NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCEs
(INSTITUTE OF NATIONAL IMPORTANCE)
PROCESS RECORDING
SUBMITTED TO: SUBMITTED BY:
DR. PRASANTHI NATTALA MS. MONALISHA SHARMA
PROFESSOR & HOD SECOND YEAR M.Sc. PSYCHIATRY NURSING
NIMHANS NIMHANS
Submitted On
1
General Information
Name -Mr. N
Age- 37 years old
Gender-male
Marital status -married
Education -7th
Occupation- Barber
Address- Chikbalapur, Karnataka.
Informants-Self, wife
Information is reliable and adequate
Chief complaints
Alcohol use for the past 20 years
Altered sensorium for 1 day
2
DIAGNOSTIC FORMULATION:
37-year-old married gentleman, educated up to 7 standard, a barber by occupation, Hindu, belonging to LSES hailing from Chikbalapur, Karnataka.
Premorbidly poor frustration tolerance, sensitive to criticism, easily irritable mood, quick-tempered, personal history of marital separation with
first wife, family history of ADS in one first-degree relative and one second-degree relative, severe IPR issues with father and mother-in-law,
presents with an illness duration of 20 years, relapsing-remitting course, with h/o alcohol use since 17 years of age with development of craving
at 23 years of age, tolerance, unable to control, salience and withdrawal symptoms of restlessness, anxiety, insomnia, fatigue, tremors by 25 years
of age, and use despite harm by 32 years of age. H/s/o withdrawal GTCS (generalized tonic-clonic seizure) twice in the past. last 4 months back,
and h/s/o withdrawal delirium twice in the past, last episode 1 year back. Positive expectancy is relief from stress and improved socialization.
Other maintaining factors are withdrawal symptoms, craving, and peer influence. IPR issues and poor coping skills. Maximum abstinence of 4
months at 25 years of age after treatment from a traditional healer with an unknown substance, and the patient being fearful of adverse outcomes
and avoiding substance use, relapsed due to social cues and craving. The current pattern of use is 24-30 units per day, with relative abstinence for
2 days and the last use being 6 units on the day of presentation. On mental status examination, the patient appeared confused, not oriented to time
and place, fearful, severe diaphoresis, and tremors of hands. elementary auditory hallucinations, lilliputian visual hallucinations, and secondary
ideas of persecution with significant bio-socio-occupational dysfunction. Elementary auditory hallucinations, lilliputian visual hallucinations,
secondary ideas of persecution, most likely due to withdrawal; Currently resolved. On general physical examination Initial PR of 130/min, later in
the ward, PR: 90/min, BP-122/84 mmHg, BMI of 22.3 Kg/m2.Motivation-Contemplation stage of motivation to quit alcohol
Impression: ADS, complicated withdrawal, DT, resolved.
Objectives
✓ To establish an effective nurse-patient relationship.
✓ To identify the patient’s level of mental function with present life events/situations.
3
✓ To help the patient to come out from the present problems.
✓ To assess the level of insight and help him gain insight into his disease
NURSES RESPONSE PATIENT RESPONSE THERAPEUTIC INFERENCE
COMMUNICATION
TECHNIQUE
Verbal Non -Verbal Verbal Non-Verbal
Good morning Mr.N Smiling I am fine.(aacha hai) Looking down Greeting Shows
and all around the disinterest
How are you? room. Hostile towards
treating team
Rapport
I'm Monalisha Sharma, M.Sc Looking at Ok ( Thik hai ) Looking down. Questioning
establishment
nursing student. can we talk his face
initiated.
for a few minutes only if you
are comfortable?
4
How did you sleep last night? Looking at No, I couldn’t sleep well Looking around. Questioning
Did you sleep well? his face last night. Shows slight
interest in the
conversation.
Did you have your breakfast? Looking at No Shows no
his face Looking up Questioning interest in
Can you tell me why are you I don’t know but I’ve not answering.
here? Intimate been feeling okay recently, Looking worried Giving broad opening
space is keep on forgetting things. & confused. Poor cognition
used. and insight.
I can understand what are you
going through. Can I know My family says I had fits
but I can’t remember Looking Focusing The patient is
what kind of things you keep Asked with
forgetting? concern anything like that. distressed sad due to
underlying
causes.
I think it's due to my
Do you know why is it .
alcohol-drinking habit. Answered with a
happening?
Asking with low tone. Clarifying The patient is
a soft tone. expressing
knowledge of his
own condition.
Looking at
It's good to know that you Giving information The patient is in
the face of Nodded with
have some idea about the Yes, but everything a confused state
the patient confusion
cause. Alcohol use can cause happened when I stopped due to
& waiting drinking for a few days.
5
many complications. But now for a Then how could it be a complicated
we can help you to recover. response. cause? withdrawal.
Yes, I understand why you are Speaking Ok may be you are right. The patient
with a soft Nodding head Explaining further understood the
having this question but
tone plan given
alcohol harms your body and
you have been using it for a information.
very long time. we will
explain to you all the causes
and ways to recover once you
get better; now our focus is to
make you stable
Ok I will do that I just want Patient
Follow all instructions given Showing Looking away
to feel better expressing
by your treating team so that concern Advising assurance
we can work on your recovery
Termination The patient is
Ok,Thank you Nodded head
If you have any doubts or Smiling and expressing
queries you can ask the showing readiness to take
doctors, nurses, or on-duty concern action
6
staff. I’ll let you rest for now
as you are not feeling well.
7
SUMMARY OF INFERENCE
Through this interview, I was able to establish rapport partially as the patient was still in a slightly confused state; as he was cooperative
understood more about patient's condition. I was able to develop skills in motivating the client, Client was able to understand the problem and
showed readiness for treatment.
BIBLIOGRAPHY
1. Sreevani R. A guide to mental health and psychiatric nursing, Jaypee publication, New Delhi, 4th edition, 2016.Page 175 – 179
2. Townsend Mary C. Psychiatric Mental Health Nursing: Concept of care in evidence-based practice. F.A Davis.Philadelphia.6th edition.
Page no.457-469.
3. Videbeck Sheila L. Psychiatric-Mental Health Nursing. Wolters Kluwer. Lippincott Williams. 5th edition. Page no. 258-265
4. Gandhi S. Textbook of Mental Health and Psychiatric Nursing. Principles and Practice. New Delhi: Elsevier; 2022. Page no. 176-185.
