BACKGROUND

As per the curriculum of Tribhuwan university for Bachelors of nursing science(BNS), 2nd
year. Students are assigned psychiatric hospital/ ward. I was also assigned to psychiatric
hospital for 2 weeks. During this period, we have to conduct in depth case study about
psychiatric illness therefore I have selected a patient diagnosed with alcohol dependent
syndrome as it is emerging problem in young and middle aged adults. The case study was
started on 2077/09/09 and lasted up to 2077/09/18.

A case study is the important method of specific educational activities. It provides

opportunity to read and discuss under mental health issues and designed to gain a
comprehensive knowledge of the mental problems, importance of their participation in
maintaining their own health, conflict between mind and environment, how to care
psychiatric patient using holistic approach.

GENERAL OBJECTIVES; The general objectives of this case study is to provide

holistic nursing care to the selected case with comprehensive knowledge of his physical,
mental, social and spiritual status.

SPECIFIC OBJECTIVES;

 To Perform history taking and mental status examination of the patient.

 To communicate effectively and pleasantly with client and family to identify his
needs of problems and to involve them in managing disease and coping with the
diseases.

 To apply the knowledge of nursing process, nursing theory, psychiatric nursing

related to course in planning and implementation of total nursing care and make it
practicable in the client.

 To abolish the misconceptions related to mental illness in the patient party and
develop positive attitude towards the patient.

 To identify the causes, diagnostic investigations and management of the detected

disorders.
  To provide education and counselling to the client and the client’s family about
the problems they face and ease in adapting the stressful periods of
hospitalization.

 To prevent further complications and impairment.

 To provide comfort to client and his family and promote recovery.

 To collaborate with client’s family and hospital members in providing care.

 Discuss the different organization involved in mental health care.

 To give education to patient regarding disease process and need of treatment.

Rationale for selection of case study;

Alcoholism is an emerging problem all over the world. With the continuous consumption
of alcohol either for fun or misery it leads to dependence eitherway. Therefore we can see
most of the young and middle aged adults have become more dependent on alcohol and
even show withdrawal syndromes. It is emerging as a major issue in substance abuse
therefore I found alcohol dependence syndrome as an important issue in mental health,
familial and social health so I have selected to do in depth study about alcohol dependent
syndrome.

HISTORY TAKING
1. Socio demographic data;
 Name ; Krishna Raj Subedi.
 Age/sex; 52 years/ Male.
 Fathers name; Ratna Raj Subedi.
  Spouses name; Devi Subedi.
 Education; MA.
 Occupation; Teacher.
 Income (per month); Enough to run a family.
 Marital status; Married
 Religion; Hindu
 Address; Modi-5, bajung, Parbat.
 Diagnosis; Alcohol Dependent Syndrome with
withdrawal symptoms..
 IP number; 01381.
 Ward; General male ward.
 Date of admission; 2077/09/09.
 Attending docters; DR. NL/ RS/ DKT.
 Date of discharge; 2077/09/16.

2. Informant; patient himself (Krishna Raj Subedi), patients

file.
3. Presenting complains; Dizziness, Headache, tremors and willingness
to drink more alcohol.
4. History of present illness;

I. Duration; patient has been drinking alcohol since 22 years.

II. Mode of onset; patient has started to drink alcohol continuously for 3
days.
III. Course; Episodic.
IV. Precipitating factors; patient cannot say NO when anyone offers him to
drink for entertainment and relaxation.
V. Associated disturbances; No associated disturbances.

5. Past medical and surgical history; patient has been suffering from hypertension
since 5 years and consumes amlod5mg and telmisartan10mg. patient has femoral
implant about 14 months ago.
6. Past psychiatric illness; no history of past psychiatric illness.
7. Family History;
I. Type of family; Nuclear family.
II. Head of family; patient himself.
III. Socio-economic status; All members in the family are employed so they
have enough incone to run family.
IV. Communication; patient communicates well with family.
V. Child rearing practices;
 VI. Interpersonal relationship; he has good interpersonal relationship with
family members.
VII. Social positions; patient holds a good social position.
VIII. Social support system; he has good support system.
IX. History of illness in the family; there is no recent history of illness in the
family.

FAMILY TREE;

60 years. 52years 48 years 45 years.

29 years 32 years 26 years 26 years.

Index;

1. Male
2. Female
3. Deaths
4. Patient

5. Married
8. Personal history;
1. Birth and development history;
 Prenatal History
 Antenatal period;
 Birth history;
 Post natal history;
 Immunization history; patient doesnot knows about his birth, natal
and immunization history.
 Developmental History;
 Childhood health; he had no serious illness during his childhood.
 Behavioural and emotional problems;
 Emotional problems in adolescence;
 Parental lack; he didn’t had any childhood problems.
2. Educational History;
 Age of beginning; 3-4 years of age.
 Age of finishing; 22 years of age.
 Grade reached(if discontinued reason); completed upto masters
degree.
 Relationship with teachers; he had good relationship with his
teachers.
 Relationship with schoolmates; he had good relationship with his
schoolmates.
 Position in the class; he used to stand 3rd in his class.
 Special abilities; No any special abilities.
 Active participation in games; he was active in games.
 Extra curricular activities; he used to take part in extracurricular
activities.
3. Occupational history;
 Age at time starting the work; 24 years.
 Job held in the past; he was social teacher in school at parbat.
 Present job; he is still holding the same occupation i.e.
school teacher.
 Satisfaction with work; he is quiet satisfied with his work.
 Work record; his work record was good.
 Frequent changes of jobs; he has not changed jobs frequently. He has
been teaching in the same school for 20 years.
 Work position; school teacher. He has been teaching social studies for
20 years.
4. Sexual and marital history;
 Type of marriage; arranged marriage.
 Date/years of marriage; 30 years.
 Duration; 30 years.
  Spouse; 1.
 Children; 2.
 Marital relationship; good.
 Contraceptive practices; he is not sexually active.

5. Premorbid personality;
 Social relations; patient has good social relationship.
 Intellectual activities; patient likes to spend time by reading Nobels,
and loves to spend time with his family.
 Mood; he has no mood problems.
 Character and attitude; he is a good person respects others as well
as self.
 He is a energetic person having good relationship with family, friends
and society.

Physical examination;
General appearance
Patient walked straight , appeared cheerful with appropriate reaction to time . nutritional
status was maintained , appeared hygienic well groomed appearance and hygienic clothes.
Skin
He had brown skin all over the body no rashes and oedema present except mild blueness
appeared on the left thigh. Skin was smooth with normal body temperature that is 98.40F
there was no sign of dehydration.
Lymph nedes
Lymph nodes were not visible and palpable. It means no inflammed lymph node.
Head
Inspection: head was uniform in shape and size no scaliness, lump or other lesion seen.
Palpation : there was no tenderness, swelling and depression present on head.
Face: no edema, swelling, masses and there was uniform movement of sides of face.
Sinuses: no tenderness present on frontal, maxillary, ethmoidal and sphenoidal sinuses.
Eyes: equal distribution in both sides, no infection, swelling, redness and bulging and
foreign body found on both eyes. Pupils are round and uniform in size and shape and
react to the light. Colour of sclera was slight yellow but no signs of anemia was present.
Ear : inspection : there was no lump lesions, redness, masses, discharge and foreign body
was present on ear but slight cerumen was present on both ear. He had pain in left ear.
Top of the pinna crosses the eye –occiput line
Palpation : no tenderness present on pinna and mastoid area. Rinne test and weber test
was positive.
Nose: nose was centrally located, nostrils was uniform in size and no nasal flare present.
There was no polyp and discharge present on nose with no nasal deviated nasal septum.
Dark pink mucosa was present. Smell was intact.
Mouth and throat:
Inspection ; colour of the lips was slight black but no blueness ,discolouration and
cracks was present on lips. Mucous membrane of the mouth and gums was pink and no
gum bleeding and dental carries there was black stain present on teeth.. Papilla and
midline fissure present and no difficulty in swallowing.
Palpation there was no swelling, tenderness and loose teeth.
Smell: foul odour smell present.
Neck :
Inspection : there was no tilting of head and neck as well as no scar and masses present.
Thyroid gland was not visible.
Palpation: no tenderness and tightness of neck and no swelling and inflammation of
thyroid glands.
Chest and lung:
Inspection: chest was symmetrical in shape and sternum is located at the midline of the
chest. There was no intercostal retraction, cough and sputum present. There was even
expansion of chest during breathing. Anterio-posterior diameter was greather than lateral
diameter .
Palpation; there was no lump, tenderness and depression as well as faracture of ribs with
even expansion of chest on both side.
Percussion; deep resonant sound heard over the lung.
Auscultation: breath sound was heard in all areas of the lungs. No rales, ronchi and
wheezing sound heard. Inspiration is longer than expiration.
Heart :
Inspection : there was no enlarge of neck vein.
Auscultation: clear and regular heart rate of 88b/min heard. No murmur sound was
present.
Genitalia: by asking,there was no difficulty in micturation as well in defecation, no blood
present in urine as well in stool. He had no problem of itchind around genitelia.
Musculoskeletal system:
Inspection: there was no bone or joint deformity present. He can move his limbs easily in
all direction except left leg due to injury. Spine was present on midline with normal
curvature.
Palpation: no joint swelling or tenderness present with normal body temperature.
Nervous system: equal strength in both hands but no equal strength in feet. Tactile
sensation is intact.

Findings of physical examination

 Slight yellowish sclera
 Pain in left ear was present
 Foul odour present on mouth with black staining on teeth
 Difficulty in movement of left leg

yellowish of sclera is due to his disease condition so first of all focus was given on
controlling of alcohol and regular follow up visit. Ear ache was eased by giving analgesic
medication as per the prescribtion. As foul smell was present on mouth encouraged for
brushing 2 times a day after having meal and if persistent foul smell is present, instruct to
visit with doctor. There was difficulty in movment of leg so encouraged for regular range
of motion exercise and ambulation and follow up.

MENTAL STATUS EXAMINATION(date of interview:2077-09-13)

1. GENERAL APPEARANCE AND BEHAVIOUR
Patients general appearance seems normal on the 4th day of admission. He seems
middle aged adult and appropriate to his age that is 45 years, height and weight
and his body build was appropriate to his age. He was dressing appropriate to
season and had clean cloths on. There was no any fluctuation in motor activity, he
was restless some times but self destructive behavior was absent. He had sad face
 as he felt guilt about his deeds. He could make proper eye contacts while talking.
Pupillary reaction was normal.
Patient was responsive to what he was being asked and responded well according
to question.

2. SPEECH; his speech initiation, reaction time and response time was normal.
His speech was audible and reaction to the question was appropriate.
Abnormalities in his speech like rhyming, neologism, perservation, stuttering,
circumstantiality, tangentiality, serotype clang association difficulty in speaking,
flights of ideas was not present. His answer was relevent to the question being
asked.

Question asked to identify patient’s speech

1)circumstantiality
 aaja bihana k khaja khanu bhayo?
Ans.: chiya, donout and curry.
Inference: patient answered question correctly. He remembered what he had in
breakfast.
2)Neologism
 tapaain ko ghar kaha ho?
Ans; parbat
Inference: neologism was absent he used relevant and meaningful word.
3. Tangentiality
 Tapaile hijo beluka k khanu bhayo?
Ans.: daal, bhaat ra saag.
Inference : tangentiality was absent

3) MOOD AND AFFECT:

Objective :
Patient was calm, looked a bit sad about the alcoholism.
Subjective :
 tapain ko maan aajha kasto chha?
Ans: thikai xa, ghar ko yaad aairaxa tei bhayera ali dukhi xu.
Inference: patient mood was a bit sad as he missed his family and felt bad about
alcohol.
4) THOUGHT :
Stream and forms of thought
To understand his stream and forms of thoughts following questions were asked
a) association
 Tapain yaha bata ghar janu paryo bhane kasari januhunchha?
Ans.: bus ma janxu.
Inference: there was no any loosening association present in his thoughts as he
replied straight and relevant answer to the question being asked.
b) Preservation
 Tapainko kati jana chora chori hunuhunchha?
Ans; 1 wota chora 1woti chhori.
Inference : preservation was absent as there was no repetition of words or
beyond the point of relevance.
Contents of thoughts
To identify the contents of thoughts following questions was asked
a) Obsessive ideas:
 Tapailai tapaile nachahada nachandai pani kunai kura barambar dimagma
aaye jasto lagchha? Ya aaunchha?
Ans.: lagdaina
Inference :obsessive ideas was absent as his thoughts was fixed.

b) Phobias:
 Tapainlai kunai chis wa bastu dekhi tesko name sunda dherai daar lagchha
jasle garda tapain pasina pasina hunuhunchha?
Ans.: aile samma testo bhayeko thaha xaina.
Inference : patient hasnot experienced any phobias yet.

Depressive ideas:
 Tapainlai ahile kehi kurako chinta pareko chha? Aafno jindagi dekhera
dikka lagchha?
Ans.: afno bare ma bhanda pani pariwar lai dukkha diye jasto lagxa.
 Jindagi dekhera kahile kahin marna paaye hunthiyo jasto lagchha? Kasari?
Ans.: marna paye hunthyo jasto tw lagdaina.
Inference : mild depressive ideas was present but due to withdrawl as well
as sedative effect he was unable to answer the some question being asked.
c) Delusion:
 Persecutory delusion
 Tapainlai kasaile hela gare jasto lagchha?
Ans. Lagdaaina

Inference: he had absence of persecutory delusion as he had no feelings of

discrimination and threatened giving by anyone.

 Delusion of grandiose:
 Tapainlain j kam pani garna sakchhu jasto lagchha?
Ans.: lagdaina.

 Tapainlai ma sansarko saabaibhanda thulo manchhe ho jasto lagchha?

Ans.: lagdaina.

Inference : delusion was not present.

  Hypochondriac delusion:

 Tapainlai aafno sarir ma kunai niko nahune rog lage jasto lagchha?
Ans.: niko nai nahune rog bhako jasto lagdaina tara khutta ko plate le
garda ali comfortable hudaina basna.

 Delusion of guilt and sin:

 Tapainlai aghillo janmako paaple garda yasto bhaye jasto lagchha?
Ans; hoina.

Inference : patient had no delusion of guilt and sin as he believed that

becoming of disease is not due to sin of previous life.
 Delusion of reference
 Tapainlai dui jana manchhe kura garda aafno barema nai kura gare jasto
lagchha?
Ans; lagdaina.

Inference: delusion of reference was not present as he had no belief of

someone is referring to his or planning to destroy to him.

 Nihilistic delusion:
 Tapainlai aafno sarirko kunai ek angale kam nai nagarejasto lagchha?
Ans.: lagdaina.
 Tapainlai yo sansarnai chhaina, aru kohi pani chhaina ma aafu pani
sansarmai chhaina jasto lagchha?
Ans.: lagdaina

Inference: nihilistic delusion was absent as he had no belief that oneself,

other or the world do not exist.

 Delusion of control:
 Tapailai, tapainko kam ani bichar dhara ma aru kasaile niyantran gare jasto
lagchha?

Ans.: lagdaina
Inference ; delusion of reference was absent as he had no feeling that someone or external
force was controlling on his work.
 Peculiar ideas about interpersonal relationship:
 Tapainlai tapainko shreematile tapailai bhanda badhi maya aru kasailai
gare jasto lagchha?
 Ans.: lagdaina

Inference : peculiar ideas about interpersonal relationship was absent as he

was not suspicious towards his wife.

5. PERCEPTION
a) Hallucination:

 Auditory hallucination
 Tapainlai aruley nasuneko kunai aawas aafunley matrai sunekojasto
lagchha?
Ans.: chhaina

Inference: auditory hallucination was absent as he had no any false

perception of voice.
 Visual hallucination:
 Tapainlai woripori aru kasaile nadekheko bastu aafun le matrai dekhe jasto
lagchha?
Ans.: chhaina

Inference : visual hallucination was absent as he had no any false

perception about image either formed or unformed.

 Olfactory hallucination
 Tapainlai woripori kehi naulo gandha aaye jasto lagchha?
Ans.: lagdaina.

Inference: auditory hallucination was absent as he had no any false

perception of smell.
 Gustatory hallucination
 Tapaile ahile kesaiko swad tha paunubhayeko chha?
Ans.: bha chha mukh purai tito bhako chha.

Inference: gustatory hallucination was present as he had a false belief of

taste of bitter.
Jamai vu:
 Tapainlai pahila gariraheko kamma naulopana mahasush hunchha?
Ans.: hudaina.

Inference: jamai vu was absent as the patient was able to recall and
recognize the activities that he have been encountered before.
  Déjà vu:
 Tapainlai jo naya manche lai dekhe pani chineko jasto lagchha? Ya aafnai
manche ho jasto lagchha?
Ans.: lagdaina
Inference: déjà vu was absence as he had no any false perception that he was well
known to all people around him.

6. ORIENTATION:
Questions Answer
1time
Aajha kati gate ho? Poush 13.
Aajha kun bar ho? sombar
Ahile kati bajhyo hola? 11 bajyo
2.place BG hospital ma xu.
Tapain kaha hunuhunchha?
3.malai chinnuhunchha ma ko ho? Bidyarthi nani.

Inference : patient was not oriented to time , place and person.

7. MEMORY
a) Immediate

 Ma tapainlai 3 wota chese bhanchhu ani teslai 5 minute pachi sodhchhu

yaad garnu hai. (glass, thal ani kachaurea)
Ans.: he was able to memorize the words.
 Hijo rati hajurlai kurna ko basnu bhayeko thiyo?
Ans; yeha afanta basna paidaina.

Inference: immediate memory was intact as he was able to answer the task being asked.
c) Recent
 Hijo beluka tarkari k khanu bhako thiyo?
Ans.: aloo rah roti.
Inference: his recent memory was also impaired as he couldn’t remember
the events of 24 hours.

d) Remote :
 hajurko bihe kati sal ma bhayeko ho?
Ans.: 2047 sal ma. 30 barsa bhayo.
 Hajur kati sal ma janmanu bhayeko ho?
Ans.:2025 sal ma.

Inference: his remote memory was intact.

8.ATTENTION AND CONCENTRATION
He was easily aroused but distracted immediatelt.
-to judge his attention and concentration following question was asked.
I. Barha mahina ko name bhannush ta sulto ani ulto dubai tira bata.
Ans; baisakh, jestha, asar, shawan, bhadau, asoj, kartik, mangsir, push,
magh, fagun, chaith. He was confused to say it from end.
.

II.Saat bar ko name haru bhannush tah sulto ani ulto dubai gari.
Ans; Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, saturday.
He couldnot say it from backward.
Simple numerical problem
20-3= 17
17-2= 15
14-5=9
11-3=9
Patient couldnot answer backward answers.
Inference: patient attention and concentration was disturbed.
9. INTELLIGENCE
Based on his educational background following questions was asked.
 10 ma 10 jodda kati hunchha?
Ans.: 20.
 Nepal ko pradhanmantri ko ho tha chha hajurlai?
Ans; KP sharma oli.
 Pokhara kun Pradesh ma parchha?
Ans.: Gandaki anchal, kaski jilla, Pradesh no;4.

Inference: his intelligence was not impaired.

10.ABSTRACT THINKING
Patient’s abstract thinking was tested by using proverb, and similarities
and differences testing.
 Proverb test
a) Nachna najanne aangan tedho bhaneko k hola dai?
Afule le garna najanne ani aru lai dosh dine.
b) Hune biruwako chillo patt.
Thulo bhayera manxe kasto banxa bhanera usko sano huda ko behora le thaha
hunxa.

Inference : patient was able to give the meaning of proverb being asked it
proved that his concept formation ability was intact.
.
  Similarities and difference test
a) Biralo rah kukurma k samanata chh
Ans: biralo sano hunxa , kukur thulo hunxa.

Inference: his abstract thinking was not impaired

11.INSIGHT
Patient’s insight was judge by using following questions
 Tapailai aafu birami chhu jasto lagchha?
Ans; lagchha ,.
 Kasto rup ma birami chhu jasto lagchha ? (sararik/manasik)

Ans; manasik ra saririk pani birami xu.

 Aausadhi khanu parchha jasto lagchha ki lagdaina?
Ans; khanu parchha.
 Hajurlai chalairakheko aausadhile kam garla jasto lagchha?
Ans; kaam garxa. Paile pani khayeko ho.
Inference: Insight was present.

12. JUDGEMENT
a) hajur hiddai bazaar jandai hunuhunchha , hiddahiddai bato ma sarpa dekhnu
bhayo bhane k garnu hunchha?
Ans; sarpa dekhera malai khasai dar lagdaina, teshlai afno bato jana dinxu, ma
afno bato janxu.

a) yadi hajurko ghar najikai ko chimeki ko ghar ma aago lagyo lageko

dekhnu bhayo bhane k garnuhunchha?
Ans: manxe jutayera sahayog ko lagi janxu.
b) Yadi bato ma bachha roi raheyeko bhete ma k garnuhunchha?
Ans; kei gardina, usko afnai kei kura hola.

Inference: judgement was present as the patient provide relevant answer

of the question being asked.

SUMMARY OF MENTAL STATUS EXAMINATION:

 Mental status examination of patient named Krishna Raj Subedi was done
on 2077-09-13. He was admitted in BG hospital on 2077-09-09 with the
diagnosis of ADS with AWS for better treatment and refrain from alcohol.
After completion of mental status examination it showed that there was
almost no impairment of all aspect of criteria of mental status examination
that was general appearance and behavior, speech, mood and affect,
thought, perception, orientation, memory, attention and concentration,
intelligence, abstract thinking, insight and judgement. At the time of
examination certain question was asked to met the criteria set but patient
gave proper answers to most of the questions.

Patients mental status seems normal throughout the time of hospital stay as
I checked it frequently. Patient was quiet normal during his stay and
discharged early as well.

DISEASE PORTION

(F 10.2 ) ALCOHOL DEPENDENCE SYNDROME

ALCOHOL

The word alcohol has been derived from Arabic word “Alkhul” meaning
Essense. It is a clear coloured liquid with strong burning taste. The rate of absorption of
alcohol into blood stream is more rapid than its elimination. Absorbtion of alcohol into
the blood stream is slower when food is present in the stomach. A small amount is
excreted through urine and a small amount is exhaled as well. Alcohol produces
intoxicating action by interacting with normal function of brain. Acute effect of alcohol
are determined by the concentration of alcohol in blood.

Blood Alcohol Level and Possible Consequences

Level Likely Impairment

20–30 mg/dL Slowed motor performance and decreased thinking ability

30–80 mg/dL Increases in motor and cognitive problems

80–200 mg/dL  Increases in incoordination and judgment errors

Mood lability
Deterioration in cognition
200–300 mg/dL Nystagmus, marked slurring of speech, and alcoholic blackouts
 >300 mg/dL Impaired vital signs and possible death

INTRODUCTION OF ALCOHOL DEPENDENCE SYNDROME

Alcohol dependence syndrome refers to the use of alcoholic beverages to the point of
causing damage to the individual , society or both.
Alcohol dependence is a psychiatric diagnosis (a substance related disorder DSM-IV)
describing an entity in which an individual uses alcohol despite significant areas of
dysfunction, evidence of physical dependence, and/or related hardship, and also may
cause stress and bipolar disorder.
A central descriptive characteristics of alcohol dependence syndrome is the desire (often
strong, sometimes overpowering) to take alcohol. There may be evidence that return to
alcohol use after a period of abstinence leads to a more rapid reappearance of other
features of the syndrome than occurs with non dependent individuals. Alcohol
dependence differs from alcohol abuse although both conditions represent drinking
problems. People who abuse alcohol may have problems but do not necessarily have a
physical addiction. Alcohol Dependence occurs when people become physically addicted
to alcohol. Alcohol dependence is differentiated from alcohol abuse by the presence of
symptoms such as tolerance and withdrawal.
ICD 10 criteria for alcohol dependence;
 A strong desire to take the substance.
 Difficulty in controlling substance taking behavior.
 A physiological withdrawal state.
 Development of tolerance.
 Progressive neglect of alternative pleasures or interests.
 Persisting with substance use despite clear evidence of harmful consequences.

DEFINITION

 According to ICD 10 criteria developed by the WHO “ A Alcohol Dependence

Syndrome is a cluster of physiological behavioral and cognitive phenomenon in
which the use of alcohol takes on a much higher priority for a given individual
than other behaviors that once had greater value’’.
 According to Kapoor B; Alcohol dependence is defined as chronic dependence
characterized by compulsive drinking of alcohol to such degree that it produces
mental disturbances, interfere with social economic functioning. Major signs of
the addiction are increasing consumption, sneaking and glimpsing drinks, morning
 drinking, excessive drinking when alone, confusion and tremors, uninhibited
behavior and severe withdrawal symptoms.
 According to S. Nambi; Alcohol dependence is defined as chronic disease
manifested by repeated drinking that produced injury to the drinker’s health or to
his social, economic functioning.

EPIDEMIOLOGY OF ALCOHOL DEPENDENCE SYNDROME

Global status report on alcohol and health -2014 –WHO.
 Worldwide consumption of alcohol is increasing in ratio. In 2010, worldwide 6.2
liter of pure alcohol per person is consumed that is equal to 13.5gm of pure
alcohol per day.
 A quarter of this consumption that is 24.8% was unrecorded .
 Worldwide 16.0% of drinker is engaged in heave episodic drinking
 In general the greater the economic wealth of the country, the more alcohol is
consumed and smaller the abstainer.
 In 2012, 3.3 million of deaths or 5.9% of global deaths are attributed due to
alcohol consumption.
 In 2012, 7.6% of death among male and 4.0% deaths among female was
attributed due to alcohol
 5.1% global burden of disease and injuries were attributable to alcohol.
Findings of study done in Nepal
 Age of starting alcohol use 15 to 20 years in 80 percent population;

 Home-brewed alcohol is used by more than 90% of rural alcohol users;

 Another study of alcohol use in Kathmandu metropolitan city (Shrestha et al

2001) showed:
  31% of general population aged 12 years and above used alcohol (22%
men and 9% women)

 Prevalence of alcohol dependence in general population is 5.5%

 Prevalence of alcohol dependence among alcohol users 17.7% (male :

female ratio 5.6:1)

RISK FACTORS :

 Equal dosages of alcohol consumption by men and women generally result in

women having higher blood concentration. Those can be attributed to many
reasons the main being that women have less body water than men do. A given
amount of alcohol therefore becomes more highly concentrated in women’s body.
A given amount of alcohol cause greater intoxication for women due to differently
alcohol release compared to men.

 People are at risk of developing alcohol dependence include men who have 15 or
more drinks a week and women who have 12 or more drinks a week . A drink
includes a 12 oz bottle of beer, 5 oz glass of wine, or 1and 1/2oz shot of liquor.

 A study has found that alcohol use at an early age may influence the expression of
genes which increase the risk of alcohol dependence. Individuals who have a
genetic disposition to alcoholism are more likely to begin drinking at an early age
than average. A younger age of onset of drinking is associated with an increased
risk of the development of alcoholism, and about 40 percent of alcoholics will
drink excessively by their late adolescence

 Alcohol dependence is more common in anxiety or cyclothymic personality and

antisocial personality.

 A high testosterone concentration during pregnancy may be a risk factor for later
development of alcohol dependence.

ETIOLOGY OF ALCOHOL DEPENDENCE SYNDROME;

1. Biological factor  There was no family
 Genetic vulnerability:family history of alcohol history of alcoholism
use disorder of siblings of his used
 Co-morbid personality disorders the alcohol similar
 Co-morbid medical disorders ration to the patient.
 Personality factors:alcoholism is more common  Used alcohol due to
in anxiety and antisocial personality peers influence
 Reinforcing effect of drug:continuation of drug  Withdrawl effect and
use was also one of the
 Withdrawl effects and craving most important cause
of his alcoholism

2.psychological factors Psychological factors

 Curiosity includes
 Early initiation of alcohol  Curiosity
 Poor impulse control  Early initiation of
 Low self esteem alcohol
 Concerns regarding personal autonomy  Stress.
 Poor stress management skills  Low self esteem.
 Childhood trauma or loss
 Lack of interest in conventional goals
 Psychological distress
 Poor coping strategies: the person unable to
face stress often report to alcoholism
 Psychiatric disorders: some patients with
depressive disorders take alcohol I the
mistaken hope that it will alleviate low mood.
3.social factors Social factor includes
 Peer pressure  Peer pressure
 Modeling: imitating behavior of important  Easily availability of
other alcohol
 Easily availability of alcohol
 Interfamilial conflict
 Religious region
 Poor family/ social support
 Availability
 Isolation, unemployment, loss, injustice
 High risk group: person suffering from
chronic illness, business executives, travelling
salesperson, industrial workers, military
person, commercial travelers
 Broken or disturbed family

PATHOPHYSIOLOGY:
  Alcohol increase the stimulation of GABA receptor promoting central nervous
system depression.
 With the repeated heavy consumption of alcohol these receptors are desensitized
and reduced in number resulting in tolerance and physical dependence.
 When alcohol consumption is stopped too abruptly the person nervous system
suffers from uncontrolled synapse firing. This can result in symptoms that include
anxiety, life threatening seizures , delirium tremens, hallucinations, shakes and
possible heart failure.
 Other neuro transmitters systems are also involved especially dopamine, and
glutamate.

SIGN AND SYMPTOMS OF ALCOHOL DEPENDENCE

SYNDROME
According to book According to patient
Minor complaints:- Malaise, dyspepsia, Minor complains like dyspepsia and
mood swing, depression, malaise was present.

Poor personal hygiene, untreated injuries Personal hygiene was satisfactory, injuries
were not present.
Unusual high tolerance Tolerance was present
Nutritional deficiency(vitamins and Vitamin deficiency especially vitamin B1
minerals) was present so vitamin supplementation
was done.
Denial problem This was absent
Consumption of alcohol containing This was also absent
products e.g. mouthwash, after shave
lotion, hair spray, lighter liquid.
Tendency to blame other and rationalize It was absent
problem
Alcohol withdrawal features like anxiety, Alcohol withdrawal features like tremor,
tremor, sweating, insomnia, muscle pain, sweating, insomnia were present.
confusion, disorientation, and disturbances
on consciousness.

Losing interest in activities and hobbies Interest in activities and hobbies was
present.
Having legal problems with relationship, This was absent
employment and finance.
Physical complications of alcohol use eg: This was also present like gastritis.
liver disease, gastritis, jaundice

DIAGNOSIS OF ALCOHOL DEPENDENCE SYNDROME

Diagnosis (according to book)
1. History taking about the genetic
influence, other stressful situation and
predisposing factors along with features
2. Physical examination from head to toe to
find out the physical problems
3. Mental status examination
4. Laboratory tests:
 Blood investigations i.e. Blood alcohol
level to indicate intoxication(200mg/dl)
 Hematologic workup possibly revealing
anemia thrombocytopenia (TC, DC,
RBC, WBC, HB%)
 Serum electrolyte analysis revealing
electrolyte abnormalities associated with
alcohol use
 Liver function studies demonstrating
alcohol related liver damage(Total
Protein, Albumin, Globulin, A/G
ratio, ,Bilirubin, SGOT, SGPT, ALKP,
Gamma-GT)
 Thyroid function test
Diagnosis (done in patient)
1.History taking was done
2. Physical examination was done
3. Mental status examination was
odne.
4. laboratory investigation was done
Investigations
 Hematological test(TC, DC).
 Renal function test:(serum urea,
serum creatinine)
 Liver function test(Total Protein,
Albumin, Globulin, A/G Ratio,
Total Bilirubin, Direct Bilirubin,
Indirect Bilirubin, SGOT(AST),
SGPT(ALT), ALKP, Gamma-
GT)
 Electrolytes (sodium, potassium)

5.Urine toxicology to reveal use of other

drugs  Electrocardiography was done.

6.Echo cardiography and electrocardiography

demonstrating cardiac problems
 ICD and DSM as well as
7.MCV (mean corpular volume):- . CAGE questionares was used.

9.Based on ICD10 and DCM -IV criteria

10.Specialized instruments, such as AUDIT,

MAST, CAGE

INVESTIGATIONS REPORTS(2077/09/09) AND DURING HOSPITALIZATION:

Investigations Patients value Normal range

Hematology
Hemoglobin 9.8 gm% 12-16 gm%

RBC 2.35 unit=10’3/UL 3.50-5.50

WBC 6.65, 10’3/UL 4.00-11.00
72.4%
Neutrophils 45.0-75.0%
17.2%
Lymphocytes 20.0-45.0%
9.8%
Monocytes 2.0-12.0%
0.5%
Eosinophils 0.5-12.0%
0.1% 0.5% to 1%.
Basophils

Bio- chemistry

Blood sugar(R) 90 mg/dl 70-140mg/dl

Blood urea 26 mg/dl 15-40 mg/dl
Serum Creatinine 0.8mg/dl 0.6-1.5mg/dl
Sodium 129 m.mol/l 135-150 m.mol/l
Potassium 4.1 m.mol/l 3.5-5.3 m.mol/l
LFT

Total Protein 7.0 mmol / lt 6.0-8.0 gm/dl

Albumin 4.0 mmol / lt 3.2-5.5 gm/dl
Globulin 3.0.mmol / lt 2.5-3 gm/dl
A/G Ratio 1.3 1.0-1.8
Total Bilirubin 2.0 0.3-1.0 mg/dl
Direct Bilirubin 0.5 0.1-0.3 mg/dl
Indirect Bilirubin 1.5 0.2-0.7 mg/dl
SGOT(AST) 25 <40 U/L
SGPT(ALT) 30 <40 U/L
ALKP 121 Children: 270-810 IUL

Adult: 110-310 IUL

ECG(2077-09-09 )

 Heart rate =103b/min

 P duration:120ms

 QRS duration:116ms

 QT/QTC int: 347/455ms

 P/QRS/T axis:59/41/30

 RV5/SV1 amp:1.81/0.28mv

 RV5+SV1 amp:2.09 mv

 RV6/SV2 amp:1.14/1.03 mv
 CAGE questionnaire:-

Questions Answer of patient

Have you ever had to cut down on Yes
alcohol (amount)?

Have you ever been annoyed by peoples No

criticism of alcohol?

Have you ever felt guilty about drinking,? Yes

Have you ever had a drink first thing in Yes

the morning to steady your nerves or get
rid of a hangover (Eye-opener)?

ICD 10 criteria for alcohol dependence syndrome

According to book Presence in patient

A strong desire or sense of compulsion to -patient has strong desire or compulsion
to take alcohol.
take alcohol.

Difficulty in controlling alcohol taking He is unable to control his drinking

behavior in terms of its onset, termination pattern.
or level of use
A physiological withdrawal state when Patient has developed withdrawn
alcohol use has ceased or been reduced as symptoms like tremor, sweating
evidence by characteristics withdrawal vomiting.
syndrome for alcohol or use of alcohol
with the intention of relieving or avoiding
with drawl symptoms
Evidence of tolerance such that increased There is a evidence of tolerance as the
patient increased his drinking pattern
dosages of alcohol are required in order
 to achieve effects originally produced by from 1-1.5 liter to 2-3 liter to achieve
same benefit.
lower dosages.

Progressive neglect ofalternative Patient neglected his family while

drinking with friends.
pleasures or interests because of alcohol
use, increased amount of time necessary
to obtain or take alcohol or to recover
from its effect.

Persisting with alcohol use despite clear Patient drank alcohol for 3 days
continuously even he knew it was
evidence of overtly harmful
harmful.
consequences.

DSM-IV criteria for alcohol dependence

According to the DSM-IV criteria for alcohol dependence, at least three out of seven of
the following criteria must be manifest during a 12 month period:

According to book Presence in patient

 Tolerance Symptoms of tolerance is present like

tremor, sweating, nausea/vomiting and
incontinence.

 Withdrawal symptoms or Withdrawl symptoms like tremor, nausea,

clinically defined Alcohol vomiting, loss of appetite was present
Withdrawal Syndrome

 Use in larger amounts or for Patient used large amount of alcohol and
longer periods than intended also used in empty stomach too.
  Persistent desire or unsuccessful Patient was unable to stop his pattern of
efforts to cut down on alcohol use alcohol use despite visiting to traditional
healers.

 Time is spent obtaining alcohol or Patient spend his most of the time in
recovering from effects taking alcohol

 Social, occupational and Patient was withdrawn form society and

recreational pursuits are given up has less interest in recreational activities
or reduced because of alcohol use like watching television, chating with
similar age mates.

 Use is continued despite He was well known that alcohol harms

knowledge of alcohol-related the body and health but used excessively.
harm (physical or psychological)

PSYCHIATRIC DISORDER DUE TO ALCOHOL DEPENDENCE (BOOK PICTURE):

 Acute intoxication

 Withdrawal syndrome

 Alcohol-induced amnestic disorders

 Alcohol-induced psychiatric disorder

1) ACUTE INTOXICATION:

Acute intoxication develops during or shortly after alcohol ingestion. It is characterized

by clinically significant maladaptive behaviour or psychological changes, for e.g.,
inappropriate sexual or aggressive behaviour, mood liability, impaired judgement, slurred
speech, in coordination, unsteady gait, nystagmus, impaired attention and memory finally
resulting in stupor or coma.
The duration of intoxication depends on the amount and the rapidity of ingestion of
alcohol.

Occasionally a small dose of alcohol may produce acute intoxication in some persons. It
is known as pathological intoxication. Sometimes, amnesia or blackouts may developed
in acute intoxication.

2) WITHDRAWAL SYNDROME:

In persons who have been drinking heavily over a prolonged period of time, any rapid
decrease in the amount of alcohol in the body is likely to produce withdrawal
symptoms.

 The most common withdrawal syndrome -hangover on the next morning.

 Mild tremors, weakness, sweating, tachycardia, irritability, insomnia and anxiety –
common .

 Severe withdrawal syndrome

 Delirium tremens
 Alcoholic Seizures
 Alcoholic Hallucination

DSM-IV Alcohol Withdrawal Criteria

A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.

B. Two (or more) of the following, developing within several hours to a few days after
Criterion A.
1. Autonomic hyperactivity (e.g., diaphoresis or HR>100)
2. Increased hand tremor
3. Insomnia
4. Nausea and vomiting
5. Transient visual, tactile, or auditory hallucinations or illusions
6. Psychomotor agitation
7. Anxiety
8. Grand mal seizures
C. The symptoms in Criterion B cause clinically significant distress or impairment in
functioning.
D. The symptoms are not due to a general medical condition and are not better accounted
for by another mental disorder.

a. Delirium tremens:

Delirium tremens is the most severe alcohol withdrawal syndrome. It occurs

usually within2-4 days of complete or significant abstinence from heavy alcohol
drinking in about 5% of patients, as compared to acute tremulousness which
occurs in about 34% of patients. The course is short, with recovery occurring
within 3-7 days. This is an acute organic brain syndrome (delirium) with the
characteristic features of;

 A dramatic and rapidly changing picture of disordered mental activity, with

clouding of consciousness and disorientation of time and place.
 Poor attention span.
 Vivid hallucination which are usually visual ; tactile hallucinations can also occur.
 Severe psychomotor agitation, shouting and evident fear.
 Grossly tremulous hands which sometimes pick up imaginary objects; truncal
ataxia.
 Autonomic disturbances such as sweating, fever, tachycardia, raised blood
pressure, papillary dilation.
 Dehydration with electrolyte imbalance
 Reversal of sleep –wake pattern or insomnia .
 Blood tests reveal leukocytosis and impaired liver function.
 death may occur due to cardiovascular collapse, infection , hyperthermia or
self –inflicted injury.
Most common sign and symptoms of delirium tremens

Symptoms

 Confusion

 Hallucinations

 Hyper-responsiveness

Signs

 Hypertension

 Tachycardia

 Fever

b. Alcoholic seizures:

Generalized tonic clonic seizure occurs in about 10% of alcohol dependence patients,
usually 12-48 hours after a heavy bout of drinking. Often, these patients have been
drinking alcohol in large amounts on a regular basis for many years.

 Multiple seizures (2-6 at one time ) are more common than single seizures.
Sometimes , status epilepticus may be precipitated . In about 30% of the cases,
delirium tremens follows ,40% are single episodes.

c. Alcoholic hallucinosis: Alcoholic hallucinosis is characterized by the

presence of hallucinations ( usually auditory) during partial or complete abstinence ,
following regular alcohol intake .It occurs in about 2% of patients.These hallucinations
persist after the withdrawal syndrome is over, and classically occur in clear
consciousness. Usually recovery occurs within one month and the duration is very
rarely more than six months.

3) ALCOHOL- INDUCED AMNESTIC DISORDERS:

 Chronic alcohol abuse associated with thiamine deficiency is the most frequent cause
of amnestic disorders. This condition is divided into:

i. Wernicke’s syndrome: this is characterized by prominent cerebellar ataxia,

palsy of the 6th cranial nerve, peripheral neuropathy and mental confusion.
ii. Korsakoff’s syndrome; the prominent symptoms in korsakoff’s syndrome is
gross memory disturbance. Other symptoms include:
 Disorientation
 Confusion
 Confabulation
 Poor attention span
 Impairment of the insight

4) ALCOHOL –INDUCED PSYCHIATRIC DISORDERS:

 Alcohol-induced dementia: It is a long term complication of alcohol abuse,

characterized by global decrease in cognitive functioning (decreased intellectual
functioning and memory). This disorder tends to improve with abstinence , but
most of the patients may have permanent disabilities.
 Alcohol –induced mood disorder: Excess drinking may induce persistent
depression or anxiety.
 Suicidal behavior: Suicidal rates are higher in alcoholics when compared to
non-alcoholics of the same age. The risk factors for suicidal behavior are
continued drinking, co –morbid major depression, serious medical illness ,
unemployment and poor social support.
 Alcohol induced anxiety disorder: Alcohol persons report panic attacks
during acute withdrawal , similarly during the first 4 to 6 weeks of abstinence.
 Impaired psychosexual function: Erectile dysfunction and delayed
ejaculation are common in chronic alcoholics.
 Pathological jealousy: Excessive drinkers may develop and over valued idea or
delusion that the partner is being unfaithful. )
 Alcohol seizures(rum fits) : generalized tonic clonic seizure occurs usually
within 12-48 hours after heavy bout of drinking. Sometimes status epilepticus may
be precipitated.
 Alcoholic hallucinosis: this is characterized by the presence of
hallucinations(auditory) during abstinence, following regular alcohol intake.
Recovery occurs within one month.

COMPLICATIONS (BOOK PICTURE):

1. Cardiopulmonary complications
 thrombosis
 heart failure
 hypertriglyceridemia
 cardiomyopathys
 hypertension
 stroke
 anemia
 Arrhythmias
 COPD
 Pneumonia
 Increased risk of pneumonia and tuberculosis

2. Neurologic Complications
 brain shrinkage,
 dementia,
 physical dependence,
 increases neuropsychiatric and cognitive disorders
 causes distortion of the brain chemistry
 peripheral neuropathy
 Alcohol dementia
 Alcoholic hallucinations
 Alcohol withdrawal delirium
 Korsakoff's syndrome
 Seizures disorders
 Wernicke's encephalopathy
 Cerebellar degeneration
 Central pontine myelinosis

3. GI complications
 Chronic Diarrhoea
 Esophagitis
 Esophageal cancer
 Esophageal varices
 Gastric ulcers
 Gastritis
 GI bleeding
 Mal-absorption syndrome (protein-losing enteropathy)
 Pancreatitis
 Carcinoma stomach and esophagus
4. Hepatic complications:
 Liver: fatty liver, cirrhosis of liver, hepatitis, liver cell carcinoma and liver failure.
5. Psychiatric complications
 Amotivational syndrome
 Depression
 Impaired social and occupoational functioning
 Multiple substance abuse
 suicide
6. Social complications
 Accidents: head injury and fractures
 Suicide
 Marital disharmony
 Divorce
 Occupational problems, with loss of productive man-powers
 Increased incidence of drug dependence
 Criminality, occasionally
 Financial difficulties

7. Other Complications
 Beriberi
 Fetal alcoholic syndrome
 Hypoglycemia
 Leg and foot ulcers
 Prostatitis

COMPLICATIONS SEEN IN PATIENT : Occupational problems, with loss of

productive man-powers, hepatomegaly, fatty liver, Gastritis, physical dependence,
withdrawl features.

PREVENTION OF ALCOHOLWITHDRAWL SYNDROME

 Pricing of alcohol beverage
 Controlling of advertising
 Control on sale
 Health education
 Enhancing legislation
 Strong legislation against drunk driving

TREATMENT MODALITIES OF ALCOHOLISM

1. Treatment of withdrawal
1. Detoxification
2. Supplementation Therapy
3. Supportive Treatment
4. Psycho-social Intervention
 2. Treatment of dependenc

 Psycho Social Intervention

 Behavioural Therapy,

I. Aversion Therapy
II. Cue exposure
III. Behavioural Self- control Training
IV. Assertiveness Training

 Psychotherapy

I. Motivational Interviewing
II. Individual and Group Therapy
III. Marital Counselling

 Cognitive Behavioural Therapy

2. Alcoholic Anonymous Group

3. Pharmacotherapy

I. Deterrent Drugs
II. Anticraving Drugs
III. Other Drugs

4. Nursing Management

5. Rehabilitation

Pre-requisite to Start other Treatment

 Ruling out any physical disorder

 Ruling out any psychiatric disorder and co-morbid substance use disorder
 Assessment of motivation for treatment
 Assessment of social support system
 Assessment of personality characteristics of person
 Assessment of current and past inter-personal and occupational functioning.
TREATMENT OF ALCOHOL WITHDRAWL

A. DETOXIFICATION:

 Alcohol detoxification is the removal of alcohol from the body of an individual

who is alcohol dependent or alcoholic. It is the abrupt cessation of alcohol intake
coupled with the substitution of alcohol with drugs used to prevent alcohol
withdrawal. It is not possible to control the alcohol without support from friends
and family. Initially Medications are given at high dosages, but is gradually
tampered down over a week.
 The aim of detoxification is the management of emergent withdrawal symptoms.

Methods of Detoxification

 Gradual reduction of the substance in de-creasing amounts

 Abrupt cessation of the substance of abuse and administration of specific
medication which have cross tolerance to the substance of use: e.g.
benzodiazepine for alcohol
 have some specific pharmacological properties to suppress withdrawal,
e.g.carbamazepine for alcohol withdrawal,
 Provide general symptomatic relief, e.g. hypnotics (benzodiazepine as well as
non-benzodiazepines, anti-emetics, antidiarrheals etc).

Duration of detoxification

 Alcohol detoxification can be completed in 7-10 days.

 However, the duration will depend on severity of dependence, drugs used for
detoxification (their half life).
 Longer (week or months, even up to 6 months) in elderly patients, and debilitated
and medically or surgically ill patients.

Drugs in Detoxification

 The drugs of choice are benzodiazepines . The most commonly used drugs from
this class are chlordiazepoxide 80-200mg /day and diazepam 40-80 mg/day, in divided
dose.
A typical dose of Chlordiazepoxide in moderate alcohol dependence is,

20 mg Q.I.D. on day 1.

15 mg Q.I.D. on day 2.

10mg Q.I.D. on day 3.

5 mg Q.I.D. on day 4.

5 mg B.D. on day 5.

2.For vitamin B deficiency:

Inj. Thiamine 100mg B.D. parentally for 3-5 days,then after, oral administration of
Vitamin B1 for at least 6 months.

Supportive Treatment

 Care of hydration
 Do not administer 5% dextrose or any carbohydrate in delirium tremens or in any
uncomplicated withdrawal without thiamine.
 Protective environment
 Effort should be made to orient the patient.
 Sensory stimuli should be minimized in case of a delirious patient.
 With treatment, the features of Delirium tremens are usually con-trolled within 2-
3 days, though patient usually requires inpatient treatment for another week.

B. TREATMENT OF DEPENDENCE

After detoxification is over, several methods are used for further management these are
1.Behavioural Therapy

a) Aversion Therapy

 The most commonly used in the past was aversion therapy - using either a
subthreshold electric shock or an emetic such as apomorphine.
 Currently, considered unethical to use aversion therapy.
 Now pharmacological Aversion therapy- disulfiram

b) Cue exposure

 Based on both learning theory models and social learning theory and suggests that
environmental cues associated with drinking can elicit conditioned responses
which can in turn lead to a relapse.
 Treatment is designed to reduce craving for alcohol by repeatedly exposing the
service user to alcohol-related cues until they habituate to the cues and can hence
maintain self-control in a real life situation where these cues are present.

a) Behavioural self-control training

 Also referred as behavioural self-management training

 Patients are taught to
 set limits for drinking,
 self-monitor drinking episodes,
 refusal skills training and
 training for coping behaviours in high-risk relapse situations.

 Behavioural self-control training is focused on a moderation goal rather than

abstinence

b) Assertiveness Training

 Assertiveness is one’s ability to act in harmony with one’s values and self-
esteem, without hurting others.
 Assertive behavior is a socially appropriate behavior, involving a straight
forward expression of thoughts and feelings, consistent with one’s value system
and self-esteem; and at the same time, avoiding hurting others to the greatest
extent possible.
2. Psychotherapy:

Both group and individual therapy are used. The patient should be educated about the
risks of continuing alcohol use, ask to assume personal responsibility for change and be
given a choice of option for change.

a)Motivational Interviewing:

Motivational interview can be done by establishing a positive relationship with

patient,understanding his non condemning, non judgemental attitude and acceptance of
the addicted client to help to overcome his guilt feelings, self hate, and self destructive
tendencies.

After motivational interviewing, patient will be ready to:

I. Giving up the alcohol

II. Desire to make changes in one’s own lifestyle
III. Realization that it is essential to take an active part in the treatment program

The motivation of the client can be assessed, based on the following factors:

a. Accepting that there is a problem with alcohol

b. Asking for the help for the same
c. Reporting for treatment without coercion
d. Compliance with the term laid down by the centre
e. A past history of abstinence
f. Internal locus of control i.e. a desire to get better for own shake

b) Individual /Group Therapy:

 Both group and individual psychotherapy have been used.
 The patients should be educated about the risk of continuing alcohol use, asked to
resume personal responsibilities for change and be given a choice of options for
change.
 Motivational enhancement therapy with or without cognitive behavioural therapy
and lifestyle modification is often useful

The major tasks of group therapy are:

 Helping the client to verbalize the alcohol taking episodes and their consequential
adverse behavioural experiences.
  The topic can be flexible- depending upon the stage of group and can include
problems like damage, feelings, worst alcohol taking episode, past adverse life
style, symptoms of dependency, denial, powerlessness and unmanageability,
commitment to change and problems in society.
 Helping the clients begin working through the mechanism of denial, thereby
making the gradual emergence of reality possible.
 In first phase - focus on damages and on similar concrete,
identifiable issues in the supportive and accepting group, which
acknowledges concerns and physical effects.
 In second phase, the feedback from other members help to them to
work through denial. This is achieved by confronting others with
similar attitudes and defenses.
 By third phase, the group experience would enabled the members
to reach a where in they are reared to concentrate on recovery
plans.
 In between group sessions, the members also require support through individual
sessions in order to counter shame, guilt, anger and ensure continued participation.
 Extremely personal and intimate issues can be handled in the ‘one-to-one’
sessions with the counsellor.

b. Marital Counselling
 Needs to first develop a mutual trusting relationship with the couple.
 The couple’s motivation for change needs to be assessed.
 The couple needs to be assisted in identifying problem behavior/areas.
 Factors that initiate and maintain these behaviours need to be identified.
 The counselor also needs to be as specific as possible in his identification of
problem behavior and planning remedial strategies.
 This is to avoid any confusion or use of manipulation on the either partners.
 Appropriate behavior to substitute problem behaviors need to be selected by
mutual consent of the couple.
 Communication skills and problem solving skills, should be mastered by the
couple in marital therapy.

3. Cognitive Behavioural Therapy

Cognitive behavioural therapy can be done by four methods they are:

• Standard CBT,
• Relapse prevention Technique,
• Coping skills and
• Social skills training

 Standard cognitive behavioural therapy

 Standard CBT is a discrete, time-limited, structured psychological intervention,

derived from a cognitive model of drug misuse.

 There is an emphasis on identifying and modifying irrational thoughts, managing

negative mood and intervening after a lapse to prevent a full-blown relapse.

 Relapse-prevention
 This incorporates a range of cognitive and behavioural therapeutic techniques:
 To identify high risk situations,
 To alter expectancies and
 To increase self-efficacy.
 This differs from standard CBT in the emphasis on training people who misuse
alcohol to develop skills:
 To identify situations or states where they are most vulnerable to alcohol use,
 To avoid high-risk situations,
 To use a range of cognitive and behavioural strategies to cope effectively with
these situations.
 Coping and Social Skills Training
 It is based on social learning theory of addiction and the relationship between
drinking behaviour and life problems.
 Treatment is manual-based and involves increasing the individual‘s ability to cope
with high-risk social situations and inter-personal difficulties.

4. ALCOHOLIC ANONYMOUS GROUP

 Important voluntary self help group
 Known as AA (Alcoholic Anonymous),
 Branches all over the world and a membership in hundreds of thousands.
 Approach is quite religious in nature, many patients derive benefits from the
group meetings
 Non professional in nature.
 Twelve-Step Facilitation (TSF)
 Concept that alcoholism is a spiritual and medical disease.
  As well as a goal of abstinence, this intervention aims to actively encourage
commitment to and participation in AA meeting.
 Participants are asked to keep a journal of AA attendance and participation and
are given AA literature relevant to the step of the programme the client patient has
reached.
 TSF is highly structured and involves a weekly session in which the patient is
asked about their drinking, AA attendance and participation, given an explanation
of the themes of the current sessions, and goals for AA attendance are set.

5. PHARMACOTHERAPY
a) Alcohol deterrent therapy:
These are also known as alcohol sensitising drugs. Disulfiram is the most commonly used
deterrent agent which in use requires avoidance of alcoholic products as the both reaction
leads to accumulation of acetaldehyde in the blood. The onset of reaction occurs within
30 minutes and usually subsides within 2hrs of alcohol intake but this depend upon the
amount taken which is life threatening in case of massive use of ethanol. Metronidazole,
citrated calcium carbimide and animal charcoal are also some deterrent agents.

 DISULFIRAM: is a medicine used in long term treatment of patient with

alcohol misuse. It produces extremely unpleasant reaction in a person who ingest
even a small amount of alcohol while taking disulfiram. The usual dosages ranges
from 125 to 500 mg/day. The dose shouldn’t usually exceed 500mg a day. It is
convenient to take disulfiram in the morning after breakfast.

Mechanism of action: disulfiram is an aldehyde dehydrogenase inhibitor that interferes

with the metabolism of alcohol and produces a marked increase in blood acetyldehyde (to
a level of 10times more than that which occurs in the normal metabolism of alcohol)
produces a wide array of reactions characterized by:

- Throbbing headache - Thirst

- Blurring of vision - sweating

- Difficulty breathing - convulsion

- Nausea and vomiting - Giddiness

- chest pain - Facial flushing

- If untreated death.
 The usual dose
 250-500 mg/day (taken before bedtime to avoid drowsiness in daytime) in the
first week and 250 mg/day subsequently for the maintenance treatment.
 The effect begins within 12 hours of first dose and remains for 7-10 days after the
last dose.

The contraindications for disulfiram use are:

 the first trimester of pregnancy,
 coronary artery disease,
 liver failure,
 chronic renal failure,
 peripheral neuropathy,
 muscle disease,
 psychotic symptoms presently or in the past.

Side effects:

Disulfiram in absence of alcohol can produce

- Lethargy -Tingling and numbness of hands and feet

- Itching - Worsening depression and psychosis

- Nausea - Constipation

- Drowsiness - Decreased sleep.

- Headache

Good Prognostic indicators of Disulfiram

 An older age group,
 Good motivation,
 Good social support,
 Absent underlying psychopathology
 Good treatment concordance
 In addition to oral preparation, subcutaneous disulfiram implants are also now
available.
 However, they provide unpredictable blood levels of disulfiram.
Nursing responsibility:

 An informal consent should be taken before starting treatment.

 Ensure that at least 12 hours have elapsed since the last ingestion of alcohol
before administering drug.

 Patient must have instructed that ingestion of even the smallest amount of
alcohol brings on a disulfiram ethanol reaction with all its unpleasant effect, he
should therefore be strictly warned not to take any alcohol.

 Patient should also be warned against ingestion of any alcohol containing

preparations such as cough syrup, drugs of any kind and alcohol containing
foods. Advice against use of alcohol based after shaves lotions, inhalation of
paints, any topical applications containing alcohol should be avoided.

 Caution against taking CNS depressant or any OTC medications during

therapy.

 Instruct patient to avoid drinking or other activities requiring alertness until

response to drug is known.

 Patient should be warned that the disulfiram alcohol reaction may continue for
as long as 1 to 2 weeks after last dose of disulifarm

 Patient should carry identification cards describing disulfiram alcohol reaction

and listing the name and telephone number of physician to be called.

 Emphasis the importance of follow up visit to the physician to monitor progress

in long term therapy.

Other deterrent agents:

 Citrated Calcium Carbimide (CCC): The mechanism of action is similar to
disulfiram but onset of action occurs within 1 hour and is reversible.
 Metronidazole
  Animal charcoal, a fungus (coprinus atrametarious) and certain
cephalosporins also cause a disulfiram like action.

 Anticraving Agents
a. Acamprosate,
b. Naltrexane and
c. Serotonin re-uptake inhibitor( SSRIs): such as Fluxetine

 Acamprosate:

 Mechanism of Action: It predominantly suppresses excitatory glutaminergic

neurotransmitters and decreases craving.
 Side effects: mild and transient. Diarrhoea occurs in few patients but is reduced
by taking medication with a meal
 Contraindications: renal insufficiency, hepatic failure
 Dose and duration: available as 333mg/tablet. <50kg=4tablets in three divided
dose, >50kg = 6tablets in three divided dose.
 Special nursing considerations: Ensure the abstinence, barrier contraception
recommended for patient.

 Naltrexane:

 Mechanism of Action: Alcohol consumption is thought to produce a feeling of

well being brought about by the release of endorphins in the brain and stimulation
of opiate receptors. This reinforces drinking of alcohol and ultimately leads to
relapse. Naltrexone competitively blocks opioid receptors and reduces the
reinforcing and rewarding effects of alcohol.
 Dose: Naltrexone at 50 mg/day significantly reduces the risk of relapse to heavy
drinking and the frequency of drinking.
 Side effects: Anxiety, difficulty in sleeping, rashes, itching
 Nursing Consideration: Do not administer until patient has passed naltrexane
challenge test (2 ampoule i.e. 2ml drugs given through IV and observed the
withdrawal effects).

 Other Medications
 Baclofen (Derivative of GABA)
 Fluxetine
5.NURSING CARE
Nursing care according to book
 Identify the amount, frequency,
length of time of alcohol use.
 Supervise and prevent injuries,
institute seizure precautions
during withdrawl
 Monitor for ( CNS) and
respiratory depression if
intoxicated
 Administer prescribed
medications that supports
nutritional status and limits signs
and symptoms of withdrawal.
 Provide support during alcohol
withdrawl delirium
 Monitor visitors because they may
supply the client with alcohol
 Provide support during
hallucination and illusions occurs,
stay with client and point out
reality.
 Provide a well controlled alcohol
free environment , explain the unit
routines.
 Plan a full program of activity but
provide for adequate rest,
environment should be well lit
and quiet.
 Avoid attempting to talk client out
of the problem or making client
feel guilty.
 Accept hostility and acting out
behaviours without criticism or
relation, set a appropriate limits if
hostility is physical or escalates
 Recognize ambivalence and limit
the need for decision making
 Maintain clients interest in a
therapy program.
 Provide education on alcohol as a
disease with negative effects on
physical and mental health.
Nursing care provided in patient
 Amount, frequency and length of
alcohol use was identified by
history taking.
 Patient was supervised and
injuries prevention technique was
used by using side rails.
 During administration of sedative
CNS depression and respiratory
depression was assessed by taking
frequent vital signs andassessing
patients condition.
 All the prescribed medicine was
adminixstered timely.
 Patient was supported during
delirium
 Visitors was taught about need of
avoidance of alcohol during
treatment as well as in future and
restricted to hidden supply of
drinking.
 Patient was oriented to reality and
staid near by him
 Alcohol free environment was
provided
 Although there was no any
specific activities provided to
psychiatric patient, patient was
engaged in active and passive
range of motion exercise with
adequate rest period.
 All types of behavior and
activities exhibited by the patient
was accepted without criticizing
him and feeling of guilt towards
his illness was avoided.
 Patient and his family members
was educated about alcoholism,
it’s effects on health,
complications, prevention of
alcoholism and its management.
 Family members was taught about
  Provide family counseling and
refer to the self help group to
address effects of alcohol drinking
and sobriety on the family.
 Maintain appropriate hydration
and nutrition.
 Involve the patient in group
interaction
 Teach about anxiety relieving
methods like relaxation therapy.
especial support group available
to prevent alcoholism including
rehabilitation.
 Adequate hydration as well as
nutrition was maintained by
administering prescribed fluid and
vitamin .encouraging for frequent
feeding .
 Stress relieving measure was
taught.

Nursing Management
Assessment
Recognition of alcohol abuse: The CAGE questionnaire may be adopted for this purpose:
C: Have you ever felt you ought to CUT down on your drinking?
A: Have people ANNOYED you by criticizing your drinking?
G: Have you ever felt GUILTY about your drinking?
E: Have you ever had a drink first thing in the morning (an EYE-OPENER) to steady
your nerves or get rid of a hang over?
Care during acute intoxication
1) Place the patient in a room near the nursing station or where the staff can observe
the patient closely.
2) Montor the patient’s sleep pattern, he may need to be restrained at night if
confused or if wanders or attempts to climb out of bed.
3) Decrease invironmental stumuli (bright lights, teleision, visitors) when the patient
is restless, irritable or tremulous.
4) Institute seizure precaution (padded tongue blade and airway at bed side, raise
side rails etc.)
5) Reorient the patient to person, time, place as situation as needed.
6) Talk to the patient in simple, direct, concrete language.
Care to improve health status of alcoholic
1) Monitor the patient’s health status. Administor medications as prescribed by
physician. Observe the patient for any behavioural changes and inform physician
when necessary.
2) Maintain fluid and electrolyte balance.
3) Provide food or nurishing fluids as soon as the patient can tolerate eating.
4) Ensure that amount of protein in the diet is correct for individual patient condition.
5) Provide small frequent feedings of patient’s favourite foods. Supplement with
vitamins and minerals.
6) Assist the patient in self care activities; it may be necessary to provide complete
physical care, depending on the severity of the patient’s withdrawl.

Care to improve adaptive behaviour

 1) Develop trust, convey an attitude of acceptance. Insure the patient understands it
is not him but his behaviour that is unacceptable.
2) Identify recent maladaptive behaviours or situations that have occured in the
patient’s life and discuss how use of durg / alcohol may be a contributing factor.
3) Do not allow the patient to rationalize or blame others for behaviours associated
with substance abuse.
4) Provide positive reinforcement when the patient shows insight into his behaviour.

Care to improve adaptive coping skills among alcoholic

1) encourage patient to explore option available to deal with stress, rather than
resorting to substance use. Practice these techniques.
2) Give positive reinforcement for ability to delay gratification and respond to stress
with adaptive coping strategies.
3) Teach patient and family that alcoholism is a disease that requires long term
treatment and follow up.
4) Maintain frequent contact with the patient, even if it is only by a brief telephone
call.
5) If drinking occurs, discuss the events that led to the incident with the patient in a
non-judgemental manner. Discuss ways to avoid similar circumstances in the
future.
6) Assist the patient weekly, or even daily, schedules of purposeful activities, such as
appontment, talking walks, etc.

6. ALCOHOLIC REHABILITATION
 The American medical Association has classified alcoholism as a disease since
1960s .
 Alcoholic Rehabilitation is not a place for guilt or shame, it is a place to treat or
recover dependence. If left untreated, excessive alcohol abuse can ultimately
destroy the liver, produce heart disease, gastrointestinal problems, decreased bone
density and blood cell production. Simple daily life can also become a struggle,
with depressive episode, severe anxiety and even thoughts of suicide.
 Alcoholic rehabilitation provides the best chance at starting a healthier and
happier life. It provides both inpatient and outpatient service and provides
confidential treatment to make the patient comfortable.
 Outpatient treatment is good for the people who have develop a drinking problem
but are not yet addicted to alcohol and inpatient treatment facility is good for those
people who have emotional attachment to alcohol and have develop a physical and
psychological dependence and tolerance.
 Treatment occurs in a period of 30, 60 and 90 days. 30 days is the minimum
amount of time needed for treatment to be effective. Treatment process begins
with an alcohol detox period between 5-7 days, during which the body is cleansed
of toxins of wine, liquor or beer. This cleansing process can include unpleasant
withdrawl symptoms such as irritability, depression, sweats and chills. But it is
necessary step in combating the disease. During detox process, medication,
 nutritious meal and rest is provided for better prognosis. Once the detox process is
complete, inpatient counselling begin to discover the underlying issues causing
addiction. This is sometimes done through group therapy session in which
individual can received emotional support, and sometimes individual therapy is
also done.

Prevention
A) Primary prevention:
 Primary prevention can be done with information, education and other awareness
raising activities. Primary prevention helps to reduce the incidence of alcohol used
problem. This can be :
If you have a teenagers :
 Help prevent teenage alcohol use, start by setting by setting a good example
with your own alcohol.
 Talk openly with your child and spend quality time together , but respect yours
Childs needs for independence
 Make sure child understand the legal and medical consequences of drinking.
 Be alert to sign and symptoms that may indicate a problem with alcohol.
 Putting up the priest of alcohol and alcoholic beverages.
 Restricting the availability and lessening social deprivation.
 Controlling or abolishing the advertisement of the alcoholics drinks.
 Controls on sales.
 Health education to school, colleges ,student and youths about the dangers of
alcohol abuses through the curriculum and the mass media( radio,newspaper
,television).
 Incorporate substance related issues in the high school curriculum.
 Some NGOs like rotatory , lions involved in creating public awareness against
alcohol.
 Distribution of education materials against alcohol by ministry of health ,Nepal
government.
 School community talk programmes against alcohol.
 Regulation of production , distribution ,sell and consumption with special
consideration of age bar ,time and location of sell.
 Integration of substance use related problem with general health system.
B) Secondary prevention
 Secondary prevention can be done with early identification of heavy alcohol
drinker and their treatment.
C) Tertiary prevention
 Tertiary prevention is mainly concerned with relapse prevention and
rehabilitation.
Progonosis

About 30% of alcoholics are able to abstain from alcohol permanently without the help of
formal treatment or a self-help program. For the rest, the course of the illness is very
varied. Some people will go through periods where they remain sober, but then relapse.
Others have a hard time sustaining any period of sobriety.It is clear, however, that the
more sober days you have, the greater the chance that you will remain sober. Another
motivating fact – remaining sober can increase life expectancy by 15 or more years.

Alcoholic rehabilitation centres available in nepal

a. Addiction recovery centre, jhapa
b. Dharan youth centre –sunsari
c. Bijam rehabilitation centre.parsa
d. Nava kiran, makawanpur
e. Support and care rehabilitation centre, chitwan
f. Swastha sikchha thatha margasandhi nepal.latitpur
g. Jyoti female rehabilitation centre, kathmandu
h. Youth vision kathmandu
i. Gateway foundation, kaski
j. Nauloghumti, kaski etc.

TREATMENT ON PATIENT:

 Supplementation Therapy
 Supportive Treatment
 Motivational Interviewing
 Individual and Group Therapy
 Pharmacological therapy
 Nursing management

Pharmacological treatment
 T. Pantocid 40 mg PO, OD.
 Inj. Cynocal 1 ampule in inj DNS I/V stat.
 T. B ONE 100 mg PO, TDS.
 T. Loree 2mg PO, OD.
 Syrup Easilac 15 ml PO, HS.
 T. ursodex 150mg PO, HS.
 Otorex eardrop 2 drops, BD left ear.
DISCHARGE DRUGS;

 T.Topaz 25 mg PO, OD.

 T. Ursodex 150 mg PO, BD for 1 week.
 T. Pantop 40 mg, PO, OD for 1 week.
 T. Telmi 40 mg PO, OD.
 T. Loree 2 mg, PO, SOS.
 Otorex 2 drops BD left ear.

DETAILED DESCRIPTION OF PHARMACOLOGICA THERAPY

USED IN PATIENT:
1) PANTOCID;
Generic name: Pantoprazole

• Most effective drugs in antiulcer therapy

• Pro drugs requiring activation in acid environment

• Activated forms binds irreversibly to H+K+ATPase and inhibit it

• It is a powerful inhibitor of gastric acid: can totally abolish HCL secretion both
resting as well as stimulated by food without much action on pepsin, intrinsic
factor, juice volume or gastric motility

Mechanism of action

• since it is a pro drug that undergoes conversion to it’s active form within the
parietal cells of stomach. The active form causes irreversibly inhibition of H +, K+-
ATPAase (responsible in generating HCL) as well as block the final conversion
pathway of gastric acid production.
 • Dose : oral : 40 mg OD, PANTOCID, PANTODAC 20,4O MG enteric coated
tablet; pantium, pantin 40 mg tab.
• Inj:40 mg once daily slow IV or by IV infusion

Indications:

– Gastroesophageal reflux disease (GERD)

– Peptic Ulcer - Gastric and duodenal ulcers

– Bleeding peptic Ulcer

– Zollinger Ellison Syndrome

– Prevention of recurrence of nonsteroidal antiinflammatory drug (NSAID) -

associated gastric ulcers in patients who continue NSAID use.

– Reducing the risk of duodenal ulcer recurrence associated with H. pylori

infections

– Aspiration Pneumonia

Contraindication:

It is contraindicated in patients with known hypersensitivity to any component of the

formulation.

Side Effects

 Nausea, loose stools, headache abdominal pain, constipation,

 Muscle & joint pain, dizziness, rashes

 Rare

o Gynaecomastia, erectile dysfunction

o Leucopenia and hepatic dysfunction

 o Osteoporosis in elderly on prolonged use

o Vitamin B12 deficiency

o Hypergastrinemia which may predispose to rebound hypersecretion of gastric

acid upon discontinuation of therapy and may promote the growth of
gastrointestinal tumors.(carcinoid).

Nursing considerations

 The volume of reconstituted solution to be injected may be administer

intravenously over at least 2 minutes.
 Infusion should be infused over 15 minutes at a rate not to exceed 3mg/minute
 Use cautiously in hepatic failure, children, pregnancy and lactation
 When reconstitute with 10 ml normal saline it should be used within 24 hours.
 Instruct the patient to avoid alcohol because it may reduce the effect of medicine

2)CYANOCOBALAMINE(CYANOCAL, vitamin B12);

Cynacobalamine and hydroxycobalamine are complex cobalt containing compounds.

It is a water soluble vitamin which is necessary for cell replication, haematopoesis and
nucleoprotein and myelin synthesis.

Mechanism of action

It acts as a co-enzyme in the synthesis of methionine, that stimulates metabolic function,

essential for the formation and maturation of RBC and maintain integrity of nervous
system(myelin).

Dose:

Adult: 250 mcg by mouth.

Neuribion Forte (1000 ug/3ml inj; 15 ug/tab).

Fesovit(15ug/cap), polybion(15 ug/cap).

Indications :
  Chronic impairment of hepatic parenchyma.
 Alcoholism
 Pernicious anemia, macrocytic anemia
 Mal absorption syndrome disease trigeminal neuralgia
 Prophylaxis in gastrectomy and ileal resection.

Contraindications

Known hypersensitivity

Adverse effects :

 Peripheral vascular thrombosis

 Transient diarrhea
 Itching, urtecaria, anaphylactic reactions

Nursing considerations :

 Monitor vital signs frequently

 Tell the patient about the side effects of drug like diarrhea, urticaria ,itching and if
severe side effect present instruct to visit the hospital immediatelys
 Encourage to take fish, meat, milk, liver and milk products.
 Instruct to take full dose of medicine.

3).Tab. B-one 100 mg( Thiamine, vitamin B1);

A colourless, crystalline compound containing a pyrimidine and a thiazole ring.

Vitamin B1 is important for normal carbohydrate oxidation.it is also called anti neurotic
vitamin.
Mechanism of action
It combines with adenosine triphosphate to form a coenzyme necessary for carbohydrate
metabolism; decarboxylation of ketoacids and hexose monophosphate shunt.
Dose:
 Mild chronic thiamine deficiency:10-25 mg daily
 Severe deficiency:200-300 mg daily
 Alcoholic neuritis:40 mg daily
 Cardiovascular disease due to thiamine deficiency:10-30 mg slow IV
  Prophylaxia:2.5 mg daily
 Child: mild infantile beriberi 10 mg daily
 If acute collapse occurs:25 mg slow IV

Indications:

 Beriberi
 Anorexia nervosa
 Persistent vomiting
 Mental disorder associate with alcoholism
 Peripheral neuritis
 polyneuritis

contraindications;
 It is contraindicated in patients with hypersensitivity.

Adverse effects; Thiamine is non toxic. Sensitivity reactions sometimes occur on

parenteral injection.

Nursing considerations

 Follow the rights of medicine administration

 Inform the patient about the side effects of drug

 Advise the patient to take full dose of medicine

4). Tab Loree 2mg, PO, OD.

LORAZEPAM

Introduction
It is a short acting benzodiazepine. It is an ill- defined drug, mostly mild CNS
depressants, which are aimed to control the symptoms of anxiety, produce a restful state
of mind without interfering with normal mental or physical functions.

Mechanism of action

• They act very selectively on the GABA receptors. GABA exert an inhibitory
effect by opening the chloride channel. The effect of lorazepam is to enhance the
response of GABA by facilitating the opening of chloride channel and
producing the inhibitory effect.

Dose:
 1-6 mg; laprose, Ativan 1,2 mg tab, calmese 1,2 mg, 4mg/2ml.Inj.
 Dose is needed to be reduced in elderly patients.

Indications:

 Short term treatment of anxiety disorders

 As hypnotic
 Short term management of insomnia
 Anticonvulsant in status epilepticus
 Also used as sedative and amnestic properties in pre-medication.

Contraindication:
 Acute angle closure glaucoma
Side Effects
 CNS: drowsiness, sedation, disorientation, amnesia
 GIT: change in appetite, abdominal discomfort
 Miscellaneous: acute withdrawal syndrome.

Nursing considerations

• Tell the patient that the medicine may causes dizziness, and sleepiness.

• Instruct the patient not to drink alcohol

 • Do not mix the injection with other drugs in the same syringe as the colour may
change cloudy.

• Give IM injection in large muscle, make sure that IV injection is given into vein
because thrombophlebitis may occur.

• IV medicine should be given very slowly.

• Instruct the patient to avoid prolong use as dependence may occur.

• Instruct the patient not to discontinue the medicine abruptly as tapering of the
dose is needed.

5). Tab. Ursodex 150mg. PO, HS

Ursodiol; It is hydroxyl epimer of chenodial, is more effective and needs to be used at
lower doses. Complete dissolution of cholesterol stone has been achieved in upto 50%
cases. It is also much better tolerated.
Mechanism of action; it acts primarily by inhibiting intestinal cholesterol absorption. It
doesnot rise plasma LDL-CH level. Promptly reduces cholesterol secretion in bile.
Promotes solubilization by liquid crystal formation.
Dose; 450-600 mg daily in 2-3 divided doses after meals.

Indications;
 Dissolution of cholesterol rich gall stones.
 Primary biliary cirrhosis.
 Cystic fibrosis.

Contraindications;
 Known allergy to bile acids.
 Biliary tract disorder.
 Gall bladder disorder( non functional GB).
 Presence of calcified gall stones.
  Chronic liver disease.
 Inflammatory bowel disease.
 Patients requiring cholecystectomy.

Side effects;
 Diarrhea
 Nausea, abdominal pain.
 Fatigue.
 Headache, pruritus.
 Rash, vomiting.
 Dyspepsia, Metallic Taste.

Nursing considerations;
 Instruct the patient about proper doses, side effects and usage.
 Advise patient to consult docter if any severe side effect occurs.

NURSING THEORY APPLICATION

NURSING THEORY APPLIED IN MY PATIENT:

The role and functions of professional nurses vary with the situation. Although
there is always a role for family and the patient, the pie wedges for team members
vary in size according to:

 The problem of the patient.

 The patient’s self help ability
 The help resources.
Central to nursing that seeks to help patients toward independence is
empathetic, understanding and unlimited knowledge. The patient is an individual
who requires help toward independence. The nurse assists the individual whether
ill or not, to perform activities that will contribute to health, recovery or peaceful
death, activities that the individual who had necessary strength, will or knowledge
 would perform unaided. That’s why, I used this theory” Virginia Henderson
Theory”.

INTRODUCTION TO VIRGINIA HENDERSON’STHEORY:

The Henderson theory of nursing was developed by Virginia Henderson. She did
not believe that she was setting out a theory, and preferred it to be thought of as a
definition. Whether it is considered a definition or a theory, it has had a wide
influence on concept and practice of nursing.

Virginia Henderson was born on November 30, 1897, in Kansas City, Missouri.
She began her nursing education in the U.S. Army School of Nursing during
World War I, from which she graduated in 1921. She died March 19, 1996, when
she was 98 years old. The definition of nursing is the fundamental part of
Henderson's theory of nursing.

Henderson also enumerated the 14 functions she believed to be part of basic

nursing care. The nurse should help the patient to perform the following functions

Henderson’s 14 basic needs

14. Learn, 1. Normal breaths 2. Adequate eat and drink

Discover satisfy curiosity.

3. Elimination of body wastes

13 .Participate in recreations.

4. Desirable movement & position Henderson

12. Work sense accomplishments. and position.
14 Basic Needs.

11.Worship in faith 5. Sleep and rest

6. Suitable dress and undress.

10.Proper Communication

8. Clean and grooming 7. Maintaining body temperature

9. Avoid dangers.

ASSESSMENT OF MY PATIENT
  Patient had disturbed sleep pattern.
 Foul smelling with alcoholic smell was coming from mouth and staining of teeth
and food particle was present on mouth and teeth.
 Body temperature is fluctuating and reached up to 1010F.
 He has risk of injury due to uncoordinated movement induced by alcoholism and
frequent fall injuries.
 Patient has risk of development of malnutrition because of vomiting, diarrhea, and
vitamin deficiency induced by alcoholism.
 Patient and his relatives have a chance of developing stress because of long term
hospitalization, unknown about treatment and disease prognosis.
 Patient has low self esteem due to alcoholism.
 There is a chance of development of disturbed family equilibrium and social
relations.
 They are unknown about disease process, treatment modalities and prognosis of
disease.

CONCEPT USED BY HENDERSON

NEEDS NURSING CARE

1.Breathe Patient was breathing normally respiration rate was within the
Normally normal range that is 20-28 b/min.
2.Eat, drink Patient had loss of appetite and vomiting so there was risk of
adequately developing malnutrition due to vitamin deficiency and unable to
met the body requirements so following measures was done to
maintain nutritional status:
• Patient dietary pattern and like and dislike of food was
assessed.
• Height, weight oral condition, activity and rest level was
assessed.
• Sensible as well as insensible fluid loss was monitored like
vomiting, sweating and diarrhea
• Intake and output charting was done and patient was helped
to eat.
• Patient was encouraged to choose the food that he like
• Intravenous fluid i inj.DNS was administered by adding in
cynical 1 ampoule in each drip as well as encourage for
adequate fluid intake.
• Small but frequent meal was provided.
• Frequent mouth care was provided as well as encouraged for
frequent mouth care.
3.Elimination of Patient was stable and can go to toilet and do self care activities
bodily waste by himself. He was encouraged to void before sleep.
4.Desirable As the patient had difficulty in range of motion of his left leg,
movement and following intervention was done:
position • Patient was kept in comfortable position that is supine
position.
• Ice compression was applied over swollen part
• As there was reduction in swelling and pain, active and
passive range of motion exercise was done
• Ambulation was done.
5.Sleep and rest. Patient had disturbed sleep pattern as he was chronic alcoholic ,
there was difficulty in initiation of sleep as well as frequent
awakening and awakening in early morning after the effect of
alcohol was subside so following measures was done to
maintain sleep and rest.:
• Kept in comfortable position
• Removed unnecessary crowd
• Provided non stimulating environment
• Administered medication lorazepam as prescribed.
• Reduced day time sleep by engaging the patient in
activity
6.Suitable Patient was dressed appropriate to the season.
Clothing
7.Maintain body Patient body temperature was fluctuating so following measures
temperature. was done to maintain normal body temperature.:
• Frequent assessment of body temperature was done that
is half an hourly ,hourly and 2 hourly as needed
• Cross ventilation was maintained by opening windows
• Cold sponging was given
• Encouraged to take adequate fluid
8.Keep patient Inorder to keep the patient clean and well grommed following
clean and well measures was done
groomed • His dirty clothes was removed
• Oral care was given.
• Instructed for whole body bath.
9. Avoid danger • As the patient had tremor and delirium due to alcoholism
environment side rails was kept on bed
• Harmful object was removed near from him
• Crowd was removed

10. • Maintained good IPR with patient and patient party.

Communication.
• Gave enough time to express feeling and listen them
carefully .
• Maintained therapeutic nurse patient relationship.
• Explained the diagnostic procedure and daily progress
report of the patient.
• Psychological support to the patient and patient party
 was provided.
11. Worship Patient believed on Hinduism . sometimes visit to temple also.
according to
patient party in
their own faith
12. Work sense Now patient was actively involve in his daily care like brushing,
accomplishments. clothing etc.
13. Participate in Sometimes he participate in recreation like listening songs etc.
recreation
14. Learn, Patient and his relatives asked the queries related to disease and
discover and it’s prognosis.
satisfy curiosity.

NURSING CARE PLAN ON PATIENT WITH ADS

Nursing diagnosis

 Alteration in sleep pattern related to alcohol dependence as evidenced by tiredness

and fatigue present in patient at day time.

 Alteration in body temperature related to disturbance in temperature regulating centre

in brain as evidence by increase in body temperature up to 101.80F.

 Imbalanced nutrition: less than body requirements related to alcohol dependence as

evidence by loss of appetite and weight loss than before

 Ineffective coping related to impairment of adaptive behavior and problem solving

abilities as evidenced by use of substances as coping mechanism.

 Chronic low self-esteem related to as evidence by worried about hospitalization,

treatment and guilt of taking alcoholism

 Dysfunctional family processes related to Abuse of alcoholism as evidence Disturbed

family dynamics and closed communication.

 Deficient knowledge related to Effects of Substance Abuse on the Body as evidence

by lack of education and continuous heave drinking.

 Potential to altered cardiac output related to direct effect of alcohol on heart muscle.

 Risk for injury related to substance withdrawal as evidence by seizure/confusion and

knee injury.
NURSING CARE PLANS OF PATIENT;
S.N. ASSESSMENT NURSING NURSING PLAN OF RATIONAL IMPLEMENTATION EVALUATION.
DIAGNOSIS GOAL ACTION
1. Subjective data; Alteration of Patient will -To assess the -It helps to collect - Information was
Patient said he sleep pattern have sleep pattern of the necessary collected by history My goal was
could not sleep related to improved patient. information about taking, observing fully met as
well at night for alcohol sleep pattern sleep habit of patients behaviour, and patients sleep
first few days. dependence as and feel patient. taking handovers from pattern was
evidenced by relieved. -To provide a -Too many previous shifts. gradually
Objective data; tiredness and calm and stimuli in the -calm and soothing improved and
patient looked fatigue at day soothing environment may environment was had well sleeping
tired and fatigue time. environment. increase provided. habits till day of
at the day time. restlessness. discharge.
-To engage
patient in play - Keeping -patient was engaged in
and recreation engaged at day play and recreation at
during day time. helps to initiate day time.
-To avoid day sleep at night. -patient was not
time naps. - Avoiding naps allowed to sleep at day
helps to initiate time.
and maintain
-To help patient sleep at night. -patient was informed
to avoid -Avoiding to avoid stimulants at
stimulants at stimulants helps evening time.
evening time. CNS to relax at
-To give night. -patient was given the
prescribed -prescribed prescribed medications.
medication for medication was
sleep. given.
S.N. Nursing Nursing Nursing Goal Plan of action Rational Implementation Evaluation
Assessment Diagnosis.
2. Subjective data; Alteration in Temperature  Assess the body  It provides  Temperature My goal was
Patient said he body (99- will be temperature. baseline data for and vital signs fully met as
feels too cold 101.80F) reduced up to Management. was assessed patients
and wants to get temperature 980F within 1-  Remove all extra  All extra clothes temperature has
2 hour after clothes and  Heat loss through and blanket was
wrapped in related to been reduced to
intervention. blanket from radiation. removed.
blanket 98 degree
everytym and
body.  Cross farenheit.
 Heat loss through ventilation was
have a feeling
 Maintain cross convection. maintained by
of bodyache. ventilation by opening door
opening door and  Heat loss through and window.
Objective data; windows. convection.  Fan was opened
patients body  Cold sponging
feels hot and  Open fan If  Heat loss through was applied.
thermometer available. conduction.  Patient was
showed high encouraged to
temperature i.e.  Apply cold  Replace fluid drink plenty of
1oodegree sponge for 20-30 loss. oral fluid. Like
farenhiet. m minute. water, juice
soup etc.
 Encourage to
drink oral fluids.

S.N. Nursing Nursing Nursing goal Plan of action Rational Implementatio Evaluation
assessment diagnosis. n
3. Subjective Altered Patient will -To assess the eating- Helps to - patients eating My goals were
data; patient nutrition, less have improved pattern of patient. identify the pattern was fully met as
said” I don’t than body eating habits reason of loss of assessed. patients
feel like requirement during appetite. appetite was
eating”. related to loss of hospitalization. - To Instruct patient to -patient was improved and
Objective data; appetite. chew food well. - Helps to digests instructed to started to eat
patient has and absorb food chew food well. well within
decreased well. hospital stay.
eating and did - To request canteens -canteens staff
not give staff to serve food -Helps to increase were requested
enough time to attractively. appetite. to serve food
eat. attractively.

- To involve patient in -patient was

physical activities. -Helps to induce involved in
appetite. physical
activities.

-To instruct patient to -patient was

have small frequent instructed to
and variety of foods. -Helps patient to have small
complete his frequent and
nutritional need. variety of foods.

S.N. Nursing Nursing Nursing Plan of action. Rational Implementation Evaluation

 assessment diagnosis goal.
4. Subjective Chronic low Patients -To assess the level -Helps to understand -patients guilt level My goal was
data; patient self esteem self esteem of guilt present. the patients level of was assessed. partially met as
said that he related to guilt would be tension. patient has
felt bad about of alcoholism increased -To encourage the -Helps to know -patient was slowly started
drinking as evidenced within patient to verbalize patients feelings. encouraged to to express
alcohol. by patients hospital his feelings. verbalize his himself, enjoy
Objective data; verbalization. stay( woul feelings. others
Patient looked d be taught -To encourage patient -Helps patient to -patient was company and
sad because of to be happy to spend time with realize that he is not encouraged to speak well in
his deed. with self). people of same only one having such spend time with group
condition. problem. peope having same discussion.
problem.
-To provide -Helps patient to feel - Information of his
information related to at ease. condition was
his condition . provided to patient.

-To provide -Helps patient to feel -Information about

instruction to patient relieved and get preventing relapse
about preventing chance to be happy and spending time
relapse of his again with family. with family was
condition and spend provided.
time with his family.
-To inform to follow -Helps to feel relaxed -Informed patient
relaxation technique and refreshed and to follow relaxation
and start new life start new life again. technique and start
again. new.
S.N. Nursing Nursing Nursing Plan of action Rational Implementation Evaluation
Assessment Diagnosis Goals
5. Subjective Knowledge Patient will -To assess the level of - Helps to understand -patients level of My goals
data; patient deficit related gain knowledge level. how to provide knowledge was were fully met
said” I am follow up, information information. assessed. as I was able
afraid that I continuity of regarding his to provide
may not care and conditions, -To provide -Helps to reassure the -Information regarding detailed
recover well treatment. follow up, information related to patient. his condition and information
because I continuity of his condition and treatment was about his
have care and treatment process. provided. condition,
experienced treatment. follow up,
relapse”. -To provide - Helps to prevent the -Information regarding treatment and
continuity of medicine
information of relapse of condition. prevention.
and follow up was
Objective continuity of provided.
data; patient medicine and follow
seemed up.
fearful about -Helps to reduce risk -patient was advised to
being -To suggest patient to factor. avoid bad circle.
addicted avoid bad circle.
again.”
- helps not to think -patient was advised to
- To advise patient to about the alcohol and do productive work
and spend time with
utilize his leisure time decreases attraction
family in leisure time.
by doing either towards alcohol.
productive work or
spend time with
family.
DAILY PROGRESS REPORT;
Admission day (2077/09/09); patient named Krishna raj subedi of 52 years/male from
parbat was received in high care unit from emergency ward with a diagnosis of alcohol
dependence syndrome with alcohol withdrawal syndrome. patient was received with
intravenous drip (DNS with cyanacol 1 amp). His investigations were already carried out.
patient was admitted with the complain of continuous drinking of alcohol for 3 days since
the party and started to show tremers, anxiety etc. vital signs were normal and recorded
as;
T: 980F
P: 100b/min
R:28b/min
B.P:130/90 mm of HG
SPO2:93%

1st day of admission(2077/09/10); It is the 1st day of admission. General condition of

patient looked better. He was shifted to general male ward. Complete orientation about
hospital, its policy and about the patient was given today because patient is well oriented
today. There were no new complications. Patient had little bit problem in falling a
sleep.Prescribed medications were given. His vital signs were stable and recorded as;
T: 980F,990F, 1000F
P: 108-122b/min
R:22-26b/min
B.P:110/70-130/100 mm of HG
SPO2:96-98%

2nd day of admission(2077/09/11); Saturday . patients general condition was normal. He

had been adopting to other patients. There were no any further complains. His sleeping
pattern was improved. He had normal bladder and bowel pattern. Prescribed medication
were given by staff sisters. Vital signs were normal and recorded as;
T: 980F
P: 100b/min
R:28b/min
B.P:130/90 mm of HG
SPO2:93%

3rd day of admission(2077/09/12); patients general condition was fair. His eating
pattern was improving. There were no new complains of alcoholism but he had left
earache so it was informed to the docter during round so, otorex eardrop was added in the
treatment regimen and advised to visit ENT consultant after discharge. Tab loree was
reduced to 2mg. his bowel and bladder pattern were normal. Prescribed medication was
done. Vital signs were stable and recorded as;
T: 980F,990F,
P: 100-120b/min
R:26-28b/min
B.P:120/70 mmhg.

4th day of admission(2077/09/13); On 4th day of admission, there was pretty well
improvememt in the patients condition. He had normal eating, sleeping, bowel and
bladder. He had been using his day time with other patients. Also, encouraging other
patient in substance abuse to get out of this habit. There were no further complications,
prescribed medications were given by staff sisters. Mental status examination was
performed and he had total insight but has problem in memory. Vital signs were
monitored and recorded as;
T: 980F,
P: 76b/min
R: 24b/min
BP:130/80mmhg.
5th day of admission(2077/09/14); patients general condition in the 5th day of admission
was normal. There were no signs of withdrawal syndrome and patient had full insight. In
the docters round, discharge was planned i.e. he could be discharged in 2 days. There was
no any complain. His eating, sleeping, bowel and bladder pattern were normal. Vital signs
were normal and recorded as;
T: 980F,
P: 80b/min
R :24b/min
BP:110/80mmhg.
6th day of admission(2077/09/15);
Patients general condition is normal. He has no any further complains. His family were
informed about discharge by staff sisters. He had normal eating, sleeping, bowel and
bladder. Prescribed medications were given by staff sisters. Vital signs were monitored
which were as follows;
T: 970F
P: 76b/min
R:24b/min
B.P:130/90mmhg.

7th day of admission(2077/09/16);

It’s the 7th day of admission. Patients general condition is fair. No any complains. His
family were coming to take him. His condition was improved. His vital signs were normal
and recorded as;
T: 980F,
P: 80b/min
R:20b/min
BP:130/80mmhg. Discharge teaching was given as per the instructions.

DISCHARGE TEACHING
At the time of discharge patient needs a lot of information regarding disease process and
prevention of further progression of disease. Discharge teaching is an integral part of the
nursing process and it is a important responsibility of the nurse to plan a discharge
teaching and suggest the patient and family members for the continuity of care at home
and further investigation of disease process. It is the most important part in providing
holistic nursing care to the patient.

Objectives of discharge teaching

 To provide a great deal of health education.
 To consider primary health care concept in teaching.
 To increase the efficiency of family members to care the patient.
 To maintain continuity of care and better recovery.
 To promote and maintain health and prevent from illness in home after discharge.
 To encourage for healthy behavior and provide holistic care to patient.
 To help patient recognize their condition for indication of urgent follow up.
Patient name Krishna raj subedi was discharged on 2077/09/16 according to doctor’s
order. While planning the discharge of patient, I considered many topics as an integral
part of discharge teaching. Following topics were included in discharge teaching:

Rest and sleep:

As sound sleep helps to feel relaxed and leads to allay anxiety, patient was advised to
sleep about 5-6 hours a day by making environment quiet and calm. Rest helps the body
in healing process.

Nutritious diet:

I encouraged him to take low protein, high calorie ,high fiber and vitamin containing
foods in his daily diet. I advised him to drink plenty of fluids and avoid spicy food, take
small but frequent meal. I also encouraged healthy eating patterns and help the patient’s
food preference positively. I advised family members and patient to limit junk foods and
strictly avoid alcohol

Exercise and Activity:

Exercise is essential for muscular development, refinement of coordination and gaining

strength and enhancing other body functions such as circulation, aeration and waste
elimination. Encouraged the patient to involve in regular daily activities and exercise, and
also encouraged to remain busy by involving in social work and kitchen garden work as
well as instructed for active range of motion exercise of left leg.

Maintenance of clean environment and personal hygiene

I advised to maintain environmental sanitation and personal hygiene by regular bath,

changing clothes and so on. I explained about the relationship between proper
environment and health.

Coping Measures

I taught him to become relaxed and free of tension as these measures are related to poor
health. I emphasized on reduction of anxiety, depression and change in life style that
makes the patient irritable and apprehensive. My patient was anxious related to his
disease condition so I gave psychological support by emphasizing the importance of
precautions and medications, so that symptoms can be minimized. I also advised the
family members about the role and support of family to enhance the patient’s wellness
and ability to cope the disease process. Different methods of stress reduction like yoga,
imaginary visualization, deep breathing and listening music was advised.

Medication and follow up:

I advised to my patient to take complete course of medications for complete cure and
prevent recurrences also advised for follow up as ordered by the doctor for complete
treatment and detecting any early complications. Informed to come after 1 week for
follow up. Discharge medicines were as follows;

 T.Topaz 25 mg PO, OD.

 T. Ursodex 150 mg PO, BD for 1 week.
 T. Pantop 40 mg, PO, OD for 1 week.
 T. Telmi 40 mg PO, OD.
 T. Loree 2 mg, PO, SOS.
 Otorex 2 drops BD left ear.

DIVERSIONAL THERAPY DONE TO REDUCE STRESS

OF THE PATIENT AND FAMILY:-
I. STRESS MANAGEMENT:-
Stress is a state produced by a change in the environment that is perceived as
challenging, threatening or damaging to the persons dynamic equilibrium. There is an
actual or perceived imbalance in the person’s ability to meet the demand of the new
situation or the person is or feels unable to meet the demand of the new situation.
As my patient party is much more worried regarding disease condition as well as patient
was anxious about his hospitalization. Therefore, I had given an informal teaching on the
disease process, diagnosis, treatment, prognosis, recovery and health teaching which
help them to relieve their anxiety.

II. DIVERSIONAL THERAPY:-

Due to hospitalization patient seems anxious and bored. To deal with this situation I had
given some diversion therapies that are as follows:
 a. Teaching and demonstration about relaxation therapy was done to refresh and
reduce stress of the patient. Patient was made frequently engaged in various
activities like exercise, watching television, sitting with other patient and talking
with other patient etc.
b. The patient and family made aware about stressful situation and the means to
overcome were explained. The holistic care was provided.
Diversion therapy is the action to minimize the stress of illness and hospitalization.
Stress management is the vital aspect of patient with psychiatric problems.
Diversional therapy which I used for my patient:

 Talk therapy: I frequently talked with the patient. Ask about his family,
interesting past days. I introduced myself with him. Encouraged him to express
his feelings, listened and responded to his feelings and expression. Encourage
patient to talk with other patient.
 Guided imaginary: This method is mind body interaction. It helped a lot to
decrease stress in my patient. Reminded him of his happy movement of his past
life. Helped him to recall event which he enjoyed. Helped him imagine of being or
meeting with the person who he liked. But I did not focus too much on
imagination as there was risk to aggravate hallucination and loss of insight.
 Distractions: Encouraged his relatives to visit him and talk with him frequently.
Helped him communicate with other person in the ward. Involved him in non-
intellectual activities like yoga and exercise singing, playing games and other
activities. Looking him out of ward around corridor for refreshment.
 Others:
 The patient and family were made aware of such stressful situation and the
means to overcome were explained. The holistic care was provided.
 Teaching and demonstration about relaxation therapy was done to refresh and
reduce stress of the patient.
 Talked and listen to the problems and complains with adequate time and
patience.
 Gave explanation and information about each therapies and other procedure e.g.
blood pressure monitoring, medication
 Provide adequate time for the patient to express his feelings.
  Regular schedule was made for patient including when to get up, morning care,
bowel habit, exercise, time of breakfast, meals, group therapy. Snacks dinner
time and time of sleeping etc.

LEARNING FROM CASE STUDY

Case study is a very effective method of learning. It provides chance to apply theoretical
knowledge into practice. It provides opportunity to study certain disease by analyzing it in
depth. It provides comprehensive study of one selected patient and book in real situation.
During case study we also give complete nursing care to the patient and find its result at
the same time, which is a great source of self satisfaction.

To sum up I learned so many things which aids my knowledge and give chance to learn
new things which helped me in further develop the competency in practical skills in
future on providing nursing care and dealing with same patient. The things I learned are
described below:

1. About the disease

I learned about the disease in depth analyzing its causes, pathophysiology, signs and
symptoms, diagnosis and management by referring the different resources available in
library, literatures, research, internet and journals. The comparative study of disease in
book and real situation helped me to differentiate between theory and real situations and
understand about the disease in depth.

2. About the patient

During case study I took complete history of patient which provided the chance to
analyze the relationship between person’s behavior and life style to the disease condition,
also gained broader knowledge and skills about history taking and physical examination.

3.About the family and environment

By holistic approach, I didn’t only focus on the patient but also learned about the family
members’ thinking and attitude towards health and illness. I also learned what type of
past and present illness as well as hereditary disease present in the family and how it
affects the offspring. By this, I gained knowledge about genetic disease and how it affects
family members as well as what type of environment leads to certain disease .Similarly I
also knew the close relationship between family, environment and disease condition.

4.About the Nursing Care

By providing complete care to the patient I learned the systemic process of nursing care
plan and how it can be applicable to real situation and I also applied Henderson’s theory
which was very effective on the progress of my patient. So I learned how theoretical
knowledge can be applied to practice and the uniform methodology of nursing process.

2. About the stress and its management

During initial days of admission my patient was so anxious, fearful and irritable; his
family members were also worried about the disease condition . So I applied different
stress management techniques and diversional therapies to reduce fear and worries . After
my effort, eventually my goal was met which helped me to learn and apply the stress
management and diversional therapy in patient,

3. About the Documentation

Documentation is an important and useful skill for professional growth. Without

documentation our work can’t be proved. By this case study I knew how to document our
practice in report. This case study enhanced my knowledge of documentation, with the
help of different activities like observation, findings and conclusion.

At last, to prepare this case study, I have consulted many books in the library and
internet so it provided me an opportunity to use different kinds of references, search for
different sources to make my case more effective so, this case study provided me the
opportunity to update my knowledge about how to use books, how to apply theories and
how to search for references and complete the knowledge about the case.

Lastly, I was able to gain the knowledge about differential diagnosis, treat modalities,
nursing care and consideration ,ward environment required to treat the psychiatric patient
than other.
SUMMARY OF CASE STUDY
During 2 weeks posting in psychiatric ward of a case study was planned and
accomplished. All the objective of the case study suggested by the curriculum were
fulfilled. I selected Mr. krisna raj subedi diagnosed with Alcohol dependence syndrome
with withdrawal syndrome for my case study. He was provided holistic care by provided
nursing process based on Virginia Henderson’s theory.

The knowledge from the basic science, nursing theories and other related courses were
applied while planning and implementing the nursing care during my case study. During
the period of hospitalization, I found out that the patient was co-operative.

The condition of the patient during hospitalization was improving day by day so he was
discharged according to doctor’s advice.

During the case study, I gave health education to patient party regarding nutrition, rest
and sleep, stress management, medication and follow up. I explained about the disease
process, diagnostic procedure and treatment measures and side effects of medicines.

While caring my patient , I applied Virginia Henderson’s theory. I cared him for 7days. My
patient was discharged from the hospital on 2077-09-16. During his hospital stay, I
encouraged him to take nutritious diet, to maintain the personal hygiene and to avoid
behavior that may contribute to alcohol dependence..

I am satisfied with my case study because I applied my best knowledge and skills on it and
got an opportunity to gain knowledge and skills and upgrade my knowledge about the
case, I had taken.
CONCLUSION
During 2weeks of posting in Psychiatric unit of BG Hospital we had to take one case
study for the practical fulfillment of BNS curriculum nursing practicum in psychiatric
nursing. During that time, I took Mr.krishna raj poudelfor my case study. His diagnosis
was Alcohol dependence syndrome with withdrawal syndrome . I collected subjective
and objective data for my case study, history taking, mental status examination and
physical examination. I collected more information through lab investigations and by
asking with the doctors who was looking after him. I got opportunity to study about the
Alcohol dependence syndrome in detail, its diagnosis, signs and symptoms, causes,
complications, management and so on.
During his hospitalization I developed good interpersonal relationship with him and his
family. I found different nursing problems and solved those problems by using nursing
process. I gave holistic and quality nursing care. During hospitalization, I gave different
informal health teaching regarding his condition and health status. Thus, I am satisfied
with my case study.

REFERENCES
 Dhami. J.(2014).Essential Tentbook of Mental health and Psychiaric Nursing.
(1stedi).Medhavi Publication. Page no.245-260.
 Kapoor, B. (2008), “Text Book of Psychiatric Nursing” Volume II,(2nd edi). Kumar
Publication New Delhi, Page no .189-190.
 Khadka, A. (2074).Comprehensive Textbook of Psychiatric Nursing
(1stedi)Samiksha Publication. Pageno .227.
 Niraj, A.(2006). A short text book of psychiatry, (6th edi), Medical publishers P.
Ltd, India. Page no 38-45.
 Sharma, C. and Sharma, P. (2016).Essentials of Psychiatric & Mental Health
Nursing.( 2st edition) , Saurav & Awish Kathmandu Nepal. Page no: 317-322
 Sreevani, R. (2010). A Guide to Mental health and Psychiatric Nursing (3rd
edition) Jypee Brothers Medical Publishers (P), New Delhi, page no 193-206.
 Subedi,D.(2010). Mental Health and Psychiatric Nursing, (2nd edi).Makalu
Publication House Kathmandu Nepal. page no 172-186.
 Thapa, R.K.(2015). A companion Pocket Book of Pharmacology.(5th edi). Taleju
Prakashan. Page no: 390-391