Elimination

Positive Adaptation
- Disorientation coping
- O2, Food and
- Destructive - Positive feed back
Electrolyte
- Aggressive
- Orientation
- Irrelevant talk
Stimuli

- Impaired Adaptation Level - Prevent injury

Relationship - Promote Sleep
- Self care Deficit Cognator
- Perception of past
- Disturbed thought
- Educate about coping methods, - personal and present
process
hygiene, - disease condition, - medications,
- Low self esteem & - Normal sleep
- follow up, - Safe environment, - Positive
confidence reinforcement, - Cognition assessment, - pattern
- Disabled family IPR, - reality orientation, - Coping
coping - Accept the reality
according to the situation, family
counseling, psycho education.
Health Education:
Health education given regarding
 Identify reality.
 Encourage social interaction.
 Improve the self care needs (personal hygiene) independently.
 Sleep hygiene techniques.
 Family’s to use alternative coping methods.
 Prevention of violent behavior.
 Taught about the positive coping methods.
 Prevention of self harm and others.
 Educated the patient and family members regarding medication- dosage and
side effects of the medication.
 Advice the patient for regular checks up and follows up.
 Advice to start the work gradually. Initially start with fulfill his own needs and
home works.
 Psycho education related to disease condition, sign and symptoms,
complications, treatment regimen explained.
Discharge Plan:
Summary:
Mr. Vinoth Kumar Shukla 48 years old, brought up by his family members with chief
complaints of impaired memory, disoriented to person, place, restlessness,
decreased sleep, irrelevant talk, irritability past 15 days and has history of 28 years
of alcohol habits 3 to 4 quarter for day, use to take morning and evening along with
smoking habits. He admitted in deaddiction ward in NIHMANS and given treatment
like anticraving, antianxiety, antidepressant, sedations and other therapies like
motivational intervening, individual and family psychotherapy. As a psychiatric nurse
have the reasonability to orient to present situations, improve the client individual
functioning, increased the family members coping strategies, improve the
independent work at the end of discharge. Now the client have prognosis with his
daily activities, and his cognitive functions at some extent.
Bibliography:
5. Townsend.M, (2007), “Psychiatric Mental Health Nursing”, Jaypee brothers,
New Delhi, Pp. -
6. Doenges M.E. et al., (1995), “Psychiatric Care Plans Guidelines for Planning
and Documenting Client Care”, 2nd ed. F. A. Davis Company, Philadelphia,
PA, Pp. -
7. Ahuja.N, (2006), “A Short Text Book of Psychiatry”, Jaypee brothers, New
Delhi, Pp. -
8. Sreevani.R, (2008), “A Guide to Mental Health and Psychiatric Nursing”,
Jaypee Brothers, New Delhi, Pp. -
 MENTAL HEALTH NURSING

CASE STUDY ON
SUBSTANCE
ABUSE
SUBMITTED TO
Mr. RAHUL SRIVASTAVA
HOD,
ASSOCIATE PROFESSOR
MENTAL HEALTH NURSING
YASHRAJ COLLEGE OF NURSING

SUBMITTED BY
Mr. BOBY DWIVEDI
M.Sc. NURSING 2nd YEAR,
YASHRAJ COLLEGE OF NURSING

DATE OF SUBMISION____________
 Patient’s Profile

XXX. Identification data

Client name : Mr.Raju
Age : 47years
Sex : Male
Father name : Mr.Suresh
Address : Haripur
Gonda
Education : 10th standard
Occupation : Driver
Income : Rs. 6000/ month.
Marital status : Married
Religion : Hindu
Date of admission : 15.09.2020.
Provisional diagnosis : Substance abuse
Final diagnosis : Alcohol dependence syndrome
XXXI.Informant…………………………………………..
: Son
XXXII. Presenting Chief Complaints:
According to Patient :
o Nausea
o Vomiting
o Weakness
o Irritability
o Insomnia
According to Informant :
o Insomnia
o Shouting
o Loss of appetite
 o Unsteady gait, talking to self and tremors
XXXIII. History of Present Illness:
Mr.Raju apparently normal before four months then he developed the
symptoms like nausea, vomiting, weakness, irritability, insomnia mild tremors,
loss of appetite and eye opener of alcohol.
XXXIV. Treatment History:
There is no past treatment history. At present patient receiving Tab.Nitrozepam
5mg/day, Tab.Diazepam 40 mg/day, Tab.Becosules 100mg/day, IV.Ringer lactate
500ml/day and alcohol anonymous therapy
XXXV. Past Psychiatric History:
There is no significant history of psychiatry illness.
XXXVI. Past Medical History:
There is no significant history of medical illness.
XXXVII. Past surgical History:
There is no significant surgical history for the patient.

XXXVIII. Family History:

(b) Family Characteristics:

Age &
S. Relationship
Name of the Age/ Educationa Health mode
No with the Occupation
family members Sex l Status Status of
. Patient
death
1 Mr.Suresh Father 74/M Illiterate - - 74/MI
2 Mrs.Bhayawati Mother 68/F Illiterate House wife Healthy -
3 Mrs.Shanti Wife 41/F 6th std House wife Healthy -
4 Mr.Harikumar Son 20/M B.com - Healthy -
5 Mr.Rajkumar Son 16/M 11th std - Healthy -

(c) Genogram:
Key:-

74 yrs 68 yrs - Male

- Female

- Patient
50yr 47 yrs 41yrs
- Death
 20 yrs 16 yrs
There is no family history of Hypertension/Diabetes mellitus/Psychiatric
illness/Alcoholism or suicide.
XXXIX. Personal History:
(k) Perinatal history
Mr.Raju’s mother had proper antenatal checkup and period
was eventful. Baby delivered as full term normal vaginal delivery.
Child cried immediately after birth and there is no postnatal
complication like cyanosis, convulsions and jaundice.
(l) Childhood history
Primary caregiver was a mother and he had both breastfed
and artificial. Weaning started at the age of six months and
developmental milestones was normal. There was no behavior
and emotional problems like thumb sucking, temper tantrums,
head banging, nail biting and enuresis.
(m) Educational history
Education was started at the age of 5 years. He is an
average in academic performance and had good relationships
with teachers and peers. There is no school phobia. He left the
study after 10th standard because no interested in studies.
(n) Play history
He started to play at the age of 4 years and had good
relationship with peers.
(o) Emotional problems during adolescence
There is no significant history of emotional problems like
running away from home, smoking and drug abuse.
(p) Puberty
Secondary sexual characteristics appeared at the age of
14 years. There is no anxiety regarding sexual changes.
(q) Occupational history
Mr.Raju started to work at the age of 19 years as a driver.
He is satisfied with his job and having good interpersonal
relationship with his co-worker.

(r) Sexual and marital history

The marriage was arranged and not a consanguineous.
Duration of marriage is 20 years. He doesn’t have good
interpersonal relationship with his wife and sexual relationship
also unsatisfactory due to alcoholism and conflict with wife.

(s) Premorbid personality

xii. Interpersonal relationships: Introvert

xiii.Use of leisure time: Watching TV and intake of alcohol

xiv. Predominant mood: Fluctuating mood

xv. Attitude to self and others: Self-appraisal of abilities and

behaving normally with others.

xvi. Attitude to work and responsibility: He is an irregular in work

for past one year.

xvii. Religious beliefs and moral attitudes: Having faith on

religious and participating in religious activity.

xviii. Fantasy life: There is no daydreams

xix. Habits:
 Eating pattern, elimination, sleep is irregular. He is a chronic
alcohol abuser for past 20 years.

XL. Physical Examination:

(b) General assessment:
 Appearance : Late adulthood
 Body built : Average
 Looking : Dull
 Height : 168 cm
 Weight : 66 kg
(c) Eye :Vision power is normal
(d) Nose : No nasal polyp or tumors
(e) Oral cavity : Dental caries is present
(f) Ear : Hearing acuity is normal
(g) Chest : S1 and S2 sounds heard
(h) Extremities : Motors activity decreased & tremors
present
(i) Respiratory system : No bronchial congestion
(j) Cardiovascular system : No hypertension and murmur
(k) Gastrointestinal system: Nausea and vomiting is present and
hepatomegaly present.
(l) Integumentary system: Loss of skin integrity
(m) Genito-urinary system : Bladder movement is normal

XLI.Mental Status Examination

(g) General appearance and behavior
 Appearance : Looking older
 Level of grooming : Normal
 Level of cleanliness : Adequate
 Level of consciousness : Drowsy
 Mode of entry : Persuaded by son
 Cooperativeness : Normal
 Eye-to-eye contact : Maintained
 Psychomotor activity : Increased activity
 Rapport : Spontaneous
 Gesturing : Exaggerated
 Posturing : Normal posture
 Other movements : Tremors present
 Other catatonic phenomena : Not present
 Conversion and
dissociative signs : Not present
 Compulsive acts or rituals : Not present
 Hallucinatory behavior : Smiling and talking to self is present
(h) Speech
 Student Nurse : What is your name?
 Client : Raju
 Initiation : Patient spoken when talk
 Reaction time : Normal
 Rate : Slow
 Productivity : Pressured speech
 Volume : Increased
 Tone : Normal variation
 Relevance :Some time off target
 Stream : Normal
 Coherence :Loosening of associations
 Others : No rhyming, punning, echolalia or neologism.
(i) Mood
 Subjective : Student nurse : Are you feeling happy?
Patient : No I am feeling irritations, sad and
tiredness.
 Objective : Irritable mood and looking dull
(j) Thought
Student Nurse : How do you feel now?
Client : Fine
 Stream : Normal thought is present. There is no retarded thinking
thought block and flight of ideas.
Form : No thought disorder is present
Content
Student nurse : Do you feel anything come to your mind frequently and
thinking that you can do anything possible?
Client : Not like that
Remarks : There is delusion, hypochondrical and obsessive
compulsive disorder.

(k) Perception
 Hallucinations: auditory/ visual/ olfactory/ gustatory/tactile
Student Nurse : Do you hear any sound or talk when you are alone?
Client : Yes. Some sound is hearing when I am alone.
Remarks : Auditory hallucinations present

(l) Cognitive Functions:

 Consciousness:
Student Nurse : Hello. Mr.Raju
Client : Yes
Remarks : Patient has obeyed by calling his name
 Orientation:
vii. Person
Student Nurse : Who is sitting nearby you?
Client : My son
Remarks : Oriented to person
viii. Place
Student Nurse : Where are you now?
Client : I am in SCPM hospital
Remarks : Oriented to place
ix. Time
Student Nurse : What is the day today?
Client : Wednesday
 Remarks : Oriented to time
 Attention:
Student Nurse : Repeat the digit backward 2, 4, 6,8,10?
Client : 10,8…6..2..4.
Remarks : Attention aroused with difficulty

 Concentration:
Student Nurse : Name the months in backward?
Client : December, November…September, October, June,
July, …August, March, ….January.
Remarks : Concentration sustained with difficulty
 Memory:
i. Immediate
Student Nurse : Repeat the word what I say Table, Pen, Rose, Bus and
Tree
Client : Table, Pen, Rose, Bus and Tree
Remarks : Immediate memory present
ii. Recent
Student Nurse : What you had in breakfast?
Client : Three Puri with Achar
Remarks : Recent memory present
iii. Remote
Student Nurse : When is your birthday?
Client : I don’t remember
Remarks : Remote memory poor
 Intelligence:
Student Nurse : Who is the chief minister of U.P.?
Client : Mr.Aditya Nath Yogi
Remarks : Normal intelligence
 Abstraction:
Student Nurse : What is the similarity and dissimilarity between Dog and
Lion?
 Client : Both are animal. Dog is the domestic animal and Lion is
the violent animal.
(m) Insight: (grade1 to 6)
Student Nurse : Do you accept your illness and require treatment?
Client : Yes. Drinking is affected my health
Remarks : Grade VI Insight is present

(n) Judgment:
Student Nurse : What you will you do if you find “House on fire”?
Client : I will call nearby peoples to put off the fire.
Remarks : Judgment is intact
XLII. Vital Signs
S. No. Vital Sign Normal Value Patient’s Value
1. Temperature 98.60 F 98.40 F
2. Pulse 72-90 Beats/M. 84 Beats/M.
3. Respiration 14-20 Breath/M. 22 Breath/M.
4. Blood Pressure 80-120mmHg 80-130mmHg
XLIII. Investigation:
S.No Name of the investigation Patient’s value Normal value
1 Blood
 Heamoglobin 11.7 gm/dl 14-16
 Red blood cell
5.47 milcmm 4.5-6.51
 PCV
 Platelets 39.9% 20-54
 Total WBC different count
2.43 lacs 1.5-4.5
 Neutrophil
 Lymphocytes 9400 cu/mm 5000-11000
 Esinophills
84% 40-75
 Monocytes
 MCV 29% 20-45
 MCH
06% 1-6
 MCHC
 ESR 01% 1-6

Routine Investigation
20mm/hr 0-20

 RBS
 Blood urea 152 mgs/dl < 150
 S. Creatinine 19 mg/dl 20-45
 S. Sodium 1.2mgs/dl 0.7-1.2
 S. Potassium
142 meq/l 135-145
LFT
5.0 meq/l 3.5-4.5
 S. Bilirubin
 S. total protein 1
1.2 mgs/dl
 S. Albumin 6-8
8.1 gm/dl
 S. Globulin 3-5
4.7 gm/dl
 A/G ratio 1.8-3.6
3.4 gm/dl
 SGOT 2-20
1.4
 SGPT 2-22
32 u/l
128 u/l 80-120
XLIV.Other therapeutic investigation:
USG abdomen done on 15/09/2020 result revealed that presence of
Hepatomegaly.
XLV. Medication chart:
3. Tab. Carbamazepine 600 mg/day OD × 7days
4. Tab. Diazepam 40mg HS × 7 days
5. Tab. Becosules 100mg BD × 7days
6. Tab.Nitrozepam 5mg PO × 5days
7. Olanzapine 5 mg BD x 5 days
8. Inj.Normal saline IV QDS × 3ays
 Pharmacologica

Responsibility
Trade Name

Side-effects
Indications
Frequency

Indication

Contra-
S.

l Name

Action
Doses
Group

Route

Nsg.
No
.

Tegr Carbam Mood 600 Oral OD Its mood Seizures, Drowsine Check the physician’s
etol azepine stabili mg stabilizing GTCS, ss, order.
zer mechanism is Seizure due to confusion, Medication given must
not clearly alcohol headache be charted on the
established. Its withdrawal, , patient’s case sheet.
anticonvulsant Bipolar hypertens Check the five rights for
action may disoerder, ions, drug administration
1. however be by acute arrhythmi Always address the
decreasing depression, as, patient by name and
synaptic impulse make certain
transmission in control identification
the CNS. disorder, Do not leave the
episepsy, patient until the drug is
Schizoaffectiv swallowed
e disorders. Do not allow the patient
Beco Thai Thiam Vit 100 I.M. O.D. It prevent to carry drugs
2. sules in ami mg peripheral - - Do not force oral
n neuropathy medication
3. Nitrizepa Benzo 5 Oral PO Benzodiazepin Anxiety Nausea, Check drug daily
m diaze mg es bind to disorders, vomiting, Observe for drug
pine specific sites insomnia,depr weakness specific side-effects
on the GABA ession, panic , vertigo, Instruct the family
receptors and disorders, blurring of members when to
increase GABA OCD, PTSD, vision, contact psychiatrist
 level. Since Bipolar epigasric
GABA is an disorders, pain,
inhibitory alcohol diarrhea,
neurotransmitte induced impotenc
r, it has a withdrawal e,
calming effect and substance sedation,
on the central induced ataxia,
nervous psychotic dry
system, thus agitation. mouth,
reducing retrograd
anxiety. e
amnesia.
Prod Fluxetin SSRI 20 Oral B.D. It blocks the Depressive Severe constipatio
ep e mg serotonin episode, renal n, urinary
reuptake depression failure, retention,
channel and with psychotic hypersensi hypotensi
4. increase symptoms, tivity, on,
serotonin level dysthymia, concomita impotenc
at post- ADHD, panic nt MAOI’s e,
synaptic space. attack, PTSD priapism,
and ADS. sedation
Oliza Olanzapi Thien 5 Oral BD It is an atypical Schizophrenia Hypersensi Sedation
ne obenz mg antipsychotic , acute tivity and
odiaz drug. It mainly psychosis, Hypotensi
5 epine act on 5HT2 mania, on (rare)
and D4 delusional
receptors. disorder,
ADHD.
XLVI.Other therapeutic therapies:
Yoga therapy, Group therapy and family counseling.

XLVII. Process Recording:

Time : 30 Minutes
Date : 15-09-2020
Place : Interview room of male psychiatric ward
Objectives : To
- maintain rapport
- obtain psychiatrist history
- make the patient ventilate feelings
- improve communication skills

Person Conversation Inference

Student Nurse Hello, Mr. Raju Responding
Client Hello, Sir properly
Student Nurse How are you? Anxious mood
Client I am feeling tired and fatigue
Student Nurse Had your food? Self care deficit
Client No, I am not feeling hungry
Student Nurse Did you have taken bath? Poor personal
Client No, I don’t want to take hygiene
Student Nurse Did you join exercise today with others? Loss of interest
Client No, I am tired, I am not able to do exercise
Student Nurse Can you repeat it 2…..6…..9…4…..1…..7….8 Immediate
Client 2…..6…..9…4….8 memory impaired
Student Nurse Can you tell me your birthday Remote memory
Client I don’t remember impaired
Student Nurse Who is with you in this hospital? Oriented to
Client My son person
Student Nurse What is the time now? Oriented to time
Client This is 11.00 AM
Student Nurse Which is this place? Oriented to place
Client This is SCPM hospital
Student Nurse Why you came here? Insight absent
Client No, this is not an illness, if I will drink, I will be (Level-1)
fine.
Student Nurse But, drinking is injurious to health. Denial
Client No, I am drinking since 32 years, I have no
problem, I am not habitual
Student Nurse Now it is not possible for you to stop drinking. Not aware
Client No, it is not a big problem, I can stop whenever regarding
I want. condition
Student Nurse Then why can’t you stop drinking Alcohol
Client If I will stop drinking alcohol, I will get more dependence
problem
Student Nurse What you will do after going from here? Able to take
Client I will continue my job decision.
Student Nurse Ok. Mr. Raju bye, take care Termination of
Client Bye process recording

Assessment techniques
 Observation
 Interview
 communication
Summary:
Mr. Raju is a 47 years male patient diagnoses as alcohol dependence with
psychosis. He is responding well but anxious. He is having self care deficit and poor
personal hygiene. He is having loss of interest in doing work. His immediate and
remote memory is impaired. He is oriented to time, place and person. Insight is
absent. He is not aware regarding his condition. He is able to take decision
 Disease Condition (Literature Review)
Introduction:
Substance use disorders constitute a public health problem of prime
importance. The social and health morbities are apparent in both developed and
developing countries more than the known, direct impact on health parameters.

Definition
ICD-10 alcohol dependence is a cluster of physiological, behavioral, and
cognitive phenomena in which the use of alcohol takes on a much higher priority for
a given individual than other behaviors that once had greater value

Etiology
1. Physiological theories
A. Genetic theory (Goodwin, 1979)
Some workers in the field of theories that alcoholism may be inherited.
Alcoholism appears to run in families.

B. Endocrine theory
Another major physiological theory of the cause of alcoholism indicates a
dysfunction of the endocrine function.

C. Genetotrophic theory
The genetotrophic theory of alcoholism combines the concept of genetic
trait and nutritional deficiencies.

D. Neurological theory (Gardener EL, 1997)

The neurobiological mechanisms, which have studies for understanding the
etiology of substance use disorders, are wide ranging and also vary according to the
substance.

2. Psychological theories
A. Psychoanalytic theory
The Freudian view as expressed by a number of people related alcoholism to
such factors as repressed urges, oral dependency, need for security, self
punishment and parental hatred.
 B. Learning theory
The learning and reinforcement theory explain alcoholism by considering
alcohol ingestion as a reflex response to some stimulus and as a way to reduce an
inner drive such as fear or anxiety.

C. Personality trait theory

Psychological research has also attempted to define the cause of
alcoholism in terms of an alcoholic personality.

3. Sociological theories (Johnson B.D., 1997)

A. Cultural theory
The cultural theory of alcoholism suggests that within a given society.
Societies may provide alternatives to or substitute for alcohol use.

B. Deviant behavior theory

Depending on the context, the use of alcohol can be illegal or only
illegitimate, acceptable or even sanctified.

Book Pictures Patient Pictures

Clinical Features
Psychopathology Alcohol is often As describe in book picture
misunderstood as a stimulant
because it appears to make
people more lively and less
inhibited. It is actually a
depressant. If taken in small
quantities, it depresses that
part of the brain controls
inhibitions, so the person
feels relaxed. When blood
alcohol concentration is low,
the drinker experiences a
feeling of relaxation,
tranquility and a sense of well
being. It slightly increases the
heart rate. When blood
 alcohol concentration is high,
it depresses the other areas
of the central nervous system
result in severe problems

Diagnostic  Blood investigation  Blood investigation

Evaluation  Observation  Observation
 Physical examination  Physical examination
 Mental status  Mental status examination
examination  History collection
 History collection
Treatment  Anti craving agent  Anti craving agent
Psychopharmaco  Anti anxiety  Anti anxiety
logy  Anti depressant  Anti depressant
 Anti psychotic  Anti psychotic
 Deterrent agent  Deterrent agent
Psychotherapy  Yoga therapy,
 Individual psychotherapy,
 Group therapy
 Family counseling.
 Behavior therapy
ECT Not recommended Not given

Nursing Process:
Day 1
S. Needs Problems
No.

Safety and security measures for Risk for injury

1 free from injury

Maintain the normal sensory Hearing sounds

2 perception and eliminate the
hallucinations

Nursing Diagnosis:

 At risk of injury as a result of environmental conditions interacting with the

individual’s adaptive and defensive resources.

 Disturbed sensory perception (auditory) related to withdrawal into the self as

evidenced by inappropriate responses
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Risk for Risk of injury as a The client will:  Place the client in a room near  Placed the client in a room Risk of
injury result of  Be safe and the nurses’ station or where the near the nurses’ station or injury has
environmental
free from staff can observe the client where the staff can observe minimized
conditions
interacting with injury closely. the client closely. to some
the individual’s  Respond to  Institute seizure precautions  Provided seizure extent.
adaptive and
reality according to hospital policy precautions like padded
defensive
resources as orientation (padded side rails, side rails up, side rails, side rails up,
evidenced by  Demonstrate airway at bedside, and so forth). airway at bedside.
uncooperative
decreased  Monitor the client’s sleep pattern;  Monitored the client’s sleep
behavior and
aggressive aggressive or he may need to be restrained at pattern.
behavior. threatening night if confused or if he wanders
behavior or attempts to climb out of bed.
 Talk to the client in simple, direct,  Talked to the client in
concrete language. Do not try to simple, direct, concrete
discuss the client’s feelings, language.
plans for treatment, or changes in
lifestyle when the client is
intoxicated or in withdrawal.
  Reorient the client to person,  Reoriented the client to
time, place, and situation as person, time, place, and
needed. situation as needed.
 Do not moralize or chastise the  Not moralized the client for
client for his alcoholism. Maintain his alcoholism. Maintained
a nonjudgmental attitude. a nonjudgmental attitude.
Abnormal Disturbed sensory Maintain the  Observe the client for sings of  Observed the client (pt has Client able
perception perception normal sensory hallucinations. talking to self) to define
like (auditory/visual) perception and  Avoid touching the client without  Maintain the IPR and the reality
hallucinati related to eliminate the warning. distance. and
ons withdrawal into hallucinations  Do not reinforce the  Encouraged his self eliminate
the self as hallucinations. esteem. the
evidenced by  Distract the client from the  Tried to involve in personal hallucinatio
inappropriate hallucinations. Encourage the tasks. ns in some
responses client to share hallucinations. extent
 Day 2

S. Needs Problems
No.

Use coping mechanisms instead of Ineffective coping

substance abuse.

Maintain normal nutritional balance Loss of weight, poor skin turgor and
electrolyte imbalance.

Nursing Diagnosis:

 Ineffective coping related to inadequate coping skills evidenced by use of substance as coping mechanism.

 Imbalanced nutrition less than body requirements/deficient fluid volume related to use of substances instead of eating as
evidenced by loss of weight, poor skin turgor and electrolyte imbalance.
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Ineffective coping Client will be  Set limits on manipulative  Set limits on manipulative
related to inadequate able to verbalize behavior. Administer behavior.
coping skills evidenced adoptive coping consequences when limits are
by use of substance as mechanisms to violated.
coping mechanism. use, instead of  Obtained routine urine
 Obtain routine urine samples
substance samples for laboratory
for laboratory analysis of
abuse, in analysis of substances.
substances.
response to
stress.  Exploreed options available
 Explore options available to
to assist with stress rather
assist with stress rather than
than reporting to substance
reporting to substance abuse.
abuse.
Practice these techniques.
 Given positive
 Give positive reinforcement for
reinforcement for ability to
ability to delay gratification and
delay gratification &
respond to stress with adoptive
respond to stress with
coping strategies.
adoptive coping strategy.
2. Imbalanced nutrition Client will be  Parenteral support may be  Given IV Normal saline Maintained
less than body free of required initially. 500ml BD/day. client
requirements/deficient signs/symptoms  Encourage cessation of  Encouraged cessation of nutritional
fluid volume related to of malnutrition alcoholism alcoholism balance and
use of substances and dehydration.  Consult dietitian. Determine the  Consulted dietitian. electrolyte
instead of eating as number of calories required Determine the number of imbalance
evidenced by loss of based on body size and level of calories. to some
weight, poor skin turgor activity. extent.
and electrolyte  Document intake and output,  Maintained I/O Chart and
imbalance. calorie count and weight daily. weight (66kg)
 Ensure that the amount of
protein in the diet is correct for  Ensured that the amount of
the client’s condition. protein for client’s condition.
 Sodium may need to be  Sodium is restricted
restricted
 Provide foods that are non -
 Provided non irritating foods
irritating to clients with
to esophageal varies.
esophageal varies.
Provided small frequent
 Provide small frequent feeding
feeding of clients favorite.
of clients favorite.
 Day 3

S. Needs Problems
No.

Ineffective denial (Weak and

1 Maintain effective denial
underdeveloped ego)

2 Proper health maintenance Poor personal hygiene

Nursing Diagnosis:

 Ineffective denial related to weak, underdeveloped ego evidenced by statements indicating no problem with substance use.
 Ineffective Health Maintenance related to Inability to identify, manage, and/or seek out help to maintain health evidenced by
sleep disturbances and dependence on alcohol
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Underdeveloped Ineffective denial Client will  Develop trust. Convey an attitude  Developed trust. Maintained
ego related to weak, demonstrate of acceptance. Ensure that client Conveyed an attitude of acceptance of
underdeveloped acceptance of understands it is not the person but acceptance. patient
ego evidenced by responsibility for the behavior that is unacceptable.  Corrected responsibility
statements own behavior  Correct any misconceptions, such misconceptions, such as for own
indicating no and as “I don’t have drinking problem. I “I don’t have drinking behavior and
problem with acknowledge can quit anytime I don’t want to.” problem. acknowledge
substance use. association Do this in a matter –of-fact, association
between nonjudgmental manner. between
substance use  Identify recent maladaptive  Identified recent substance
and personal behaviours or situations that have maladaptive behaviours use and
problems. occurred in the client life and or situations that have personal
discuss how use of substances occurred in the client life problems to
may be a contributing factor. and discussed it effect. some extent.
 Do not allow client to rationalize or  Not allowed client to
blame others for behaviours rationalize or blame
associated with substance use. others for behaviours.
Poor personal Ineffective Health The client will:  Complete the physical assessment  Completed the physical Maintained
hygiene Maintenance of the client; ask what and how assessment of the client; the normal
 Establish
related to Inability much the client usually drinks, as asked what and how daily activities
nutritious
to identify, eating well as the time and amount of the much the client usually of the client.
manage, and/or patterns last drink of alcohol. drinks.
seek out help to  Establish  Offer fluids frequently, especially  Offered fluids frequently,
maintain health physiologic juices and malts. Serve only especially juices and
evidenced by homeostasis decaffeinated coffee. malts.
sleep  Establish a  Monitor the client’s fluid and  Monitored the client’s
disturbances and balance of electrolyte balance. fluid and electrolyte
dependence on rest, sleep,  Provide food or nourishing fluids as balance.
alcohol and activity soon as the client can tolerate  Provided food or
 Maintain eating; have something available at nourishing fluids as soon
personal night. as the client can tolerate
hygiene and  Administer medication to minimize eating.
grooming the withdrawal or complications and  Administered medication
to facilitate sleep. to facilitate sleep.
 Encourage the client to bath, wash  Encouraged the client to
his hair & wear clean cloths. bath, wash his hair &
wear clean cloths.
 Day 4
S. Needs Problems
No.

1 Gain in knowledge about client Family members are unaware about

disease condition and prognosis. disease condition and treatments.

2 Client able to attempt the new Low self-esteem

activities without fear of failure.

Nursing Diagnosis:
 Knowledge deficit regarding disease condition and prognosis as evidenced by lack of information, unfamiliarity with
information resources.
 Low self esteem related to feeling of abandonment and impaired cognition functions as evidenced by not engaging in any
activities.
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Client’s family Knowledge Improve  Discuss the client disease condition  Discussed the client’s Family
members have deficit regarding the family with family members. Provide condition and prognosis members
poor disease member’s written handout and allow time to of the condition with knowledge
knowledge condition and knowledge ask questions and clarify the doubts. family members. improved
regarding prognosis as regarding  Discuss the client’s abnormal  Explained the client’s regarding
disease evidenced by disease behavior and causes of its. abnormal behaviors why disease
condition and lack of condition  Educate the family members on the he/she has. condition and
treatment, information, and use of medications and response  Cautionally explained prognosis of
prognosis. unfamiliarity with prognosis. anticipated. about the medications the client.
information  Arrange the small group activities uses and side effects.
resources. and allow the family members  Small group activities
exchange their feelings and arranged and outcome
knowledge regarding client’s was assessed.
condition and prognosis.
Client has low Low self esteem Client able  Be accepting of client and spend  Accepted the client Client self
self esteem related to feeling to attempt time with him even though thoughts and feelings it esteem
and of abandonment the new pessimism and negativism. makes positive improved at
confidence and impaired activities contribution. some extent.
cognition without  Focus on strength and  Talked about the client’s
functions as fear of accomplishments and minimize strengths and victory.
evidenced by not failure. failures.
engaging in any  Provide opportunities for success;  Repeated success
activities. plan activities with short time span improves the client’s self
and appropriate ability level. esteem.
 Help the client set realistic, concrete  Engaged in new tasks
goals and determine appropriate promotes personal
actions to meet these goals and growth and new skills.
encourage involvement of new
activities/ tasks.
 Theory Application
King’s theory:
King’s theory of goal attainment encompasses three broad interlocking open systems, the personal and interpersonal and
social system. The personal system and social system influence the quality of care and the major elements in the goal attainment
are contained in the interpersonal system. In these system two or more persons come together under the guidance if health care
organization to promote an optimal state of health.
The major concepts are –
 Interaction
 Perception
 Communication
 Transaction
 Roles
 Stress
 Growth and development
 Time and space.
 Transaction
Try to stop alcohol intake

Stress
Role
Environmental
- Use of Coping
Stresses
Methods
- Communication
- Therapies
- Educational
experience
- Socioeconomic
status
- Identify needs
problems
- Perception
- Solve the
problems
- Concerns
regarding
patient Time
- IPR
Space - Aware of
course
awareness
- Interaction

Kings Goal Attainment Theory

Health Education:
 Health education given regarding prevention and ill effects of alcohol.
 Identify difference between delusion and reality.
 Encourage social interaction.
 Improve the self care needs (personal hygiene) independently.
 Sleep hygiene techniques.
 Family’s to use alternative coping methods.
 Prevention of violent behavior.
 Taught about the positive coping methods.
 Prevention of self harm and others.
 Advised to spend more time with family when he feels to drink alcohol.
 Educated the patient and family members regarding medication- dosage and
side effects of the medication.
 Advice the patient for regular checks up and follows up.
 Advice to start the work gradually. Initially start with fulfill his own needs and
home works.

Discharge Plan:
Patient not yet discharged and receiving treatments.

Summary:
Mr.kanagarag brought to the psychiatric ward on 27/12/2008 with the
complaints of alcohol abuse, hallucination, irritability, psychomotor agitation, tremor
etc. Then he is diagnosed as a case of alcohol dependence syndrome. I have taken
this case for my case study and given four days care with counseling and health
education from 03/01/09 to 06/01/09.

Bibliography:
9. Townsend.M, (2007), “Psychiatric Mental Health Nursing”, Jaypee brothers,
New Delhi, Pp. -
10. Doenges M.E. et al., (1995), “Psychiatric Care Plans Guidelines for Planning
and Documenting Client Care”, 2nd ed. F. A. Davis Company, Philadelphia,
PA, Pp. -
11. Ahuja.N, (2006), “A Short Text Book of Psychiatry”, Jaypee brothers, New
Delhi, Pp. -
12. Sreevani.R, (2008), “A Guide to Mental Health and Psychiatric Nursing”,
Jaypee Brothers, New Delhi, Pp. -
 MENTAL HEALTH NURSING

CASE STUDY ON
SUBSTANCE
ABUSE
SUBMITTED TO
Mr. RAHUL SRIVASTAVA
ASSOCIATE PROFESSOR
HOD, MENTAL HEALTH NURSING
YASHRAJ COLLEGE OF NURSING

SUBMITTED BY

MR BOBY DWIVEDI
M.SC.NURSING 2ND YEAR,
YASHRAJ COLLEGE OF NURSING

DATE OF SUBMISION____________
 Patient’s Profile

XLVIII. Identification data

Client name : Mr. Sahil
Age : 28 years
Sex : Male
Father name : Mr. Khudabaksh
Address : Haripur
Gonda
Education : B.A.
Occupation : Automobile Shop
Income : Rs. 9000/ month
Marital status : Married
Religion : Muslim
Date of admission :02.09.2020
Provisional diagnosis : Substance abuse
Final diagnosis : Alcohol and nicotine withdrawal syndrome

XLIX.Informant : Father

L. Presenting Chief Complaints

According to Patient
o Lack of sleep
o Lack of appetite
o Weakness
o Nausea
o Vomiting
o Confusion
o Fearfulness
o Irritability
According to Informant (Father)
 o Irritability
o Shouting
o Mood alteration
o Decreased sleep
o Loss of appetite
o Trembling walk
o Mild tremors

LI. Family History

(t) Family Characteristics
Age
S. Relationship Age &
Name of the Educational Health
No with the (yr.)/ Occupation mode
family members Status Status
. Patient Sex of
death
1 Mr. Khudabaksh Father 54/M B.A Shopkeeper Healthy -
2 Mrs. Fathima Mother 50/F 8th std House wife Healthy -
3 Mrs. Naseema bibi Wife 25/F 10th std House wife Healthy -
4 Master Rafeek Son 2/M Nursery - Healthy -

(u) Genogram:
Key:-

54 yrs 50 yrs - Male

- Female

28yr 25 yrs - Patient

2 yrs
There is no family history of hypertension/diabetes mellitus/psychiatric
illness/alcoholism and suicide.

LII. Socio-economic history

Mr. Sahil is a shopkeeper. He and his father are the earning members in his
family. His monthly family income is 22000/ per month. He belongs to a middle class
family. He is living in ranted house. Electricity and water facility is available in house.
Drainage is proper.

LIII. History of Present Illness

Mr. Sahil apparently normal before one month then he developed the
symptoms like Insomnia, lack of appetite, weakness, nausea, vomiting, confusion,
fearfulness, irritability, mild tremors, and eye opener of cigarette and alcohol
consumption. Mr. Shahil did not take any psychiatric and de-addiction treatment
before. At present patient taking Tab. Carbamazepine 600 mg/day, Tab. Nitrozepam
5mg/day, Tab. Diazepam 40 mg/day, Inj. Neurobin fort 5 ml 4 time/ 7day and alcohol
anonymous therapy.

LIV.Past Psychiatric History

No significant data found related to the psychiatric illness in past life.

LV. Personal History

(f) Perinatal history
Mr. Sahil’s mother had proper antenatal checkup and period was
eventful. Baby delivered as full term normal vaginal delivery. Child cried
immediately after birth and there was no postnatal complication like cyanosis,
convulsions and jaundice.
(g) Childhood history
Primary caregiver was mother. Weaning started at the age of five months
and all developmental milestones was achieved at appropriate age period.
There was no behavior and emotional problems like temper tantrums, head
banging, nail biting and enuresis except thumb sucking and that behavior
changed at the age of one year.
(h) Educational history
Education was started at the age of 5 years. He was average in
academic performance and had good relationships with teachers and peers.
He never dropout from school. He left the study after BA and started to work
in automobile shop due to interest.
(i) Play history
 He used to play with both sex peer group and had good relationship with
peers.

(j) Emotional problems during adolescence

There is no significant data found of emotional problems like running
away from home, aggressiveness and assault.
(k) Puberty
Secondary sexual characteristics appeared at the age of 14 years. He did
not have anxious mood regarding sexual changes.
(l) Occupational history
Mr. Shahil started to work at the age of 20 year in the automobile shop.
He is satisfied with his job and having good interpersonal relationship with his
co-worker.
(m) Sexual and marital history
He got arrange marriage at the age of 25 year and it was
consanguineous marriage. He doesn’t have good interpersonal relationship
with his wife and sexual relationship also unsatisfactory due to alcoholism,
cigarette smoking and conflict with wife.
(n) Premorbid personality
xx. Interpersonal relationships : Extrovert
xxi. Use of leisure time : Going
out with the friends and co-worker
xxii. Predominant mood : Mood alteration
xxiii. Attitude to self and others :
Self-appraisal of abilities and
behaving normally with others.
xxiv. Attitude to work and
responsibility : He is going
regular to work and irresponsible
for any task.
xxv. Religious beliefs and moral
attitudes : Having faith on religious
 and participating in religious
activity.
xxvi. Fantasy life : No complaint of daydreams
xxvii. Habits : He is a taking alcohol
since last 6 years and smoking
cigarette from last 7 years.

LVI.Physical Examination:
During physical examination all the finding found normal rather than
(a) Extremities : Motor activity decreased & mild
tremors present
(b) Gastrointestinal system : Nausea and vomiting is present
and hepatomegaly present.
LVII. Mental Status Examination
(i) General appearance and behavior
 Appearance : Looking older
 Level of grooming : Normal
 Level of cleanliness : Adequate
 Level of consciousness : Drowsy
 Mode of entry : Persuaded by father and wife
 Cooperativeness : Normal
 Eye-to-eye contact : Maintained
 Psychomotor activity : Slightly Increased activity
 Rapport : Spontaneous
 Gesturing : Exaggerated
 Posturing : Normal posture
 Other movements : Slightly tremors present
 Other catatonic phenomena : Not present
 Conversion and dissociative signs : Not present
 Compulsive acts or rituals : Not present
 Hallucinatory behavior : Not present
(j) Speech
Student Nurse : What is your name?
 Client : Sahil
 Initiation : Patient responded when talk
 Reaction time : Normal
 Rate : Slow
 Productivity : Pressured speech
 Volume : Increased
 Tone : Normal variation
 Relevance : Some time off target
 Stream : Normal
 Coherence : Loosening of associations
 Others : No rhyming, punning, echolalia perseveration or
neologism.
(k) Mood
 Subjective
Student nurse : How do you feel?
Patient : I do not feel comfort in any situation and
everything irritating me and getting tired easily.
 Objective : Irritable mood.
(l) Thought
Student Nurse : What type of the ideas comes in your mind?
Client : Not anything specific but I have confusion in
taking decision.
 Stream : Normal thought is present. There is no retarded
thinking thought block and flight of ideas.
 Form : No thought disorder is present
 Content
Student nurse : Do you think that you can do anything possible?
Client : No it’s not like that.
Remarks : There is no delusion, hypochondrical and
obsessive compulsive disorder.
(m) Perception
 Hallucinations
 Student Nurse : Do you hear any sound or able to see someone
whenever you are alone?
Client : No. I don’t feel anything like that.
Remarks : No hallucinations present
(n) Cognitive Functions
 Consciousness
Student Nurse : Hello. Mr. Sahil
Client : Yes sir
Remarks : Patient has obeyed by calling his name
 Orientation
x. Person
Student Nurse : Who is sitting nearby you?
Client : My father
Remarks : Oriented to person
xi.Place
Student Nurse : Where are you now?
Client : I am in SCPM hospital
Remarks : Oriented to place
xii. Time
Student Nurse : What is the day today?
Client : Tuesday
Remarks : Oriented to time
 Attention
Student Nurse : Repeat the digit backward 2, 4, 6, 8, 10.
Client : 10, 8…4..6..2.
Remarks : Attention aroused with difficulty
 Concentration
Student Nurse : Name the months in backward?
Client : December, November…September, October,
June, July …August, March ….January.
Remarks : Concentration sustained with difficulty
 Memory
iv.Immediate
 Student Nurse : Repeat these word Table, Pen, Bus and Tree.
Client : Table, Pen, Bus and Tree
Remarks : Immediate memory present
v. Recent
Student Nurse : What you had in breakfast?
Client : Poori and Palak
Remarks : Recent memory present
vi.Remote
Student Nurse : When is your birthday?
Client : I don’t remember
Remarks : Remote memory poor
 Intelligence
Student Nurse : Who is the Prime Minister of India?
Client : Mr.Narendra Modi.
Remarks : Normal intelligence
 Abstraction
Student Nurse : What is the similarity and dissimilarity between
Dog and Lion?
Client : Both are animal. Dog is the domestic animal and
Lion is the king of forest.

(o) Insight: (grade1 to 6)

Student Nurse : Do you accept your illness and need treatment?
Client : Yes. Drinking and smoking affected my health
badly.
Remarks : Grade 6 Insight is present

(p) Judgment:
Student Nurse : What you will do if you find “Close latter on the
road”?
Client : I will take that and put in to postbox.
Remarks : Judgment is intact
LVIII. Vital Signs:
S. No. Vital Sign Normal Value Patient’s Value
1. Temperature 98.60 F 98.40 F
2. Pulse 72-90 Beats/M. 84 Beats/M.
3. Respiration 14-20 Breath/M. 22 Breath/M.
4. Blood Pressure 80-120mmHg 80-130mmHg

LIX.Investigation:
S. Patient’s
Investigations Normal Value Interpretation
No Value
1 Blood
 Heamoglobin 15 gm/dl 14-16 Normal
 Red blood cell 5.47 milcmm 4.5-6.51 Normal
 PCV 39.9% 20-54 Normal
 Platelets 2.43 lacs 1.5-4.5 Normal
 Total WBC
different count 9400 cu/mm 5000-11000 Normal
 Lymphocytes 29% 20-45 Normal
 Esinophills 06% 1-6 Normal
 Monocytes 01% 1-6 Normal
 MCV Normal
93fl 80-99
 MCHC
33.7g/dl 32-37 Normal
 ESR
LFT 20mm/hr 0-20 Normal
 S. Bilirubin
 S. total protein 1.2 mgs/dl 1 Slightly elevated
 S. Albumin 8.1 gm/dl 6-8 Normal
 S. Globulin 4.7 gm/dl 3-5 Normal
 A/G ratio 3.4 gm/dl 1.8-3.6 Normal
 SGOT 1.4 Normal
 SGPT 32 u/l 2-20 High
 Alkaline 28 u/l 2-22 High
phosphate
64 IU/l 80-120 Low

Patient is clinically normal except S. bilirubin is slightly elevated and SGOT,

SGPT are high whereas Alkaline phosphate is low.

LX. Other therapeutic investigation:

USG abdomen done on 2/2/2009 result revealed that presence of
Hepatomegaly.

LXI.Medication chart:
9. Tab. Carbamazepine 600 mg/day OD × 7days
10. Tab. Diazepam 40mg HS × 7 days
11. Tab. Nitrozepam 5mg OD × 5days
12. Inj. Neurobin Fort 5ml IM 4time/7days
 Pharmacologica

Responsibility
Trade Name

Side-effects
Indications
Frequency

Indication

Contra-
l Name

Action
Doses

Group
Route
S.

Nsg.
No

1. Teg Car 600 Or OD Moo Its mood stabilizing, Seizures, Seizure Pregnancy, Drowsiness, Advise him to avoid
reto bam mg al d Its anticonvulsant due to alcohol lactation, CVS confusion, driving and other
l aze stab action may however withdrawal, acute disease, headache, activity requiring
pine ilizer be by decreasing depression, impulse hepatic or hypertension alertness
synaptic transmission control disorder, renal arrhythmias, Advise patient not
in the CNS. Schizoaffective disorders. to consume
disorders. alcohol when he is
on the drug
Emphasize the
importance of
regular visit
2. Vali Dia 40 Or HS Ben Benzodiazepines Anxiety disorders, Lactation, Nausea, Report promptly if
um zep mg al zodi bind to specific sites insomnia, impaired renal vomiting, occipital
am aze on the GABA depression, OCD, & hepatic weakness, headache,
pine receptors and PTSD, alcohol function, vertigo, nausea, vomiting
increase GABA level. induced withdrawal reparatory blurring of chest pain these
it has a calming and substance insufficiency, vision, may be
effect on the central induced psychotic elderly, impotence, hypertensive crisis
nervous system, thus agitation. psychotic sedation, Caution the patient
reducing anxiety. patients, retrograde to change his
epileptics. amnesia. position slowly

3. Bar Nitr 5 Or OD Ben Benzodiazepines Anxiety disorders, Elderly, Nausea, Report promptly if
onit oze mg al zodi bind to specific sites insomnia, lactation, vomiting, occipital
 e pam aze on the GABA depression, OCD, sudden weakness, headache,
pine receptors and PTSD, Bipolar withdrawal, vertigo, nausea, vomiting
increase GABA level. disorders, alcohol pregnancy. blurring of chest pain these
Thus reducing induced withdrawal vision, may be
anxiety. and substance impotence, hypertensive crisis
induced psychotic sedation, Caution the patient
agitation retrograde to change his
amnesia. position slowly

4. Ne Neu 5ml IM 4ti Mult It is the vitamin Alcohol withdrawal Hypersensitivit Pain at the
uro robi me/ ivita supplement and symptoms and y injection site,
bin n 7da min reducing the vitamin deficiency excess really
For Fort ys withdrawal symptoms no serious
t side effects.
dizziness or
headache,
nausea,
diarrhea, or
constipation,
fatigue or
weakness,
and dry
mouth
LXII. Other therapeutic therapies:

Therapy Indication Nurses responsibility

Yoga therapy Almost all condition  Provide correct guidance

 Provide calm environment
 Help during the difficulties in yoga
Individual Stress related  Deliberately establishes a professional
psychotherapy disorder, alcohol and relation
drug dependence,  Remove or modify existing symptoms
sexual disorder and  Promote positive personality growth and
marital disharmony development
Group therapy Homogenous group,  Use any transference situations to
personality disorders, develop insight into their problems
families where the  Provide positive reinforcement, this
system needs gives ego support and encourages
change future growth
Family Psychosis, reactive  Assessment of family, roles,
counseling depression, anxiety, boundaries, resources, communication
psychosomatic patterns and problem solving skills
disorder, substance  Teaching communication skills
abuse  Teaching problem solving skills
LXIII. Process Recording:
Time : 30 Minutes
Date : 02-09-2009
Place : Interview room of male psychiatric ward
Objectives : To
- maintain rapport
- obtain psychiatrist history
- make the patient ventilate feelings
- improve communication skills

Person Conversation Inference

Student Nurse Hello, Sahil Responding
Client Hello minimum
Student Nurse How you are feeling? Anxious and
Client I am not feeling comfort, I am not able to looking drowsy
concentrate in the work
Student Nurse What you had in breakfast? Loss of appetite
Client No I don’t feel hungry
Student Nurse Did you have bath? Self care deficit
Client No, I will take later.
Student Nurse Did you join exercise today with others? Loss of interest
Client No, I am tired, I don’t want to do that.
Student Nurse Why you are not interested to do exercise? Irritability
Client I don’t want to do.
Student Nurse Can you repeat it 2…..6…..9…4…..1…..7….8 Immediate
Client 2…..6…..9…4…..1………..7……………..….8 memory Present
Student Nurse Can you tell me your birthday Poor remote
Client I don’t remember memory
Student Nurse What you will do after going from here? Not able to take
Client I will go to work regularly decision.
Student Nurse Now how do you feel about your health Inferiority feeling
Client It is really very bad habit I want to leave it and insight
present
Student Nurse Ok who is Prime minister of India Intelligence
Client Manmohan Singh normal
Student Nurse So now how do you feel Irritable mood
Client I do not feel comfort in any situation and
everything irritating me and getting tired easily
Student Nurse Ok. Sahil bye, take care Termination of
Client Bye process recording

Assessment techniques
 Observation
 Communication
 Interview

Summary
Mr. Sahil is a case of Alcohol and nicotine withdrawal syndrome. He is
responding minimum, Anxious and looking drowsy, loss of appetite, self care deficit,
loss of interest, Irritability, inferiority feeling, intelligence normal. His immediate and
remote memory is intact but he is able to take decision and having irritable mood.

Literature Review

Introduction:
Substance use disorders constitute a public health problem of prime
importance. The social and health morbidities are apparent in both developed and
developing countries more than the known, direct impact on health parameters.

Definition
ICD-10 alcohol dependence is a cluster of physiological, behavioral, and
cognitive phenomena in which the use of alcohol takes on a much higher priority for
a given individual than other behaviors that once had greater value

Book Pictures Patient Pictures

Etiology 4. Physiological theories  Deviant behavior
E. Genetic theory (Goodwin, 1979):- theory: - Depending
Some workers in the field of theories on the context, the
that alcoholism may be inherited. use of alcohol can
Alcoholism appears to run in families. be illegal or only
F. Endocrine theory:- Another major illegitimate,
physiological theory of the cause of acceptable or even
alcoholism indicates a dysfunction of sanctified.
the endocrine function.  Learning theory:-
G. Genetotrophic theory:- The The learning and
genetotrophic theory of alcoholism reinforcement
combines the concept of genetic trait theory explain
and nutritional deficiencies. alcoholism by
H. Neurological theory (Gardener considering alcohol
EL, 1997):- The neurobiological ingestion as a reflex
mechanisms, which have studies for response to some
understanding the etiology of stimulus and as a
substance use disorders, are wide way to reduce an
ranging and also vary according to inner drive such as
the substance. fear or anxiety.
5. Psychological theories  Personality trait
D. Psychoanalytic theory:- The theory:-
Freudian view as expressed by a Psychological
number of people related alcoholism research has also
to such factors as repressed urges, attempted to define
oral dependency, need for security, the cause of
self punishment and parental hatred. alcoholism in terms
E. Learning theory:- The learning of an alcoholic
and reinforcement theory explain personality.
alcoholism by considering alcohol
ingestion as a reflex response to
some stimulus and as a way to
reduce an inner drive such as fear or
anxiety.
 F. Personality trait theory:-
Psychological research has also
attempted to define the cause of
alcoholism in terms of an alcoholic
personality.
6. Sociological theories (Johnson
B.D., 1997)
C. Cultural theory: - The cultural
theory of alcoholism suggests that
within a given society. Societies may
provide alternatives to or substitute
for alcohol use.
D. Deviant behavior theory: -
Depending on the context, the use of
alcohol can be illegal or only
illegitimate, acceptable or even
sanctified.
Clinical Features  Insomnia  Insomnia
 Lack of appetite  Lack of appetite
 Weakness  Weakness
 Nausea  Nausea
 Vomiting  Vomiting
 Confusion  Confusion
 Fearfulness  Fearfulness
 Irritability  Irritability
 Irritability  Irritability
 Shouting  Shouting
 Mood alteration  Mood alteration
 Insomnia  Insomnia
 Loss of appetite  Loss of appetite
 Unsteady gait  Unsteady gait
 Mild tremors  Mild tremors
Psychopathology Alcohol is often misunderstood As describe in book
as a stimulant because it appears to picture
make people more lively and less
inhibited. It is actually a depressant. If
taken in small quantities, it depresses
that part of the brain controls inhibitions,
so the person feels relaxed. When
blood alcohol concentration is low, the
drinker experiences a feeling of
relaxation, tranquility and a sense of
well being. It slightly increases the heart
rate. When blood alcohol concentration
is high, it depresses the other areas of
the central nervous system result in
severe problems

Diagnostic  Blood investigation  Blood investigation

Evaluation  Observation  Observation
 Physical examination  Physical
 Mental status examination examination
 History collection  Mental status
examination
 History collection
Treatment  Anti craving agent  Anti craving agent
Psychopharmaco  Anti anxiety  Anti anxiety
logy  Anti depressant  Anti depressant
 Anti psychotic  Mood stabilizer
 Mood stabilizer
Psychotherapy  Yoga therapy,  Yoga therapy,
 Individual psychotherapy,  Individual
 Group therapy psychotherapy,
 Family counseling.  Group therapy
 Behavior therapy  Family counseling.
 Behavior therapy
 Nursing Process:
Day 1
S. Needs Problems
No.
Safety and security measures for Risk for injury
1 free from injury

Improve self esteem and gain good Feeling of abandonment and impaired
2 confidence. cognition functions

Nursing Diagnosis:

 At risk of injury as a result of environmental conditions interacting with the

individual’s adaptive and defensive resources.

 Low self esteem related to feeling of abandonment and impaired cognition

functions as evidenced by not engaging in any activities.
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Risk for Risk of injury as The client will:  Place the client in a room near  Placed the client in a room Risk of
injury a result of  Be safe and the nurses’ station or where the near the nurses’ station or injury has
environmental
free from staff can observe the client where the staff can observe minimized
conditions
interacting with injury closely. the client closely. to some
the individual’s  Respond to  Institute seizure precautions  Provided seizure extent.
adaptive and
reality according to hospital policy precautions like padded
defensive
resources as orientation (padded side rails, side rails up, side rails, side rails up,
evidenced by  Demonstrate airway at bedside, and so forth). airway at bedside.
uncooperative
decreased  Monitor the client’s sleep pattern;  Monitored the client’s sleep
behavior and
aggressive aggressive or he may need to be restrained at pattern.
behavior. threatening night if confused or if he wanders
behavior or attempts to climb out of bed.
 Talk to the client in simple, direct,  Talked to the client in
concrete language. Do not try to simple, direct, concrete
discuss the client’s feelings, language.
plans for treatment, or changes in
lifestyle when the client is
intoxicated or in withdrawal.
  Reorient the client to person,  Reoriented the client to
time, place, and situation as person, time, place, and
needed. situation as needed.
 Do not moralize or chastise the  Not moralized the client for
client for his alcoholism. Maintain his alcoholism. Maintained
a nonjudgmental attitude. a nonjudgmental attitude.
Client has Low self esteem Client able to  Be accepting of client and spend  Accepted the client Client self
low self related to feeling attempt the time with him even though thoughts and feelings it esteem
esteem of abandonment new activities pessimism and negativism. makes positive improved
and and impaired without fear of  Focus on strength and contribution. at some
confidence cognition failure. accomplishments and minimize  Talked about the client’s extent.
functions as failures. strengths and victory.
evidenced by not  Provide opportunities for  Repeated success
engaging in any success; plan activities with short improves the client’s self
activities. time span and with ability level. esteem.
 Help the client set realistic,  Engaged in new tasks
concrete goals and determine promotes personal growth
appropriate actions to meet these and new skills.
goals and encourage
involvement of new activities/
tasks.
 Day 2
S. Needs Problems
No.
1. Use coping mechanisms instead of Ineffective coping
substance abuse.

2. Maintain normal nutritional balance Loss of weight, poor skin turgor and
electrolyte imbalance.

Nursing Diagnosis:

 Ineffective coping related to inadequate coping skills evidenced by use of substance as coping mechanism.

 Imbalanced nutrition less than body requirements/deficient fluid volume related to use of substances instead of eating as
evidenced by loss of weight, poor skin turgor and electrolyte imbalance.
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Ineffective Ineffective coping Client will be  Set limits on manipulative  Set limits on manipulative Client is able
coping related to inadequate able to verbalize behavior. Administer behavior. to verbalize
coping skills evidenced adoptive coping consequences when limits are adoptive
by use of substance as mechanisms to violated. coping
coping mechanism. use, instead of  Obtained routine urine mechanisms
 Obtain routine urine samples
substance samples for laboratory to use in
for laboratory analysis of
abuse, in analysis of substances. response to
substances.
response to stress.
stress.  Explored options available
 Explore options available to
to assist with stress rather
assist with stress rather than
than reporting to substance
reporting to substance abuse.
abuse.
Practice these techniques.
 Given positive
 Give positive reinforcement for
reinforcement for ability to
ability to delay gratification and
delay gratification &
respond to stress with adoptive
respond to stress with
coping strategies.
adoptive coping strategy.
Loss of Imbalanced nutrition Client will be  Parenteral support may be  Given IV Normal saline Maintained
weight, poor less than body free of required initially. 500ml BD/day. client
skin turgor and requirements/deficient signs/symptoms  Encourage cessation of  Encouraged cessation of nutritional
electrolyte fluid volume related to of malnutrition alcoholism alcoholism balance and
imbalance use of substances and dehydration.  Consult dietitian. Determine the  Consulted dietitian. electrolyte
instead of eating as number of calories required Determine the number of imbalance to
evidenced by loss of based on body size and level of calories. some extent.
weight, poor skin turgor activity.
 Maintained I/O Chart and
and electrolyte  Document intake and output,
weight (66kg)
imbalance. calorie count and weight daily.
 Ensure that the amount of
 Ensured that the amount of
protein in the diet is correct for
protein for client’s condition.
the client’s condition.
 Sodium is restricted
 Sodium may need to be
restricted  Provided non irritating
 Provide foods that are non - foods to esophageal varies.
irritating to clients with  Provided small frequent
esophageal varies. feeding of clients favorite.
 Provide small frequent feeding
of clients favorite.
 Day 3
S. Needs Problems
No.

Ineffective denial (Weak and

1 Maintain effective denial
underdeveloped ego)

2 Proper health maintenance Poor personal hygiene

Nursing Diagnosis:

 Ineffective denial related to weak, underdeveloped ego evidenced by statements indicating no problem with substance use.

 Ineffective Health Maintenance related to Inability to identify, manage, and/or seek out help to maintain health evidenced by
sleep disturbances and dependence on alcohol
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Underdeveloped Ineffective denial Client will  Develop trust. Convey an attitude of  Developed trust. Maintained
ego related to weak, demonstrate acceptance. Ensure that client Conveyed an attitude of acceptance of
underdeveloped acceptance of understands it is not the person but acceptance. patient
ego evidenced responsibility for the behavior that is unacceptable.  Corrected responsibility
by statements own behavior  Correct any misconceptions, such misconceptions, such as for own
indicating no and as “I don’t have drinking problem. I “I don’t have drinking behavior and
problem with acknowledge can quit anytime I don’t want to.” Do problem. acknowledge
substance use. association this in a matter-of-fact, association
between nonjudgmental manner. between
substance use  Identify recent maladaptive  Identified recent substance
and personal behaviours or situations that have maladaptive behaviours use and
problems. occurred in the client life and or situations that have personal
discuss how use of substances may occurred in the client life problems to
be a contributing factor. and discussed it effect. some extent.
 Do not allow client to rationalize or  Not allowed client to
blame others for behaviours rationalize or blame
associated with substance use. others for behaviours.
Poor personal Ineffective Health The client will:  Complete the physical assessment  Completed the physical Maintained
hygiene Maintenance of the client; ask what and how assessment of the client; the normal
 Establish
related to much the client usually drinks, as asked what and how daily activities
nutritious
Inability to eating well as the time and amount of the much the client usually of the client.
identify, manage, patterns last drink of alcohol. drinks.
and/or seek out  Establish  Offer fluids frequently, especially  Offered fluids frequently,
help to maintain physiologic juices and malts. Serve only especially juices and
health evidenced homeostasis decaffeinated coffee. malts.
by sleep  Establish a  Monitor the client’s fluid and  Monitored the client’s
disturbances and balance of electrolyte balance. fluid and electrolyte
dependence on rest, sleep,  Provide food or nourishing fluids as balance.
alcohol and activity soon as the client can tolerate  Provided food or
 Maintain eating; have something available at nourishing fluids as soon
personal night. as the client can tolerate
hygiene and  Administer medication to minimize eating.
grooming the withdrawal or complications and  Administered medication
to facilitate sleep. to facilitate sleep.
 Encourage the client to bath, wash  Encouraged the client to
his hair & wear clean cloths. bath, wash his hair &
wear clean cloths.
 Day 4
S. Needs Problems
No.
1 Gain in knowledge about client Family members are unaware about
disease condition and prognosis. disease condition and treatments.

2 Client able to attempt the new Low self-esteem

activities without fear of failure.

Nursing Diagnosis:

 Knowledge deficit regarding disease condition and prognosis as evidenced by lack of information, unfamiliarity with
information resources.

 Low self esteem related to feeling of abandonment and impaired cognition functions as evidenced by not engaging in any
activities.
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Client’s family Knowledge Improve  Discuss the client disease condition  Discussed the client’s Family
members have deficit regarding the family with family members. Provide condition and prognosis members
poor disease member’s written handout and allow time to of the condition with knowledge
knowledge condition and knowledge ask questions and clarify the doubts. family members. improved
regarding prognosis as regarding  Discuss the client’s abnormal  Explained the client’s regarding
disease evidenced by disease behavior and causes of its. abnormal behaviors why disease
condition and lack of condition  Educate the family members on the he/she has. condition and
treatment, information, and use of medications and response  Cautionally explained prognosis of
prognosis. unfamiliarity with prognosis. anticipated. about the medications the client.
information  Arrange the small group activities uses and side effects.
resources. and allow the family members  Small group activities
exchange their feelings and arranged and outcome
knowledge regarding client’s was assessed.
condition and prognosis.
Client has low Low self esteem Client able  Be accepting of client and spend  Accepted the client Client self
self esteem related to feeling to attempt time with him even though thoughts and feelings it esteem
and of abandonment the new pessimism and negativism. makes positive improved at
confidence and impaired activities contribution. some extent.
cognition without  Focus on strength and  Talked about the client’s
functions as fear of accomplishments and minimize strengths and victory.
evidenced by not failure. failures.
engaging in any  Provide opportunities for success;  Repeated success
activities. plan activities with short time span improves the client’s self
and appropriate ability level. esteem.
 Help the client set realistic, concrete  Engaged in new tasks
goals and determine appropriate promotes personal
actions to meet these goals and growth and new skills.
encourage involvement of new
activities/ tasks.
 Theory Application

King’s theory:
King’s theory of goal attainment encompasses three broad interlocking;
- Open systems,
- The personal and interpersonal and
- Social system
The personal system and social system influence the quality of care and the
major elements in the goal attainment are contained in the interpersonal system. In
these system two or more persons come together under the guidance if health care
organization to promote an optimal state of health.
The major concepts are –
 Interaction
 Perception
 Communication
 Transaction
 Roles
 Stress
 Growth and development
 Time and space.
 Transaction
Try to stop alcohol intake

Stress
Role
Environmental
- Use of Coping
Stresses
Methods
- Communication
- Therapies
- Educational
experience
- Socioeconomic
status
- Identify needs
problems
- Perception
- Solve the
problems
- Concerns
regarding
patient Time
- IPR
Space - Aware of
course
awareness
- Interaction

Kings Goal Attainment Theory

Health Education:
 Health education given regarding ill effects of alcohol and smoking & prevention.
 Encourage social interaction.
 Improve the self care needs (personal hygiene) independently.
 Sleep and hygiene techniques.
 Family’s to use alternative coping methods.
 Prevention of violent behavior.
 Taught about the positive coping methods.
 Prevention of self harm and others.
 Advised to spend more time with family.
 Educated the patient and family members regarding dosage and side effects of
the medication.
 Advice the patient for regular checks up and follows up.
Discharge Plan:
Patient not yet discharged and receiving treatments.
Summary:
Mr. Sahil brought to the psychiatric ward on 2/1/2009 with the complaints of
Insomnia, lack of appetite, weakness, nausea, vomiting, confusion, fearfulness,
irritability, mild tremors, and eye opener of cigarette and alcohol consumption. Then
he is diagnosed as a case of alcohol and nicotine withdrawal syndrome. I have taken
this case for my case study and given four days care with counseling and health
education from 06/01/09 to 09/01/09.
Bibliography:
13. Townsend.M, (2007), “Psychiatric Mental Health Nursing”, Jaypee brothers,
New Delhi, India.
14. Doenges M.E. et al., (1995), “Psychiatric Care Plans Guidelines for Planning
and Documenting Client Care”, 2nd ed. F. A. Davis Company, Philadelphia,
PA.
15. Ahuja.N, (2006), “A Short Text Book of Psychiatry”, Jaypee brothers, New
Delhi, India.
16. Sreevani.R, (2008), “A Guide to Mental Health and Psychiatric Nursing”,
Jaypee Brothers, New Delhi, India.

140
 MENTAL HEALTH NURSING
CASE STUDY ON
ALCOHOL
DEPENDENCE WITH
PSYCHOSIS
SUBMITTED TO
Mr. RAHUL SRIVASTAVA
ASSOCIATE PROFESSOR
HOD, MENTAL HEALTH NURSING
YASHRAJ COLLEGE OF NURSING

SUBMITTED BY
MR BOBY DWIVEDI
M.Sc. NURSING 2ND YEAR
YASHRAJ COLLEGE OF NURSING

DATE OF SUBMISION____________

141
 Patient’s Profile

LXIV. Identification data

Client name : Mr. Satya
Age : 52 Years
Sex : Male
Father / Spouse name : Mr. Narendra
Address : haripur
Gonda
U.P.
Education : No formal education
Occupation : Agriculture
Income : Rs. 2000/ month.
Marital status : Married
Religion : Hindu
Date of admission : 11.09.2020
Provisional diagnosis : Alcohol dependence with psychosis
Final diagnosis : Alcohol dependence with psychosis
Informant : Son (Reliable)

LXV. Presenting Chief Complaints

According to Patient
o Difficulty in getting sleep up to late night
o Difficulty in recalling
o Seizures
o Hearing unusual voices
o Tremers
o Not able to control taking alcohol

According to Informant
o Dependence on alcohol
o Frequent ingestion of alcohol

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 o Physical exhaustion
o Confusion
o Uncooperative behavior
o Talking to self
o Aggressive behavior

LXVI. History of Present Illness

Mr. Satya , a 52 year male patient admitted in NIMHANS hospital, male close
ward with the complaints of not getting sleep till late night. He is a known alcoholic
since 32 years. He is daily taking about 400-500ml alcohol. When he is not getting
alcohol he will be aggressive, having tremors and seizures. He is having poor
impulse control to take alcohol and continue taking alcohol. He is hearing unusual
voices and talking to self. Previously he was refusing to take treatment. 10.12.208
he was brought to NIMHANS by his son. He was diagnosed as alcohol dependence
with psychosis. He was admitted in male close ward for further investigation and
treatment.

LXVII. Family History

(v) Family Characteristics
Age
Name of the Relationship Age &
S. Educationa Occupatio Health
family with the (yr.)/ mode
No. l Status n Status
members Patient Sex of
death
No formal Alcohol
1 Mr. Satya Patient 52/M Agriculture -
education dependence
No formal
2 Mrs. Laxmi Wife 49/F House wife Healthy -
education
3 Mr. Basavraj Son 24/M B.Ed. Teacher Healthy -
4 Mr. Kumar Son 22/M Degree Student Healthy -
5 Mr. Kishor Son 18/M Degree Student Healthy -
12th
6 Mrs. Kanga Daughter in law 21/F House wife Healthy -
standard

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 (w)Genogram:
Key:-

53 yrs 49 yrs - Male

- Female

- Patient

18yrs 22yrs 24yrs 21yrs

Mr. Satya’s father was an alcoholic. There is no family history of

psychiatric illness, suicide, epilepsy or endocrinological problems.

LXVIII. Socio-economic history

Mr. Satya is living in his own house. He is having joint family. His son is
earning member in his family working as a teacher. His monthly income is
12000/- and belongs to middle income group. He is having electricity and water
facilities in his house. Ventilation is adequate. Drainage facility is also hygienic.
The living space is adequate.

LXIX. Treatment History

 Chlordiazepoxide – 20mg Q.I.D.
 Carbamazepine – 600mg B.D.
 Thiamin – 100mg O.D.
 Fluxetine – 20mg B.D.
 Haloperidol – 10mg B.D.
 Olenzepine – 5mg B.D.

LXX. Past Psychiatric History

Mr. Satya have no significant psychiatric history

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LXXI. Past Medical History
Mr. Satya did not have any major medical illness history.

LXXII. Past surgical History

There is no significant surgical history.
LXXIII. Personal History
(o) Perinatal history
No perinatal history is available
(p) Childhood history
Primary caregiver was mother. There was no behavior and emotional
problems like temper tantrums, head banging, nail biting and enuresis except
thumb sucking and that behavior changed at the age of one year.
(q) Educational history
No formal education

(r) Play history

He used to play with both sex peer group and had good relationship with
peers.
(s) Emotional problems during adolescence
There is no significant history of emotional problems like running away
from home, aggressiveness and assault.
(t) Puberty
Secondary sexual characteristics appeared at the age of 14-16 years. He
did not have anxious mood regarding sexual changes.
(u) Occupational history
Mr. Satya is a farmer. He is having his own agriculture land.
(v) Sexual and marital history
He got arrange marriage at the age of 23 year and it was
consanguineous marriage. He had good interpersonal relationship with his
wife and sexual relationship also satisfactory.
(w)Premorbid personality
xxviii. Interpersonal relationships : Extrovert
xxviv. Use of leisure time : Chatting with age groups

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 xxix. Predominant mood : Mood alteration
xxx. Attitude to self and others :
Self-appraisal of abilities and
behaving normally with others.
xxxi. Attitude to work and
responsibility : He is going
regular to work and responsible for
any task.
xxxii. Religious beliefs and moral
attitudes : Having faith on religious
and participating in religious
activity.
xxxiii. Fantasy life
: When he drunken that time
talking irrelevantly
xxxiv. Habits : He is drinking alcohol
last 32 years.

LXXIV. Physical Examination:

During physical examination all the finding found normal expect
(c) Extremities : Having tremors
(d) Gastrointestinal system : Nausea and vomiting is present
and hepatomegaly present.

LXXV.Mental Status Examination

(q) General appearance and behavior
 Appearance : Looking same age
 Level of grooming : Ungroomed
 Level of cleanliness : Unhygienic
 Level of consciousness : Conscious
 Mode of entry : Persuaded by son
 Cooperativeness : Cooperative
 Eye-to-eye contact : Maintained

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  Psychomotor activity : Decreased activity, tremors
 Rapport : Maintained properly
 Gesturing : Exaggerated
 Posturing : Normal posture
 Other movements : Retarded
 Other catatonic phenomena : Not present
 Conversion and dissociative signs : Not present
 Compulsive acts or rituals : Not present
 Hallucinatory behavior : Auditory hallucination

(r) Speech
Student Nurse : What is your name?
Client : Satya
 Initiation : Patient responded when talk
 Reaction time : Normal
 Rate : Slow
 Productivity : Pressured speech
 Volume : Decreased
 Tone : Normal variation
 Relevance : Some time off target
 Stream : Normal
 Coherence : Loosening of associations
 Others : No rhyming, punning, echolalia perseveration or
neologism.
(s) Mood
 Subjective
Student nurse : How do you feel?
Patient : I do not feel comfort till I won’t drink .
 Objective : Irritable mood.

(t) Thought
Student Nurse : What type of the ideas comes in your mind?

147
 Client : Not anything specific but I have repeated urge to
drink
 Stream : Normal thought is present. There is no retarded
thinking thought block and flight of ideas.
 Form : No thought disorder is present
 Content
Student nurse : what you feel about yourself?
Client : I will not live if I won’t drink
Remarks : No delusional thinking

(u) Perception
 Hallucinations
Student Nurse : Do you hear any sound or able to see someone
whenever you are alone?
Client : Yes, I usually hear a sound that motivate me
when I will not drink
Remarks : Auditory hallucinations present

(v) Cognitive Functions

 Consciousness
Student Nurse : Hello, Mr. Satya
Client : Hello, sir
Remarks : Patient has obeyed by calling his name
 Orientation
xiii. Person
Student Nurse : Who is sitting nearby you?
Client : My son
Remarks : Oriented to person
xiv. Place
Student Nurse : Where are you now?
Client : I am in SCPM hospital
Remarks : Oriented to place
xv. Time

148
 Student Nurse : What is the day today?
Client : Saturday
Remarks : Oriented to time
 Attention
Student Nurse : Repeat the digit backward 2, 4, 6, 8, 10.
Client : 10, 8…4..6..2.
Remarks : Attention aroused with difficulty
 Concentration
Student Nurse : Name the months in backward?
Client : December, November…September, October,
June, July …August, March ….January.
Remarks : Concentration sustained with difficulty
 Memory
vii. Immediate
Student Nurse : Repeat the word what I say Table, Pen, Rose,
Bus and Tree.
Client : Table, Pen, Rose, Bus and Tree
Remarks : Immediate memory present
viii. Recent
Student Nurse : What you had in breakfast?
Client : Poori and Sabji
Remarks : Recent memory present
ix.Remote
Student Nurse : When is your birthday?
Client : I don’t remember
Remarks : Remote memory poor
 Intelligence
Remarks : Normal intelligence
 Abstraction
Student Nurse : What is the similarity and dissimilarity between
Dog and Lion?
Client : Both are animal. Dog is the domestic animal and
Lion is the king of forest.

149
 (w)Insight: (grade1 to 6)
Student Nurse : Do you accept your illness and require
treatment?
Client : No, this is not an illness, if I will drink, I will be
fine
Remarks : Grade 1 Insight is present

(x) Judgment:
Student Nurse : What you will you do if you find “Close latter on
the road”?
Client : I will check it.
Remarks : Judgment is normal
LXXVI. Vital Signs:
S. No. Vital Sign Normal Value Patient’s Value
1. Temperature 98.60 F 1000 F
2. Pulse 72-90 Beats/M. 96 Beats/M.

3. Respiration 14-20 Breath/M. 22 Breath/M.

4. Blood Pressure 120/80mmHg 120/90mmHg

150
LXXVII. Investigation:
S.N. Investigation Patient’s value Normal value Interpretation

151
1 Blood
 Heamoglobin 12.3 gm/dl 14-16 Normal
 Red blood cell 5.24 milcmm 4.5-6.51 Normal
 PCV 38.4% 20-54 Normal
 Platelets 2. 34 lacs 1.5-4.5 Normal
 Total WBC
different count Normal
8900 cu/mm 5000-11000
 Neutrophil Increase
77% 40-75
 Lymphocytes Normal
34% 20-45
 Esinophills Normal
05% 1-6
 Monocytes Normal
02% 1-6
 ESR
18mm/hr 0-20

Routine
Investigation

 RBS Normal
143 mgs/dl < 150
 Blood urea Normal
44 mg/dl 20-45
 S. Creatinine Normal
1.4mgs/dl 0.7-1.2
 S. Sodium Normal
 S. Potassium 141 meq/l 135-145
Normal
4.0 meq/l 3.5-4.5 Normal
LFT

 S. Bilirubin
1.4 mgs/dl 1 Increase
 S. total protein
8.0 gm/dl 6-8 Normal
 S. Albumin
3.7 gm/dl 3-5 Normal
 S. Globulin
3.2 gm/dl 1.8-3.6 Normal
 A/G ratio
1.7 2-20 Normal
 SGOT
44 u/l 2-22 Increase
 SGPT
132 u/l 80-120 Increase

LXXVIII. Medication chart:

8. Chlordiazepoxide – 20mg Q.I.D.
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9. Carbamazepine – 600mg B.D.
10. Thiamin – 100mg O.D.
11. Fluxetine – 20mg B.D.
12. Haloperidol – 10mg B.D.
13. Olenzepine – 5mg B.D.

153
 Pharmacologica

Responsibility
Trade Name

Side-effects
Indications
Frequency

Indication

Contra-
l Name

Action
Doses
Group

Route
S.

Nsg.
N.

Tab. Chlordia Anxiol 20 Oral Q.I. It increases the Anxiety, Jaundice, Physical  Administer with food
Libriu zepoxid ytic mg D. activity of the phobias, myastheniaand  Advise the patient
m e inhibitory psychosomatic gravis, psycholog to take medication
transmitter disorders. acute ical exactly as directed.
GABA in pulmonary dependen  Explain about
1. different parts insufficienc
ce, adverse effects and
of CNS. Sine y and
withdrawa advise to avoid
muscle respiratory
l driving
relaxant and depression.
syndrome  Instruct patient not
anticonvulsant , sedation to take alcohol
activity. skin rash
Tab. Carbama Antico 600 Oral B.D. It reduces Epilepsy, Hypersensi Drowsines  Advise him to avoid
Tegret zepine nvuls mg polysynaptic alcohol tivity, s, driving and other
ol ant responses and withdrawal A.V.conduc lassitude, activity requiring
blocks post syndrome, tion dry mouth, alertness
titanic mania, painful abnormaliti blurred  Advise patient not
2. potentiating. diabetic es, vision, to consume alcohol
Effective in neurooathies, porphyria muscle when he is on the
partial and trigeminal weakness, drug
generalized neuralgia insomnia  Emphasize the
convulsion. importance of
regular visit
3. Tab. Olanzapi Thien 5 Oral BD It is an atypical Schizophrenia Hypersensi Sedation  Instruct the patient
Oliza ne obenz mg antipsychotic , acute tivity and to take sips of water

154
 odiaz drug. It mainly psychosis, Hypotensi  Advise the patient
epine act on 5HT2 mania, on (rare) to get up from the
and D4 delusional bed very slowly
receptors. disorder,  Observe abnormal
ADHD. movements
Inj. Thiamin Vitami 75 I.M. O.D. It prevent
Thai n mg peripheral
4. - - - -
neuropathy

Tab. Fluxetin SSRI 20 Oral B.D. It blocks the Depressive Severe constipatio  Report promptly if
Prod e mg serotonin episode, renal n, urinary occipital headache,
ep reuptake depression failure, retention, nausea, vomiting
channel and with psychotic hypersensi hypotensi chest pain these
5. increase symptoms, tivity, on, may be
serotonin level dysthymia, concomita impotenc hypertensive crisis
at post- ADHD, panic nt MAOI’s e,  Caution the patient
synaptic space. attack, PTSD priapism, to change his
and ADS. sedation position slowly
Tab. Haloperi Butyr 10 Oral B.D It antagonist at Acute mania, Closed Tardive  Instruct the patient to
Oper dol ophen mg . central and acute angle dyskinesi take sips of water
ex one peripheral schizophrenia, glaucoma, a, EPS,  Advise the patient to
dopamine bipolar prostatic anxiety, get up from the bed
7. receptors and affective hypertroph postural very slowly
selective for disorder, y, coma hypertens  Observe abnormal
the D2 receptor severe resulting ion, anti movements
produces agitation in from CNS cholinergi
calmness elderly depression c effects

155
14. Other therapies:
Psychotherapy Indication Nursing responsibilities
Individual Stress related  Deliberately establishes a
psychotherapy disorder, alcohol professional relation
and drug  Remove or modify existing
dependence, symptoms
sexual disorder  Promote positive personality
and marital growth and development
disharmony
Group psycho- Homogenous  Use any transference situations to
therapy group, develop insight into their problems
adolescents and  Protect members from verbal
patients with abuse or from scapegoating
personality  Provide positive reinforcement,
disorders, this gives ego support and
families and encourages future growth
couples where  Use silence effectively to
the system needs encourage introspection and
change facilitate insight.
Psycho- Depression,  Brought patient in directly as and
education psychosis, active participant
anxiety, phobia  Coordinate the process to attain
maximum benefit
 Educate regarding the condition
and coping mechanism
Family therapy Psychosis,  Assessment of family, roles,
reactive boundaries, resources,
depression, communication patterns and
anxiety, problem solving skills
psychosomatic  Teaching communication skills
disorder,  Teaching problem solving skills
substance abuse  Homework assignment

15. Process Recording:

156
 Time : 30 Minutes
Date : 06-01-2009
Place : Interview room of male psychiatric ward
Objectives : To
- maintain rapport
- obtain psychiatrist history
- make the patient ventilate feelings
- improve communication skills

Person Conversation Inference

Student Nurse Hello, Mr. Satya Responding
Client Hello, Sir properly
Student Nurse How are you? Anxious mood
Client I am feeling tired and fatigue
Student Nurse Had your food? Self care deficit
Client No, I am not feeling hungry
Student Nurse Did you have taken bath? Poor personal
Client No, I don’t want to take hygiene
Student Nurse Did you join exercise today with others? Loss of interest
Client No, I am tired, I am not able to do exercise
Student Nurse Can you repeat it 2…..6…..9…4…..1…..7….8 Immediate
Client 2…..6…..9…4….8 memory impaired
Student Nurse Can you tell me your birthday Remote memory
Client I don’t remember impaired
Student Nurse Who is with you in this hospital? Oriented to
Client My son person
Student Nurse What is the time now? Oriented to time
Client This is 11.00 AM
Student Nurse Which is this place? Oriented to place
Client This is SCPM hospital
Student Nurse Why you came here? Insight absent
Client No, this is not an illness, if I will drink, I will be (Level-1)

157
 fine.
Student Nurse But, drinking is injurious to health. Denial
Client No, I am drinking since 32 years, I have no
problem, I am not habitual
Student Nurse Now it is not possible for you to stop drinking. Not aware
Client No, it is not a big problem, I can stop whenever regarding
I want. condition
Student Nurse Then why can’t you stop drinking Alcohol
Client If I will stop drinking alcohol, I will get more dependence
problem
Student Nurse What you will do after going from here? Able to take
Client I will continue my job decision.
Student Nurse Ok. Mr. Satya bye, take care Termination of
Client Bye process recording

Assessment techniques
 Observation
 Interview
 communication
Summary:
Mr. Satya is a 52 year male patient diagnoses as alcohol dependence with
psychosis. He is responding well but anxious. He is having self care deficit and poor
personal hygiene. He is having loss of interest in doing work. His immediate and
remote memory is impaired. He is oriented to time, place and person. Insight is
absent. He is not aware regarding his condition. He is able to take decision

Literature Review

158
Introduction:
Substance use disorders constitute a public health problem of prime
importance. The social and health morbities are apparent in both developed and
developing countries more than the known, direct impact on health parameters.

Definition
ICD-10 alcohol dependence is a cluster of physiological, behavioral, and
cognitive phenomena in which the use of alcohol takes on a much higher priority for
a given individual than other behaviors that once had greater value

Etiology
7. Physiological theories
I. Genetic theory (Goodwin, 1979)
Some workers in the field of theories that alcoholism may be inherited.
Alcoholism appears to run in families.

J. Endocrine theory
Another major physiological theory of the cause of alcoholism indicates a
dysfunction of the endocrine function.

K. Genetotrophic theory
The genetotrophic theory of alcoholism combines the concept of genetic
trait and nutritional deficiencies.

L. Neurological theory (Gardener EL, 1997)

The neurobiological mechanisms, which have studies for understanding the
etiology of substance use disorders, are wide ranging and also vary according to the
substance.

8. Psychological theories
G. Psychoanalytic theory
The Freudian view as expressed by a number of people related alcoholism to
such factors as repressed urges, oral dependency, need for security, self
punishment and parental hatred.

H. Learning theory

159
 The learning and reinforcement theory explain alcoholism by considering
alcohol ingestion as a reflex response to some stimulus and as a way to reduce an
inner drive such as fear or anxiety.

I. Personality trait theory

Psychological research has also attempted to define the cause of
alcoholism in terms of an alcoholic personality.

9. Sociological theories (Johnson B.D., 1997)

E. Cultural theory
The cultural theory of alcoholism suggests that within a given society.
Societies may provide alternatives to or substitute for alcohol use.

F. Deviant behavior theory

Depending on the context, the use of alcohol can be illegal or only
illegitimate, acceptable or even sanctified.

Book Pictures Patient Pictures

Clinical Features  Strong desire or sense of  Strong desire or sense of
compulsion to take alcohol compulsion to take alcohol
 Difficulties in controlling  Difficulties in controlling
substance taking behavior substance taking behavior in
in terms of its onset, terms of its onset, termination
termination or levels of use or levels of use
 A physiological withdrawal  A physiological withdrawal
state when substance use state when substance use has
has ceased or reduced ceased or reduced
 Evidence of tolerance such  Evidence of tolerance such that
that increased doses of the increased doses of the alcohol
alcohol required in order to required in order to achieve
achieve effects originally effects originally produced by
produced by lower doses lower doses
 Progressive neglect of  Progressive neglect of
alternative pleasures or alternative pleasures or
interests because of interests because of
psychoactive substance use psychoactive substance use
 Persisting with alcohol use Persisting with alcohol use despite

160
 despite clear evidence of clear evidence of overtly harmful
overtly harmful consequences.
consequences.
Psychopathology Alcohol is often As describe in book picture
misunderstood as a stimulant
because it appears to make
people more lively and less
inhibited. It is actually a
depressant. If taken in small
quantities, it depresses that part
of the brain controls inhibitions,
so the person feels relaxed.
When blood alcohol
concentration is low, the drinker
experiences a feeling of
relaxation, tranquility and a
sense of well being. It slightly
increases the heart rate. When
blood alcohol concentration is
high, it depresses the other
areas of the central nervous
system result in severe
problems

Diagnostic  Blood investigation  Blood investigation

Evaluation  Observation  Observation
 Physical examination  Physical examination
 Mental status examination  Mental status examination
 History collection  History collection
Treatment  Anti craving agent  Anti craving agent
Psychopharmacolo  Anti anxiety  Anti anxiety
gy  Anti depressant  Anti depressant
 Anti psychotic  Anti psychotic
 Deterrent agent  Deterrent agent
Psychotherapy  Yoga therapy,
 Individual psychotherapy,

161
  Group therapy
 Family counseling.
 Behavior therapy
ECT Not recommended Not given

Nursing Process:
Day 1

S. Needs Problems
No.

Maintain the normal sensory Hearing sounds

1 perception and eliminate the
hallucinations
Safety and security measures for Risk for injury
2 free from injury

Nursing Diagnosis:

 Disturbed sensory perception (auditory) related to withdrawal into the self as

evidenced by inappropriate responses
 At risk of injury as a result of environmental conditions interacting with the
individual’s adaptive and defensive resources.

162
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Abnormal Disturbed sensory Maintain the  Observe the client for sings of  Observed the client (pt has Client able
perception perception normal sensory hallucinations. talking to self) to define
like (auditory/visual) perception and  Avoid touching the client without  Maintain the IPR and the reality
hallucinati related to eliminate the warning. distance. and
ons withdrawal into hallucinations  Do not reinforce the  Encouraged his self eliminate
the self as hallucinations. esteem. the
evidenced by  Distract the client from the  Tried to involve in personal hallucinatio
inappropriate hallucinations. Encourage the tasks. ns in some
responses client to share hallucinations. extent
Risk for Risk of injury as a The client will:  Place the client in a room near  Placed the client in a room Risk of
injury result of  Be safe and the nurses’ station or where the near the nurses’ station or injury has
environmental
free from staff can observe the client where the staff can observe minimized
conditions
interacting with injury closely. the client closely. to some
the individual’s  Respond to  Institute seizure precautions  Provided seizure extent.
adaptive and
reality according to hospital policy precautions like padded
defensive
resources as orientation (padded side rails, side rails up, side rails, side rails up,
evidenced by  Demonstrate airway at bedside, and so forth). airway at bedside.
uncooperative
decreased  Monitor the client’s sleep pattern;  Monitored the client’s sleep
behavior and

163
aggressive aggressive or he may need to be restrained at pattern.
behavior. threatening night if confused or if he wanders
behavior or attempts to climb out of bed.
 Talk to the client in simple, direct,  Talked to the client in
concrete language. Do not try to simple, direct, concrete
discuss the client’s feelings, language.
plans for treatment, or changes in
lifestyle when the client is
intoxicated or in withdrawal.
 Reorient the client to person,  Reoriented the client to
time, place, and situation as person, time, place, and
needed. situation as needed.
 Do not moralize or chastise the  Not moralized the client for
client for his alcoholism. Maintain his alcoholism. Maintained
a nonjudgmental attitude. a nonjudgmental attitude.

164
 Day 2

S. Needs Problems
No.

Use coping mechanisms instead of Ineffective coping

substance abuse.

Maintain normal nutritional balance Loss of weight, poor skin turgor and
electrolyte imbalance.

Nursing Diagnosis:

 Ineffective coping related to inadequate coping skills evidenced by use of

substance as coping mechanism.

 Imbalanced nutrition less than body requirements/deficient fluid volume

related to use of substances instead of eating as evidenced by loss of weight,
poor skin turgor and electrolyte imbalance.

165
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Ineffective coping Client will be  Set limits on manipulative  Set limits on manipulative
related to inadequate able to verbalize behavior. Administer behavior.
coping skills evidenced adoptive coping consequences when limits are
by use of substance as mechanisms to violated.
coping mechanism. use, instead of  Obtained routine urine
 Obtain routine urine samples
substance samples for laboratory
for laboratory analysis of
abuse, in analysis of substances.
substances.
response to
stress.  Exploreed options available
 Explore options available to
to assist with stress rather
assist with stress rather than
than reporting to substance
reporting to substance abuse.
abuse.
Practice these techniques.
 Given positive
 Give positive reinforcement for
reinforcement for ability to
ability to delay gratification and
delay gratification &
respond to stress with adoptive
respond to stress with
coping strategies.
adoptive coping strategy.
2. Imbalanced nutrition Client will be  Parenteral support may be  Given IV Normal saline Maintained
less than body free of required initially. 500ml BD/day. client
requirements/deficient signs/symptoms  Encourage cessation of  Encouraged cessation of nutritional

166
fluid volume related to of malnutrition alcoholism alcoholism balance and
use of substances and dehydration.  Consult dietitian. Determine the  Consulted dietitian. electrolyte
instead of eating as number of calories required Determine the number of imbalance
evidenced by loss of based on body size and level of calories. to some
weight, poor skin turgor activity. extent.
and electrolyte  Document intake and output,  Maintained I/O Chart and
imbalance. calorie count and weight daily. weight (66kg)
 Ensure that the amount of
protein in the diet is correct for  Ensured that the amount of
the client’s condition. protein for client’s condition.
 Sodium may need to be  Sodium is restricted
restricted
 Provide foods that are non -
 Provided non irritating foods
irritating to clients with
to esophageal varies.
esophageal varies.
Provided small frequent
 Provide small frequent feeding
feeding of clients favorite.
of clients favorite.

167
 Day 3

S. Needs Problems
No.

Ineffective denial (Weak and

1 Maintain effective denial
underdeveloped ego)

2 Proper health maintenance Poor personal hygiene

Nursing Diagnosis:

 Ineffective denial related to weak, underdeveloped ego evidenced by

statements indicating no problem with substance use.
 Ineffective Health Maintenance related to Inability to identify, manage, and/or
seek out help to maintain health evidenced by sleep disturbances and
dependence on alcohol

168
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Underdeveloped Ineffective denial Client will  Develop trust. Convey an attitude  Developed trust. Maintained
ego related to weak, demonstrate of acceptance. Ensure that client Conveyed an attitude of acceptance of
underdeveloped acceptance of understands it is not the person but acceptance. patient
ego evidenced by responsibility for the behavior that is unacceptable.  Corrected responsibility
statements own behavior  Correct any misconceptions, such misconceptions, such as for own
indicating no and as “I don’t have drinking problem. I “I don’t have drinking behavior and
problem with acknowledge can quit anytime I don’t want to.” problem. acknowledge
substance use. association Do this in a matter –of-fact, association
between nonjudgmental manner. between
substance use  Identify recent maladaptive  Identified recent substance
and personal behaviours or situations that have maladaptive behaviours use and
problems. occurred in the client life and or situations that have personal
discuss how use of substances occurred in the client life problems to
may be a contributing factor. and discussed it effect. some extent.
 Do not allow client to rationalize or  Not allowed client to
blame others for behaviours rationalize or blame
associated with substance use. others for behaviours.
Poor personal Ineffective Health The client will:  Complete the physical assessment  Completed the physical Maintained
hygiene Maintenance of the client; ask what and how assessment of the client; the normal
 Establish
related to Inability much the client usually drinks, as asked what and how daily activities
nutritious

169
to identify, eating well as the time and amount of the much the client usually of the client.
manage, and/or patterns last drink of alcohol. drinks.
seek out help to  Establish  Offer fluids frequently, especially  Offered fluids frequently,
maintain health physiologic juices and malts. Serve only especially juices and
evidenced by homeostasis decaffeinated coffee. malts.
sleep  Establish a  Monitor the client’s fluid and  Monitored the client’s
disturbances and balance of electrolyte balance. fluid and electrolyte
dependence on rest, sleep,  Provide food or nourishing fluids as balance.
alcohol and activity soon as the client can tolerate  Provided food or
 Maintain eating; have something available at nourishing fluids as soon
personal night. as the client can tolerate
hygiene and  Administer medication to minimize eating.
grooming the withdrawal or complications and  Administered medication
to facilitate sleep. to facilitate sleep.
 Encourage the client to bath, wash  Encouraged the client to
his hair & wear clean cloths. bath, wash his hair &
wear clean cloths.

170
 Day 4
S. Needs Problems
No.

1 Gain in knowledge about client Family members are unaware about

disease condition and prognosis. disease condition and treatments.

2 Client able to attempt the new Low self-esteem

activities without fear of failure.

Nursing Diagnosis:
 Knowledge deficit regarding disease condition and prognosis as evidenced by
lack of information, unfamiliarity with information resources.
 Low self esteem related to feeling of abandonment and impaired cognition
functions as evidenced by not engaging in any activities.

171
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Client’s family Knowledge Improve  Discuss the client disease condition  Discussed the client’s Family
members have deficit regarding the family with family members. Provide condition and prognosis members
poor disease member’s written handout and allow time to of the condition with knowledge
knowledge condition and knowledge ask questions and clarify the doubts. family members. improved
regarding prognosis as regarding  Discuss the client’s abnormal  Explained the client’s regarding
disease evidenced by disease behavior and causes of its. abnormal behaviors why disease
condition and lack of condition  Educate the family members on the he/she has. condition and
treatment, information, and use of medications and response  Cautionally explained prognosis of
prognosis. unfamiliarity with prognosis. anticipated. about the medications the client.
information  Arrange the small group activities uses and side effects.
resources. and allow the family members  Small group activities
exchange their feelings and arranged and outcome
knowledge regarding client’s was assessed.
condition and prognosis.
Client has low Low self esteem Client able  Be accepting of client and spend  Accepted the client Client self
self esteem related to feeling to attempt time with him even though thoughts and feelings it esteem
and of abandonment the new pessimism and negativism. makes positive improved at
confidence and impaired activities contribution. some extent.

172
cognition without  Focus on strength and  Talked about the client’s
functions as fear of accomplishments and minimize strengths and victory.
evidenced by not failure. failures.
engaging in any  Provide opportunities for success;  Repeated success
activities. plan activities with short time span improves the client’s self
and appropriate ability level. esteem.
 Help the client set realistic, concrete  Engaged in new tasks
goals and determine appropriate promotes personal
actions to meet these goals and growth and new skills.
encourage involvement of new
activities/ tasks.

173
 Theory Application
King’s theory:
King’s theory of goal attainment encompasses three broad interlocking open
systems, the personal and interpersonal and social system. The personal system
and social system influence the quality of care and the major elements in the goal
attainment are contained in the interpersonal system. In these system two or more
persons come together under the guidance if health care organization to promote an
optimal state of health.
The major concepts are –
 Interaction
 Perception
 Communication
 Transaction
 Roles
 Stress
 Growth and development
 Time and space.

174
 Transaction
Try to stop alcohol intake

Stress
Role
Environmental
- Use of Coping
Stresses
Methods
- Communication
- Therapies
- Educational
experience
- Socioeconomic
status
- Identify needs
problems
- Perception
- Solve the
problems
- Concerns
regarding
patient Time
- IPR
Space - Aware of
course
awareness
- Interaction

Kings Goal Attainment Theory

175
 Health education
I. Patient teaching on discharge plan
 Instruct the patient not to take alcohol
 Advise the patient to take bath daily
 Advise to change cloths daily
 Encourage social interaction.
 Improve the self care needs (personal hygiene) independently.
 Sleep and hygiene techniques.
 Instruct to use relaxation when getting aggressive
 Taught about the positive coping methods.
 Advise to spend time in recreational activities.
 Advised to spend more time with family.
 Advice the patient for regular checks up and follows up.

II. Family teaching on discharge plan

 Family’s to use alternative coping methods.
 Educated regarding medication- dosage and side effects of the medication.
 Advise to spend more time with patient

Summary:
Mr. Mylara brought to the psychiatric ward on 10/12/2008 with the complaints
of alcohol abuse, hallucination, irritability, psychomotor agitation, tremor etc. Then
he is diagnosed as a case of alcohol dependence with psychosis. I have taken this
case for my case study and given four days care with counseling and health
education from 06/01/09 to 09/01/09.

Bibliography:
17. Townsend.M, (2007), “Psychiatric Mental Health Nursing”, Jaypee brothers,
New Delhi, Pp. -
18. Doenges M.E. et al., (1995), “Psychiatric Care Plans Guidelines for Planning
and Documenting Client Care”, 2nd ed. F. A. Davis Company, Philadelphia,
PA, Pp. -

176
 MENTAL HEALTH NURSING

CASE STUDY ON
DEPRESSION

SUBMITTED TO
MR RAHUL SRIVASTAVA
ASSOCIATE PROFESSOR
HOD, MENTAL HEALTH NURSING
YASHRAJ COLLEGE OF NURSING

SUBMITTED BY
MR. BOBY DWIVEDI
M.Sc. NURSING 2nd YEAR
YASHRAJ COLLEGE OF NURSING

DATE OF SUBMISION____________

Patient’s Profile

177
LXXIX. Identification data
Client name : Mr. Dhanjayan
Age : 27 Years
Sex : Male
Father : Let. Mr. Kishor
Address : Gonda
Education : B.Com.
Occupation : Salesman
Income : 5500/-
Marital status : Unmarried
Religion : Hindu
Date of admission : 25.08.2020
Provisional diagnosis : Mood disorder
Final diagnosis : Generalized Anxiety Disorder

LXXX. Informant : Mother

LXXXI. Presenting Chief Complaints

According to Patient
o Decreased attention
o Restlessness,
o Irritability
o Lack of confidence
o Poor desire control
o Feelings of discomfort,
o Helplessness
o Hearing some sound
o Decreased ability to communicate verbally
o Repeated thoughts related to particular events
o Worries about future and family members
o Decreased sleep

178
 o Decreased appetite
According to Informant (Mother)
o Inability to experience pleasure
o Sleep disturbances
o Hyperactivity
o Suicidal behavior
o Not taking food
o Talking to self

LXXXII. Family History

 Family Characteristics
Age
Relationship Age &
S. Name of the Educational
with the (yr.)/ Occupation Health Status mode
No. family members Status
Patient Sex of
death
54/
No formal Hyper
1 Let. Mr. Kishor Father - Driver -
education tensio
n
No formal
2 Mrs. Kamala Mother 52/F House wife Healthy -
education
3 Mr. Dhanjayan Patient 27/M B.Com. Salesman Unhealthy -
4 Mr. Ranjeet Brother 23/M B.A. Salesman Healthy -
5 Mr. Raju Brother 20/M B.A. Student Healthy -
6 Miss. Disha Sister 17/F 12th Std Student Healthy -

Key:-
(x) Genogram:
- Male

52 yrs
- Female

- Patient

27yrs 23 yrs 20yrs 17yrs - Death

There is family history of hypertension and patient’s father died due to hypertension.

179
LXXXIII. Socio-economic history
Mr. Dhanjayan is a salesman. He and his brother are the earning members in his family.
His monthly family income is 15000/ per month. He belongs to a lower middle class family.
He is living in ranted house. Electricity and water facility is available in house. Drainage is
proper.

LXXXIV. History of Present Illness

Mr. Dhanjayan was apparently normal before one year. He lost his father due to
Hypertension. Since that time he developed these symptoms. He was not interesting to do
work. He was not taking proper food. He was having continuous feeling of hopelessness and
intermediate insomnia. On 25/1/2017 he was brought in hospital and diagnosed as
generalized anxiety disorder and admitted in male open ward for further evaluation and
treatment. Mr. Rameshwar did not go for any psychiatric treatment before. At present patient
receiving Tab. Fluoxetine – 50mg/day, Tab. Olanzapine – 25mg/day and Tab. Clonazepam –
1mg/day along with yoga therapy, individual psychotherapy, group therapy and family
counseling.

LXXXV. Past Psychiatric History

No significant data found related to the psychiatric illness in past life.

LXXXVI. Personal History

(a) Perinatal history
Mr. Dhanjayan was delivered as full term normal vaginal delivery. He cried
immediately after birth and there was no postnatal complication like cyanosis,
convulsions and jaundice.
(b) Childhood history
Primary caregiver was mother. Weaning started at the age of 5 month and all
developmental milestones was achieved at appropriate age period. He was very much
emotionally attached with his father and getting easily emotionally disturbed.
(c) Educational history
Education was started at the age of 6 years. He was average in academic
performance and had good relationships with teachers and peers. He never dropout
from school. He left the education after finishing his B.Com. and started to go for
earning.

180
 (d) Play history
He used to play with both sex peer group and had good relationship with peers.
(e) Emotional problems during adolescence
In his adolescence period he was very much emotionally attached with his father
and got easily emotionally disturb.
(f) Puberty
Secondary sexual characteristics appeared at the age of 14 years. He did not have
anxious mood regarding sexual changes.
(g) Occupational history
Mr. Dhanjayan is a salesman. He was performing well in his work but after death of
his father he lost interest in the work. He is having less number of friends.
(h) Premorbid personality
xxxv. Interpersonal relationships : Introvert
xxxvi. Use of leisure time : Watching
movies on TV
xxxvii. Predominant mood : Easily get
irritation, immediate reaction to
stressful events
xxxviii. Attitude to self and others : Don’t
discuss his problems with others.
xxxix. Attitude to work and
responsibility : He was going regular
to work and try to escape from
responsibilities for any task.
xl.Religious beliefs and moral attitudes : Having more faith on religious and
participating in religious activity.
xli. Fantasy life : No complaint of daydreams
xlii. Habits : He is not having any
habit like smoking and drinking.

LXXXVII. Physical Examination:

During physical examination all the finding found normal in head to foot examination
and there is no clinically significant finding.

181
LXXXVIII. Mental Status Examination
(y) General appearance and behavior
 Appearance : Looking dull and anxious
 Level of grooming : Groomed
 Level of cleanliness : Unhygienic
 Level of consciousness : Conscious
 Mode of entry : Persuaded by mother
 Cooperativeness : Cooperative
 Eye-to-eye contact : Maintained
 Psychomotor activity : Normal activity
 Rapport : Established properly
 Gesturing : Exaggerated
 Posturing : Normal posture
 Other movements : Normal
 Other catatonic phenomena : Not present
 Conversion and dissociative signs : Not present
 Compulsive acts or rituals : Not present
 Hallucinatory behavior : Some time talking to self

(z) Speech
Student Nurse : What is your name?
Client : Dhanjayan
 Initiation : Patient responded when talk
 Reaction time : Normal
 Rate : Normal
 Productivity : Elaborate speech
 Volume : Normal
 Tone : Normal tone
 Relevance : Relevant
 Stream : Tangential
 Coherence : Fully associated
 Others : No rhyming, punning, echolalia perseveration.

182
(aa) Mood
 Subjective
Student nurse : How do you feel?
Patient : I am anxious about my future and my family.
 Objective : Anxious and furious with confused mood.

(bb) Thought
Student Nurse : What type of the ideas comes in your mind?
Client : I am not able to think about my future and having
worry about my family.
 Stream : Pressure of thoughts.
 Form : Unwanted thought
 Content
Student nurse : Do you feel that someone may harm you?
Client : Who will harm me! but it is very difficult to live.
Remarks : Suicidal thought.

(cc) Perception
 Hallucinations
Student Nurse : Do you hear any sound or see someone whenever you
are alone?
Client : Yes some time my father voice I can hear.
Remarks : Auditory hallucinations present

(dd) Cognitive Functions

 Consciousness
Student Nurse : Hello, Mr. Dhanjayan
Client : Yes sir
Remarks : Patient has obeyed by calling his name
 Orientation
xvi. Person
Student Nurse : Who is sitting nearby you?
Client : My Brother and my mother
Remarks : Oriented to person

183
 xvii. Place
Student Nurse : Where are you now?
Client : I am in SCPM hospital
Remarks : Oriented to place
xviii. Time
Student Nurse : What is the day today?
Client : Tuesday
Remarks : Oriented to time
 Attention
Student Nurse : Repeat the digit backward 2, 4, 6, 8, 10.
Client : 10, 8…4..6..2.
Remarks : Attention aroused with difficulty
 Concentration
Student Nurse : Name the months in backward?
Client : December, November…September, October, June,
July …August, March ….January.
Remarks : Concentration sustained with difficulty
 Memory
x. Immediate
Student Nurse : Repeat the word what I say Table, Pen, Rose, Bus and
Tree.
Client : Table, Pen, Rose, Bus and Tree
Remarks : Immediate memory present
xi.Recent
Student Nurse : What you had in breakfast?
Client : Idli and Vada
Remarks : Recent memory present
xii. Remote
Student Nurse : When is your birthday?
Client : han……..…………..12th June
Remarks : Remote memory poor
 Intelligence
Student Nurse : Who is the Prime Minister of India?
Client : Narendra Modi.
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 Remarks : Normal intelligence
 Abstraction
Student Nurse : What you will do if you see fire in your neighbor
house?
Client : I will call upon fire brigade.

(ee) Insight: (grade1 to 6)

Student Nurse : Do you accept your illness and require treatment?
Client : Yes, I am feeling helpless and hearing father’s voice.
Remarks : Grade 6 Insight is present

(ff)Judgment:
Student Nurse : What you will you do if you find “Close latter on the
road”?
Client : I should not touch.
Remarks : Judgment is impaired

LXXXIX. Vital Signs:

S. No. Vital Sign Normal Value Patient’s Value

1. Temperature 98.60 F 99.00 F

2. Pulse 72-90 Beats/M. 78 Beats/M.
3. Respiration 14-20 Breath/M. 16 Breath/M.
4. Blood Pressure 120/80mmHg 120/80mmHg

XC. Investigation:
S. Patient’s
Investigations Normal Value Interpretation
No Value
1 Blood
 Heamoglobin 13 gm/dl 13-15 Normal
 Red blood cell 4.8 milcmm 4.5-6.51 Normal
 PCV 38.2% 20-54 Normal
 Platelets 2.89 lacs 1.5-4.5 Normal
 Total WBC different
count

185
  Lymphocytes 9700 cu/mm 5000-11000 Normal
 Esinophills 37% 20-45 Normal
 Monocytes 03% 1-6 Normal
 MCV 04% 1-6 Normal
 MCH 87fl 80-99 Normal
 MCHC 30pg 27-33 Normal
 ESR 33.7g/dl 32-37 Normal
Routine Investigation 14mm/hr 0-20 Normal
 RBS
 Blood urea 129 mgs/dl < 150 Normal
 S. Creatinine 28 mg/dl 20-45 Normal
 S. Sodium 1.0mgs/dl 0.7-1.2 Normal
 S. Potassium 137 meq/l 135-145 Normal
LFT 4.4 meq/l 3.5-4.5 Normal
 S. Bilirubin
 S. total protein
0.9 mgs/dl 1 Normal
 S. Albumin
6.5 gm/dl 6-8 Normal
 S. Globulin
4.2 gm/dl 3-5 Normal
 Alkaline phosphate
2.2 gm/dl 1.8-3.6 Normal
64 IU/l 80-120 Low

Patient is clinically normal except Alkaline phosphate is low.

XCI. Medication chart:

a. Tab. Fluoxetine – 50mg/day,
b. Tab. Olanzapine – 25mg/day and
c. Tab. Clonazepam – 1mg/day

186
 Pharmacological

Responsibility
Trade Name

Side-effects
Indications
Frequency

Indication

Contra-
Group

Action
Route
Name

Doses
S.

Nsg.
N.

1. Prodep Fluoxetine 50 Oral BD SSRI It block the Depressive Severe renal Administer with
constipation,
mg serotonin episode, failure, urinary
food to minimize
reuptake depression with hypersensitiv retention,
gastric irritation.
channel and psychotic ity, Advise the patient
hypotension,
increase symptoms, concomitant impotence,
to take
serotonin dysthymia, MAOI’s priapism,
medication
level at ADHD, panic sedation
exactly as
post- attack, PTSD directed. Abrupt
synaptic and ADS. withdrawal may
space. cause insomnia,
irritability and
seizures.
Explain about
adverse effects
and advise to
avoid activities
that require
attention.
2. Epitral Clonazepam 1 Oral BD BDZ It act on Generalized Hypersensiti Drowsiness,  Report promptly
mg BDZ anxiety disorder, vity, somnolence, if occipital
receptor I panic disorder, pulmonary fatigue, headache, nausea,
and II and agoraphobia, insufficiency, vertigo, loss of vomiting chest
enhance sleep disorder, respiratory libido pain these may be
GABA convulsion, depression hypertensive

187
 transmission alcohol crisis
in the brain. dependence, Caution the
acute mania and patient to change
narcoanalysis. his position
slowly
3. Zyprexa Olanzapine 25 Oral OD Thien Acts only Apathy, Hypersensiti Common  Instruct the
mg obenz on the decreased vity, MI, sedation patient to take
odiaz mesolimbic sociality, hepatic Hypotension, sips of water
epine system. anhedonia, imparimeme Diabetes and Advise the patient
chronic nt EPS may and to get up from the
schizophrenia, may not be bed very slowly
Acute psychoses, present Observe abnormal
delusional movements
disorders, and
hallucinations

188
XCII.Other therapeutic therapies:
Therapy Indication Nurses responsibility

Yoga therapy Almost all condition  Provide correct guidance

 Provide calm environment
 Help during the difficulties in yoga
Supportive Depression, psychosis,  Brought patient in directly as and active
psychotherapy anxiety, phobia participant
 Coordinate the process to attain maximum
benefit
 Educate regarding the condition and coping
mechanism
Individual Stress related disorder,  Deliberately establishes a professional
psychotherapy alcohol and drug relation
dependence, sexual  Remove or modify existing symptoms
disorder and marital  Promote positive personality growth and
disharmony development
Group therapy Homogenous group,  Use any transference situations to develop
personality disorders, insight into their problems
families where the  Provide positive reinforcement, this gives
system needs change ego support and encourages future growth
Family Psychosis, reactive  Assessment of family, roles, boundaries,
counseling depression, anxiety, resources, communication patterns and
psychosomatic problem solving skills
disorder, substance  Teaching communication skills
abuse  Teaching problem solving skills

XCIII. Process Recording:

Time : 30 Minutes
Date : 06-1-2009
Place : Interview room of male psychiatric ward
Objectives : To
- maintain rapport
189
 - obtain psychiatrist history
- make the patient ventilate feelings
- improve communication skills
Person Conversation Inference
Student Nurse Hello, Mr. Dhanjayan Responding
Client Hello sir Normal
Student Nurse How you are feeling? Anxious, irritable
Client I am not good sir, I have anxiety about my family
and hearing my father voice.
Student Nurse What you had in breakfast? Decreased appetite
Client I had idali but I don’t feel hungry
Student Nurse Did you take bath? Conscious about
Client Yes I took. hygiene
Student Nurse Did you join exercise today with others? Loss of interest
Client No, I don’t feel to do exercise
Student Nurse Why you are not interested to do exercise? Helplessness and
Client No mood no use of life and it’s not easy to live. suicidal gesture
Student Nurse Can you repeat it 2…..6…..9…4…..1…..7….8 Immediate memory
Client 2…6..8…..9…4……..6…..7………1…..3…8 present
Student Nurse Can you tell me your birthday Remote memory
Client han……..…………..12th June poor
Student Nurse Who is the prime minister of India? Intelligence normal
Client Narendra modi
Student Nurse What you will do if you find “latter on the road”? Judgment is poor
Client I will not touch that
Student Nurse What you will do if you see fire in your neighbor Abstract reasoning
house? present
Client I will call upon fire brigade
Student Nurse Ok. Dhanjayan bye, take care Termination of
Client Bye, sir. process recording

Assessment techniques

190
  Observation
 Communication
 Interview

Summary:
Mr. Dhanjayan is a case of generalized anxiety disorder. He is responding minimum,
anxious, having loss of appetite, loss of interest, suicidal gesture, helplessness, worry about
family, have auditory hallucination and inferiority feeling. His immediate and recent memory
is intact but remote memory is poor he is not able to take decision.

Literature Review

Introduction:
Manifestations of anxiety are the major symptoms of these disorders and are not
restricted to any particular environmental situation. Depressive and obsessional symptoms,
and even some elements of phobic anxiety, may also be present, provided that they are
clearly secondary or less severe.

Definition
Anxiety is a ‘normal’ phenomenon, which is characterized by a state of apprehension
or unease arising out of anticipation of danger. Anxiety is often differentiated from fear, as
fear is an apprehension in response to an external danger while in anxiety the danger is
largely unknown (or internal).

Book Pictures Patient Pictures

Etiology I. Biological theories  Stress and Family condition

a. Genetic hypothesis
b. Biochemical theories
c. Neuro-endocrine theories
d. Organic anxiety disorder
II. Psychological theories
e. Stress
f. Family theories

191
 g. Cognitive behavior theories
h. Psychoanalytic theories
III. Socio-cultural theories
IV. Behavioral theory
V. Cognitive behavioral theory
Types  Panic disorder  Generalized anxiety disorder
 Generalized anxiety disorder
 Mixed anxiety and depressive
disorder
 Other mixed anxiety disorders
 Other specified anxiety disorders
 Anxiety disorder, unspecified
Clinical Features  Tremors  Decreased attention span
 Restlessness  Restlessness,
 Muscle twitches  Irritability
 Fearful facial expression  Lack of confidence
 Palpitations  Poor impulse control
 Tachycardia  Feelings of discomfort,
 Sweating  Helplessness
 Flushes  Hyperactivity
 Dyspnea  Perceptual field deficits
 Hyperventilation  Decreased ability to
 Constriction in the chest communicate verbally
 Dry mouth  Repeated thoughts related to
 Frequency and hesitancy of particular events
micturition  Worries about future and
 Dizziness family members
 Diarrhea  Decreased sleep
 Poor concentration  Decreased appetite
 Distractibility  Inability to experience
 Negative automatic thoughts pleasure
 Derealization  Sleep disturbances
 Depersonalization  Suicidal behavior

192
  Inability to relax  Not taking food
 Irritability  Talking to self
 Insomnia  Hyperactivity
Psychopathology The psychodynamic view focuses Same as described in book
on the inability of the ego to intervene picture
when conflict occurs between the id
and the superego, producing anxiety.
For various reasons (unsatisfactory
patent-child relationship; conditional
love or provisional gratification), ego
development is delayed. When
developmental defects in ego
functions compromise the capacity to
modulate anxiety, the individual
resorts to unconscious mechanisms to
resolve the conflict. Overuse or
ineffective use fo ego defense
mechanisms results in maladaptive
responses to anxiety.
Diagnostic  History collection  History collection
Evaluation  Mental status examination  Mental status examination
Treatment
Psychopharmaco  Benzodiazepines  Benzodiazepine
logy  SSRIs  SSRI
 Antipsychotics  Antianxiety
 Antianxiety  Antipsychotic
Psychotherapy  Yoga therapy,  Yoga therapy,
 Individual psychotherapy,  Individual psychotherapy,
 Group therapy and  Group therapy and
 Family counseling  Family counseling

Nursing Process:

193
 Day 1

S. No. Needs Problems

1 Be free from self-inflicted harm Suicidal ideas or behavior

2 Maintain the normal sensory Abnormal perception like hallucinations

perception and eliminate the
hallucinations
3 Patient will experience reduced Anxiety
anxiety by identified precipitant
situations

Nursing Diagnosis:

 Ineffective coping related to inability to form a valid appraisal of the stressors and
inability to use available resources evidenced by suicidal ideas.

 Disturbed sensory perception auditory related to withdrawal into the self as evidenced
by inappropriate responses

 Anxiety related to environmental conflict evidenced by client focus on self and

tendency to become rattled.

194
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Suicidal Ineffective coping Be free from self-  Provide a safe environment  Provided a safe environment Client free from
ideas or related to inability inflicted harm for the client. for the client. self-inflicted
behavior to form a valid evidenced by  Continually assess the client’s  Continually assessed the harm evidenced
appraisal of the express feelings potential for suicide. client’s potential for suicide. by express
stressors and directly with  Observe the client closely,  Observed the client closely, feelings directly
inability to use congruent verbal especially after antidepressant especially After antidepressant with congruent
available resources and nonverbal medication begins to raise the medication begins to raise the verbal and
evidenced by messages client’s mood client’s mood nonverbal
suicidal ideas.  Reorient the client to person,  Reoriented the client to person, messages
place, and time as indicated place, and time as indicated
 Spend time with the client.  Spent time with the client.
 Initially, assign the same staff  Initially, assigned the same
members to work with the staff members to work with the
client whenever possible. client whenever possible.
 When first communicating  When first communicating
with the client, use simple, with the client, used simple,
direct sentences; avoid direct sentences; avoid
complex sentences or complex sentences or

195
 directions. directions.
Abnormal Disturbed sensory Maintain the  Observe the client for sings of  Observed the client (pt has Client able to
perception perception normal sensory hallucinations. talking to self) define the
like (auditory/visual) perception and  Avoid touching the client  Maintain the IPR and distance. reality and
hallucinatio related to eliminate the without warning.  Encouraged his self esteem. eliminate the
ns withdrawal into hallucinations  Do not reinforce the  Tried to involve in personal hallucinations in
the self as hallucinations. tasks. some extent
evidenced by  Distract the client from the
inappropriate hallucinations. Encourage the
responses client to share hallucinations.
Anxiety Anxiety related to Patient will  Identify feelings to keep them  Identified feelings to keep Patient
environmental experience from interfering with them from interfering with experienced
conflict evidenced reduced anxiety by treatment treatment reduced anxiety
by client focus on identified  Accept patient as is  Accepted patient as is by identified
self and tendency precipitant  Explore factors that  Explored factors that precipitant
to become rattled situations precipitate phobic reactions precipitate phobic reactions situations
and anxiety. and anxiety.
 Reassure patient he is safe  Reassured patient he is safe
 Support patient with  Supported patient with
desensitization techniques to desensitization techniques to
help him overcome problem help him overcome problem

196
 Give patient chance to  Given patient chance to
ventilate feelings. ventilate feelings.
 Teach relaxation techniques  Taught relaxation techniques
such as breathing exercises, such as breathing exercises,
progressive muscles progressive muscles relaxation,
relaxation, guided imagery guided imagery
 Help patient set limits and  Helped patient set limits and
compromises on behavior compromises on behavior
where ready and allow patient where ready and allow patient
to be afraid. Fear is a feeling, to be afraid. Fear is a feeling,
neither right nor wrong. neither right nor wrong.

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 Day 2
S. Needs Problems
No.
1. Be free from self-inflicted harm Suicidal ideas or behavior

2. Evaluate own strengths realistically Feelings of inferiority

Nursing Diagnosis:

 Ineffective coping related to inability to form a valid appraisal of the stressors and inability to use available resources evidenced by
suicidal ideas.

 Chronic low self-esteem related to longstanding negative self-evaluation/feelings about self or self-capabilities evidenced by feelings of
inferiority.

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 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Suicidal ideas Ineffective coping Engage in  Provide a safe environment for  Provided a safe environment Engaged in
or behavior related to inability to reality based the client. for the client. reality based
form a valid appraisal of interactions  Continually assess the client’s  Continually assessed the interactions
the stressors and evidenced by potential for suicide. client’s potential for suicide. evidenced
inability to use available client will  Observe the client closely,  Observed the client closely, by client
resources evidenced by express especially After antidepressant especially After will express
suicidal ideas. feelings medication begins to raise the antidepressant medication feelings
directly with client’s mood begins to raise the client’s directly with
congruent  Reorient the client to person, mood congruent
verbal and place, and time as indicated  Reoriented the client to verbal and
nonverbal  Spend time with the client. person, place, and time as nonverbal
messages.  Initially, assign the same staff indicated messages.
members to work with the client  Spent time with the client.
whenever possible.  Initially, assigned the same
 When first communicating with staff members to work with
the client, use simple, direct the client whenever possible.
sentences; avoid complex  When first communicating
sentences or directions. with the client, used simple,

199
 direct sentences; avoid
complex sentences or
directions.
Feelings of Chronic low self-esteem Improve self-  Encourage the client to become  Encourage the client to Improved
inferiority related to longstanding esteem involved with staff and other become involved with staff self-esteem
negative self- evidenced by clients in the milieu through and other clients in the evidenced
evaluation/feelings patient will interactions and activities. milieu through interactions by patient
about self or self- verbalize  Give the client positive feedback and activities. verbalize
capabilities evidenced increased for completion of  Give the client positive increased
by feelings of feelings of responsibilities, such as self-care feedback for completion of feelings of
inferiority. self-worth activities and interactions with responsibilities, such as self- self-worth
others. care activities and
 Involve the client in activities interactions with others.
that are pleasant or recreational  Involve the client in
as a break from self-examination. activities that are pleasant or
 Explore with the client his or her recreational as a break from
personal strengths. self-examination.
 Explore with the client his or
her personal strengths.

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 Day 3
S. Needs Problems
No.
1 Be free from self-inflicted harm Suicidal ideas or behavior

2 Maintain the normal or more adaptive low confidence and confusion regarding
coping strategies for dealing with client’s disease condition
client

Nursing Diagnosis:

 Ineffective coping related to inability to form a valid appraisal of the stressors and inability to use available resources evidenced by
suicidal ideas.

 Disabled family coping strategies related to difficulty coping with client’s illness as evidenced by neglectful care of the client.

201
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Suicidal Ineffective coping Be free from  Provide a safe environment for the  Provided a safe environment for Client free
ideas or related to inability self-inflicted client. the client. from self-
behavior to form a valid harm  Continually assess the client’s  Continually assessed the client’s inflicted
appraisal of the evidenced by potential for suicide. potential for suicide. harm
stressors and express  Observe the client closely,  Observed the client closely, evidenced
inability to use feelings especially after antidepressant especially After antidepressant by express
available resources directly with medication begins to raise the medication begins to raise the feelings
evidenced by congruent client’s mood client’s mood directly with
suicidal ideas. verbal and  Reorient the client to person,  Reoriented the client to person, congruent
nonverbal place, and time as indicated place, and time as indicated verbal and
messages  Spend time with the client.  Spent time with the client. nonverbal
 Initially, assign the same staff  Initially, assigned the same staff messages
members to work with the client members to work with the client
whenever possible. whenever possible.
 When first communicating with  When first communicating with
the client, use simple, direct the client, used simple, direct
sentences; avoid complex sentences; avoid complex
sentences or directions. sentences or directions.

202
Family Disabled family Maintain the  Identify level of family  Identified the family member’s Family
members coping strategies normal or functioning. Assess the lacks and knowledge level of the members
has low related to difficulty more adaptive communication pattern, client’s disease condition. maintain the
confidence coping with coping interpersonal relationships between more
and client’s illness as strategies for members, role expectations, adaptive
confusion evidenced by dealing with problem solving skills and  Adequate information given to the coping
regarding neglectful care of client. availability of outside support family members regarding disease methods.
client’s the client. systems. condition and prognosis.
disease  Provide information for the family  Assisted the family members to
condition about the client’s illness, what will respond adaptively in the face of
be required in the treatment what they may consider to be a
regimen and long term prognosis. crisis situation.
 With family members practice how
to respond to bizarre and
communication pattern and in the
event that the client becomes
violent.

203
 Day 4
S. Needs Problems
No.
1 Communicate with others Impaired social interaction

2 Evaluate own strengths realistically Feelings of inferiority

Nursing Diagnosis:

 Impaired social interaction related to insufficient or excessive quantity or ineffective quality of social exchange evidenced by withdrawn
behavior

 Chronic low self-esteem related to longstanding negative self-evaluation/feelings about self or self-capabilities evidenced by feelings of
inferiority.

204
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Impaired Impaired social To improve  Teach the client social skills, and  Teach the client social skills, and Improved
social interaction related social encourage him or her to practice encourage him or her to practice social
interaction to insufficient or interaction these skills with staff members and these skills with staff members and interaction
excessive quantity evidenced by other clients. other clients. evidenced
or ineffective patient will  Initially, interact with the client on  Initially, interact with the client on by patient
quality of social communicate a one-to-one basis. Progress to a one-to-one basis. Progress to will
exchange with others facilitating social interactions facilitating social interactions communicat
evidenced by between the client and other between the client and other e with others
withdrawn clients, then in small groups and clients, then in small groups and
behavior gradually larger groups. gradually larger groups.
 Encourage the client to pursue  Encourage the client to pursue
personal interests, hobbies, and personal interests, hobbies, and
recreational activities. recreational activities.
Consultation with a recreational Consultation with a recreational
therapist may be indicated. therapist may be indicated.
 Encourage the client to identify  Encourage the client to identify
supportive people outside the supportive people outside the
hospital and to develop these hospital and to develop these

205
 relationships. relationships.
Feelings of Chronic low self- Improve self-  Encourage the client to become  Encourage the client to become Improved
inferiority esteem related to esteem involved with staff and other involved with staff and other self-esteem
longstanding evidenced by clients in the milieu through clients in the milieu through evidenced
negative self- patient will interactions and activities. interactions and activities. by patient
evaluation/feelings verbalize  Give the client positive feedback  Give the client positive feedback verbalize
about self or self- increased for completion of responsibilities, for completion of responsibilities, increased
capabilities feelings of such as self-care activities and such as self-care activities and feelings of
evidenced by self-worth interactions with others. interactions with others. self-worth
feelings of  Involve the client in activities that  Involve the client in activities that
inferiority. are pleasant or recreational as a are pleasant or recreational as a
break from self-examination. break from self-examination.
 Explore with the client his or her  Explore with the client his or her
personal strengths. personal strengths.

206
 Theory Application

Peplau’s Interpersonal theory:

The core of Peplau’s approach is interpersonal relations. The theory includes the
concept such as
 Communication,
 Roles and growth and
 Development.
Communication us a problem solving process whereby the nurse and client
collaborate to meet the clients need.
The nurse may assume the roles of
 Counselor,
 Leader,
 Resource,
 Surrogate, and
 Teacher.
These roles are designed to lead to growth and development.

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 Growth and Development

Orientation
- Established working relationship
- Collected history of illness
- Oriented to hospital
Identification
- Classify perceptions
Teacher - Identify problems
- Discussed the solutions
Resource

Counselor Nurs COMMUNICATION Patien

e Exploitation
t
Leader
- Create a non threatening
Surrogate atmosphere
- Encourage client participation in
problem solvingInterpersonal Framework
Peplau’s Nurse-client
Resolution
- Evaluated the outcomes
- Reduced anxiety
- Increased problems solving
activities

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Health Education:
 Support patient with desensitization techniques to help him overcome problem
 Give patient chance to ventilate feelings.
 Teach relaxation techniques such as breathing exercises, progressive muscles
relaxation, guided imagery
 Help patient set limits and compromises on behavior where ready and allow patient to
be afraid. Fear is a feeling, neither right nor wrong.
 Health education given regarding nutrition.
 Encourage social interaction.
 Sleep and hygiene techniques.
 Family’s to use alternative coping methods.
 Taught about the positive coping methods.
 Prevention of self harm.
 Advised to spend more time with family.
 Avoid conveying to the client the belief that hallucinations are real. Do not converse
with the “voices” or otherwise reinforce the client’s belief in the hallucinations as
reality
 Educated the patient and family members regarding medication- dosage and side
effects of the medication.
 Advice the patient for regular checks up and follows up.

Summary:
Mr. Dhanjayan brought to the psychiatric ward on 25/12/2008 with the complaints of
decreased attention span, restlessness, irritability, lack of confidence, poor impulse control,
feelings of discomfort, helplessness, hyperactivity, perceptual field deficits, decreased ability
to communicate verbally, repeated thoughts related to particular events, worries about future
and family members, decreased sleep, decreased appetite, inability to experience pleasure,
sleep disturbances, suicidal behavior, not taking food, talking to self, hyperactivity.
Then he is diagnosed as a case of generalized anxiety disorder. I have taken this case
for my case study and given four days care with counseling and health education from
06/01/09 to 08/01/09.

Bibliography:
209
19. Townsend.M, (2007), “Psychiatric Mental Health Nursing”, Jaypee brothers, New
Delhi, India.
20. Doenges M.E. et al., (1995), “Psychiatric Care Plans Guidelines for Planning and
Documenting Client Care”, 2nd ed. F. A. Davis Company, Philadelphia, PA.
21. Ahuja.N, (2006), “A Short Text Book of Psychiatry”, Jaypee brothers, New Delhi,
India.
22. Sreevani.R, (2008), “A Guide to Mental Health and Psychiatric Nursing”, Jaypee
Brothers, New Delhi, India.

210
 MENTAL HEALTH NURSING

CASE STUDY ON
PERSONALITY
DISORDER
SUBMITTED TO
Mr. RAHUL SRIVASTAVA
ASSOCIATE PROFESSOR
HOD, MENTAL HEALTH NURSING
YASHRAJ COLLEGE OF NURSING

SUBMITTED BY
Mr BOBY DWIVEDI
M.Sc. NURSING 2nd YEAR
YASHRAJ COLLEGE OF NURSING

DATE OF SUBMISION____________

211
 Patient’s Profile

XCIV. Identification data

Client name : Miss Amita Yadav
Age : 19 years
Sex : Female
Father name : Mr. Anand Yadav
Address : 786, Bareilly.
Education : 12th class
Occupation : Studying
Religion : Hindu
Date of admission : 22.08.2020
Provisional diagnosis : Personality disorder
Final diagnosis : Borderline personality disorder

XCV. Informant : Mother

XCVI. Presenting Chief Complaints

According to patient
o Inability to express feelings verbally
o Inability to delay gratification
o Inability to tolerate frustration, anxiety
o Intolerance of being alone
o Ineffective coping skills
o Dissatisfaction with life
o Chronic feelings of boredom or emptiness
According to Informant (Mother)
o Physically self-damaging acts
o Displays of temper
o Attention-seeking behavior
o Avoidance behavior in relationships
o Excessive dependency needs

212
 o Manipulation of others for own needs
o Sense of power
o Conflicting behavior
o Uncertainty about identity
o Poor desire control
o Alcohol use

XCVII. Family History

(y) Family Characteristics
Age &
Relationship Age
S. Name of the Educational Health mode
with the (yr.)/ Occupation
No. family members Status Status of
Patient Sex
death
1 Mr. Anand Father 48/M BA Lawyer Healthy -
Chief of
2 Mrs. Sardha Mother 44/F BA Healthy -
dowry dep.
Miss. Amita
3 Patient 17/F 12th Std. Student Unhealthy -
Yadav

(z) Genogram:
Key:-

45 yrs 48 yrs 44 yrs - Male

- Female
18 yrs 17 yrs
- Patient

XCVIII. Socio-economic history

Miss Amita Yadav is a student. Her father and mother are the earning members in the
family. His monthly family income is 40000/ per month. He belongs to a upper middle class
family. She is living her father’s own house. Electricity and water facility is available in
house. Drainage is good.

XCIX. History of Present Illness

213
 Miss Amita Yadav apparently normal before 10 month then she got failure in love and
developed the symptoms like impulsive behavior, inability to express feelings verbally,
inability to delay gratification, inability to tolerate frustration, anxiety, intolerance of being
alone, ineffective coping skills, dissatisfaction with life, chronic feelings of boredom or
emptiness, physically self-damaging acts, displays of temper, attention-seeking behavior,
alternate clinging and avoidance behavior in relationships, excessive dependency needs,
manipulation of others for own needs, sense of entitlement, lack of insight, inconsistent
behavior, uncertainty about identity, poor impulse control, mood swings, alcohol or drug use,
frequent somatic complaints. Miss Amita Yadav took the psychiatric treatment for the same
problem before in another clinic. At present she is receiving Tab. Lithium 150mg/day, Tab.
Rispridone 1mg/day, Tab. Oxcarbazepine 150mg/day, Tab. Qutace 50mg/day, Tab.
Lopez .5mg/day along with behavior modification, counseling and supportive psychotherapy.

C. Past Psychiatric History

Ms Amita Yadav had same complaints 10 month back than she took treatment in the
local clinic and symptoms reduced at some extent.

CI. Personal History

(x) Perinatal history
Miss Amita Yadav’s mother had proper antenatal checkup and period was
eventful. Baby delivered as full term normal vaginal delivery. Child cried
immediately after birth and there was no postnatal complication like cyanosis,
convulsions and jaundice.
(y) Childhood history
Primary caregiver was mother. Weaning started at the age of six months and all
developmental milestones was achieved at appropriate age period. There was no
behavior and emotional problems like temper tantrums, head banging, nail biting,
thumb sucking and enuresis.
(z) Educational history
Education was started at the age of 4 years. She is good in academic performance
and had good relationships with teachers and peers. She never dropout from school
but got fail mark in the 12th class.
(aa) Play history

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 She used to play with both sex peer group and had good relationship with
friends.
(bb) Premorbid personality
xliii. Interpersonal relationships : Maintained good relationship
Temperament: Short temperament
xliv. Use of leisure time : Watching TV
and dancing
xlv. Predominant mood : Mood alteration
xlvi. Attitude to self and others : Self-
appraisal of abilities and not listening
others.
xlvii. Attitude to school and responsibility
: She was going to school regular and
irresponsible for any task.
Xlviii: Religious beliefs and moral attitudes : Not having faith on religious and not
participating in religious activity.
xlviii. Fantasy life : No complaint of daydreams
xlix. Habits : She consume alcohol
two times.

CII. Physical Examination:

During physical examination all the finding found normal except
Abdomen : Pain like cramps specially during
menstruation cycle.

CIII. Mental Status Examination

(gg) General appearance and behavior
 Appearance : Looking same age
 Level of grooming : Not well groomed
 Level of cleanliness : Not adequate
 Level of consciousness : Fully conscious
 Mode of entry : Persuaded by mother
 Cooperativeness : Not cooperative
 Eye-to-eye contact : Not Maintained

215
  Psychomotor activity : Increased
 Rapport : Spontaneous
 Gesturing : Exaggerated
 Posturing : Normal posture
 Other movements : Not abnormal movement present
 Other catatonic phenomena : Not present
 Conversion and dissociative signs : Not present
 Compulsive acts or rituals : Aggressiveness present
 Hallucinatory behavior : Not present
(hh) Speech
Student Nurse : What is your name?
Client : Amita Yadav
 Initiation : Patient responded when talk
 Reaction time : Slightly fast
 Rate : Sudden
 Productivity : Pressured speech
 Volume : Increased and high pitch
 Tone : Normal variation
 Relevance : Some time off target
 Stream : Circumstantial
 Coherence : Loosening of associations
 Others : Rhyming words used by patient.
(ii) Mood
 Subjective
Student nurse : How do you feel?
Patient : I do not feel comfort here and I want Munna.
 Objective : Irritable mood.
(jj)Thought
Student Nurse : What type of the ideas comes in your mind?
Client : I always want to be with Munna but..stopped talk.
 Stream : Pressure of thought.
 Form : No thought disorder is present
 Content

216
 Student nurse : Do you feel anything come to your mind frequently or
like you can do anything possible?
Client : No it’s not like that but I can’t control on myself and
always thinking about Munna.
Remarks : Compulsive thought present.
(kk) Perception
 Hallucinations
Student Nurse : Do you hear any sound or see someone whenever you
are alone?
Client : No. I don’t feel anything like that.
Remarks : No hallucinations present
(ll) Cognitive Functions
 Consciousness
Student Nurse : Hello Amita Yadav
Client : Yes sir
Remarks : Patient has obeyed by calling his name
 Orientation
xix. Person
Student Nurse : Who is sitting nearby you?
Client : My mother
Remarks : Oriented to person
xx. Place
Student Nurse : Where are you now?
Client : I am in hospital
Remarks : Oriented to place
xxi. Time
Student Nurse : What is the day today?
Client : Tuesday
Remarks : Oriented to time
 Attention
Student Nurse : Repeat the digit backward 2, 4, 6, 8, 10.
Client : 10, 8…4..6..2.
Remarks : Attention aroused with difficulty

217
  Concentration
Student Nurse : Name the months in backward?
Client : December, November…September, October, June,
July …August, March ….January.
Remarks : Concentration sustained with difficulty
 Memory
xiii. Immediate
Student Nurse : Repeat the word what I say Table, Pen, Rose, Bus and
Tree.
Client : Table, Pen, Rose, Bus and Tree
Remarks : Immediate memory present
xiv. Recent
Student Nurse : What you had in breakfast?
Client : Fried rice
Remarks : Recent memory present
xv. Remote
Student Nurse : When is your birthday?
Client : 23 October
Remarks : Remote memory present
 Intelligence
Student Nurse : Who is the Prime Minister of India?
Client : Narendra modi
Remarks : normal intelligence
 Abstraction
Student Nurse : Tell me one proverb and meaning.
Client : patient said “A drop in the ocean” and said the
meaning of it.
(mm) Insight: (grade1 to 6)
Student Nurse : Why do you come here?
Client : I am not able to forgot about Munna.
Remarks : Grade 5 Insight is present
(nn) Judgment:
Student Nurse : What you will do if you find “Close latter on the road”?

218
 Client : I will take that and I will put in postbox.
Remarks : Judgment is intact

CIV. Vital Signs:

S. No. Vital Sign Normal Value Patient’s Value
1. Temperature 98.60 F 98.40 F
2. Pulse 72-90 Beats/M. 76 Beats/M.
3. Respiration 14-20 Breath/M. 18 Breath/M.
4. Blood Pressure 80-120mmHg 80-120mmHg

CV. Investigation:
S. Patient’s
Investigations Normal Value Interpretation
No Value
1 Blood
 Heamoglobin 13 gm/dl 13-15 Normal
 Red blood cell 5.47 milcmm 4.5-6.51 Normal
 PCV 39.9% 20-54 Normal
 Platelets 2.43 lacs 1.5-4.5 Normal
 Total WBC different
count
9400 cu/mm 5000-11000 Normal
 Lymphocytes
29% 20-45 Normal
 Esinophills
06% 1-6 Normal
 Monocytes
01% 1-6 Normal
Routine Investigation
 RBS < 150 Normal
140 mgs/dl
 Blood urea Normal
19 mg/dl 20-45
 S. Creatinine Normal
1.1mgs/dl 0.7-1.2
 S. Sodium Normal
 S. Potassium 142 meq/l 135-145
3.5-4.5 Normal
LFT 4.0 meq/l
 S. Bilirubin
 S. total protein 1.2 mgs/dl 1 Slightly high
 S. Albumin 8.1 gm/dl 6-8 Normal
 S. Globulin 4.7 gm/dl 3-5 Normal
 Alkaline phosphate 3.4 gm/dl 1.8-3.6 Normal
64 IU/l 80-120 Low

Patient is clinically normal except S. Bilrubin that is slightly high and Alkaline
phosphate that is low

CVI. Medication chart:

219
13. Tab. Lithium 150mg/day,
14. Tab. Rispridone 1mg/day,
15. Tab. Oxcarbazepine 150mg/day,
16. Tab. Qutace 50mg/day
17. Tab. Lopez .5mg/day

220
 Pharmacological

Responsibility
Trade Name

Side-effects
Indications
Frequency

Indication

Contra-
Group

Action
Route
Name

Doses
S.

Nsg.
No.

1. Tab. Lithiu 150 Oral bd Mood Exact mechanism Acute mania, Renal and Tremors Check blood pressure
Lith m mg stabilizer is not clear but hypomania cardiac hypothyorism, Observe for abnormal
osun alters the Na+ recurrent patients major depression movement
transport in manic episode surgery, Instruct the patient not to
neurons pregnancy drive vehicle while on
treatment
Provide rest
2. Tab. Oxcar 150 Oral od Anticonv It reduces Epilepsy, Hepatic Pancreatitis,  Drug should not give
Oxc bazep mg ulsant, polysynaptic alcohol disease, behavioral empty stomach
arb ine mood responses and withdrawal pregnancy changes, Do not leave the patient
stabilizer blocks post syndrome, nausea, until the drug is
synaptic mania vomiting swallowed
potentiation Observe for drug specific
side-effects
3. Tab. Respe 1 Oral od Antipsyc It is atypical Acute and Hepatic and Hypotension  Use safety measures to
Resp ridon mg hotic antipsychotic chronic renal Constipation prevent fall

221
 idon e been proposed psychosis impairment NLEP Provide adequate rest
that mediation of patient syndrome Instruct patient to take
the D2 receptor more fluid
4. Tab. Queti 50 Oral bd Antipsyc Quetapine is an Schizophrenia, History of Extra  Give plenty of fluid
Quta apine mg hotic antagonist at behavioral cardiac pyramidal Instruct the patient to
ce multiple disorder arrhythmias, reactions take fibrous food such as
neurotransmitter epilepsy, irritability cabbage
receptors pregnancy weakness Don’t give medication
dizziness with tea or milk
6 Tab. Loraz 5 Oral od Benzodia Facilitate effects Acute Pregnancy, Drowsiness, Use safety measures to
Lore epam mg zepine in GABA activity psychosomatic hypersensitivi headache, prevent fall
az Anxiloyti and panic ty to confusion, Provide adequate rest
c attacks lorazepam blurred vision Instruct patient to take
more fluid

222
CVII.Other therapeutic therapies:
Therapy Indication Nurses responsibility
Yoga therapy Almost all condition  Provide correct guidance
 Provide calm environment
 Help during the difficulties in yoga
Behavior adolescents and  Deliberately establishes a professional
modification patients with relation
personality disorders,  Remove or modify existing symptoms
families and couples  Promote positive personality growth and
where the system needs development
change
Supportive Depression, psychosis,  Brought patient in directly as and active
psychotherapy anxiety, phobia participant
 Coordinate the process to attain maximum
benefit
 Educate regarding the condition and coping
mechanism
Individual Stress related disorder,  Deliberately establishes a professional
psychotherapy alcohol and drug relation
dependence, sexual  Remove or modify existing symptoms
disorder and marital  Promote positive personality growth and
disharmony development
Group therapy Homogenous group,  Use any transference situations to develop
personality disorders, insight into their problems
families where the  Provide positive reinforcement, this gives
system needs change ego support and encourages future growth
Family Psychosis, reactive  Assessment of family, roles, boundaries,
counseling depression, anxiety, resources, communication patterns and
psychosomatic problem solving skills
disorder, substance  Teaching communication skills
abuse  Teaching problem solving skills
CVIII. Process Recording:
Time : 30 Minutes

223
 Date : 27-01-2009
Place : Interview room of child psychiatric ward
Objectives : To
- maintain rapport
- obtain psychiatrist history
- make the patient ventilate feelings
- improve communication skills

Person Conversation Inference

Student Nurse Hello, Amita Yadav Responding good
Client Hello sir
Student Nurse How you are feeling? Eye contact
Client I am good sir maintained
Student Nurse What you had in breakfast? Decreased appetite
Client No, I don’t feel to take
Student Nurse Did you take bath? Self care deficit
Client No, I will take later.
Student Nurse Did you join exercise today with others? Interest to do work
Client Yes I did and here they don’t do nicely but I did
according me.
Student Nurse How you can say that here they don’t do nice Blaming others and
exercise? superiority
Client Because I know I used to go before? complex
Student Nurse Can you repeat it 2…..6…..9…4…..1…..7….8 Immediate memory
Client 2…6..8…..9…4……..6…..7………1…..3…8 present
Student Nurse Can you tell me your birthday Remote memory
Client 23 October intact
Student Nurse Who is the prime minister of India? Normal
Client Manmohan Singh Intelligence
Student Nurse What you will do if you find “latter on the road”? Judgment is intact
Client I will take that and I will put that in postbox
Student Nurse Can you tell me one proverb with meaning? Abstract reasoning
Client “A drop in ocean” and said the meaing present

224
Student Nurse Ok. Amita Yadav bye, take care Termination of
Client Bye, sir. process recording

Assessment techniques
 Observation
 Communication
 Interview

Summary
Miss Amita Yadav is a case of borderline personality disorder. She is responding
well, over active and irritable, decreased appetite, self care deficit, interest to do work,
attention deficit, intelligence poor, judgment is intact, abstract reasoning present. Her
immediate and remote memory is intact but she is irritable mood.
Literature Review

Introduction
Individual’s characteristics are combined product of heredity, early life experiences
and environmental influences. Healthy individual will be able to adjust and adopt/
accommodate to the changes, which are occurring in the life and its environmental situations.
When personality disorder occurs, individual will have fixed fantasies, rigid and ongoing
patterns of thought and action; the inflexibility and alteration in behavioral patterns causes
serious personal and social difficulties; in socially distressing ways, which often limit their
ability and function in relationships and at work.

Definition
‘An enduring pattern of inner experience and behavior that deviates markedly from
the expectations of the culture of the individual who exhibits it.”
“When personality traits are inflexible maladaptive and can cause either significant
functional impairment or subjective distress.”
“A morbid perversion of natural feelings, afflictions, inclinations, temper, habits,
moral disposition and natural impulses without any remarkable disorder or intellect defects or
knowing and reasoning faculties and particularly without any insane illusion or
hallucination.”

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 “A mental illness is characterized by emotional dysregulation, extreme ‘black and
white’ thinking or splitting and chaotic relationships.”

Book Pictures Patient Pictures

Etiology  Traumatic childhood  Reactive attachment disorder

 Vulnerable temperament  Chronic stress
 Stressful maturational events  Low level stressors
in adolescence and adulthood  Unresolved life events
 Failing in accomplishing
developmental tasks
 Childhood abuse or trauma or
neglect
 Abuse by the care takers
 Affective disorders
 Substance abuse disorder
 Reactive attachment disorder
 Ill treatment by parents
 Post traumatic stress disorder
 Defective family environment
 Genetics
 Chronic stress
 Low level stressors
 Unresolved life events
 Over involvement or under
involvement of parents
Types Cluster A (Odd and Eccentric)  Borderline (Emotionally
 Paranoid personality disorder unstable) personality disorder
 Schizoid personality disorder
 Schizotypal personality
disorder
Cluster B (Dramatic, Emotional
and Erratic)
 Antisocial or Dissocial

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 personality disorder
 Histrionic personality
disorder
 Narcissistic personality
disorder
 Borderline (Emotionally
unstable) personality disorder
Cluster C (Anxious and Fearful)
 Anxious (Avoidant)
personality disorder
 Dependent personality
disorder
 Obsessive Compulsive
(Anankastic) personality
disorder
Clinical Features  Avoid real or imagined  Impulsive behavior
abandonment  Inability to express feelings
 Unstable and intense verbally
interpersonal relationships  Inability to delay gratification
 Extremes of idealization and  Inability to tolerate frustration,
devaluation anxiety
 Identity disturbance, unstable  Intolerance of being alone
self image or sense of self  Ineffective coping skills
 Recurrent suicidal behavior,  Dissatisfaction with life
gestures, threats or self  Chronic feelings of boredom
mutilation or emptiness
 Affective instability due to  Physically self-damaging acts
marked reactivity of mood  Displays of temper
behavior  Attention-seeking behavior
 Emptiness feelings, difficulty  Alternate clinging and
in controlling anger avoidance behavior in
 Sever dissociative symptoms relationships
 Lability between ager and  Excessive dependency needs

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 anxiety or between depression  Manipulation of others for
and anxiety and own needs
temperamental sensitivity to  Sense of entitlement
emotive stimuli  Lack of insight
 Negative emotional states  Inconsistent behavior
 Insecure  Uncertainty about identity
 Ambivalent  Poor impulse control
 Paranoid ideas  Mood swings
 Relationship instability  Alcohol use
 Angry out bursts, abundant  Frequent somatic complaints
fears
 Suicidal behavior
Diagnostic Evaluation  History collection  History collection
 Clinical examination  Clinical examination
 Mental status examination  Mental status examination
Treatment
Psychopharmacology  Mood stabilizer  Mood stabilizer
 Anticonvulsant, mood  Anticonvulsant, mood
stabilizer stabilizer
 Antipsychotic  Antipsychotic
 Benzodiazepine Anxiloytic  Benzodiazepine Anxiloytic
Other therapies  Yoga therapy  Yoga therapy
 Behavior modification  Behavior modification
 Supportive psychotherapy  Supportive psychotherapy
 Individual psychotherapy  Individual psychotherapy
 Group therapy  Group therapy
 Family counseling  Family counseling
ECT In the case if drug is not Not given
responding

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 Nursing Process:
Day 1
S. Needs Problems
No.
1 Establish contact with reality Disturbed Personal Identity

2 increase feelings of self-worth Social Isolation

3 Participate in self-care activities Self-Care Deficit

Nursing Diagnosis:

 Disturbed Personal Identity related to Inability to distinguish between self and non-
self evidenced by bizarre behavior.

 Social Isolation related to aloneness experienced by the individual and perceived as

imposed by others and as a negative or threatening state evidenced by poor
interpersonal relationships.

 Self-Care Deficit related to impaired ability to perform or complete bathing/hygiene

activities for oneself evidenced by poor personal hygiene.

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 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Disturbed Disturbed Personal To establish  Reassure the client that the  Reassured the client that the Established
Personal Identity related to contact with environment is safe by briefly and environment is safe by briefly and contact with
Identity Inability to reality simply explaining routines simply explaining routines reality
distinguish evidenced by  Protect the client from harming  Protected the client from harming evidenced
between self and client will herself or others herself or others by client
non-self evidenced participate in  Remove the client from the group  Removed the client from the participate
by bizarre the therapeutic if her behavior becomes too group if her behavior becomes too in the
behavior. milieu bizarre, disturbing, or dangerous bizarre, disturbing, or dangerous therapeutic
to others. to others. milieu
 Help the client’s group accept the  Help the client’s group accept the
client’s "strange" behavior. client’s "strange" behavior.
 Consider the other clients’ needs.  Considered the other clients’
Plan for at least 1 staff to be needs. Planed for one staff to be
available to other clients available to other clients
 Explain to other clients that they  Explained to other clients that
have not done anything to warrant they have not done anything to
the client’s verbal or physical warrant the client’s verbal or
threats physical threats

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Social Social Isolation increase  Provide attention in a sincere,  Provided attention in a sincere, Increased
Isolation related to feelings of self- interested manner. interested manner. feelings of
aloneness worth  Support any successes or  Supported any successes or self-worth
experienced by the evidenced by responsibilities fulfilled, projects, responsibilities fulfilled, projects, evidenced
individual and client will interactions with staff members interactions with staff members by client
perceived as demonstrate and other clients and other clients demonstrate
imposed by others appropriate  Avoid trying to convince the  Avoided trying to convince the appropriate
and as a negative emotional client verbally of her own worth. client verbally of her own worth. emotional
or threatening state responses  Teach the client social skills.  Taught the client social skills. responses
evidenced by poor Describe and demonstrate specific Describe and demonstrate specific
interpersonal skills, such as eye contact, skills, such as eye contact,
relationships. attentive listening, nodding attentive listening, nodding
 Help the client improve her  Help the client improve her
grooming; assist when necessary grooming; assist when necessary
Self-Care Self-Care Deficit Establish an  Be alert to the client’s physical  Alerted to the client’s physical Established
Deficit related to impaired adequate needs needs an adequate
ability to perform balance of rest,  Observe the client’s pattern of  Observed the client’s pattern of balance of
or complete sleep, and food and fluid intake; you may food and fluid intake rest, sleep,
bathing/hygiene activity need to monitor and record intake, and activity
activities for evidenced by output, and daily weight evidenced
oneself evidenced the client will  Monitor the client’s elimination  Monitored the client’s elimination by the client

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by poor personal complete daily patterns patterns will
hygiene tasks with  Explain any task in short, simple  Explained any task in short, complete
minimal steps simple steps daily tasks
assistance  Using clear, direct sentences,  Used clear, direct sentences, with
instruct the client to do one part instructed the client to do one part minimal
of the task at a time of the task at a time assistance
 Tell the client your expectations  Told the client your expectations
directly. Do not ask the client to directly. Did not asked the client
choose unnecessarily. to choose unnecessarily.
 Allow the client ample time to  Allowed the client ample time to
complete any task. complete any task.

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 Day 2
S. Needs Problems
No.
1. Poor diet, Insomnia, restless sleep Ineffective health maintenance

2. Non–reality-based thinking Disturbed auditory perception

Nursing Diagnosis:

 Ineffective health maintenance related to inability to identify, manage and seek out
help to maintain health evidenced by poor hygiene.

 Disturbed auditory perception related to change in the patterning of incoming stimuli

accompanied by a impaired response to such stimuli evidenced by talking out loud
when no one is present.

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 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Ineffective Ineffective health Complete  If the client has delusions that  The client has delusions that Completed
health maintenance related to necessary daily prevent or limit rest, sleep, or prevent or limit rest, sleep, necessary daily
maintenance inability to identify, activities with food or fluid intake, it may be or food or fluid intake, it is activities with
manage and seek out minimal necessary to institute measures necessary to institute minimal
help to maintain health assistance that deal directly with physical measures that deal directly assistance
evidenced by poor health. with health.
hygiene.  If the client thinks that her  The client thinks that her
food is poisoned or that she is food is poisoned or that she
not worthy of food, it may be is not worthy of food, it is
necessary to alter routines. necessary to alter routines.
 If the client is too suspicious to  The client is too suspicious
sleep, try to allow the client to to sleep, try to allow the
choose a place and time in client to choose a place and
which she will feel most time in which she feel most
comfortable sleeping. comfortable sleeping.
Sedatives as needed may be Sedatives needed may be
indicated indicated
Disturbed Disturbed auditory Demonstrate  Be aware of all surrounding  Be aware of all surrounding Demonstrated

234
auditory perception related to decreased stimuli, including sounds from stimuli, including sounds decreased
perception change in the patterning hallucinations other rooms from other rooms hallucinations
of incoming stimuli interact with  Try to decrease stimuli or  Tried to decrease stimuli or interact with
accompanied by a others in the move the client to another area. move the client to another others in the
impaired response to external  Avoid conveying to the client area. external
such stimuli evidenced environment the belief that hallucinations  Avoided conveying to the environment
by talking out loud are real. client the belief that
when no one is present.  Explore the content of the hallucinations are real.
client’s hallucinations during  Explored the content of the
the initial assessment to client’s hallucinations
determine what kind of stimuli during the initial assessment
the client is receiving to determine what kind of
 Communicate with the client stimuli the client is
verbally in direct, concrete, receiving
specific terms. Avoid gestures,  Communicated with the
abstract ideas, and innuendos client verbally in direct,
concrete, specific terms.
Avoid gestures, abstract
ideas, and innuendos.

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 Day 3
S. Needs Problems
No.

1 Be free from injury Violence directed to other

2 Non–reality-based thinking Disturbed thought processes

Nursing Diagnosis:

 Risk for violence directed to other related to delusional thought evidenced by aggressive behavior.

 Disturbed thought processes related to disruption in cognitive operations and activities evidenced by non–reality-based thinking.

236
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Mistrust or Risk for violence client will  Be aware of all surrounding  Be aware of all surrounding Client
suspicion directed to other express stimuli, including sounds from stimuli, including sounds from expressed
related to decreased other rooms (such as television or other rooms (such as television decreased
delusional feelings of stereo in adjacent areas). or stereo in adjacent areas). feelings of
thought agitation, fear,  Try to decrease stimuli or move  Tried to decrease stimuli or agitation,
evidenced by or anxiety the client to another area. moved the client to another fear, or
aggressive  Avoid conveying to the client the area. anxiety
behavior. belief that hallucinations are real.  Avoided conveying to the client
Do not converse with the “voices” the belief that hallucinations are
or otherwise reinforce the client’s real. Did not converse with the
belief in the hallucinations as “voices” or otherwise reinforce
reality. the client’s belief in the
 Communicate with the client hallucinations as reality.
verbally in direct, concrete,
specific terms. Avoid gestures,
abstract ideas, and innuendos
Non–reality- Disturbed The client will  Be sincere and honest when  Be sincere and honest when The client
based thinking thought respond to communicating with the client. communicating with the client. responded to

237
processes related reality-based Avoid vague or evasive remarks. Avoid vague remarks. reality-based
to disruption in interactions  Be consistent in setting  Be consistent in setting interactions
cognitive initiated by expectations, enforcing rules, and expectations, enforcing rules, initiated by
operations and others so forth. and so forth. others
activities  Do not make promises that you  Do not make promises that you
evidenced by cannot keep cannot keep
non–reality-  Encourage the client to talk with  Encourage the client to talk with
based thinking. you, but do not pry or cross- you, but do not pry or cross-
examine for information examine for information
 Explain procedures, and try to be  Explain procedures, and try to
sure the client understands the be sure the client understands
procedures before carrying them the procedures before carrying
out. them out.
 Give positive feedback for the  Give positive feedback for the
client’s successes. client’s successes.

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 Day 4
S. Needs Problems
No.
1 Non–reality-based thinking Disturbed thought processes

2 Non–reality-based thinking Disturbed auditory perception

Nursing Diagnosis:

 Disturbed thought processes related to disruption in cognitive operations and activities evidenced by erratic, impulsive behavior.

 Disturbed auditory perception related to change in the patterning of incoming stimuli accompanied by a impaired response to such
stimuli evidenced by talking out loud when no one is present.

239
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Non–reality- Disturbed The client will  Be sincere and honest when  Be sincere and honest when The client
based thinking thought respond to communicating with the client. communicating with the client. responded to
processes related reality-based Avoid vague or evasive remarks. Avoid vague remarks. reality-based
to disruption in interactions  Be consistent in setting  Be consistent in setting interactions
cognitive initiated by expectations, enforcing rules, and expectations, enforcing rules, initiated by
operations and others so forth. and so forth. others
activities  Do not make promises that you  Did not make promises that i
evidenced by cannot keep cannot keep
erratic,  Encourage the client to talk with  Encourage the client to talk
impulsive you, but do not pry or cross- with me, but did not pry and
behavior. examine for information cross-examined for information
 Explain procedures, and try to be  Explained procedures, and
sure the client understands the tryed to be sure the client
procedures before carrying them understands the procedures
out. before carrying them out.
 Give positive feedback for the  Given positive feedback for the
client’s successes. client’s successes.
Disturbed Disturbed Demonstrate  Be aware of all surrounding stimuli,  Be aware of all surrounding Demonstrated

240
auditory auditory decreased including sounds from other rooms stimuli, including sounds from decreased
perception perception hallucinations  Try to decrease stimuli or move the other rooms hallucinations
related to interact with client to another area.  Tried to decrease stimuli or interact with
change in the others in the  Avoid conveying to the client the move the client to another area. others in the
patterning of external belief that hallucinations are real.  Avoided conveying to the external
incoming stimuli environment  Explore the content of the client’s client the belief that environment
accompanied by hallucinations during the initial hallucinations are real.
a impaired assessment to determine what kind  Explored the content of the
response to such of stimuli the client is receiving client’s hallucinations during
stimuli  Communicate with the client the initial assessment to
evidenced by verbally in direct, concrete, specific determine what kind of stimuli
talking out loud terms. Avoid gestures, abstract the client is receiving
when no one is ideas, and innuendos  Communicated with the client
present. verbally in direct, concrete,
specific terms. Avoid gestures,
innuendos.

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 Theory Application

King’s theory:
King’s theory of goal attainment encompasses three broad interlocking;
- Open systems,
- The personal and interpersonal and
- Social system
The personal system and social system influence the quality of care and the major elements in the goal attainment are contained in the
interpersonal system. In these system two or more persons come together under the guidance if health care organization to promote an optimal
state of health.
The major concepts are –
 Interaction
 Perception
 Communication
 Transaction
 Roles
 Stress
 Growth and development
 Time and space

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 Transaction
Try to control the activities

Stress
Role
Environmental
- Use of Coping
Stresses
Methods
- Communication
- Therapies
- Educational
experience
- Socioeconomic
status
- Identify needs
problems
- Perception
- Solve the
problems
- Concerns
regarding
patient Time
- IPR
Space - Aware of
course
awareness
- Interaction

Kings Goal Attainment Theory

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Health Education:
 Health education given regarding nutrition, sleep and hygiene techniques.
 Improve the self care needs (personal hygiene) independently.
 Encourage social interaction.
 Taught about the positive coping methods.
 Prevention of violent behavior.
 Prevention of self harm and others.
 Advised to spend more time with family.
 Family’s to use alternative coping methods.
 Educated the patient and family members regarding medication- dosage and side
effects of the medication.
 Advice the patient for regular checks up and follows up.
Summary:
Miss Amita Yadav brought to the psychiatric ward on 22/12/2008 with the
complaints of impulsive behavior, inability to express feelings verbally, inability to delay
gratification, inability to tolerate frustration, anxiety, intolerance of being alone, ineffective
coping skills, dissatisfaction with life, chronic feelings of boredom or emptiness, physically
self-damaging acts, displays of temper, attention-seeking behavior, alternate clinging and
avoidance behavior in relationships, excessive dependency needs, manipulation of others for
own needs, sense of entitlement, lack of insight, inconsistent behavior, uncertainty about
identity, poor impulse control, mood swings, alcohol or drug use, frequent somatic
complaints. Then she is diagnosed as a case of borderline personality disorder. I have taken
this case for my case study and given four days care with counseling and health education
from 26/01/09 to 29/01/09.
Bibliography:
23. Townsend.M, (2007), “Psychiatric Mental Health Nursing”, Jaypee brothers, New
Delhi, India.
24. Doenges M.E. et al., (1995), “Psychiatric Care Plans Guidelines for Planning and
Documenting Client Care”, 2nd ed. F. A. Davis Company, Philadelphia, PA.
25. Ahuja.N, (2006), “A Short Text Book of Psychiatry”, Jaypee brothers, New Delhi,
India.

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 MENTAL HEALTH NURSING
CASE STUDY ON
BORDERLINE
PERSONALITY
DISORDER
SUBMITTED TO
Mr. RAHUL SRIVASTAVA
ASSOCIATE PROFESSOR
HOD, MENTAL HEALTH NURSING
YASHRAJ COLLEGE OF NURSING

SUBMITTED BY
Mr BOBY DWIVEDI
M.Sc. NURSING 2nd YEAR,
YASHRAJ COLLEGE OF NURSING

DATE OF SUBMISION____________

245
 Patient’s Profile

CIX. Identification data

Client name : Ms. Meena
Age : 19years
Sex : Female
Father / Spouse name : Mr. Rksharam
Address : Haripur
:Gonda
:U.P..
Education : 11th standard
Occupation : student
Income : Rs. 3500/ month.
Marital status : unmarried
Religion : Hindu
Date of admission : 03.08.2020.
Provisional diagnosis : Mood disorder
Final diagnosis : Borderline personality disorder with?
Impulsive disorder
CX. Informant : Parents

CXI. Presenting Chief Complaints:

According to Patient :
1. Getting anxiety and irritation
2. Lack of sleep
3. Not concentrate with studies
According to Informant : (Parents)
1. Attempts suicide by cutting the radial vein (threatening)
2. Using the bad words and shouted like anything
3. Beating the parents if she is not getting what she likes
4. Smoking and drinking alcohol
5. Wandering outside of the home
6. Frequently telling lies, not sleeping during the night time
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 7. Always fight with others, threaten the family members and make self
injuries.
CXII. History of Present Illness:
Ms. Meena 19yr young girl was apparently normal before three months; now
she came with the history of not sleeping at night, wandering outside, asking
money to others, threaten the family members, abusing bad words, self injuries
(written her teacher name in LT forearm), hyperactivity, taking alcohol and
smoking, fight with her class friends, not going to the school (morning attended
the class and afternoon she goes outside) past three months. The client is only
one girl in her family and low socioeconomic family – when she got failed in
secondary education parents decided to send her to tuition centre it was ruined
by local teacher. After going tuition centre she got pass in secondary level, so
the parents decided to send her same tuition centre for higher level education.
After six months she use to go morning and evening to the tuition centre, and
she was very much font with her tuition teacher she use to stay with teacher
house, and cut the afternoon classes and go to the where her teacher is
working and waited outside of office past three months. During this period she
never listen her parents words, and adamant character, not doing any work in
home, not sleeping at night time, beating and abusing the bad words to
parents. One day her younger father seen her note book, she written regarding
her teacher and her husband name, so he beat up her and tied in home after
that she threaten her family members that suicide and cutter her vein and
scratch her hand with blade. So, the parents gave compliant against the
teacher and they drawn conclusion in front of the client that there is no more
relationship between the client and teacher in written letter. After that client
symptoms was very severe and admitted the client hospital.
When history collected from the teacher through phone she said there is no
abnormal relationship with her and she has some bad friends, very much
interested to get marriage and always talk about love and sex. After admitted
the client she tried more times to conduct her teacher through mobile and
always talk about her teacher. She said that in her classmates most of the girls
got married and got child. While in class room she was very much possessing
character like her friend talks to other person she uses to fight with her friend

247
 and make self injury herself. So, most of her classmates have fear about her
character and they said that she helped her friends to get love marriage. After
admission she has good prognosis but her aggressive behavior and
hyperactivity was not reduced.
CXIII.Treatment History:
After admission the client was treated with sedation for control her aggressive
behavior and antimanic and mood stabilizer. Individual & cognitive behavior
and family therapy given by psychologist. Multidisciplinary approach was
used to control her aggressive behavior and educated about her position.
Tab. Oxcarbazepine 150mg Bd, Tab.Lithium 150mg Bd, Tan. Rispridone
1mg, Tab.Qutace 50mg, Inj. Lopea 2mg Hs, Inj. Sernac 5mg HS (sos).
CXIV. Past Psychiatric History:
There is no history of conduct disorder and other specific psychiatric history.
CXV. Past Medical History:
She had urinary tract infection and taken treatment outside. At present there is
complaints related to genti-urinary system.
CXVI. Past surgical History:
There is no significant past surgical history.
CXVII. Family History:
(d) Family Characteristics:
Name of Relations Healt
S. Educatio Age &
the hip with Age/ Occupati h
No nal mode of
family the Sex on Statu
. Status death
member Patient s
Rkshara 52Yr/ Health
1 Father 5TH Std Former -
m M y
48Yr/ House Health
2 Pramila Mother - -
F wife y
24Yr/ Health
3 Prabudh Brother 9th Std Former
M y
After
delivery
Baby of Expire she died
4
Pramila d due to
hypotherm
ia
19Yr/
5 Meena Client 11th Std Student BPD -
F

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 (e) Genogram:
Key:-

- Male
52 yrs 48 yrs
- Female

- Patient
24 yrs
After delivery 19yrs

There is no history of psychiatric illness. Her sister expired due to

hypothermia and delivery conducted in local dais. There is no history of
consiagunious marriage and communicable disease like diabetes, asthma,
tuberculosis and hypertension. There is no suicidal history.
Socio-economic history;
They are living in own house. House is Pukka and having all the facilities like
water facility and electrical and closed drainage system. The communication
pattern of the family is normal. The total family income is Rs. 3500/month. Her
father is the leader of the family.
CXVIII. Personal History:
Perinatal history collected from client’s mother. While in antenatal
period she doesn’t have febrile illness and unwanted medications. The
child was wanted child and mostly like female child. The delivery
conducted in home and conducted by local dais and normal vegenal
delivery. After birth she cried immediately. The birth weight is normal
and there is no significant history of postpartum complication, like birth
defects and severe bleeding to mothers
(aa) Childhood history
Ms. Meena brought up by her biological parents. During childhood
history she is active and normal developmental milestone. She had
breast feeding and artificial feeding, the weaning started at after
6month. There is no significant history of childhood psychiatric
behaviors. She developed normal motor and sensory functions.
(bb) Educational history

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 She started the education at the age of 5yrs in govt. school. The
client’s academic function was normal and good relationship with peer
groups and teachers. After completed the primary education she
stared the secondary level near to her village school, she use to go by
walk to the school. There is no history of conduct disorder and phobic
disorder. During academic session she was average student and calm
and introvert character. She hasn’t had more friends during the school
period. She failed in 10th standard in English subject and she felt that
she needed help to pass the subject, so she attained the tuition centre.
In between the one year she went work for outside and household
work she did.
(cc) Play history
During childhood she use play with peer groups. She had good
relationship with her friends and elders. She always like group plays
(dd) Emotional problems during adolescence
She has taken alcohol and smoking before three months. She use
to speak about her friendship and affection
(ee) Puberty
She attained her menarche at the age of 13yrs and she had normal
development of secondary sexual characteristics. The client has
conscious about her bodily changes
(ff)Occupational history
During the one year she went for daily wager work and use to do
household works. She use sale the flowers at evening time. She was
regular in work during the one year.
(gg) Premorbid personality
l. Interpersonal relationships:
She has more socialization interactivity with others. More talkative,
using fun words and rhyming sentences sometimes. While talking to
others she has inflated herself, grandiosity with her activities. She has
good relationship with her family members.
Use of leisure time:

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 She uses to watch television and read weekly magazines. She use to
play the indoor games
li. Predominant mood:
She always has optimistic mood, easily get irritation, immediate
reaction to stressful events, blunted mood.
lii. Attitude to self and others:
She has self centered thoughts and inflated self confidence. She
always talks about her failures related to education
liii. Attitude to work and responsibility:
She has poor attitude, poor knowledge regarding problems and
taking decision. She doesn’t have responsibility regarding her
behaviors and other works
liv. Religious beliefs and moral attitudes:
She has religious beliefs and moral attitudes
lv. Fantasy life:
She had frequent and recurrent dreams related to her teacher and
married life.
lvi. Habits:
She use to take mixed food and she has the habits of alcohol, cigarette
smoking. Client has regular bowel and bladder habits.
CXIX. Physical Examination:
(n) General assessment:
 Appearance: young adulthood
 Body built: moderated built
 Looking: excited, elevated mood
 Height: 143cm
 Weight:52kg
During the physical examination she has written her teacher name in LT
forearm and many scratching scars.
CXX. Mental Status Examination
(o) General appearance and behavior
 Appearance: young adult hood
 Level of grooming: Average grooming

251
 Level of cleanliness: adequate
 Level of consciousness: fully conscious
 Mode of entry: brought by her parents
 Cooperativeness: normal cooperativeness
 Eye-to-eye contact: maintain the good eye to eye contact
 Psychomotor activity: increased psychomotor activity (singing song, using fun
words)
 Rapport: spontaneous rapport maintained
 Gesturing: normal
 Posturing: normal
 Other movements: not present
 Other catatonic phenomena: not present
 Conversion and dissociative signs: not present
 Compulsive acts or rituals: not present
 Hallucinatory behavior: not present
(p) Speech
 Student Nurse: why you are not going to the school properly?
 Client: No, I am going to school regularly
 Student Nurse: then, why your parents and teacher reported about you, you are
not attending the afternoon class?
 Client: I use go to teacher house or where she is working.
 Initiation: when spoken to her
 Reaction time: immediately
 Rate: rapid
 Productivity: very fast and elaborate replies
 Volume: increased and shouted
 Tone: variation present
 Relevance: fully relevant
 Stream: normal
 Coherence: fully coherent
 Others: during the conversation use rhyming and funning words
(q) Mood
 Subjective: anxiety and aggressive mood

252
 Objective: she has anxiety and irritable mood first few days after the
implementation of the drugs she has appropriate mood.
(r) Thought
 Student Nurse: why you so much affection with your teacher?
 Client: she taught lot of new things to me, although she uses to give money to
me. She had love marriage one who work with her, she is the second wife of him.
Due to family problems she stayed her parent’s house. She use to advice to me
you shouldn’t love anyone and cried many times.
 Stream: normal and pressure of thought
 Form: normal
 Content: normal
(s) Perception
 Student Nurse: are you hearing any external and internal voice?
 Client: no
There is no abnormal perception behavior present
(t) Cognitive Functions:
 Consciousness:
- Student Nurse: what is your name?
- Client: meena
- Client has normal consciousness
 Orientation:
xxii. Person
- Student Nurse: what is your teacher name?
- Client: Mangalam
xxiii. Place
- Student Nurse: who brought you to here and what id name of
the hospital?
- Client: my parents, SCPM hospital
xxiv. Time
- Student Nurse: what is the time now?
- Client: around 11’o clock
- Client has normal orientation to person, place and time
 Attention:

253
 Student Nurse: can you repeat the digit 23, 45, 66 and 58
Client: she has difficult to repeat the digit
Client has poor attention span and easy distractibility
 Concentration:
- Student Nurse: can you tell the answer 91 – 8 = ?
- Client: she said correct answer.
- Student nurse: can you say the name of month in backwards:
- Client: answered correctly
- Client has normal concentration power.
 Memory:
iv. Immediate
- Student Nurse: can you repeat the digit with backwards?
28,54, 76, 92
- Client: she answered correctly
v. Recent
- Student Nurse: when did you see your teacher at lastly?
- Client: last week
vi. Remote
- Student Nurse: what is your birthday date?
- Client: she answered correctly and confirm with her mother
- Client has normal memory power
 Intelligence:
- Student Nurse: who is president of india?
- Client: not answered
- Student Nurse: I will give some sums can you able to solve it?
1580 × 18÷34 +=?
- Client: she answered correctly.
- Client has normal intelligence
 Abstraction:
- Student Nurse: can you any proverb and meaning:
- Client: she said grittiness not at all gold and given meaning to
the proverbs
- Client has normal abstract thinking

254
 (u) Insight: (grade1 to 6)
- Student Nurse: can you accept you have some illness?
- Client: yes
- Client has normal insight
(v) Judgment:
- Student Nurse: in front of you someone picked other person
money purse that time what is your reaction?
- Client: I will to others and I try to beat the person
- Client has normal judgment
CXXI. Vital Signs
S. No. Vital Sign Normal Value Patient’s Value
1. Temperature 98.60 F 98.4F
2. Pulse 72-90 Beats/M. 86 Bts/m
3. Respiration 14-20 Breath/M. 15 Br/m
4. Blood Pressure 70/110 - 80/140mmhg 80-110mmhg
CXXII. Medication chart:
18. Tab. Oxcarbazepine 150mg Bd 15 days
19. Tab.Lithium 150mg Bd 15 days
20. Tan. Rispridone 1mg od 5days
21. Tab.Qutace 50mg, bd 10days
22. Inj. Lopea 2mg Hs 3days
23. Inj. Sernac 5mg Hs (sos) 3 days

255
 Pharmacologica

Responsibility
Trade Name

Side-effects
Indications
Frequency

Indication

Contra-
S.

l Name

Action
Doses
Group

Route

Nsg.
No
.

Lithosun Lithium Anti 150 Oral bd Exact Acute Renal Tremors Check the physician’s
order.
mani mg mechanism mania, and hypothy
Medication given
c is not clear hypomani cardiac orism, must be charted on
the patient’s case
but alters a patients depressi
1. sheet.
the Na+ recurrent major on Check the five rights
for drug
transport in manic surgery,
administration
neurons episode preganc Always address the
patient by name and
y
make certain
2. Oxcarb Oxcarba Antic 150 Oral Bd It reduces Epilepsy, Hepatic Pancrea identification
Do not leave the
zepine onvul mg polysynapti alcohol disease, titis,
patient until the drug
sant, c responses withdrawal pregnan behavior is swallowed
Do not allow the
moo and blocks syndrome, cy al
patient to carry drugs
d post mania changes Do not force oral
medication
stabil synaptic ,
Check drug daily
izer potentiation nausea, Observe for drug
specific side-effects
vomiting

256
 Respidon Resperi Antip 1mg Oral Od It is atypical Acute and Hepatic Hypoten Instruct the family
members when to
done sych antypsychot chronic and sion
contact psychiatrist
otic ic been psychosis renal Constipa
proposed impairm tion
3.
that ent NLEP
mediation of patient syndrom
the D2 e
receptor
Qutace Quetiapi Antip 50m oral Bd Quetapine Schizophr History Extrapyr
ne sych g is an enia, of amidal
otic antagonist behavioral cardiac reaction
at muliptle disorder arrythmi s
4. neurotrans as, irritability
mitter epilepsy, weaknes
receptors preganc s
y dizzines
s
5 Inj.serence Haloperi Antip 5mg IM Hs Potent Acute Cardiov Neurolo
5mg dol sych antagonist mania, ascular petic
otics for D2 acute disease maligna
receptors, schizophr CNS nt

257
 controlled enia, injury syndrom
bizarre bipolar and e coma,
behaviors mood depress confusio
disorders ants. n
Inj. loreaz Lorazep Benz 2mg IM Hs Facilitate Acute Pregnan Drowsin
am odiae effects in psychoso cy, ess,
pine GABA matic and hyperse headach
Anxil activity panic nsitivity e,
6
oytic attacks to confusio
lorazepa n,
m blurred
vision

258
CXXIII. Other therapeutic therapies:
Behavioral and supportive psychotherapy
Behavior therapy is a form of treatment for problems in which a trained person
deliberately establishes a professional relationship. Behavior therapy involves
identifying maladaptive behaviors and seeking to correct these by applying the
principles of learning conditions.
Here Ms. Meenakachi have significant and persistent disturbance of
uncertainty about major issues of life, impulsivity, unstable emotional responses,
with rapid shifts, anger outburst, inability to stay alone, deliberate self harm, suicidal
gestures and self mutilation past three months. During the behavioral therapy the
client educated and instructed to how to behave with other person, what are all the
good habits, when she did mistakes given negative reinforcement and gradually
desensitize the her aggressive behavior by positive reinforcement process. During
the supportive therapy the client educated about her studies and in future how she
could be come up from the problems, encourage the client to continue the studies
after discharge from the hospital.

CXXIV. Process Recording:

Time : 30 Minutes
Date :
Place :

Objectives :
To- maintain rapport
Obtain psychiatrist history
Make the patient ventilate feelings
Improve communication skills
Purpose and uses:
 Assists the nurse or student to plan, structure and evaluate the interaction
on a conscious than institutive level
 Assists the client to gain competency in interpreting and synthesizing raw
data under supervision

259
  Helps to consciously apply theory to practice
 Helps the student to develop an increased awareness of her habitual
verbal and non verbal communication pattern and the effect of those
patterns on others
 Helps the nurse to learn to identify thoughts and feelings in relation to self
and others
 Helps to increase observational skills as there is a conscious process
involved in thinking sorting and classifying the interaction under the
various headings
 Helps to increase the ability to identify problems and gian skills in solving
them.
Pre-requisites for process recording:
Physical setting
Getting consent of the patient
Maintain the Confidentiality

Person Conversation Inference

Student Good morning Ms. Meena Client maintain
Nurse the normal
Client Good morning sir, had your rapport
breakfast?
Student Do you finish your personal hygiene Client feel lazy
Nurse today? and dizzy
Client No sir, I am not interest to take bath.
Student What you had in the morning? Client has
Nurse anxiety towards
Client I asked chicken Briyani, but (she her mother
scolded her mother by bad words)
didn’t given to me
Student Why you are scolded your mother? Client has
Nurse And I heard about that you beaten unstable
your mother yesterday night? relationship
Client Yes, sir, she didn’t allow me to talk with her

260
 with teacher and she didn’t given parents, and
mobile also. So, I want to go down to she has very
make a one rupee phone call that much intense
time also she not allows me to go affection with
down. That’s why I beaten her. her teacher.
Student What is the reason to write your She has
Nurse teacher name in your hand by blade? disturbance her
Client I am so affection with my teacher, identity and so
she use to give money to enjoy, she intense
is pretty in her life. Her husband left relationship
her and went so I am the only person with her
close with her teacher.
Student What you do your leisure time? She has
Nurse impulsivity
Client I use to watch the movies, serials in character
sun TV, I like more ‘Veiyra Necham”
in this heroine also like my teacher.
Student Why you are so much affection with There is no
Nurse your teacher? And any other other abnormal
relationship with her? relationship
Client No sir, she refused immediately with teacher
Student Why you drunk and smoked once? She has
Nurse uncertainty
Client Simply sir I want to know what is in about major life
that issues
Summary:
Ms. Meena 19 year young girl have blunted behavior, intense relationship with her
teacher, beating and scolding her parents, threatening her family members
regarding suicidal activities, decreased sleep, not concentrate with her studies,
wandering outside during school time, fight with her neighbors and friends past three
months. She was diagnosed initially mood disorder –manic episode and finally she
diagnosed as borderline personality disorder. After implementation of treatment and

261
therapies she realized her behavior and she assured that I wouldn’t be do in my
future and agreed for regular treatment.

Disease Condition (Literature Review)

Introduction:
Personality disorder differ from personality change in their timings and
the mode of their emergence: they are developmental conditions, which
appear in childhood or adolescence and continue into adulthood. They are not
secondary to another mental disorder or brain disease, although they may
precede and coexist with other disorder. in contrast, personality change is
acquired usually during adult life, following severe or prolonged stress,
extreme environmental deprivation, serious psychiatric disorder or brain
disease or injury.
Definition
A personality disorder in which there is a marked tendency to act
impulsively without consideration of the consequences, together with affective
instability. The ability to plan ahead may be minimal and out bursts of intense
anger may often lead to violence or “behavioral explosions”.
Personality is defined as a deeply ingrained pattern of behavior that
include of perception, relating to and thinking about oneself and the
surrounding environment.
Personality traits are normal prominent aspects of personality.
Personality disorders result when these personality traits become abnormal.
According to the National Institute of Mental Health (NIMH), borderline personality
disorder is:
"A serious mental illness characterized by pervasive instability in moods,
interpersonal relationships, self-image, and behavior. This instability often disrupts
family and work life, long-term planning, and the individual's sense of self-identity."

Epidemiology:
Prevalence estimates of borderline personality range from 2 to 3 percent. It is
more common in women than in men (the ratio is 4:1)

262
Etiology
Hereditary factor:
Chromosomal abnormality or genetic predisposition can be responsible for a
psychopathic personality.
Relation of personality disorder to mental disorder:
:
Disturbed parent child relationship
Other causes:
Maternal deprivation, especially in antisocial personality
Borderline personalities are more likely to report physical and sexual abuse in
childhood
Histrionic personality is said to occur as a result of failure to resolve oedipal
complex and excessive use of repression as mechanism of defense.
Predisposing factors:
Biological influences:
Biochemical hypothesis suggested a possible serotonergic defect in clients
with borderline personality disorder.
Genetic- decrease in serotonin may also have genetic implications for
borderline personality disorder. Depression is common in the family
background of client with borderline personality disorder.
Psychosocial influences:
Childhood trauma:
Family environment characterized by trauma neglect and separation:
exposure to sexual and physical abuse and serious parental psychopathology
such as substance abuse and antisocial personality disorder.

Book Pictures Patient Pictures

Types Emotionally unstable Borderline personality
personality disorder disorder.
1. Impulsive personality
disorder

263
 2. Borderline personality
disorder
Clinical Features Unstable relationship Unstable relationship
Impulsive behavior impulsive behavior
Variable moods Mood variables
Lack of control on anger Lack of control on anger
Recurrent suicidal threats or Recurrent suicidal threat
behavior Smoking and alcohol habits
Chronic feeling or emptiness Lack of sleep
Efforts to avoid Wandering outside
abandonment Difficulty in find the gender
Transient stress-related Frequent lies
paranoid or dissociate Abusing bad words
symptoms Violent behavior

Psychopathology Biological hypothesis: Client has abrupt changes

Cummings and Mega (2003) of her behavior within six
suggested a possible months. After her father
serotonergic defect in clients beaten and tied in home
with borderline personality she developed more
disorder. In positron maladaptive and behavioral
emission tomography using changes. She was very
methyl-L-tryptophan which much attached with her
reflects serotonergic tuition teacher. So the client
synthesis capability clients has unresolved grief results
with BPD demonstrated in internalized rage that
significantly decreased (C) manifests itself in the
MTrp in medial frontal, depression so common in
superior temporal borderline personality
disorder.
Diagnostic Evaluation PET and CT – BRAIN
showing decreased

264
 secretion of serotoneric
neurotransmitter.
Family history of depression
and behavioral disorder.
According to ICD-10 and
DSM IV criteria:
Significant and persistent Client has significant
disturbance of identity disturbance of identity
Unstable and intense Unstable relationship with
interpersonal relationship family members
pattern
Impulsivity Impulsivity presents
Unstable emotional Anger outburst present
responses with rapid shifts.
Anger outbursts may occur
Chronic feelings of boredom -
or emptiness with inability to
stay alone
Deliberate self harm is Deliberate self harm and
common in the form of self suicidal gestures present
mutilation, suicidal gestures
or accident proneness.
Differential diagnosis Borderline personality
disorder and mood disorders
often appear concurrently.
Some features of borderline
personality disorder may
overlap with those of mood
disorders, complicating the
differential diagnostic
assessment. Both
diagnoses involve
symptoms commonly known

265
 as "mood swings". In
borderline personality
disorder, the term refers to
the marked lability and
reactivity of mood defined as
emotional dysregulationThe
behavior is typically in
response to external
psychosocial and
intrapsychic stressors, and
may arise or subside, or
both, suddenly and
dramatically and last for
seconds, minutes, hours or
days
Treatment Psychopharmacology; Tab. Oxcarbazepine 150mg
Psychopharmacology If client has other mental Bd 15 days
disorder like schizoid and Tab.Lithium 150mg Bd 15
mood disorder, necessitates days
antidepressant and Tan. Rispridone 1mg od
antipsychotic therapy to 5days
control the bizarre behavior. Tab.Qutace 50mg, bd
Occasionally antipsychotics, 10days
lithium and carbamazepine Inj. Lopea 2mg Hs 3days
have been used when Inj. Sernac 5mg Hs (sos) 3
aggression and impulsivity days
are prominent.

Psychotherapy Psychodynamic Behavioral and supportive

psychotherapy, behavioral therapy – to change her
therapy and supportive attitude, impulsivity, anger,
psychotherapy moral life behavior taught
to client.

266
ECT Not advisable -

Nursing management:
 Observe patient’s behavior frequently. Do this during routine activities and
interaction avoid appearing watchful and suspicious
 Secure a verbal contract from patient that he will seek out staff members for
help when urge for self mutilation is felt.
 If self mutilation occurs, care for patient’s wounds in matter of fact matter. Do
not give positive reinforcement to this behavior by offering sympathy or
additional attention. Assign staff on a one to one basis if need arises
 Encourage patient to talk about feelings he was having just prior to this
behavior, act as role model for appropriate expression of angry feelings. Give
positive reinforcement when attempts on conform are made.
 Set limits on acting out behavior.
 Rotate staffs who work with the patient to prevent the patient from developing
dependence on particular staff members.
 Explore feelings that relate to fears of abandonment. Help client understand
that these fears are causing his clinging and distancing behaviors. Helps
patient understand bow these behaviors interfere with satisfactory relations,

Nursing Process:
Day 1

267
S. Needs Problems
No.

1 Prevent the self harm and reduce Self mutilating and others
the aggressive behavior

2 Accept the reality Dysfunctional grieving

Nursing Diagnosis:

Risk of self mutilation related to emotional deprivation as evidenced by

scratching herself, beating parents
Dysfunctional grieving related to internalized loss as evidenced by acting out
behaviors (anxiety towards to patents)

268
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Self mutilating Risk of self Client not  Maintain the low level stimuli in  Low lighting, few people, Client self
and others / mutilation related harm client’s environment low noise level maintained harm
Prevent the to emotional herself and  Remove all dangerous objects  Sharp objects and behavior,
self harm and
deprivation as others from client’s environment instruments were removed thoughts
reduce the  Redirect violent behavior with  Physical exercise reduced at
evidenced by
aggressive physical outlets for the anxiety. implemented to out the some
scratching
behavior  Nurse should maintain a calm anxiety extent
herself, beating
attitude towards client  Maintain the IPR.
parents
 Administer tranquilizing  Inj. Lorazepam 2mg iv
medications as per physicians given
order.  Advised the client if she
 Act as role model for appropriate has anxiety or self
expression of angry feelings and mutilated thoughts express
give positive reinforcement to to inanimate objects
client when attempts to conform (pillow)
are made

Dysfunctional Dysfunctional Client  Convey an accepting attitude one Accepted her emotions it Client

269
grieving / grieving related accept the that creates a nonthreatening makes trust and enhances grieving
Accept the to internalized reality and environment for the client to the relationship. anger
reality loss as express express feelings, be honest and reduced at

evidenced by her keep all promises some

emotions  Identify the function that anger Verbalization of feelings may extent.
acting out
in socially frustration and rage serve for the help client come to terms
behaviors
acceptable client allow him or her to express with unresolved issues.
(anxiety towards
manner these feelings within reason.
to patents)
 Encourage client to discharge Physical exercise helps to
pent up anger through reduce the anger and
participation in large motor discharge the client tension
activities (physical exercise)
 Explore with client the true Reconciliation of the feeling
source of the anger. This is a associated with grieving
painful therapy that often leads to phase.
regression as the client deals
with feeling of early
abandonment.

270
 Day 2
S. Needs Problems
No.

1 Prevent or remove the suicidal Suicidal thoughts and gestures, threats

thoughts

2 Client not interested to continue Low self esteem

the education due to
hopelessness, worthlessness
feelings

Nursing Diagnosis:

1. Risk for suicide related to unstable emotional behavior as evidenced by feeling of worthlessness, hopelessness

2. Low self esteem related to feeling of abandonment and impaired cognition functions as evidenced by not interested to
continue her studies.

271
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Suicidal Risk for suicide Client not  Ask the client directly “have you  Identified and assessed Client
thoughts and related to harm self thought about harming yourself in the client’s suicidal suicidal
gestures, unstable and any way, what your plan, how to thought by asking the thought
threats / emotional eliminate carry out the plan? direct question. eliminated at
Prevent or behavior as the  Create the safe environment for the  Removed all potential some extent.
remove the evidenced by suicide client. Remove the all potentially harmful objects from the
suicidal feeling of thought harmful objects from client’s ward.
thoughts worthlessness, environment.
hopelessness  Maintain the close observation of  One to one basis
client. Provide one-to- one contact observation made and
and place the patient near to nurse’s placed the patient near
station. to the nurse’s station.
 Encourage the client to express  Allowed the client to
honest feelings, including his/her ventilate his feelings and
anger. anxiety.
Maintain the special care in  Removed all medication
administration of medications from the client’s room.
Low self Low self esteem Client  Be accepting of client and spend  Accepted the client Client self

272
esteem / Client related to feeling able to time with him/her even though thoughts and feelings it esteem
not interested of abandonment attempt pessimism and negativism. makes positive improved at
to continue the and impaired the new  Focus on strength and contribution. some extent.
education due cognition activities accomplishments and minimize  Talked about the client’s
to functions as without failures. strengths and victory.
hopelessness, evidenced by not fear of  Provide opportunities for success;  Repeated success
worthlessness engaging in any failure. plan activities with short time span improves the client’s self
feelings activities. and appropriate ability level. esteem.
 Help the client set realistic, concrete Engaged in new tasks
goals and determine appropriate promotes personal growth
actions to meet these goals and and new skills
encourage involvement of new
activities/ tasks

273
 Day 3
S. Needs Problems
No.

1 Maintain the normal sleeping Decreased sleep pattern

pattern

2 Maintain the normal social Impaired social interaction

interaction

Nursing Diagnosis:

1. Disturbed sleeping pattern related to unemotional behaviors as evidenced by client has aggressive and wandering
behaviors.
2. Impaired social interaction related to inability to trust, extreme fears of abandonment and engulfment as evidenced by
alternatively changing behavior

274
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Decreased Disturbed sleeping Maintain To promote sleep: Before bed time allow the Maintain the
sleep pattern / pattern related to the normal vi. Encourage activities that client to hear the soft music normal
Maintain the unemotional sleeping prepare one for sleep: soft (radio given to client) sleeping
normal behaviors as pattern music, warm bath Restricted the client to take pattern after
sleeping evidenced by client vii. Control intake of caffeine coffee and tea at evening implementation
pattern has aggressive and containing substances within time of the
wandering behaviors. 4hr of bedtime During night time allow the intervention
viii. Provide a high carbohydrate client to take a glass of milk
snack before bedtime. During the day time short
ix. Discourage the daytime term menu was given to the
napping. Increase the client (activities like
program of activities to keep drawing, working in
the client busy. rehabilitation centre)
x. Make the client to go for Instruct the client to go bed
regular bed time. It may before 9’o clock.
helps to maintain the regular Tab. Librium 20mg given
circadian rhythm.
Use short term sleep medications
Impaired social Impaired social Maintain  Encourage the client to examine Recognition must occur Client social
interaction interaction related to the normal these behaviors before change can occur. interaction

275
inability to trust, social  Help client realize that you will be Knowledge may provide improved at
extreme fears of interaction available without reinforcing needed security for the some extent
abandonment dependent behaviors client
evidenced by  Give positive reinforcement for Positive reinforcement
alternating changing independent behaviors enhances the self esteem
behavior  Rotate staff members who work with Rotation of staff members
the client to avoid client’s developing improves client security
dependence on particular individuals Exploration of feeling with a
 Explore feeling that relate to fears of trusted individual may help
abandonment and engulfment with the client come to terms
client Client accepts her
 Help client understand how these maladaptive behavior.
behavior interfere with satisfactory It resolves fears of
relationships abandonment
 Assist client to work toward
achievement of object constancy.

276
 Day 4
S. Needs Problems
No.

1 Improve the client coping Low coping strategies

strategies

2 Enhances the Family members Ineffective family members coping

strategies

Nursing Diagnosis:
1. Ineffective coping strategies related to impaired cognitive functions as evidenced by severe anxiety, uncontrolled behaviors
2. Disabled family coping strategies related to difficulty coping with client’s illness as evidenced by neglectful care of the client

277
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Patient has Ineffective Maintain the  Reassure the client of safety and  Reassured the client by Client
low self coping strategies more security through your presence. making trustful relations. maintain the
esteem and related to adaptive  Identify the severe stressors and  The stressful stimulus normal
coping impaired ways of remove the stimuli. was removed. coping
strategies cognitive coping in  Help the client define more  Taught the new coping method
functions as stressful adaptive coping strategies. Make strategies to the patient.
evidenced by environment suggestions of alternatives that 
severe anxiety, might be tried.  Positive reinforcement
uncontrolled  Provide positive reinforcement for was given.
behaviors client’s attempts to change. Used the available
Identify the community resources to resources help to the
which the individual may go for client from
support if past maladaptive coping decompensating
patterns return.
Family Disabled family Maintain the  Identify level of family functioning.  Identified the family Family
members has coping strategies normal or Assess the communication pattern, member’s lacks and members
low related to more interpersonal relationships between knowledge level of the maintain the
confidence difficulty coping adaptive members, role expectations, client’s disease more

278
and confusion with client’s coping problem solving skills and condition. adaptive
regarding illness as strategies availability of outside support  Adequate information coping
client’s evidenced by for dealing systems. given to the family methods.
disease neglectful care with client.  Provide information for the family members regarding
condition of the client. about the client’s illness, what will disease condition and
be required in the treatment prognosis.
regimen and long term prognosis. Assisted the family
With family members practice how to members to respond
respond to bizarre and adaptively in the face of
communication pattern and in the what they may consider
event that the client becomes violent. to be a crisis situation

279
 Theory Application
Peplau’s Interpersonal theory:
The core of Peplau’s approach is interpersonal relations. The theory includes the concept such as:
 Communication,
 Roles and
 Growth and development.
Communication as a problem solving process whereby the nurse and client collaborate to meet the clients need. The nurse
may assume the roles of:
 Counselor,
 Leader,
 Resource,
 Surrogate, and
 Teacher.
These roles are designed to lead to growth and development.

280
 Growth and Development

Orientation
- Established working relationship
- Collected history of illness
- Oriented to hospital, ward and them self
Identification
- Classify perceptions (unstable emotional)
- Identify problems (impaired social and
Teacher moral behavior)
- Discussed the solutions (attain the normal
Resource behavior, resolve the grief)

Counselor Nurs COMMUNICATION Patien

e Exploitation
t
Leader
- Create a non threatening atmosphere
Surrogate (psychological support)
- Encourage client participation in problem
solving (recognize her maladaptive behavior
and independent decision related to her future)
Resolution
- Evaluated the outcomes
- Reduced aggressive behavior, normal social
interaction and coping methods at crisis
situation
- Increased problems solving activities

Peplau’s Nurse-client Interpersonal Framework

281
282
Health Education:
Health education given regarding
 Encourage social interaction.
 Improve the self care needs (personal hygiene) independently.
 Sleep hygiene techniques.
 Family’s to use alternative coping methods.
 Prevention of violent behavior.
 Taught about the positive coping methods.
 Prevention of self harm and others.
 Educated the patient and family members regarding medication- dosage and
side effects of the medication.
 Advice the patient for regular checks up and follows up.
 Advice to start the work gradually. Initially start with fulfill his own needs and
home works.
Discharge Plan:
Summary:
Ms. Meenakchi 19 year young girl has blunted behavior, intense relationship with her
teacher, beating and scolding her parents, threatening her family members
regarding suicidal activities, decreased sleep, not concentrate with her studies,
wandering outside during school time, fight with her neighbors and friends past three
months. She was diagnosed initially mood disorder –manic episode and finally she
diagnosed as borderline personality disorder. After implementation of
multidisciplinary treatment approach she realized her maladaptive behavior and she
was taught regarding problems solving technique and advised to come regular follow
up and medications.
Bibliography:
26. Townsend.M, (2007), “Psychiatric Mental Health Nursing”, Jaypee brothers, New Delhi, Pp. -
27. Doenges M.E. et al., (1995), “Psychiatric Care Plans Guidelines for Planning and
Documenting Client Care”, 2nd ed. F. A. Davis Company, Philadelphia, PA, Pp. -
28. Ahuja.N, (2006), “A Short Text Book of Psychiatry”, Jaypee brothers, New Delhi, Pp. -
29. Sreevani.R, (2008), “A Guide to Mental Health and Psychiatric Nursing”, Jaypee Brothers,
New Delhi, Pp. -

283
 MENTAL HEALTH NURSING

CASE STUDY ON
SCHIZOPHRENIA

SUBMITTED TO
Mr RAHUL SRIVASTAVA
ASSOCIATE PROFESSOR
HOD, MENTAL HEALTH NURSING
YASHRAJ COLLEGE OF NURSING

SUBMITTED BY
Mr BOBY DWIVEDI
M.Sc. NURSING 2nd YEAR
YASHRAJ COLLEGE OF NURSING

DATE OF SUBMISION____________

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 Patient’s Profile

CXXV. Identification data

Client name : Mr. Himanshu
Age : 45 Years
Sex : Male
Father : Mr. Brij Bhushan
Address : Gonda
Education : 12th
Occupation : Business
Income : 13000/-
Marital status : Married
Religion : Hindu
Date of admission : 20.08.2020
Provisional diagnosis : Schizophrenia
Final diagnosis : Catatonic Schizophrenia

CXXVI. Informant : Son

CXXVII. Presenting Chief Complaints

According to Patient
o Irritability
o Anxiety
o Decreased sleep
o Irrelevant and inappropriate laugh
o Mostly kept quite and don’t speak anything
According to Informant (Son)
o Decreased sleep and appetite
o Restlessness and irritability
o Anxiety
o Roaming outside
o Initially irrelevant and repeated talk but after few moths kept quiet

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 o Don’t speak with family members
o Seat at a place and don’t move
o Poor personal hygiene
o Not performing daily living activities

CXXVIII. Family History

 Family Characteristics
Age
Relationship Age &
S. Name of the Educational
with the (yr.)/ Occupation Health Status mode
No. family members Status
Patient Sex of
death
1 Mr. Himanshu Patient 45/M 12th Std Business Unhealthy -
2 Mrs. Nirmala Wife 40/F 8th Std House wife Healthy -
3 Mr. Lokesh Son 20/M ITI Student Healthy -
4 Miss. Rukmani Daughter 17/F 12th Std Student Healthy -

(hh) Genogram:
Key:-

- Male
44yrs 40 yrs

- Female

20 yrs 17 yrs - Patient

CXXIX. Socio-economic history

Mr. Himanshu is a farmer. He and his father are the earning members in his family. His
monthly family income is 15000/ per month. He belongs to a middle class family. He is
living in ranted house. Electricity and water facility is available in house. Drainage is proper.

CXXX. History of Present Illness

Mr. Himanshu brought to hospital hospital on 20/04/2017 with the complaints of not
talking to others and family members, poor personal hygiene and dependent daily activities,
restlessness and decreased sleep & appetite pattern. Initial stage she has irrelevant talk,
inappropriate laugh, getting anxiety, irritability, not interested to do work, memory loss,
disorientation, roaming outside for past three months. He diagnosed as catatonic

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schizophrenia and admitted in male close ward for further evaluation and treatment. Mr.
Himanshu is a known case of catatonic schizophrenia and he had been taken treatment in
hospital past one year’s like antipsychotic, anxioltytic, sedation & frequently given ECT and
individual counseling. At present patient receiving Tab. Thorazine 50mg/day, Tab.
Clozapine25mg/day, Tab. Olzap10mg/day and Tab. Clonazepam 0.5mg/day along with ECT,
yoga therapy, individual psychotherapy, group therapy and family counseling.

CXXXI. Past Psychiatric History

Mr. Himanshu is a known case of schizophrenia.

CXXXII. Personal History

(i) Perinatal history
Mr. Himanshu was delivered as full term normal vaginal delivery.
(j) Childhood history
Primary caregiver was mother. Weaning started at the age of 7 month and all
developmental milestones was achieved at appropriate age period.
(k) Educational history
Education was started at the age of 6 years. He was poor in academic
performance and had good relationships with teachers and peers. He left the
education at the age of 18 year due to lack of interest and poverty after that started to
work along his father.
(l) Play history
He used to play with both sex peer group and had good relationship.
(m) Emotional problems during adolescence
He has the introvert character.
(n) Puberty
Secondary sexual characteristics appeared at the age of 14 years. He did not have
anxious mood regarding sexual changes.
(o) Occupational history
Mr. Himanshu is a businessman. He was performing well in his work. He is introvert
and having less number of friends.

(p) Marital history

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 He got arrange marriage at the age of 23 year and it was consanguineous
marriage. He was having good interpersonal relationship with his wife.
(q) Premorbid personality
lvii. Interpersonal relationships : Introvert
lviii. Use of leisure time : looking after
business
lix. Predominant mood :
Optimistic mood, easily get
irritation, immediate reaction to
stressful events
lx.Attitude to self and others : He has mute stage. He always talks
about his family financial problems.
lxi. Attitude to work and responsibility:
He has poor attitude, poor knowledge
regarding problems and taking
decision.
lxii. Religious beliefs and moral attitudes
: He doesn’t have religious beliefs and
moral attitudes.
lxiii. Fantasy life : No complaint of daydreams
lxiv. Habits : He is having habit of
smoking.

CXXXIII. Physical Examination:

During physical examination all the finding found normal except
(o) General assessment:
 Looking: dull and mute
(p) Extremities: Physical activity was decreased

CXXXIV. Mental Status Examination

(oo) General appearance and behavior
 Appearance : Dull and moderate built
 Level of grooming : Ungroomed
 Level of cleanliness : Unhygienic

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  Level of consciousness : Mute stage/ Stuporous
 Mode of entry : Persuaded by wife & son
 Cooperativeness : Not co-operative
 Eye-to-eye contact : Not-maintained
 Psychomotor activity : Decreased activity
 Rapport : Not established properly
 Gesturing : Closed gestures
 Posturing : Normal posture
 Other movements : Retarded
 Other catatonic phenomena : Mute stage, negativism, waxy
flexibility
 Conversion and dissociative signs : Not present
 Compulsive acts or rituals : Not present
 Hallucinatory behavior : Talking to self and Laughing to self

(pp) Speech
Student Nurse : What is your name?
Client : No response
 Initiation : Patient on mute stage
 Reaction time : Difficulty to assess
 Rate : Very slow
 Productivity : Not present
 Volume : Decreased
 Tone : Monotonous
 Relevance : Irrelevant talk
 Stream : Not a stream thought
 Coherence : Loosening of associations
 Others : No rhyming, punning, echolalia perseveration.
(qq) Mood
 Subjective
Student nurse : How do you feel?
Patient : Not responding keeping quite.
 Objective : Mute stage.
(rr) Thought
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 Student Nurse : What type of the ideas comes in your mind?
Client : No response.
 Stream : Retarded thinking and thought block.
 Form : Not present
 Content
Student nurse : Do you feel that someone may harm you?
Client : Only crying no response.
Remarks : Difficult to assess.
(ss) Perception
 Hallucinations
Student Nurse : Do you hear any sound or able to see someone
whenever you are alone?
Client : Talking to wall.
Remarks : Auditory and Visual hallucinations present.
(tt)Cognitive Functions
 Consciousness
Student Nurse : Hello, Mr. Himanshu
Client : No response
Remarks : Client was mute stage
 Orientation
xxv. Person
Student Nurse : Who is sitting nearby you?
Client : No answer
xxvi. Place
Student Nurse : Where are you now?
Client : No response
xxvii. Time
Student Nurse : What is the day today?
Client : Kept quite
Remarks : Not oriented to person, place and time
 Attention
Student Nurse : Repeat the digit backward 2, 4, 6, 8, 10.
Client : Not answered

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 Remarks : Poor attention span

 Concentration
Student Nurse : Name the months in backward?
Client : No response.
Remarks : Poor concentration
 Memory
xvi. Immediate
Student Nurse : Repeat the word what I say Table, Pen, Rose,.
Client : Laughing
Remarks : Poor immediate memory
xvii. Recent
Student Nurse : What you had in breakfast?
Client : Laughing continuously
Remarks : Poor recent memory
xviii. Remote
Student Nurse : When is your birthday?
Client : No response
Remarks : Remote memory poor
 Intelligence
Student Nurse : Who is the Prime Minister of India?
Client : No answer
Remarks : Poor intelligence
 Abstraction
Student Nurse : What is the similarity between Dog and Lion?
Client : No response.
(uu) Insight: (grade1 to 6)
Student Nurse : Do you accept your illness?
Client : No answer.
Remarks : Grade 1 Insight is present
(vv) Judgment:
Student Nurse : What you will you do if you find “Close latter on the
road”?

291
 Client : No response.
Remarks : Judgment is impaired
CXXXV. Vital Signs:
S. No. Vital Sign Normal Value Patient’s Value
1. Temperature 98.60 F 97.80 F
2. Pulse 72-90 Beats/M. 84 Beats/M.
3. Respiration 14-20 Breath/M. 18 Breath/M.
4. Blood Pressure 120/80mmHg 120/80mmHg

CXXXVI. Investigation:
S. Patient’s Normal
Investigations Interpretation
No Value Value
1 Blood
 Heamoglobin 12 gm/dl 13-15 Low
 Red blood cell 5.82 milcmm 4.5-6.51 Normal
 PCV 42.3% 20-54 Normal
 Platelets 3.23 lacs 1.5-4.5 Normal
 Total WBC different
count 9700 cu/mm 5000-11000 Normal
 Lymphocytes 30% 20-45 Normal
 Esinophills 02% 1-6 Normal
 Monocytes 04% 1-6 Normal
 MCV 88fl 80-99 Normal
 MCH 30pg 27-33 Normal
 MCHC 34.7g/dl 32-37 Normal
 ESR 8mm/hr 0-20 Normal
Routine Investigation
 RBS
 Blood urea 123 mgs/dl < 150 Normal
 S. Creatinine 29 mg/dl 20-45 Normal
 S. Sodium 1.1mgs/dl 0.7-1.2 Normal
 S. Potassium 133 meq/l 135-145 Normal
LFT 3.9 meq/l 3.5-4.5 Normal
 S. Bilirubin
 S. total protein 0.5 mgs/dl 1 Normal
 S. Albumin 6.9 gm/dl 6-8 Normal
 S. Globulin 3.9 gm/dl 3-5 Normal
 Alkaline phosphate 2.6 gm/dl 1.8-3.6 Normal
88 IU/l 80-120 Normal
Patient is clinically normal and only heamoglobin level is low.
CXXXVII. Medication chart:
d. Tab. Thorazine 50mg × 1 month
e. Tab. clozapine 10mg × 1 month

292
f. Tab. Olzap10mg × 1 month
g. Tab. Clonazepam 0.5mg × 1 month

293
 Pharmacological

Responsibility
Trade Name

Side-effects
Indications
Frequency

Indication

Contra-
Group

Action
Route
Name

Doses
S.

Nsg.
No.

1. Tho Chlor 50 Oral Bd Phenot Acts by Atypical Renal and Tremors Check blood pressure
razi prom mg hiazin blocking the psychoisis cardiac patients Tardative Observe for abnormal
ne azine e post synaptic schizoaffective Elderly, dyskinesiadry movement
dopamine D2 disorders, epilepsy. mouth, Instruct the patient not
receptorsin the chronic constipation, to drive vehicle while
mesolinbic schizophrenia hypotension on treatment
region Provide rest
2. Clo Cloza 25 Oral Bd Bibenz Clozepine has Schiophrenia, Bone marrow Pancreatitis, Use safety measures to
paz pine mg odiaze been found refractory disorder, CNS behavioral prevent fall
pines effective in psychosis depressents, changes, Provide adequate rest
refractory severe renal and nausea, Instruct patient to take
psychosis, hepatic patients vomiting more fluid
interacts with
wide range of
transmitters
3. Zyp Olanz 10 Oral OD Antips Acts only on the Apathy, Hypersensitivit Common Drug should not give
rexa apine mg ychoti mesolimbic decreased y, MI, hepatic sedation

294
 c system. sociality, imparimement Hypotension, empty stomach
anhedonia, Diabetes and
Do not leave the
chronic EPS may and
schizophrenia, may not be patient until the drug is
Acute psychoses, present
swallowed
delusional
disorders, and Observe for drug
hallucinations
specific side-effects
4. Clo Clona 0.5 Oral Hs Benzp Facilitatie the Epilepsy, Cardiovascular Hypertension, Use safety measures to
naz zepa mg diazep GABA activity psychosis, disease CNS rare blood prevent fall
epa m ine and induce the bizarre behavior injury and dyscrasias Provide adequate rest
m antico sedation depressants. Instruct patient to take
nvulsa more fluid
nt

295
CXXXVIII. Other therapeutic therapies:

Therapy Indication Nurses responsibility

ECT Major depression,  An informed consent should take from the

severe catatonia, severe patient’s family members
psychosis, other  Before 6 hrs NPO
medical disorders  Arranged the necessary equipments
 Give pre medication
 Apply the normal saline on the electrode
 Observe the convulsions and frequency.
 Given orientation to the patient
Yoga therapy Almost all condition  Provide correct guidance
 Provide calm environment
 Help during the difficulties in yoga
Individual Stress related disorder,  Deliberately establishes a professional
psychotherapy alcohol and drug relation
dependence, sexual  Remove or modify existing symptoms
disorder and marital  Promote positive personality growth and
disharmony development
Group therapy Homogenous group,  Use any transference situations to develop
personality disorders, insight into their problems
families where the  Provide positive reinforcement, this gives
system needs change ego support and encourages future growth
Family Psychosis, reactive  Assessment of family, roles, boundaries,
counseling depression, anxiety, resources, communication patterns and
psychosomatic problem solving skills
disorder, substance  Teaching communication skills
abuse  Teaching problem solving skills

CXXXIX. Process Recording:

296
 Time : 30 Minutes
Date : 3-1-2009
Place : Interview room of male psychiatric ward
Objectives : To
- maintain rapport
- obtain psychiatrist history
- make the patient ventilate feelings
- improve communication skills
Person Conversation Inference
Student Nurse Hello, Mr. Himanshu Stuporous state
Client No response
Student Nurse How you are feeling? Mute stage
Client No response, but made eye to eye response.
Student Nurse What you had in breakfast? Decreased appetite
Client Laughing (Son said that he had little)
Student Nurse Did you took bath? Self care deficit,
Client Talking to roof. hallucination
Student Nurse Did you join exercise today with others? Catatonic posture
Client Not responding
Student Nurse Can you tell me your birthday Remote memory
Client Started to cry poor
Student Nurse Ok. Himanshu bye, take care Termination of
Client No response process recording
Assessment techniques
 Observation, communication, conformation, interview
Summary
Mr. Himanshu is a case of catatonic schizophrenia. He brought to hospital with the
complaints of not talking to others and family members, poor personal hygiene and
dependent daily activities, restlessness and decreased sleep & appetite pattern. Initial stage
she has irrelevant talk, inappropriate laugh, getting anxiety, irritability, not interested to do
work, memory loss, disorientation, roaming outside for past three months. He is not
responding to talk but laughing and talking to self.

297
 Literature Review

Introduction
The word schizophrenia was coined in 1908 by the swiss psychiatrist Eugen Bleuler. It
derived from the greak word skhizo means split and phren means mind.
Schizophrenia is a psychotic condition characterized by a disturbance in thinking,
emotions, volitions and faculties in the presence of clear consciousness, which usually leads
to social withdrawal.
Definition
Catatonia is a condition marked by changes in muscle tone or activity associated with a
large number of serious mental and physical illnesses. There are two distinct sets of
symptoms that are characteristic of this condition. In catatonic stupor the individual
experiences a deficit of motor (movement) activity that can render him/her motionless.
Catatonic excitement, or excessive movement, is associated with violent behavior directed
toward oneself or others.

Book Pictures Patient Pictures

Etiology VI. Biological theories Not known

i. Genetic hypothesis
j. Biochemical theories
k. Neuro-endocrine theories
VII. Psychological theories
l. Stress
m. Family theories
n. Cognitive behavior theories
o. Psychoanalytic theories
VIII. Socio-cultural theories
Types  Paranoid schizophrenia  Catatonic schizophrenia
 Hebephrenic schizophrenia
 Catatonic schizophrenia
 Residual schizophrenia
 Undifferentiated

298
 schizophrenia
 Simple schizophrenia
 Post-schizophrenia
Clinical Features  Extreme loss of motor skills  Irritability
 Constant hyperactive motor  Anxiety
activity  Irrelevant and inappropriate
 Hold rigid poses for hours laugh
 Ignore any external stimuli.  Mostly on mute stage
 Stereotyped,  Decreased sleep and appetite
 Repetitive movements  Restlessness
 Waxy flexibility  Roaming outside
 Repeat meaningless phrases  Irrelevant and repeated talk
 Decreased sleep and appetite initially and after few moths
 Restlessness and irritability developed mute stage.
 Roaming outside  Don’t speak with family
 Seated at one place without members
moving  Seated at one place without
 Irritability moving
 Anxiety  Poor personal hygiene and
 Poor personal hygiene and daily living activities
daily living activities
Psychopathology Increased number of stressful Same as described in book
life events before the onset or picture
relapse probably has a triggering
effect on the onset of
schizophrenia, in a genetically
vulnerable person. (Stress-
vulnerability hypothesis).
According to this hypothesis,
higher the genetic vulnerability
in a person, lesser the
environmental stress needed to
precipitate a relapse. Increased

299
 expressed emotions (hostility,
critical comments, emotional
over involvement) of significant
others in the family can lead to
an early relapse.
Diagnostic Evaluation  History collection  History collection
 Mental status examination  Mental status examination
 Psychoanalysis  Psychoanalysis
Treatment
Psychopharmacology  Phenothiazine  Phenothiazine
 Bibenzodiazepines  Bibenzodiazepines
 Antipsychotic  Anticonvulsant
 Anticonvulsant  Antipsychotic
Psychotherapy  Yoga therapy,  Yoga therapy,
 Individual psychotherapy,  Individual psychotherapy,
 Group therapy and  Group therapy and
 Family counseling  Family counseling
ECT Recommended in case of drug Given five times
resistance

Nursing Process:
Day 1

S. No. Needs Problems

1 Maintain the normal sensory

perception and eliminate the Abnormal perception like hallucinations
hallucinations
2
Participate in self-care activities Self-Care Deficit

Nursing Diagnosis:

300
 Disturbed sensory perception (auditory/visual) related to withdrawal into the self as
evidenced by inappropriate responses

 Self-Care Deficit related to impaired ability to perform or complete bathing/hygiene

activities for oneself evidenced by poor personal hygiene.

301
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Abnormal Disturbed sensory Maintain the  Observe the client for sings of  Observed the client (pt has Client able to
perception perception normal sensory hallucinations. talking to self) define the
like (auditory/visual) perception and  Avoid touching the client  Maintain the IPR and distance. reality and
hallucinatio related to eliminate the without warning.  Encouraged his self esteem. eliminate the
ns withdrawal into hallucinations  Do not reinforce the  Tried to involve in personal hallucinations in
the self as hallucinations. tasks. some extent
evidenced by  Distract the client from the
inappropriate hallucinations. Encourage the
responses client to share hallucinations.

Self-Care Self-Care Deficit Establish an  Be alert to the client’s  Alert to the client’s physical Established an
Deficit related to impaired adequate balance physical needs needs adequate
ability to perform of rest, sleep, and  Observe the client’s pattern of  Observed the client’s pattern of balance of rest,
or complete activity evidenced food and fluid intake; you food and fluid intake; you may sleep, and
bathing/hygiene by the client will may need to monitor and need to monitor and record activity
activities for complete daily record intake, output, and intake, output, and daily weight evidenced by
oneself evidenced tasks with minimal daily weight  Monitored the client’s the client will
by poor personal assistance  Monitor the client’s elimination patterns complete daily

302
hygiene elimination patterns  Explained any task in short, tasks with
 Explain any task in short, simple steps minimal
simple steps  Used clear, direct sentences, assistance
 Using clear, direct sentences, instruct the client to do one
instruct the client to do one part of the task at a time
part of the task at a time  Told the client your
 Tell the client your expectations directly. Do not
expectations directly. Do not ask the client to choose
ask the client to choose unnecessarily.
unnecessarily.  Allowed the client ample time
 Allow the client ample time to to complete any task.
complete any task.

303
 Day 2
S. Needs Problems
No.
1. Maintain the normal and appropriate Irrelevant talk, flight of ideas, unrealistic
communication thinking

2. Maintain the normal personal hygiene

and make the patient to do Poor personal hygiene, lack in daily activities
independently

Nursing Diagnosis:

 Impaired verbal communication related to disorientated as evidenced by losses associational thoughts.

 Self care deficit related to cognitive impairment as evidenced by difficulty carrying out tasks.

304
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Irrelevant talk, Impaired verbal Maintain the  Attempt to decode  Decoded the Client maintain
flight of ideas, communication related normal and incomprehensible incomprehensible the appropriate
unrealistic to disorientated as appropriate communication patterns. communication. and
thinking. evidenced by losses communication  Facilitate trust and  Constantly seen the patient comprehensibly
associational thoughts understanding by consistently and maintain the IPR. with others.
assigning the person.  Fulfilled the patient’s
 Anticipate and fulfill the needs.
client’s needs.  Every time called the
 Orient client to reality as patient by his name.
required by call the client
name.

Poor personal Self care deficit related Maintain the  Provide assistance with self  Assisted the client’s Client maintain
hygiene, lack to cognitive normal personal care needs as required. personal needs. the normal
in daily impairment as hygiene and  Encourage client to perform  Allowed the client to do ADLs.
activities evidenced by difficulty make the patient independently as many independent work.
carrying out tasks. to do activities as possible.
independently  Use concrete communication  Maintain the IPR with

305
 to show client what is good rapport.
expected.  Family food allowed and
 Creative approaches may changed the environment.
need to be taken with the  Structured schedule
client who is not eating. established a pattern so the
 Toileting needs are not being client can develop
met establish a structured independent habit.
schedule for the client.

306
 Day 3
S. Needs Problems
No.
Maintain the normal or more adaptive
Family members has low confidence and
1 coping strategies for dealing with
confusion regarding client’s disease condition
client

2 Participate in self-care activities Self-Care Deficit

Nursing Diagnosis:

 Disabled family coping strategies related to difficulty coping with client’s illness as evidenced by neglectful care of the client.

 Self-Care Deficit related to impaired ability to perform or complete bathing/hygiene activities for oneself evidenced by poor personal
hygiene.

307
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Family Disabled family Maintain the  Identify level of family  Identified the family member’s Family
members coping strategies normal or functioning. Assess the lacks and knowledge level of the members
has low related to difficulty more adaptive communication pattern, client’s disease condition. maintain the
confidence coping with coping interpersonal relationships between more
and client’s illness as strategies for members, role expectations, adaptive
confusion evidenced by dealing with problem solving skills and  Adequate information given to the coping
regarding neglectful care of client. availability of outside support family members regarding disease methods.
client’s the client. systems. condition and prognosis.
disease  Provide information for the family  Assisted the family members to
condition about the client’s illness, what will respond adaptively in the face of
be required in the treatment what they may consider to be a
regimen and long term prognosis. crisis situation.
 With family members practice how
to respond to bizarre and
communication pattern and in the
event that the client becomes
violent.
Self-Care Self-Care Deficit Establish an  Be alert to the client’s physical  Alert to the client’s physical needs Established

308
Deficit related to impaired adequate needs  Observed the client’s pattern of an adequate
ability to perform balance of  Observe the client’s pattern of food and fluid intake; you may balance of
or complete rest, sleep, food and fluid intake; you may need to monitor and record intake, rest, sleep,
bathing/hygiene and activity need to monitor and record intake, output, and daily weight and activity
activities for evidenced by output, and daily weight  Monitored the client’s elimination evidenced
oneself evidenced the client will  Monitor the client’s elimination patterns by the client
by poor personal complete patterns  Explained any task in short, simple will
hygiene daily tasks  Explain any task in short, simple steps complete
with minimal steps  Used clear, direct sentences, daily tasks
assistance  Using clear, direct sentences, instruct the client to do one part of with
instruct the client to do one part of the task at a time minimal
the task at a time  Told the client your expectations assistance
 Tell the client your expectations directly. Do not ask the client to
directly. Do not ask the client to choose unnecessarily.
choose unnecessarily.  Allowed the client ample time to
 Allow the client ample time to complete any task.
complete any task.

309
 Day 4
S. Needs Problems
No.

1 Communicate with others Impaired social interaction

2 Evaluate own strengths realistically Feelings of inferiority

Nursing Diagnosis:

 Impaired social interaction related to insufficient or excessive quantity or ineffective quality of social exchange evidenced by withdrawn
behavior

 Chronic low self-esteem related to longstanding negative self-evaluation/feelings about self or self-capabilities evidenced by feelings of
inferiority.

310
311
 Nursing Care Plan:
Needs /
Nsg. Diagnosis Goals Intervention Implementation Evaluation
Problems
Impaired Impaired social To improve  Teach the client social skills, and  Teach the client social skills, and Improved
social interaction related social encourage him or her to practice encourage him or her to practice social
interaction to insufficient or interaction these skills with staff members and these skills with staff members and interaction
excessive quantity evidenced by other clients. other clients. evidenced
or ineffective patient will  Initially, interact with the client on  Initially, interact with the client on by patient
quality of social communicate a one-to-one basis. Progress to a one-to-one basis. Progress to will
exchange with others facilitating social interactions facilitating social interactions communicat
evidenced by between the client and other between the client and other e with others
withdrawn clients, then in small groups and clients, then in small groups and
behavior gradually larger groups. gradually larger groups.
 Encourage the client to pursue  Encourage the client to pursue
personal interests, hobbies, and personal interests, hobbies, and
recreational activities. recreational activities.
Consultation with a recreational Consultation with a recreational
therapist may be indicated. therapist may be indicated.
 Encourage the client to identify  Encourage the client to identify
supportive people outside the supportive people outside the
hospital and to develop these hospital and to develop these

312
 relationships. relationships.
Feelings of Chronic low self- Improve self-  Encourage the client to become  Encourage the client to become Improved
inferiority esteem related to esteem involved with staff and other involved with staff and other self-esteem
longstanding evidenced by clients in the milieu through clients in the milieu through evidenced
negative self- patient will interactions and activities. interactions and activities. by patient
evaluation/feelings verbalize  Give the client positive feedback  Give the client positive feedback verbalize
about self or self- increased for completion of responsibilities, for completion of responsibilities, increased
capabilities feelings of such as self-care activities and such as self-care activities and feelings of
evidenced by self-worth interactions with others. interactions with others. self-worth
feelings of  Involve the client in activities that  Involve the client in activities that
inferiority. are pleasant or recreational as a are pleasant or recreational as a
break from self-examination. break from self-examination.
 Explore with the client his or her  Explore with the client his or her
personal strengths. personal strengths.

313
 Theory Application

Peplau’s Interpersonal theory:

The core of Peplau’s approach is interpersonal relations. The theory includes the
concept such as
 Communication,
 Roles and growth and
 Development.
Communication us a problem solving process whereby the nurse and client
collaborate to meet the clients need.
The nurse may assume the roles of
 Counselor,
 Leader,
 Resource,
 Surrogate, and
 Teacher.
These roles are designed to lead to growth and development.
 Growth and Development

Orientation
- Established working relationship
- Collected history of illness
- Oriented to hospital
Identification
- Classify perceptions
Teacher - Identify problems
- Discussed the solutions
Resource

Counselor Nurs COMMUNICATION Patien

e Exploitation
t
Leader
- Create a non threatening
Surrogate atmosphere
- Encourage client participation in
problem solving
Resolution
- Evaluated the outcomes
- Reduced anxiety
- Increased problems solving
activities
Peplau’s Nurse-client Interpersonal Framework
Health Education:
 Health education given regarding hygiene and nutrition.
 Encourage social interaction.
 Improve the self care needs (personal hygiene) independently.
 Sleep and hygiene techniques.
 Family’s to use alternative coping methods.
 Taught about the positive coping methods.
 Avoid conveying to the client the belief that hallucinations are real. Do not converse
with the “voices” or otherwise reinforce the client’s belief in the hallucinations as
reality.
 Educated the patient and family members regarding medication- dosage and side
effects of the medication.
 Advice the patient for regular checks up and follows up.
Summary:
Mr. Himanshu brought to the psychiatric ward on 25/12/2008 with the complaints of
not talking to others and family members, poor personal hygiene and dependent daily
activities, restlessness and decreased sleep & appetite pattern. Initial stage she has irrelevant
talk, inappropriate laugh, getting anxiety, irritability, not interested to do work, memory loss,
disorientation, roaming outside for past three months.
Then he is diagnosed as a case of Catatonic Schizophrenia. I have taken this case for
my case study and given four days care with counseling and health education from 03/01/09
to 06/01/09.
Bibliography:
30. Townsend.M, (2007), “Psychiatric Mental Health Nursing”, Jaypee brothers, New
Delhi, India.
31. Doenges M.E. et al., (1995), “Psychiatric Care Plans Guidelines for Planning and
Documenting Client Care”, 2nd ed. F. A. Davis Company, Philadelphia, PA.
32. Ahuja.N, (2006), “A Short Text Book of Psychiatry”, Jaypee brothers, New Delhi,
India.
33. Sreevani.R, (2008), “A Guide to Mental Health and Psychiatric Nursing”, Jaypee
Brothers, New Delhi, India.

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 MENTAL HEALTH NURSING

HISTORY COLLECTION
ON BIPOLAR DISORDER

SUBMITTED TO
Mr.RAHUL SRIVASTAVA
ASSOCIATE PROFESSOR
HOD, MENTAL HEALTH NURSING
YASHRAJ COLLEGE OF NURSING

SUBMITTED BY
MR. BOBY DWIVEDI
M.Sc. NURSING 2nd YAER
YASHRAJ COLLEGE OF NURSING

DATE OF SUBMISION____________

317
 Patient’s Profile

CXL. Identification data

Client name : Mr. Manish Kumar
Age : 14 years
Sex : Male
Father / Spouse name : Mr. Arvind kumar
Address : Gonda
Education : 9th Standard
Occupation : daily wager/ autoricksh driver
Income : Rs. 3500/ month.
Marital status : Unmarried
Religion : Hindu
Date of admission : 19.09. 2020.
Provisional diagnosis : Bipolar disorder with anxiety features
Final diagnosis : conduct disorder
CXLI. Informant : Mother

CXLII. Presenting Chief Complaints:

According to the patient:
5. Restlessness, irritation
6. Easily getting anxiety, excessive sweating
7. Getting failure in all tasks
8. Poor memory power, concentration
9. Not interested to study, decreased sleep. Past six months
According to the Informant 9Mother):
8. Anxiety towards to the family members
9. Beating and breaking the home objects
10. Self injuries (scratching the forearm with bangles and blades)
11. Adamant character
12. Not going to school

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 13. Habits of smoking, alcohol and pan items.
14. Not sleeping in night time and wandering outside past six months and increased
past one month.
CXLIII. History of Present Illness:
Mr. Manish Kumar14years young man came with the chief complaints of Easily getting
anxiety, beating the parents, irritability wandering outside, not going to school,
decreased sleep, abusing bad words, self harming, (scratching the forearm skin with
blade and bangles and kicking the wall, not speaking the neighbors, always roaming
with local friends and have habits of smoking and alcohol and pan items. Now he was
admitted with emergency ward and has close observation of his abnormal behavior. He
said that he doesn’t have any abnormalities his parents refusing to give money to buy
the autoricksh and argued with the physician that he need discharge from the hospital.
Initially he was diagnosed as bipolar mood disorder and after given the antimanic drugs
he doesn’t have prognosis and history collected from his parents regarding school
performance and diagnosed as conduct disorder with manic episode and undergone
multidisciplinary treatment approaches like individual psychotherapy, cognitive
behavior therapy and psychopharmacological treatment like antipsychotic, antimanic,
and benzodiazepine anxilotyic and sedations. Now he shows some prognosis after
implementation of the multidisciplinary treatment modalities.
CXLIV. Treatment History:
Mr. Manish Kumarat present under goes multidisciplinary treatment such as
psychopharmacology, psychological therapy and family therapy. Now he is treated with
Tab. Carbamazepine, Tan. Nitrosun 5mg, Tab. Qutace 100mg, Tab. Sizopin 100mg,
and Inj. Lopez 2mg, Inj. Senorm –la 10mg past one month.
CXLV. Past Psychiatric History:
There is no significant past psychiatric history
CXLVI. Past Medical History:
There is no significant history of medical illness. Before five years he had chicken pox
and taken treatment in local hospital.
CXLVII. Past surgical History:
There is no significant history of surgical history.
CXLVIII. Family History:

319
 (f) Family Characteristics:
Name of
S. the Relationshi Age &
Age/ Education Occupatio Health
No family p with the mode of
Sex al Status n Status
. member Patient death
s
Mr.Arvin
1 Father 50Yr/M 10th Std Former Healthy -
d
Mrs.
2 Mother 46Yr/F - Housewife Healthy -
lakshmi
18yrs
and did
Ms. suicide
3 Sister 18Yr/F 10th Std - Expired
Rajani due to
family
problems
Mr. Conduc
14YR/ th Daily
4. Manish Client 9 Std t -
m wager
kumar disorder

(b) Genogram:
Key:-

5o yrs 46 yrs - Male

- Female

- Patient
18yrs 14yrs - Death

There is no history of psychiatric illness present. There is no history of consiagunious

marriage and communicable disease like diabetes, asthma, tuberculosis and hypertension. His
sister attempted suicide due to her mother scolded that she is not doing household work
properly. There is no hereditary psychiatric history present.
Socio-economic history;
They are living in own house. House is Pukka and having all the facilities like water
facility and electrical and closed drainage system. The communication pattern of the family
is normal. The total family income is Rs. 5000/month. Client is only one son of the family.
Now the client asked own autoricksh but the family members said that they doesn’t have
money and client not yet major to drive the autoricksh.

320
CXLIX. Personal History:
(ii) Perinatal history:
Perinatal history collected from patient’s mother. While in antenatal period
her mother doesn’t have febrile illness, and not taken unwanted medication.
The child was wanted child. The delivery conducted first in hospital by
physician and normal vegenial delivery. After birth he cried immediately. The
birth weight is normal and there is no significant history of postpartum
complication, like severe bleeding to mothers.
(jj)Childhood history
Mr. Manish Kumar brought up by his biological parents. During childhood
history he is active and normal developmental milestone. He had breast
feeding and artificial feeding, the weaning food started after 6month. From
childhood itself he has adamant and uncontrolled anxiety behavior use to
break the objects and beat the parents if he hasn’t getting what he wants.
(kk)Educational history:
He started the education at the age of 5yrs in govt. school. The client’s
academic function was average and good relationship with peer groups and
teachers. During the school period he wouldn’t go school regularly and make
a friendship with elder person & developed the smoking and pan habits and
use play the gambling with other person. He was very poor in academic
session and he has revenge with his teacher after beaten him he didn’t go the
school. There is no history of sexual affairs and sexual acts.
(ll) Play history
During childhood he use play with his peer groups. He always like group and
opposite sex plays.
(mm) Emotional problems during adolescence:
He started the smoking and other habits after made a friendship with elder
person and he always been with them. While going to the work he stated
above habits. He has blunted emotional behavior.
(nn) Occupational history:
He starts to work at the age of 14yrs and he use goes for daily wager or
assistant with autoricksh driver. During the working period he wouldn’t go

321
 regularly and intermittently he use goes outside of his native and after two
days he will comeback his name.
(oo) Puberty
He attain the secondary sexual characteristic at the age of 14yrs
(pp) Premorbid personality
lxv. Interpersonal relationships:
He has good relationship with His family members and wife.
lxvi. Use of leisure time:
He uses to play with his peer groups and roaming outside.
lxvii. Predominant mood:
He always having anxious and irritable mood.
lxviii. Habits:
He has smoking and alcohol sometimes tobacco chewing habits past 6
months. He uses to take mixed diet and regular diet pattern.
Physical Examination:
(q) General assessment:
 Appearance: younger adulthood
 Body built: Emaciated built
 Looking: irritate and anxious
 Height: 147cm
 Weight: 45kgs
 During physical examination he has self injuries in left hand forearm like
scratching with bangles and blades
Mental Status Examination
(w) General appearance and behavior
 Appearance: young adulthood
 Level of grooming: normal grooming
 Level of cleanliness: adequate cleanliness
 Level of consciousness: Fully conscious and alert
 Mode of entry: brought by family mothers.
 Cooperative: less than normal co-operative
 Eye-to-eye contact: Maintained normal eye to eye contact

322
  Psychomotor activity: Normal psychomotor activity (sometimes he has
increased psychomotor activity)
 Rapport: Spontaneous and established rapport
 Gesturing: Normal gesture
 Posturing: Normal posture
 Other movements: Not present
 Other catatonic phenomena: Not present
 Conversion and dissociative signs: Not present
 Compulsive acts or rituals: Not present.
 Hallucinatory behavior: Not Present.
 Speech
 Student nurse: why did you discontinue your education?
 Client: I don’t have any interest to study a have interest to do work and
want to earn money. I want to enjoy with more money.
 Initiation: when spoken to the client after he gave the answer
 Reaction time: Normal
 Rate: Normal
 Productivity: Elaborate replies
 Volume: Normal volume
 Tone: Normal variation
 Relevance: Relevant talk
 Stream: stream of speech present
 Coherence: Fully coherent
(x) Mood
 Subjective: anxiety with irritation mood
 Student nurse: how do you feel now?
 Client: I am very much angry with my mother and you. They bought me
here and you are not allowed me to outside.
 client has anxious and irritable mood
 Thought
 Student Nurse: why you have angry with your parents?
 Client: I know driving so I asked to my mother to give money to buy the
autoricksh but they are refused and they said that go for daily wagers.

323
  Stream: he has pressure of thoughts
 Form: Normal thought present
 Content: He had grandiose of thought he has power to drive and he can
manage the autoricksh.
(y) Perception
 Student Nurse: Are you hearing any external and internal voice? Are you
felt that this thought comes from or inserted by anyone.
 Client: No sir.
(z) There is no auditory hallucination and delusion behavior.
(aa) Cognitive Functions:
 Consciousness:
- Student Nurse: what is your name?
- Client: Manish kumar
- Client has normal consciousness
 Orientation:
xxviii. Person
- Student Nurse: what is your mother name?
- Client: Mrs. Lakshmi
xxix. Place
- Student Nurse: can you say what is the hospital name?
- Client: SCPM Gonda
xxx. Time
- Student Nurse: what is the time now?
- Client: Around 10’o clock.
- Client has normal orientation with place, person and time.
 Attention:
- Student Nurse: can you repeat the digit 23, 45, 66 and 58
- Client: he stared correctly in between he had lacunae
- Client has average attention span.
 Concentration:
- Student Nurse: can you tell the answer 91 – 8 =?
- Client: he answered correctly 83.
- he has normal concentration

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  Memory:
vii. Immediate
- Student Nurse: can you backwards this digit 25,46,78,90.
- Client: he answered correctly.
- he has normal immediate memory power
viii. Recent
- Student Nurse: what you had in the morning?
- Client: two idly with pongal sir.
- he has normal recent memory
ix. Remote
- Student Nurse: can you tell your birth day date?
- Client: in the year of 1980, date I couldn’t remember.
- he has average remote memory
 Intelligence:
- Student Nurse: who is prime minister of India?
- Client: Mr. Narendra Modi
- Client has normal intelligence
 Abstraction:
- Student Nurse: can you tell what is different between the balls and
orange?
- Client: one is eatable thing another one is animate.
- he has normal abstract thinking
(bb) Insight: (grade1 to 6)
- Student Nurse: do you agree you’ have some illness?
- Client: yes sir, l knew what I have that is wrong.
- Client has normal insight.
(cc) Judgment:
- Student Nurse: In front of you someone picked other person money
purse that time what is your reaction?
- Client: I inform to the respective person or police
- Client has normal judgment
CL. Vital Signs
S. No. Vital Sign Normal Value Patient’s Value

325
 1. Temperature 98.60 F 98.4F
2. Pulse 72-90 Beats/M. 88 beats/mint
3. Respiration 14-20 Breath/M. 17breath/mint
4. Blood Pressure 80 -120 70 -110 mmhg

CLI. Investigation:
Sl.No Investigations Patient’s Normal
Value Value

1 Blood Heamoglobin 14.0gm/dl 14-16

 Red blood cell 3.92 34.5% 4.5-6.51
2.43 lacs 40-54
 PCV
15500 1.5-4.5
 Platelets cu/mm 5000-11000
 Total WBC different count 40-75
84%
20-45
11%
1-6
06%
 Neutrophil 1-6
01%
80-99
 Lymphocytes 83fl
27-33
28pg
 Esinophills 32-37
33.7g/dl
0-20
 Monocytes 22mm/hr

 MCV
 MCH
 MCHC
 ESR

CLII. Medication chart:

1. Tab. Carbamazepine 200mg× one month
2. Tan. Nitrosun 5mg × one month
3. Tab. Qutace 100mg × one month
4. Tab. Sizopin 25mg × one month
5. Inj. Lopez 2mg × 15 days
6. Inj. Senorm –la 10mg × 15 days

326
 Nsg. Responsibility
Contra-Indications
Pharmacological
Trade Name

Side-effects
Frequency

Indication
Action
Group

Route
Name

Doses
S.
No

Carbatol Carbamaze Anticonvulsa 200m Oral Bd It reduces Epilepsy, HepaticPancreatitis, Check the physician’s
order.
pine nt, mood g polysynaptic alcohol disease, behavioral
Medication given must
stabilizer responses and withdrawal pregnancy changes, be charted on the
1 patient’s case sheet.
blocks post syndrome, nausea,
Check the five rights
synaptic mania vomiting for drug
administration
potentiating
Always address the
Inj.senorm - Haloperido Antipsychoti 10mg IM Hs Potent Acute Cardiovas Neurolopeti patient by name and
make certain
la l cs antagonist for mania, cular c malignant identification
D2 receptors, acute disease syndrome Do not leave the
patient until the drug
2 controlled schizophre CNS coma, is swallowed
bizarre nia, bipolar injury and confusion Do not allow the
patient to carry drugs
behaviors mood depressant
Do not force oral
disorders s. medication
Check drug daily
3 Inj. loreaz Lorazepam Benzodiaepin 2mg IM Hs Facilitate Acute Pregnancy Drowsiness, Observe for drug
e Anxiloytic effects in psychosom , headache, specific side-effects
Instruct the family
GABA atic and hypersensi confusion, members when to
activity panic tivity to blurred contact psychiatrist

327
 attacks lorazepam vision
Sizopin Clozapine Dibenzpdiaze 25mg Oral Bd Clozapine has Schizophre Bone Drowsiness,
pine been found nia, marrow dizziness,
antipsyhcotic effective in behavioral disorder hypotension,
s refractory disorder, CNS tachycardia
4 psychosis it refractory depressant
interacts with psychosis s, hepatic
wide range of and
neurotransmitt cardiac
er disease.
Qutace Quetiapine Antipsychoti 100m oral Bd Quetapine is Schizophre History of Extrapyrami
c g an antagonist nia, cardiac dal reactions
5 at muliptle behavioral arrythmias irritability
neurotransmitt disorder , epilepsy, weakness
er receptors pregancy dizziness
Nitrosun Nitrazepam Benzodiazepi 5mg Oral Hs A Insomnia, Elderly, Drowsiness,
ens benzodiazepid behavioral lactationsu fatigue
6 Hypnotics es with a disorder dden dizziness
pronounced withdraw vertigo
sleep anorexia

328
CLIII. OTHER THERAPEUTIC THERAPIES:
BEHAVIOR THERAPY AND INDIVIDUAL PSYCHOTHERAY:
Behavior therapy is a form of treatment for problems in which a trained person
deliberately establishes a professional relationship. Behavior therapy involves
identifying maladaptive behaviors and seeking to correct these by applying the
principles of learning conditions.
Here Mr. Manish Kumar has a behavioral disorder and maladaptive behavior. He
doesn’t aware of his behavior and complications of it. He recurrently has anxiety and
irritability. Initially the psychologist started the cognitive behavior therapy – explained
about his abnormal behavior and how his family members suffered and what the
socially acceptable behavior is? Individual and family counseling given regarding how
to interact with the client and management of the client in crisis situation. In individual
psychotherapy the client taught about the individual person discipline and normal
behavior pattern. During the behavior therapy relaxation techniques taught to the
patient. The goal of the treatment is avoid the painful or abnormal behavior by using
simple behavioral techniques. During the behavior therapy instruct and educated the
patient regarding complication of self harming.
CLIV. Process Recording:

Time : 30 Minutes
Date :
Place : Pavilion III
Objectives :
 To gain the confidence of the patient
 To assess the condition of the patient
 To collect the psychiatric history
 To identify the patient problems
Purpose and uses:
Assists the nurse or student to plan, structure and evaluate the interaction on a conscious
than institutive level
Pre-requisites for process recording:
Physical setting
Getting consent of the patient

329
 Confidentiality
Person Conversation Inference
Student Nurse Good morning Mr. Manish kumar He maintained the
Client Good morning sir normal rapport
Student Nurse How do feel now? He has normal
Client I am not fine sir; they are not allowing go outside insight.
and I am getting boring here.
Student Nurse Do you feel angry toward your mother? He has anxiety
Client Yes sir, they are not giving money to buy autoricksh towards him family
so I said to her don’t talk to me members
Student Nurse What is the reason to abdonded your studies? Client doesn’t have
Client I am not interested to go school and I have interest interest to study.
to do work. I have lot friends they are having own
autoricksh
Student Nurse What is your future plan? He has irritation
Client My plan is I need one own autoricksh and anxiety
Student Nurse If your parents are not allow to go for jobs: whenever he fails
Client I will go out from my house. I wouldn’t comeback. to get what he likes
and he has lower
concentration
Summary:
Mr. Manish Kumar has anxiety, not interested is studies, self harming, adamant
character, had bad habits like smoking, alcohol, and made friendship with local dads. Initially
he was diagnosed as mood disorder after collected his detail school performance was
frequently telling lies and run away from the School and home, abusing bad words, beating
others, revenge with others so he was diagnosed as conduct disorder with psychotic
symptoms.

330
 Disease Condition (Literature Review)
Disease Condition (Literature Review)
Introduction:
Conduct disorder is one of the most common disorders in children and adolescents in
general population. Conduct disorder or CD involves a number of persistent patterns of
problematic behaviors, including oppositional and defiant behaviors and antisocial activities

Definition
Conduct disorder is a psychiatric category to describe a pattern of repetitive behavior
where the rights of others or the current social norms are violated.

Types
The DSM-IV-TR divides in to two types
o Childhood -onset type
o Adolescent-onset type

Childhood-onset type
It occurs prior to the age of 10 years. Individuals with this type are usually boys,
frequently display physical aggression, and have disrupted peer relationships. They have had
oppositional defiant disorder during early childhood and likely to develop antisocial
personality in adulthood.
Adolescent-onset type
Occur after 10 years of age. They less likely to develop aggressive behaviors and tend
to have more normal peer relationships than those with childhood-onset type. They are less
likely to have persistent conduct disorder or develop antisocial personality disorder than
those with childhood onset type.
Etiology
IX. Biological theories
Monozygotic and dizygotic twins as well as with non-twin siblings have
revealed a significantly higher number of conduct disorders among those
whose family members are affected with this disorders.

X. Biochemical factors
There is a possible correlation between elevated plasma levels of testosterone
and aggressive behaviours.

331
 XI. Organic factors
Children with brain damage and epilepsy are more prone to conduct disorders.

XII. Psychological factors

 Parental rejection
 Frequent shifting of parent figures
 Chaotic home conditions
 Large family size and Poverty
 Child abuse/violence and negligence
 Early maternal rejection
 Separation from parents
 Early institutionalization;
 Family neglect;
 Domestic violence
 Mentally ill parents
 Parents who are involved in law-breaking behaviour
 Crowding in home
 Alcoholic parents

XIII. Other factors which co-exist with conduct disorder are such as
 Mood disorders,
 Post-traumatic stress disorder (PTSD),
 Substance misuse,
 Anxiety,
 Learning problems,
 Oppositional defiant disorder (ODD),
 Attention deficit hyperactivity disorder (ADHD).

Book Pictures Patient Pictures

Clinical Features ♠Stealing or lying  Anxiety
♠Aggression to people or  Beating family members
animals such as often bullies,  Breaking the home objects
threatens, physically cruel to  Self injuries (scratching the

332
 animals. chest, thigh with knife and
♠Get involved in physical fights. blades)
♠Verbally abusive,  Taking alcohol and smoking
♠Using weapons in physical  Frequent lying
fights.  Stealing money from house
♠Forces someone into physical  Always fighting with friends
activity.  Not going to school
♠Early alcohol, tobacco and  Verbally abusive
substance abuse.
♠Destructive behavior that
damages or destroys property.
♠Serious violations of rules.
♠Spiteful and vengeful behavior.
♠Running away from home
Often truant from school,
beginning before age 13 years.

Psychopathology The onset of conduct disorders Same as described in book picture.

can be related to genetic factors
and psychological influences.
Additional factors that have been
implicated include biochemical
factors include elevated
testosterone levels, brain damage
and peer group relations.
Diagnostic  History collection  History collection
Evaluation  Mental status examination  Mental status examination
 Behavioral evaluation  Behavioral evaluation by child
 Psychoanalysis or adolescent psychologist and
child psychiatrist.
Treatment  Antipsychotic drugs  Antipsychotic drugs
Psychopharmacolo  Anticonvulsant  CNs stimulant
gy

333
  CNS stimulant  Anticonvulsant
 Mood stabilizer  Antidepressant
 Antidepressant  Benzodiazepine
Psychotherapy  Behavioural and psycho  Behavioural and psycho therapy
therapy  Family group therapy
 Family group therapy  Parent management training.
 Parent management training  Educational counseling.
(PMT).
 Counseling of parents and
child
ECT  Not recommended  ECT not given

334