PROCESS RECORDING
1. Identification data:
Name: Rinki Das
Age: 35years
Sex: Female
Religion: Hindu
Marital status: Married
Educational status: 10th pass
Occupation: House wife
Income per month: 5000
Languages known: Odia
IP number: 171111008
Ward: 1
Diagnosis: paranoid schizophrenia
Address :nimapada , puri, Odisha
Date of admission: 1/05/2019
Date of process recording: 1/05/2019
Brief summary of the patient problem:- patient is having auditory
hallucination , depression , delusions of persecution ,delusions of jealousy ,
anorexia .
2. Place of interaction: Male psychiatric ward , IMS and SUM
hospitals ,Bhubaneswar
3. Description of the environment: although the environment was a little bit
noisy ,but the patient was sitting quite.it was morning time ,light was coming
through the window , cool air from outside was also coming through the
window. Overally the environment was pleasant and refreshing.
4. Reason for selecting the patient: schizophrenia is a interesting topic for me ,
I am always interested to know the causes ,sign and symptoms ,
diagnosis ,treatment , therapies given to them and the prognosis of
schizophrenia. And the patient was also interesting for me , he was looking
like a gentle man ,behaving like normal man that’s why I was curious to know
what happened to him ,what was the reason for his admission.
5. Objectives:
1. To know the causes of admission of the particular patient in psychiatric
ward.
2. To know the disease(paranoid schizophrenia ) briefly.
3. To know the rate of prognosis of paranoid schizophrenia.
Nurses Response Patients Response Techniques Inference
Verbal Non- Verbal Non verbal
Verbal
1. “Hello Maintained Rinki Das Not Greeting and Patient is
sister,what eye maintainin seeking cooperative
is your contact g eye information but feels
name ? contact uncomfortable
.
2. How are Feeling
you Maintained Seeking
good
feeling? eye Talking information
contact without Patient shows
raising his that he is
head.. relaxed.
3. Have u
taken your
Maintained yes
breakfast ? Answering Seeking Patient is now
eye
in a information feeling
contact
whispering comfortable.
voice and
with
nodding his
head.
4. Who
brought my
breakfast Maintained
brother –
for you? eye Seeking
in -law Answered
contact information Patient is now
by looking
showing some
downward
interest
with a little
towards this
smile.
How many conversation
brother-in-
law you 2 and all Answered
have and are good by raising
Maintained Seeking
who is for me. his head
Eye information
best and with a Patient started
contact
according happy face. trusting me.
to you?
Are you
married?
Maintained yes
Said with Seeking
eye
nodding his information
contact Giving
head.
information
Is she
good for
you? Looking
yes Exploring
Maintained downward
eye and said Patient is
contact with feeling some
nodding his hesitation to
head. tell.
So why
you beat I have
her day Maintained never
Maintained Seeking
before eye beat her
eye contact clarification
yesterday? contact before ,thi Patient is
and said
s was the verbalizing his
with a
first time feelings.
unhappy
and due to
voice.
my disease
condition .
How you
come to Sister told
know that Maintained me, due to Seeking
this is due eye my disease clarification
to disease Looking
contact condition I
condition? downward.
am Clarifying the
suspecting question
her.
Your
brother –in
– law said
Maintained Yes
you were Nodding Re-enquiring
eye
doing head
suicide ,is contact Patient
it right ? accepted his
mistake.
Why you
want to do
Some
suicide? Maintained seeking
voices said
eye Maintained information
me to do
contact eye contact Patient is
this.
aware of his
Do you disease
recognize condition
that voice? Maintained Maintained
No seeking
eye eye contact
information Patient recalls
contact. and
that voice.
Nodding
head
Can others
listen that Maintained No
voice? eye seeking
contact. Nodding his information Patient
head.
These looks
voices are thoughtful.
coming
due to Yes ,you
your are right
disease sister. I
condition Maintained will not do Said in a
only. eye the things raised voice
Don’t contact . said by and with
listen that that voice . eye Advicing
voice and I will not contact.
don’t do Patient
beat my
anything accepted the
wife also .i
said by advice.
know she
that voice. is good
Consult enough. If
your near there is
and dear any other
ones girl she
before must have
doing given a
anything case
told by against me
that voice. for
And don’t
physical
beat you
torture.
wife .she
is taking
care of
you and is
with you With
Smiling and
since 8 smiling Closing the
nodding Patient seems
years. conversation.
head. slightly
relaxed.
Ok, thank Thank
you very you .
much.
Conclusion-next we will meet for the conversation on 25th November 2017 at
11 am here.
SUMMARY-
The patient was now some extent cured after 5 ECT but still he has auditory
hallucination .He understood that the voices saying to do the things is not real ,
he also understood that his wife’s character is not bad , suspecting nature is
due to disease condition.
Techniques used to overcome difficulties- exploring, encouraging, sympathy,
empathy ,understanding him about the disease and how to over come it.
Signature
PROCESS
RECORDING
FPRMAT
SUBMITTED TO: SUBMITTED BY:
Mrs.Suchismita Pahantasingh Priyadarshini Jena
(Assistant Professor) Msc Nursing 1st year
Department of Psychiatric Nursing
Sum Nursing College
