HISTORY OF PATIENT

1. Biodata of patient
 Name: Rajwinder Singh s/o Gurdev Singh
 Age: 26 years
 Gender: Male
 Religion: Sikh
 Address: Nagal , Faridkot
 Education: +2
 Occupation: Farmer
 Marital status: Unmarried
 Languages known: Punjabi
 Monthly income: 70000/-
 Date of Admission: 19/12/2018
 CRF: PFDGG2018035527 IP
 Reason for admission : For de addiction and treatment purpose
 Diagnosis: tramadol dependence (F 15)
Informant:
 Patient
 Reliability of Informant: reliable
RELEVANCE OF TOPIC :
Tramadol is an opioid analgesic (painkiller). It is prescribed to treat moderate to moderately
severe pain and is considered a safer alternative to other narcotic analgesics like hydrocodone
(Vicodin, Lortab) and methadone. In addition to opioid receptor activity, tramadol exerts some of its
effects via its actions on serotonergic and noradrenergic neurotransmission. For this reason, there is also a
known risk of seizures and convulsions in some patients taking tramadol, with this risk being even more
elevated in abusers seeking the euphoric effects, or "high," produced by taking large doses of the drug.

2. CHIEF COMPLAINTS:
According to patient :
 Taking tramadol 10 tablets/day X 2 years
 Tobacco filled with cannabis occasionally
 Alcohol occasionally
 Disturbed sleep pattern
 Loss of appetite
 Irritability X 2 weeks
 Generalized body ache
 Lacrimation
 Constipation
 Loss of concentration in work
3. HISTORY OF PRESENT ILLNESS:
  Mode of onset: Insidious
 Course of illness: progressive
 Progress: Deteriorating
 Predisposing factors : Stay away from father and mother
 Aggravating factors : Loneliness in the home
4. PAST HEALTH HISTORY
 Medical history:
 No h/o hypertension, Diabetes mellitus , Asthma, or any other medical illness.
 No h/o neurological disorders
 No h/o convulsions
 No h/o unconsciousness
 No h/o HIV, visceral disorders
 No h/o hypertension
 Surgical history:
No h/o any surgical illness
No h/o any medico legal case
 Psychiatric history :
H/o substance abuse * 5-6 years
h/o decreased interest in work
h/o tobacco use
h/o cigarettes filled with cannabis occasionally 2 /day
No h/o crying spells
No h/o suicidal thoughts
No h/o seizures
No h/o thought echo
No h/o thought withdrawal
5. FAMILY HISTORY
Sr. Members Relation with Education Occupation Health status
no. Patient
1. Gurdev singh Father +2 Abroad Good

2. Kuldeep kaur Mother Matric Abroad Good

3. Jashandeep kaur Sister B.Sc. nursing Nurse Good

4. Harmandeep Brother in law Graduate Abroad Alcoholic

singh
 5. Rajwinder singh Patient +2 Farmer Patient

6. Harshdeep kaur Sister BBA Student Good

 Type of family : joint

 Birth order : 1st in order
 Psychiatry history:
No h/o substance abuse in family
 Medical history: No significant history
 Surgical history: No significant history

Current housing conditions :

i. Home circumstances: conflicts with family

ii. Per capita income : 10,000 rs. per month
iii. Socioeconomic status : Upper middle class family
iv. Head of the family : father
v. Current attitude of family members towards illness : Cooperation from family
vi. Communication pattern in family : satisfactory
vii. Cultural and religious view : Sikh religion
viii. Ethnicity : Punjabi
ix. Social support systems available : From relatives

FAMILY TREE

Father mother

Sister Sister Patient

 Son

PERSONAL HISTORY
a) BIRTH & DEVELOPMENT
 Antenatal period:
o Any febrile illness : no
o Physical illness : no
o Medications / drugs use : no
o Trauma to abdomen : no
o Immunization : done
 Natal period:
o Birth : full term
o Wanted : yes
o Type of delivery : normal vaginal delivery
o Birth cry : immediate
o Birth defects : no
o Postnatal complications : no
b) CHILDHOOD HISTORY :
o Primary caregiver : mother
o Feeding : breast feed
o Age at weaning : 6 months
o Developmental milestones : normal
o Age and ease of toilet training : 2 years
o Behavioural and emotional problems :
i. Thumb sucking : YES
ii. Temper tantrums : YES
iii. Tics and head banging : YES
iv. Night terror : NO
v. Fears : YES
vi. Bed wetting : NO
vii. Nail biting : NO
viii. Stuttering : NO
ix. Enuresis: NO
x. Encopresis: NO
xi. Somnambulism : NO
c) EDUCATIONAL HISTORY :
o Age at beginning of formal education : 3 years
o Age of finishing formal education : 18 years
 o Relationship with peers and teachers : Good
o School phobia : no
o Truancy , non attendance : no
o Learning disabilities : no
o Reason for termination of studies : completion of basic study
o Bullying at school : no
d) PLAY HISTORY :
o Games played : outdoor games
o Relationship with mates : good
e) ADOLESCENCE:
Emotional problems during adolescence :
o Running away from home : NO
o Delinquency : NO
o Smoking : YES
o Drug abuse : YES
o Any other : NO SIGNIFICANT HISTORY AVAILABLE
f) PUBERTY:
o Age at appearance of secondary sexual characteristics : 14 YEARS
o Anxiety related to puberty changes : YES
o Age at menarche : N/A
o Reaction to menarche : N/A
o Regularities of menstrual cycle : N/A
o Abnormalities : N/A
g) OBSTETRICAL HISTORY :
o Any abnormalities associated with delivery / puerperium/ pregnancy : N/A
o Number of children : N/A
o Termination of pregnancy : N/A
h) OCCUPATIONAL HISTORY :
o Age at starting work : 15 YEARS
o Jobs : FARMER
o Reasons for change : NO CHANGE IN THE JOB
o Current job satisfaction : NO INTEREST IN WORK
i) SEXUAL HISTORY :
o Type of marriage : N/A
o Duration of marriage : N/A
o Interpersonal relationship with in laws: UNMARRIED
o Relationship with wife : N/A
o Relationship with children : N/A
j) SUBSTANCE ABUSE:
h/o tramadol tablet from 2 years
 h/o tobacco from 2 years
k) PRE-MORBID PERSONALITY
i. Interpersonal relationships:
o Interpersonal relationships with family : satisfactory
o Interpersonal relationships with friends : Good
o Type of personality : extroverted
o Making social relationships : good
ii. Use of leisure time :
o Hobbies : gaming , gossiping
o Interests : listening music, spending time with friends
o Intellectual activities : no
o Energetic : yes
o Sedentary : no
iii. Predominant mood :
o Optimistic
o Cheerful mood
o Not prone to anxiety
o Despondant
o Reaction to stressful events : no overt reaction to stress
iv. Attitude towards self and others :
o Self confidence level : high
o Self criticism : yes
o Self consciousness : yes
o Thoughts for others : thoughtful
o Self appraisal of activities : less
o General attitude towards others : sympathetic , loving and caring
v. Attitude to work and responsibilities
o Decision making : less
o Acceptance of responsibility : acceptance
o Flexibility : no
o Foresight : intact
o Religious beliefs : faith in god
o Fantasy life : wants a happy life
o Day dreams : yes
vi. Habits :
o Eating pattern : irregular
o Elimination : irregular
o Sleep : irregular
o Use of drugs / tobacco / alcohol: yes
ADDICTION HISTORY
  Age at start of intake of drugs : 24 years
 First drug used and its dose :
a. Tab. Tramadol
 Role model
a. In family : No
b. In society : Friends
 Loss
a. Psychological loss : Irritability , aggression , insomnia , restlessness , anxiety
b. Occupational loss : no interest in work , less productivity
c. Physical loss : Loss of appetite , headache , lacrimation
 History of abstinence: no history
 History of relapse : no history

 VITAL SIGNS

Sr. no. Vital signs Normal value Patient value Remarks

1 Temperature 98.6 F 98 F Normal
2 Pulse 72-100/min 74 /min Normal
3 Respiration 20-24/ min 20 /min Normal
4 B.P 120/80mm hg 120/80mm hg Normal

INVESTIGATION

Investigations Normal Values Patient’s Values Remarks

Bilirubin
 Total 0.0-0.2 mg / dl 0.3 mg /dl Normal
 Direct 0.2-1.2 mg / dl 0.8 mg/dl Normal

SGOT 40 U/L 30 U/L Normal

SGPT 40 U/L 35 U/L Normal
Total protein 3.5-5.3 g/dl 6.0 g/dl Normal
Albumin 3.5-5.3 g/dl 4.3 g/dl Normal
Random sugar 80-120 mg/dl 90 mg/dl Normal
Urea 15-45 mg/dl 20 mg/dl Normal
Creatinine 0.6-1.3 mg/dl 0.7 mg /dl Normal
Uric acid 3.5-7.2 mg /dl 4 mg/dl Normal
Sodium
Potassium 135-158 mmol/dl 136 mmol/dl Normal
Calcium 3.8-5.6 mmol/dl 4.5 mmol/dl Normal
1.1 – 1.3 mmol/dl 1.0 mmol/dl Normal

MEDICATION
Name the drugs Dosage Route Frequency Action

Tab. Tramadol 50 mg Oral TDS Analgesic

Tab. Clonidine 0.1 mg Oral TDS Anti anxiety

Tab. Ibuprofen 400 mg Oral TDS Analgesic

Tab. Pantoprazole 10 mg Oral OD H2 blocker

Tab. Lorazepam 2 mg Oral OD Sedative

Tab. IFA 2 tablet Oral OD Iron supplement

Iv fluid + inj. SP bol 500 ml. IV OD Fluid and

electrolyte
balance

Nursing care provided to patient

Day 1 1) Rapport established with the patient.

2) Vital signs are monitored 6 hourly .
3) Administration of medication.
4) Patient is involved in activities like prayer
Day 2 1) Co-operation of patient gained.
2) Establishment of good IPR with Patient.
3) Assessment regarding personal hygiene done.
4) Assessment regarding seizures
5) History collection is done including bio data, illness and other all
aspects.
6) Preparation of nursing care plan according to patient’s needs.
Day 3 1) Patient is involved in activities like carom board, painting
2) Deep breathing exercises are taught to patient
3) Mental status examination is conducted.
4) Play therapy is given to patient.
5) Patient is assisted in self care activities.
MENTAL STATUS EXAMINATION

I. APPEARANCE

1. GROOMING AND DRESS

Inference:
Patient is wearing appropriate dress which is according to the place and season. Hair
are also combed. He is well groomed

2. HYGIENE

Inference:
Hygienic condition of the patient is good . Patient takes bath after 2 days and also
changes his clothes. Nails are clean.

3. PHYSIQUE

Inference:
Patient has normal body physique

4. POSTURE

Inference:
Patient is having an open posture.

5. FACIAL EXPRESSIONS

Inference:
Facial expressions of the patient are anxious . They are appropriate according to the
talk of the patient.

6. LEVEL OF EYE CONTACT

Inference:
Patient maintains eye-to-eye contact throughout the conversation.

7. RAPPORT
N: good morning
P: Good morning , Ma’am
 N:ki mai tuhade nal gal kar sakdi ha…
P: Hanji, ma’am
Inference:
A good rapport is maintained with the patient. He took part in the conversation well
and responded to all the questions asked to him.

II. MOTOR ACTIVITY

Inference:
Patient is able to sit still. His psychomotor activity is normal . Unusual gestures or
mannerisms are not present.

III. SPEECH

Inference:
Patient spoke in Punjabi language. Rate of speech is normal and in normal tone.
IV. EMOTIONS

1. MOOD
N: Kiwe ho tuc ?
P: hanji thik ha ..bas nind hi nhi aundi….mann udas hai
Inference:
Patient ‘s mood is distressed.

2. AFFECT

Inference:
Patient’s emotional response is appropriate.

V. THOUGHT

1. FORMATION LEVEL

N: tuc kis vajah to ethe admit ho ?

P: nashe karn di vajah karke
Inference:
Normal formation level

2. CONTENT LEVEL
 N: tuhanu lagda hai ki tuhanu koi marn di koshish kar reha hai ?
P: nhi ..
N: Tuhanu darr lagda hai
P: nhi…

Inference:
Delusions and phobias are absent.

3. PROGRESSION LEVEL

N: ik hi khyal mann vich baar baar aunda hai ?

P: nhi…
Inference:
Progression level of thought is intact .

VI. PERCEPTION

N: Tuhanu lagda hai tuhanu koi bhula reha hai … par othe phir v koi majood nhi
hunda ?
P: Nahi.
N: Tuhanu lagda hai ki tuhanu koi dikhayi dinda hai … jo gujar chukka hai…
P: Nahi aisa bhi kuch nahi tha
Inference:
Patient is not having any kind of visual and auditory kind of hallucinations.
Perception in patient is intact.

VII. SENSORIUM AND COGNITIVE ABILITY

1. LEVEL OF ALERTNESS/CONSCIOUSNESS

Inference:
Patient is alert and conscious. He is actively listening to all the questions and is also
giving appropriate answers.

2. ORIENTATION
N: tuc ethe kad aye?
P: parso ka aye c..
N: tuc kitho de rehn wale ho?
P: mai Faridkot da rehn wala ha.
N: ajj ki din hai ?
 P: saturday
N: tuc iss time kithe ho?
P: hospital
N: tuc iss time kehre hospital ho ?
P: ggs medical college, faridkot
N: tuhade kol koun khada hai ?
P: meri mummy …
Inference:
Patient is oriented to time , place and person.

3. MEMORY

a) Immediate memory

N: mai tuhade kolo hune ki puchya c ?

P: ki tuhade nal koun aya hai
Inference:
Immediate memory of the patient is intact .

b) Recent memory

N: tuc sawere ki khana khada c ?

P: mai sawere prantha te omlette khada c ..
N: tuc dwai kado lyi c ?
P: mai sawere lyi c …
Inference:
Patient’s recent memory is also intact.

c) Remote memory

N: tuhade school da name ki hai ?

P: Dashmesh public school , Faridkot.
Inference:
Patient’s remote memory is intact.

4. CONCENTRATION AND ATTENTION

N: 10+10 ki hunde han ?

P: 20
Inference:
 Patient is having sustained concentration and attention.
N: mai tuhanu kujh word bolangi tuc uss hi sequence de vich vapis bolne ne ..?
orange , apple , papaya , grape, banana, pineapple , cherry
P: orange , apple , papaya , grape, banana, pineapple , cherry.

5. INFORMATION AND INTELLIGENCE

N: Punjab vich kinne dariya ne ?

P: 5
N: Punjab da much mantra koun hai ?
P: Capt. Amrinder Singh

Inference:
Patient general information level is good .

6. ABSTRACT THINKING

N: khana kyu khana chahida hai ?

P: jeonde rehn lyi
Inference:
Abstract thinking of the patient is good.

7. JUDGMENT

a) Social

N: Jekar tuhade kise rishtedar nu paiseya di jarurat hai ta tuck i karoge?

P: mai usdi jinni ho sake madad karn di kosish karunga …

Inference:
Patient has logical social judgment.

b) Personal

N: sanu sareya de naal kiwe rehhna chahida hai ?

P: sanu sab nal pyar nal milke rehnma chahida hai ….
Inference:
Personal judgment of the patient is appropriate.

VIII. INSIGHT
 N: tuhanu lagda hai ki tuhanu koi bimari hai?
P: hanji nashe karn di
N: Tuhanu lagda hai ki eh ik mansik bimari hai ?
P: Nhi
Inference:
Patient is having grade IV insight as he accepts his illness.

IX. GENERAL ATTITUDE

Inference:
General attitude of the patient is normal and appropriate. Patient is very co-operative.

X. SPECIAL POINTS

N: Ajj sawere khana khada tuc?

P: Hanji…..
N: Bhukh thik tarike nal lagdi hai tuhanu ?
P: Hanji …thik hi lagdi hai….
N: Nind thik aundi hai tuhanu ?
P: Nind di bhut takleef hai….
N: Kabaz di oroblem hai tuhanu ?
P: nhi…

Inference:
Patient’s appetite and sleep pattern is disturbed

XI. PSYCHOSOCIAL FACTORS

1. STRESSORS

N: Tuhanu kise cheez di pareshani hai ?

P: Na pareshani ta koi ni haigi

Inference:
He is worried about his illness.

2. COPING SKILLS

N: Tuc apni tension dur karn lyi ki karde ho ?

 P: kujh nhi goli lele landa ha

Inference:
His coping skills are accurate

3. RELATIONSHIPS

N: Tuhade rishtedaran de nal tuhade sambandh kiwe ne ?

P: Vadia ne ….
N: Ki tuhanu oh change lagde ne ?
P: Hanji oh sab bhut shayita karde ne
N: Tuc ghar vich ladayi ta nhi karde ?
P: Nhi ….

Inference
Patient has good relationship with his relatives and family .

4. SOCIO CULTURAL

N: Tuc samaj de kanoon to tang ho ?

P: Nhi …
Inference
Patient follows the rules of society.
5. SPIRITUAL
N: Tuc path karde ho ?
P: Nhi
N: Tuc gurudware jande ho ?
P: Hanji kadi kadi….
N: Tuc rabb vich yakeen karde ho ?
P: Hanji … karda ha
Inference:
Patient is spiritual and believes in god.
SUMMARY : In MSE , it has been found that patient ‘s personal hygiene is maintained .
Psychomotor activity is normal . Thought and speech are normal . There are no hallucinations
and delusions . Patient is distressed and affect is congruent. Grade IV insight is present . General
attitude is good and patient is cooperative.

NEUROLOGICAL EXAMINATION:
LEVEL OF CONCIOUSNESS:
  Alertness: patient is alert and reponse immediately & appropriately to all verbal
commands.
 Lethargic: patient does not feel drowsy.

GLASGOW COMA SCALE:

RESPONSE TYPES POINTS PATIENTS
VALUE
Best eye opening response  Spontaneously 4 4
 To speech 3
 To pain 2
 No response 1
Best motor response  Obeys verbal command 6 6
 Localizes pain
 Flexion- withdrawal 5
 Flexion- abduction 4
 Extension 3
 No response 2
1

Best verbal response  Oriented to time, place, 5 5

person
 Confused conversation 4
 Speech inappropriate
 In comprehensive 3
 No respose
2
1
Total score 15 15

ASSESSMENT OF CEREBRAL FUNCTIONS:

 Agnosia : absent as patient can recognize the common objects

 Apraxia: absent as patient can carry out some skilled activities
 Aphasia: absent; patient can communicate.
 Finger to finger test: normal
 Finger to nose test: normal
 Romberg test: negative as patient cannot maintain his balance.
 Tandom walking test: negative patient cannot walk in straight line.

CRANIAL NERVE EXAMINATION:

  CN I (Olfactory nerve): patient have the CN I functioning as he smelled and identified
the fruit orange by closing his eyes.
 CNII (Optic nerve) : inspection of the eyes was done and no obvious abnormalities was
found.
 CN III (Occulo motor) CN IV(trochlear),CN VI (Abducens) : normal control eye
movement in all six cardinal, IOP was normal,
 CN V (trigeminal nerve):corneal reflexes are observed and it was normal.
 CN VII (facial nerve): no any presence of facial palsy, and had normal taste sensation.
 CN VIII ( Vestibulo-cochlear nerve): normal auditory acuity and maintain a normal range
of balance. But patient have deviated range of motion.
 CN XII (hypoglossal nerve): there is no deviation from midline.

REFLEX TESTING:

a). Superficial reflexes:

Abdominal Reflex-Lightly stroking the skin on an abdominal quadrant normally contract the
abdominal muscle, moving the umbilicus towards the stimulated side.

 Present.

Planter reflex- Scratching the foot’s outer aspect of the planter surface from the heel towards
the toes normally contracts or flexes the toes in patients older than 2 years of age.

 Present.

Corneal reflex- Gently touching the cornea with a wisp of cotton causes blinking.

 Present.

Pharyngeal reflex- Depress the tongue with a tongue blade and have the patient say “ahh” or
yawn. Uvula and soft palate should rise. Gag reflex should be present and the voice should sound
smooth.

 Present.
b).Deep tendon reflexes: Biceps Reflex (C5 – C6): Support the forearm on the examiners
forearm. Place your thumb on the bicep tendon (located in the front of the bend of the elbow;
midline to the anticubital fossa). Tap on your thumb to stimulate a response.

 Present.

Triceps Reflex (C7-C8): Have the individual bend their elbow while pointing their arm
downward at 90 degrees. Support the upper arm so that the arm hangs loosely and “goes dead”.
Tap on the triceps tendon located just above the elbow bend (funny bone).

 Present.

Brachioradialis Reflex (C5-C6): Hold the person’s thumb so that the forearm relaxes. Strike
the forearm about 2-3 cm above the radial styloid process (located along the thumb side of the
wrist, about 2-3 cm above the round bone at the bend of the wrist). Normally, the forearm with
flex and supinate.

 Present.

Quadriceps Reflex (Knee jerk) L2 – L4: Allow the lower legs to dangle freely. Place one hand
on the quadriceps. Strike just below the knee cap. The lower leg normally will extend.and the
quadriceps will contract.

If the patient is supine: Stand on one side of the bed. Place the examiners forearm under the
thigh closest to the examiner, lifting the leg up. Reach under the thigh and place the hand on the
thigh of the opposite leg, just above the knee cap. Tap the knee closest to the examiner, (the one
that has been lifted up with the examiners forearm).

 Present.

Achilles Reflex (ankle jerks) L5 – S2: Flex the knee and externally rotate the hip. Dorsiflex the
foot and strike the Achilles tendon of the heel. In conscious patients, kneeling on a chair can
help to relax the foot.

Heel Lift While the patient is supine, bend the knee and support the leg under the thigh. Have
the leg “go dead”. Briskly jerk the leg to lift the heel of the bed. Normally, the leg will remain
relaxed and the heel will slide upward; increased tone will cause the heel and leg to stiffen and
lift off the bed.

 Present.

Babinski Response: Dorsiflexion of the great toe with fanning of remaining toes is a positive
Babinski response. This indicates upper motor neuron disease.

 Present.
Reflex responses: 0 no response 1+ diminished, low normal 2+ average, normal 3+ brisker than
normal 4+ very brisk, hyperactive

Lower motor neuron disease is associated with 0 or 1+, upper motor neuron disease is associated
with 3+ or 4+.

 Patient`s reflex were normal

REFLEXES Biceps Triceps Supinator Knee Ankle Plantar Abdominal

Right +2 +2 + + + + +
Left +2 +2 + + + + +

MINI MENTAL STATUS EXAMINATION:

COMPONENT DESCRIPTION PATIENT POINTS

SCORE
I. ORIENTATION
 What is the year? 1 1
 Season? 1 1
 Date? 1 1
 Day? 1 1
1 1
 Month?
1 1
 Which state you live?
1 1
 Country? 1 1
 Town/city? 1 1
 Hospital name? 1 1
 Floor ?
II. ATTENTION AND CALCULATION:
 Count 1-10 forward 5 5
 Count 1-10 backward
 Add 5+10= 15
 Subtract 5-2= 3
 Spell word SUMMER.

III. REGISTRATION
 Name three objects : register, cup, book 3 3
IV. RECALL:
 Register, cup book 3 3
V. LANGUAGE
 What is this ( patient was shown a book and he 2 2
gave right answer)?
 Patient was shown a wrist watch and time was
asked?
 Ask the person to repeat the following 1 1
  Command: take the pencil and draw a circle 3 3
 Fold the paper into four halves. 1 1
 write a sentence of your choice 1 1
 Copy: patient was asked to draw the following 1 1
shape and he drawed it

Shapes:

Total score: 30 30

PROCESS RECORDING

BIO –DATA OF THE PATIENT

 Name: Rajwinder Singh s/o Gurdev Singh

 Age: 26 years
 Gender: Male
 Religion: Sikh
 Address: Nagal , Faridkot
 Education: +2
 Occupation: Farmer
 Marital status: Unmarried
 Languages known: Punjabi
 Monthly income: 70000/-
 Date of Admission: 19/12/2018
 Duration : 15 minutes
BRIEF HISTORY OF PATIENT:

Patient was admitted to de addiction ward , GGS hospital , Faridkot with the chief complaints of

 Taking tramadol 10 tablets/day X 2 years

 Tobacco filled with cannabis occasionally
 Alcohol occasionally
 Disturbed sleep pattern
 Loss of appetite
 Irritability X 2 weeks
 Generalized body ache
 Lacrimation
 Constipation
 Loss of concentration in work
PROCESS RECORDING
Objectives for the patient:

1. To establish rapport and therapeutic IPR.

2. To socialize effectively.
3. To ventilate his feelings.
4. To identify the problems.
5. To learn healthy coping mechanisms.

Objectives for the nurse:

1. To develop adequate communication skill.

2. To develop confidence in maintaining therapeutic relationship.
3. To develop skill in acknowledging the problems of the patient.
4. To assist the patient in dealing with his personal problems.
5. To assist the patient in developing positive coping mechanisms.
6. To procure skill in evaluating the pre-set objectives in order to assess the effectiveness of
therapeutic IPR.
7. To judge self in dealing with anxiety, fear and sentiments while progressing through the
therapeutic IPR.

SPECIFIC OBJECTIVES :

 To establish rapport and therapeutic IPR

 To judge the mood and affect of the patient
 To evaluate the thought process of patient

GENERAL OBJECTIVES:

 To increase the self esteem of the patient

 To enable the client to interact
 To practice various communication/ interview techniques
 To gain skills in taking interview
 To ventilate the feeling of the patient
Sr. Participan Conversation Therapeutic Inference Communi
no ts techniques cation
7. 1 Nurse Good Morning Giving Initiation of Verbal
. recognition communication
Patient Good Morning Sister !
8. 2 Nurse Ki mai tuahde nal gal kar sakdi ha? Giving Initiation of Verbal
. recognition communication
Patient Hanji
9. 3 Nurse Tuc thik ho ? Exploring Maintain eye to Verbal
. eye contact
Patient Hanji thik hu
10. 4 Nurse Tuc the kyu aye ? Questioning Responding Verbal
. spontaneously
Patient Nasha chadan lyi
11. 5 Nurse Tuhanu ethe aye kinne din hoye ne Linking Answer Verbal
. adequately
Patient Parso aya c
12. 6 Nurse Tuc golian khania kad shuru kitiya Theme Answer Verbal
. ? identification adequately &
Patient Mai tramadol diyan golian 5-6 saal to made eye
kha reha ha to eye
contact.
13. Nurse Tuc hor koi nasha karde c ? Theme Answer Verbal
identification adequately &
Patient Hanji smoking v karda c made eye
to eye
contact.
14. 7 Nurse Tuc ethe apni marji nal aye ho ? Open general Answers Verbal
. lead adequately
Patient Hanji ..hun mai tang aa gya ha …
15. 8 Nurse Isto ilawa koi hor nasha karde ho ? Questioning Answers Verbal
. adequately
Patient Hanji kadi kadi shraab pee lenda ha ..
16. 9 Nurse Tuhade pita ji ki karde ne ? Questioning Answers Verbal
. adequately.
Patient Mere pita ji bahr rehnde han ….
17. 1 Nurse Tuhade pita ji nasha karde ne ? Restating Maintains eye to Verbal
0 eye contact
. Patient Nhi oh bas sharb peende c…

18. Nurse Tuc kamm ki karde ho ? Questioning Answers Verbal

adequately.
Patient Mai kheti badi karda ha
19. Nurse Nasha karke tuhanu kiwe mehsoos Restating Maintains eye to Verbal
hunda c ? eye contact

Patient Nasha karke mainu vadia mehsoos

hunda c
20. Nurse Tuc kadi nasha chadn di koshish Reinforcing Answered sadly Verbal
kiti the patient
offering
Patient Hanji … par takleef bhut hundi c general lead
…tot laggi rehndi hai …
21. 1 Nurse Ethe kiwe aye ? Reinforcing Answered sadly Verbal
1 the patient
. Patient Ethe khud di marji nal aye offering
general lead
22. 1 Nurse Nasheya lyi paise kitho milde ne Asking divert Answers Verbal
2 question adequately
. Patient Mummy daddy bahr rehnde ne

23. . Nurse Hun nashe chadn da mann bnaya Giving broad Answer Verbal
hai opening adequately

Patient Hanji
24. 1 Nurse Kamm vich mann lagda hai Encouraging Answers Verbal
4 description of adequately
. Patient Hanji golian kha ke hi mann karda hai thought
kamm karn nu…
25. 1 Nurse Kadi chori kiti hai Encouraging Answers Verbal
5 ventilation of adequately
. Patient Nhi feelings.

26. 1 Nurse Hun ki karna chahunde ne ? Divert Answers sadly Verbal

6 questioning
. Patient Hun agge bare sochna hai about his
feelings
27. 1 Nurse Isde nal tuhade ghar waleya nu Encouraging Answers Verbal
7 takleef hundi hai ? description of adequately
. Patient Hanji …ta hi chadna chahunda ha … thought
28. 1 Nurse Ethe ake koi takleef hoyi ?. Encouraging Answers Verbal
8 description of adequately
. Patient Nhi … hale tak koi nhi hoyi … thought
29. 1 Nurse Kujh fark mehsoos hoya pehla nalo Divert Answers Verbal
9 ? questioning adequately
. Patient Hanji …kujh had tak…. about his
thinking
process
30. 2 Nurse Chalo hun dwai time sir leni hai Linking with Answers Verbal
0 reality adequately
. Patient Hanji ma’am

31. 2 Nurse Psychoeducation: Suggestion Linking and Verbal

1  Tuc time sir dwai leni accepting my
. hai suggestion
 Jekar nasha karn da
mann kare ta kujh hor
 kha lena
 Jad v koi tuhanu nasha
karn lyi bole ta otho
dur aa jana
 Jyada sma apna aone
ap nu sudharn de vich
lgana hai..
 Apne khan peen da
dhyan rakhna
 Apni safai rakhni

Patient Hanji thik hai ….

32. Nurse Chalo thik hai hun mai chaldi ha Informing Behave normally Verbal
and and termination
Patient Hanji …. terminating of the interview
the interview is done in
normal way and
is accepted by
the patient.
DESCRIPTION
OF DISEASE
 TRAMADOL DEPENDENCE

Tramadol is a central nervous system (CNS) depressant. This means it slows down lung and
heart functions, allowing the user’s body to relax. Also, Tramadol binds to the Opioid
receptors in the brain, blocking the signal of pain. It will also affect the receptor responsible
for emotion, further inhibiting pain and providing the euphoric effect that Opioids are known
for.

Mechanism of action of tramadol :

Tramadol has a similar mechanism of action to other opiate drugs. Once in the system, it
attaches to the receptor sites in the brain that are involved in the subjective perception of pain
and commonly the receptor sites for the endogenous opiate neurotransmitters. Tramadol also
appears to increase the availability of neurotransmitters such as norepinephrine and serotonin.

Tramadol abuse

The maximum amount of tramadol that should be taken is reported as being 400 mg per day.
Individuals taking more than this without a specific prescription to do so would be considered
to be misusing or abusing the drug. In addition, taking the drug without a prescription, using
it in a manner that is not consistent with its prescribed purposes (e.g., using it more frequently
than prescribed or taking it for euphoric psychoactive effects), and using it in conjunction
with other drugs of abuse are also forms of misuse.

Tramadol typically produces:

 A moderate reduction in the subjective experience of pain

 Relaxation and sedation at higher doses
 Mild euphoria
 Feelings of light-headedness
PREVALENCE OF TRAMADOL ABUSE
Given the easy availability of tramadol from pharmacies in India and some other countries,
its abuse and diversion may become a bigger challenge in the future. According to the report
of National Drug Abuse Monitoring, the proportion of tramadol use among drug abusers
increased from 0.2% in 2004 to 16.0% in 2006; the trend of tramadol use varied very
smoothly from 2007 to 2009; however, the proportion of tramadol use among drug abusers
declined sharply from 13.3% in 2009 to 3.4% in 2011

CAUSES
IN BOOK IN PATIENT
Biological Factors
 Genetic vulnerability: family history Absent
 of substance use disorder, e.g. twin
studies suggest that genetic
mechanisms might account for
alcohol consumption.
 Biochemical factors: for example, Absent
role of dopamine and norepinephrine
have been implicated in cocaine,
ethanol and opioid dependence.
Abnormalities in alcohol
dehydrogenase or in the
neurotransmitter mechanism are
thought to play a role in alcohol
dependence.
 Withdrawal and reinforcing effects of Present
drugs (they serve as maintaining
factors).
 Co-morbid medical disorder (e.g. to
control chronic pain) . Present
Psychological Factors
• General rebelliousness Present
• Sense of inferiority Present
• Poor impulse control Present
• Low self-esteem Present
• Inability to cope with the pressures of living Present
and society (poor stress management skills)
• Loneliness, unmet needs Absent
• Desire to escape from reality Present
• Desire to experiment, a sense of adventure Present
• Pleasure-seeking Present
• Machoism Present
• Sexual immaturity Present
Social Factors
• Religious reasons Absent
• Peer pressure Present
• Urbanization Present
• Extended periods of education Absent
• Unemployment Present
• Overcrowding Absent
• Poor social support Absent
• Effects of television and other mass media Absent
• Occupation: substance use is more common Present
in chefs, barmen, executives, salesmen,
actors, entertainers, army personnel,
journalists, medical personnel, etc.
Easy Availability of Drugs
• Taking drugs prescribed by doctors (e.g. Absent
benzodiazepine dependence).
• Taking drugs that can be bought legally Present
without prescription (e.g. nicotine, opioids).
• Taking drugs that can be obtained from Present
illicit sources (e.g. street drugs).
Psychiatric disorders
 Depression Absent
 Anxiety disorders (particularly social Present
phobias)
 Personality disorder (especially Present, Narcissistic personality
antisocial personality)
 Organic brain disease Absent
 Schizophrenia. Absent

SIGNS OF TRAMADOL ABUSE

SIGNS IN BOOK IN PATIENT

PRESENT PRESENT
 Any regular use of tramadol without a
prescription for the drug
PRESENT ABSENT
 Attempting to get numerous prescriptions from
numerous different doctors for tramadol
PRESENT PRESENT
 Taking more tramadol than prescribed or taking
it more frequently than its prescribed
instructions dictate
PRESENT PRESENT
 Taking tramadol in a manner that is not
consistent with its intended use, such as
grinding up the pills and snorting them, mixing
them with water and injecting them, etc.
PRESENT PRESENT
 Regularly using tramadol in conjunction with
other drugs, such as alcohol, other opiates,
benzodiazepines, cannabis products, stimulants,
etc.
PRESENT ABSENT
 Signs of opiate intoxication, such as slow or
slurred speech, problems walking, problems
with coordination, lethargy, shallow breathing,
pinpoint eye pupils, mood swings, and poor
emotional control, such that the person may
become angry or sad for no apparent reason
PRESENT PRESENT
 Becoming very defensive and reactive when
someone suggests they might have a problem
 PRESENT PRESENT
 Rationalizing drug use, such that the person
claims they need to use the drug or that their
drug use is “normal” for them
PRESENT PRESENT
 Having trouble controlling use of tramadol,
such as regularly using more tramadol than
originally intended, continuing to use tramadol
even though its use is resulting in negative
ramifications, continuing to use tramadol even
though physical or mental health is negatively
affected by its use, having repeated strong urges
to use tramadol, repeatedly using tramadol in
situations where it is dangerous to do so, and
spending significant amounts of time using
tramadol, trying to get it, or recovering from
tramadol use
PRESENT PRESENT
 Finding empty prescription bottles for tramadol
in the person’s clothes, room, car, etc.
PRESENT ABSENT
 Legal or financial problems associated with
tramadol use
PRESENT PRESENT
 Needing to use increasingly higher amounts of
tramadol to get the effects once received at
much lower doses
PRESENT PRESENT
 Associating with individuals who use drugs
recreationally
PRESENT PRESENT
 Withdrawal symptoms when the individual
has stopped using tramadol or cannot get the
drug
EFFECTS OF TRAMADOL ADDICTION
EFFECTS IN BOOK IN PATIENT
Seizures
Tramadol is known to cause seizures in some users. Present
While the risk is particularly significant for those with
epilepsy, they can occur even in those with no prior
history of seizures. High doses may increase risk of
seizure for some, Overall seizure risk is estimated to
be between 8 and 35%, but research suggests that risk
increases over time, which means that long-term users
are particularly vulnerable.
Adrenal Insufficiency
Chronic tramadol use is associated with adrenal Present Present
insufficiency, which means that your body’s ability to
produce these substances is diminished. As a result, a
multitude of vital functions are compromised and you
may experience symptoms such as muscle weakness,
fatigue, and low appetite.
Androgen Insufficiency
The long term use of tramadol lead to a host of Present Present
potential symptoms including loss of libido and sexual
enjoyment, fertility problems, decreased muscle and
bone mass, and mood disturbances like depression.
While typically associated with and studied in men,
androgen deficiency can affect women as well and
produce many of the same symptoms.
Respiratory Problems
While the risk of respiratory depression as not as Present Absent
severe as that associated with other opioids, tramadol
can cause slow and shallow breathing. In turn, this can
lead to fainting, dizziness, and confusion. Risk of
respiratory depression is heightened with use of
alcohol, benzodiazepines, or hypnotics.
Hallucinations
Although not well-researched, there are anecdotal Present Absent
reports of tramadol-induced hallucinations,
particularly in elderly users.
Serotonin Syndrome
Serotonin syndrome occurs due to excessive Present Present
serotonergic activity that disrupts the normal function
of the central nervous system. As a result, you may
experience agitation, loss of muscle control, rapid
heart rate, rigid muscles, sweating, and coordination
difficulties.
Liver and Kidney Damage
Long-term tramadol use is associated with liver and Present Absent
kidney damage. In particular, high doses of tramadol
may cause liver failure.
Behavioral and Psychological Effects
Tramadol addiction, like other forms of addiction, can Present Present
produce significant behavioral changes due to
compulsive drug seeking and preoccupation with
using. This includes neglect healthy social interactions
and obligations or experience increased interpersonal
conflict, damaging even your most important
relationships.
TRAMADOL WITHDRAWAL TIMELINE
Days Symptoms
Onset of general withdrawal symptoms, including feelings of pins
Days 1-3 and needles, sweating, nervousness, nausea, anxiety, palpitations,
insomnia and drug cravings.
Drug cravings persist, along with insomnia, disorientation and
Days 4-7
confusion, and blurred vision.
Symptoms should be fairly mild by this point. Depression, anxiety,
Days 8-14
and irrational thoughts may persist.

EFFECTS OF TRAMADOL WITHDRAWAL ON BODY

SIDE EFFECTS IN BOOK IN PATIENT
 Anxiety PRESENT PRESENT
 Depression PRESENT ABSENT
 Muscle pain PRESENT PRESENT
 Sleep disturbances PRESENT PRESENT
 Gastrointestinal PRESENT PRESENT
problems
 Muscle spasms PRESENT PRESENT
 Fatigue PRESENT PRESENT
 Irritability PRESENT PRESENT
 Paranoia PRESENT PRESENT
 Confusion PRESENT ABSENT
 Psychosis PRESENT ABSENT
 Hallucinations PRESENT ABSENT
 Seizures PRESENT ABSENT
DAIGNOSIS OF OPIOID DEPENDENCE
TEST IN BOOK IN PATIENT
 Urine drug screen Present Present
 Detection of drugs in sweat and Absent Absent
hair

 LFT Present Present

 Rapid plasma reagent (RPR) Present Absent

 Hepatitis viral testing Present Present

 HIV testing Present Present

  Blood cultures (in appropriate Present Present
clinical setting)

 x-ray of the lungs Present Present

 Total protein Present Present
 Albumin Present Present
 Random sugar Present Present
 Urea Present Present
 Creatinine Present Present
 Uric acid Present Present
 Sodium Present Present
 Potassium Present Present
 Calcium Present Present
 Total protein Present Present
 Albumin Present Present
 Random sugar Present Present
 Urea Present Present
 Creatinine Present Present
 Naloxone challenge test Present Present

TREATMENT
TREATEMENT IN BOOK IN PATIENT
MEDICAL MANAGEMENT

 Metoclopramide for nausea and vomiting Present Absent

 Loperimide for diarrhea Present Present
 Ibuprofen or acetaminophen for muscle aches Present Present
 Clonidine for anxiety and sweating Present Present
 Valium for anxiety and insomnia Present Absent

COUNSELLING
 1. Individual counselling, which may include setting goals, Present Done
talking about setbacks, and celebrating progress. It may also
talk about legal concerns and family problems. Counseling
often includes specific behavioral therapies, such as
Cognitive-behavioral therapy (CBT) helps Present Done
you recognize and stop negative patterns of
thinking and behavior. It teaches you coping
skills, including how to manage stress and
change the thoughts that cause you to want to
abuse opioids.
Motivational enhancement therapy helps you Present Done
build up motivation to stick with your treatment
plan
Contingency management focuses on giving
 you incentives for positive behaviors such as Present Done
staying off the opioids
 2. Group counselling, which can help you feel that you are not
Present Done
alone with your issues. You get a chance to hear about the
difficulties and successes of others who have the same
challenges. This can help you to learn new strategies for
dealing with the situations you may come across.
 3. Family counselling/ includes partners or spouses and other
family members who are close to you. It can help to repair and Present Done
improve your family relationships.

NURSING CARE PLAN

NURSING ASSESSMENT

 Vital signs are monitored 6 hourly .

 On MSE, it is found that patient shows aggressive behavior, and has unstable
interpersonal activities.
 Nutritional status of patient is assessed.
 Collection of detailed history.
 Personal hygiene is assessed.
 Fluid electrolyte balance is maintained

NURSING DIAGNOSIS

 Anxiety/Fear may be related to Cessation of heroin intake/physiological withdrawal

evidenced by feelings of inadequacy, shame, self-disgust, and remorse
 Alterations related to Chemical alteration: Exogenous (e.g., alcohol
consumption/sudden cessation) and endogenous (e.g., electrolyte imbalance, elevated
ammonia and BUN evidenced by fear/ anxiety.
 Risk for Injury related to cessation of alcohol intake with varied autonomic nervous
system responses to the system’s suddenly altered state .

Short Term Goals:-

 To protect the patient from self injury.

 To enhance the social interaction.
 To promote coping skills.
 To promote the self esteem.

Long Term Goals:-

 To rehabilitate the patient.

 To prevent further complications.
 To assist the patient in early recovery.
 Nursing Diagnosis Expected Planning Implementation Rationale Evaluation
Outcome

Anxiety/Fear may Verbalize To assess  Determine cause  Person in acute Client start
the fear/ of anxiety, phase of withdrawal verbalizes his
be related to reduction of fear anxiety of thought to
involving patient in may be unable to
Cessation of heroin and anxiety to an the client. the process. Explain identify and accept some extent.
intake/physiological acceptable and that alcohol what is
To find the withdrawal happening. Anxiety
withdrawal manageable level.
cause increases anxiety an may be
evidenced by Express sense of behind fear/ d uneasiness. physiologically or
feelings of regaining some anxiety. Reassess level environmentally
inadequacy, shame, control of of anxiety on an caused. Continued
To give ongoing basis. alcohol toxicity will
self-disgust, and situation/life. education be manifested by
remorse Demonstrate how to  Develop a trusting increased anxiety an
problem-solving verbalize his relationship through d agitation as effects
skills and use fear/ frequent contact of medication wear
resources anxiety. being honest and off.
effectively nonjudgmental.  Provides patient
Project an accepting with a sense of
attitude about humanness, helping
heroin addiction to decrease paranoia
 Maintain a calm and distrust. Patient
environment, will be able to detect
minimizing noise biased or
 Inform patient condescending
about what you plan attitude of
to do and why. caregivers.
Include patient in  Reduces stress.
planning process
 and provide choices  Enhances sense of
when possible. trust, and
explanation may
increase cooperation
and reduce anxiety.

 Provides sense of
control over self in
circumstance where
loss of control is a
significant factor.
Note: Feelings of
self-worth are
intensified when one
is treated as a
worthwhile person.

Sensory-Perceptual Regain/maintain To assess  Assess level of  Speech may be Client shows

the sensory consciousness; garbled, confused, some
Alterations related usual level of perceptual ability to speak, or slurred. Response improvement.
to Chemical consciousness. alteration response to stimuli to commands may
alteration: Report absence and plan to and commands reveal inability to
Exogenous (e.g., of/reduced
correct it.  Observe behavioral concentrate,
responses such as impaired judgment,
alcohol hallucinations. hyperactivity, or muscle
consumption/sudden Identify external disorientation, coordination
cessation) and factors that affect confusion, deficits.
sleeplessness,  Hyperactivity
endogenous (e.g., sensory- irritability related to CNS
electrolyte perceptual disturbances may
imbalance, elevated abilities.  Provide quiet escalate rapidly.
environment. Speak Sleeplessness is
ammonia and BUN
in calm, quiet voice. common due to loss
evidenced by fear/ Regulate lighting as of sedative effect
indicated. Turn off gained from alcohol
anxiety. radio and TV usually consumed
during sleep before bedtime.
Sleep deprivation
may aggravate
disorientation
and confusion.
Progression of
symptoms may
indicate impending
hallucinations

 Reduces external
stimuli during
hyperactive stage.
Patient may become
more delirious when
surroundings cannot
be seen, but some
respond better to
quiet, darkened
room
Risk for Injury Demonstrate To check the  Check deep-tendon Reflexes may be depressed, Client accepts
risk for injury reflexes. Assess gait, absent, or hyperactive. the goals and
related to cessation absence of Peripheral neuropathies are try to prevent
if possible
of alcohol intake untoward To motivate  Assist with common, especially in risk for injury.
with varied effects of client for ambulation and self- malnourished patient. Ataxia
verbalize his care activities as (gait disturbance) is
autonomic nervous withdrawal.
feelings. needed. associated with Wernicke’s
system responses Experience
no physical  Provide for syndrome (thiamine
to the system’s injury environmental safety deficiency) and cerebellar
when indicated. degeneration.
suddenly altered
 Administer
state  Prevents falls with
medications as
indicated: resultant injury.
Benzodiazepines (BZDs):  May be required
chlordiazepoxide (Librium), when equilibrium,
diazepam (Valium), hand and eye
clonazepam (Klonopin), coordination
oxazepam (Serax), problems exist.
clorazepate (Tranxene)  Opiates are
commonly used to
control neuronal
hyperactivity because
of their minimal
respiratory and
cardiac depression
and anticonvulsant
properties.
 HEALTH EDUCATION:

1. PERSONAL HYGIENE:
 Bath daily
 Change the clothes daily
 Maintain hand hygiene

2. REST AND SLEEP:

 Calm and quit environment should be provided to enhance proper rest and sleep.
 It is good to go early to bed and to wake up early.
 Warm milk should be given before sleep for sound sleep.

3. EXCERCISE:
 Morning walk is good to maintain good health.
 Yoga was also advised.
 Deep breathing exercises.

4. FAMILY SUPPORT:
 Family should fully support the patient in his changed activities.
 Involve the patient in family discussion and communication.
 Give work with responsibility and authority to patient.
 Give importance to the patient in the family.

BIBLIOGRAPHY

1. Townsend MC. Psychiatric mental health nursing. 7th ed. Philadelphia: Jaypee
Brothers medical publishers (P) Ltd; 2012.
2. Sadock BJ, Sadock VA. Psychoneuroendocrinology, psychneuroimmunology, and
chronobiology. In: Grebb JA, Pataki CS, Sussmam N, editors. Synopsis of psychiatry.
Philadelphia: Lippincott William & Wilkins; 2007. P. 123-125.
3. Stuart GW, Laria MT. Principles and practice of psychiatric nursing. 8th ed. St. Louis:
Mosby; 2005.
4. Lalitha k. mental health and psychiatric nursing an Indian perspective.1st ed.
Bangalore: V.M.G. book house; 2010.
5. Gupta R.K. New approach to mental health nursing. 1st ed. Jalandhar: S. Vikas &
company (medical publishers); 2011.