PROCESS RECORDING OF A

CLIENT WITH ‘POLY

SUBSTANCE ABUSE’
[Document subtitle]

SUBMITTED TO –
Ms. Kalyani Saha
Professor SUBMITTED BY –
Apollo College of Nursing, Kolkata
Shubhrima Khan
M.Sc. Nursing 2nd year
Apollo College of Nursing, Kolkata
IDENTIFICATION DATA

 Name: Souvik Mukherjee

 Age: 30 years
 Sex: Male
 Father’s / spouse name: Lt. Subhasis Mukherjee
 Religion: Hindu
 Date of admission: 16/05/2021
 Hospital Reg. No.: 738/21
 Under Dr: Dr. Alok Mondal
 Address: 1/19 Kalicharan Ghosh Road, Biswanath Colony
Baranagar, Kolkata: 700050
 Education: B.tech 2nd year
 Occupation: Salesman in shopping mall
 Income: 6000/ month
 Marital Status: Unmarried
 Languages known: Bengali, Hindi
 Diagnosis: Poly Substance abuse
 Informant: Rabi chakraborty (Uncle)
 Information: Adequate and Relevant

PRESENTING CHIEF COMPLAINT:

According to patient
Lockdown er somoy amar chakri ta chole jaoar por depreeed hoye porechilam  2 years ago
Kaj khojar chesta korchilam kintu parchilamna  2 years ago
Bekar bosechilam bole barite taka poisa niye jogra jhamela hoto  2 years ago
Bari theke taka ditona bole dhar dena kortam  2 years ago
Tarpor bondhuder sathe nesha kora suru korlam  2 years ago
Barite er jonno onek asanti hoto, mama marto amake, amio kokhno kokhno gaye hat tultam 
11/2 years ago
Khub irritated thaktam, keo kichu bollei rege giye galagali kortam  11/2 years ago
Kono kaj korte icchhe kortona  11/2 years ago
Sobar sathe somporko khub khrap hoye giyechilo  11/2 years ago
Onek dhar hoye giiyechilo bole parar kichu lok ese ekdin barite khub asanti kore
Maa amake bari theke beriye jete bole  11/2 years ago
Porer dini mama amake ekta rehabilitation centre e diye ase  11/2 years ago
Okhane 4 mas thakar por abar amake barite niye asa hoi
Barite ese khub asustha hoye porechilam  1 years ago
Khabar khelei bomi hoye jeto  1 years ago
Sobsomy ghum peto  1 years ago
Matha vari hoye thakto  1 years ago
Kichui valo lagtona  1 years ago
Karor sathe kotha bolte ichhe kortona  1 years ago
Tarpor ekhane niye ese vorti koriye dei  1 years ago

According to Family member: No relatives are present at the time of process recording.

HISTORY OF PRESENT ILLNESS:

Duration: 2 years
Mode of onset: Incidious
Course: Continuous
Intensity: Decreasing
Precipitating factor: Loss of job
Predisposing factors: Death of father, Failure to exam, financial crisis, Family conflict
Perpetuating factors: Nothing significant
Description of the present illness: The patient was apparently well before 2 years, when he
became jobless due to lockdown. As he failed to get any other job, he became depressed, get
addicted to various substances. He felt very irritated, did not want to do any work. Due to his
addiction, there was lot of chaos at his home, his uncle used to beat him, sometimes the patient
got very angry toward his family members and raised his hand on his mother. As he did not get
any money from his family, he started borrowing. Due to not being able to repay the loan,
people used to come to the house and make trouble. There is a history of fighting with
somebody in neighbors. The patient got injured in his nose during this fight. Regarding family
history, his father was passed away when the patient was only 10 years old. His mother is
ahome maker. After his father’s death they moved to their maternal uncle’s house. All their
expenses bared by his uncle. When the patient was in 2nd year of his B.tech study, he failed in
two subjects and discontinued his education. Then he started tutoring to primary children at
their home. He also worked as a salesman in a shopping mall. Due to the loss of this job during
the lockdown, he became addicted to alcohol, cannabies and his abnormal behaviours started
after few months. Then he was taken to a rehabilitation center (Moonlight foundation) by his
uncle and mother. He was treated there for four months. Then he taken back to the home, after
coming home, the patient became very ill, he felt weakness, always sleepy, heaviness in the
head, nauseated after eating food. He has a history of running out from rehabilitation center
and home which is not disclosed by the patient, this history is obtained from clinical record of
the patient. The patient says that as the rehabilitation center was a private institution and his
family was unable to bare the expenses, that’s why he was brought to the Pavlov Mental
Hospital by his uncle. Since then, he was under continuous treatment and diagnosed with poly
sustanc abuse. Now his condition is stable and he was involved in various ward activities and
occupational activities provided in Pavlov hospital.

AIMS AND OBJECTIVES OF INTERVIEW

Patient’s point of view:

 To be able to quit substance consumption
 To help the patient to develop insight
 To help the patient to change his attitude towards life
 To develop healthy coping strategies.
 To be able to do proper communication with significant others.
 To be able to socialize to others.

Student’s point of view:

 To gain the patient’s confidence and get his cooperation.
 To established rapport with the patient.
 To identify the patient’s problem.
 To know about the patient’s illness and understand the psychodynamic of the illness.
 To develop skills in conducting interview.

INTERVIEW

For day 1
 Date: 22. 03. 2022
 Time: 9:30 AM
 Duration: 30 Minutes
 Place of interaction: Male Psychiatric Ward, Pavlov Mental Hospital, Kolkata
  Description of Environment: Calm and quite environment where patient can share his
feelings freely with face-to-face communication.
 Reason for selecting the patient: To facilitated the changes of behavior.

Specific objectives:
 To gain confidence of the patient
 To collect psychiatric history of the client
 To assess the condition of the patient
 To identify patient’s problem

Participants Conversation Technique Non-verbal Inference

used communication
Nurse Good morning Souvik babu, Greeting Making The patient
Kemon achen? observation answer in slow
Patient ‘Good morning didi, valo achi.’ monotonous
voice.
His mood is
incongruent
with his affect.
Nurse Kintu apnake to dekhe mone Pinpointing Smiling
hochhena apni valo ache, eto sad
keno?
Patient ‘Na na sad kothai, valo achi to’
Nurse Acchha, Breakfast korechen? Questioning Nodding head
Patient ‘Ha’
Nurse Ki chilo aj breakfast e? Broad Maintains eye Her immediate
Patient ‘Oi protidin ja dei! Pauruti, dim, opening contact memory is
kola r doodh’ intact
Nurse Sei to! Protidin eki khabar khete Restating Smiling
valo lage naki karor?
Patient ‘Valo na lagle r ki kora jabe, ja dei
tai khete hobe.’
Nurse Achha osudh keyechen apni? Questioning Nodding head
Patient ‘Ha.’
Nurse Snan kora hoyni mone hochhe Clarifying Nodding head
Patient akhno?
‘Na, ektu pore korbo’
Nurse Akhon ki korben? kichu kaj ache Broad Active listening
apnar? opening
Patient ‘Na, akhn kichu nei, ektu pore oi
Anjalir lok jon asbe tokhn block
print er kaj suru hobe’
Nurse Akhon to tahole kichukkhon somoy Offering self Maintains eye Patient was
ache apnar kache, tahole amra ektu contact cooperative,
kotha boli? but sounds in
Patient ‘Ha, bolun.’ slow voice.
Nurse Achha Souvik babu apni ekhane Exploring Patient’s
kotodin achen? attention was
Patient ‘Ager bochor May mase normally
esechilam.’ aroused.
Nurse Tokhon theke continuous ekhanei Pinpointing Sad face, head
acho naki bari jaowa hoyechilo down,
majhe? observation
Patient ‘Na na. bari theke keo nite aseni’
Nurse Acchha barite ke ke ache? Questioning
Patient ‘Amra mamabarite thaktam. Maa,
mama, mamima r mamar chele
ache’
Nurse Mamabarite keno thakten apnara? Exploring Head down.
Patient Apnar baba nei?
‘Na. baba choto belatei mara geche.
Tarpori mamabarite chole jai amra’
Nurse Oh! Apanar baba mara gelen Focusing His remote
Patient kivabe, ki hoyechilo onar? memory is
‘kichu hoini. Accident e mara intact
gechlo.’
Nurse Oh, tahole apnar baba mara jabar Clarifying Nodding head
por apnara mamabarite shift hoye
jan taito?
Patient ‘Ha’
Nurse Acchha apnar babar kotha mone Reflecting Nodding head Feeling sad
Patient pore?
‘Ha majhe majhe mone pore.’
Nurse Apnar maa kono kaj koren naki Questioning Maintains eye
Patient housewife? contact
‘Na, housewife’
Nurse Apnader somosto khoroch tahole Clarifying Nodding head
Patient mamai den?
‘Ha’
Nurse Accha souvik babu apni kotodur Questioning
Patient porasona korechen?
‘B. tech 2nd year complete
hoyechilo’.
Nurse Tarpor hotat ki holo majhe Pinpointing Sad face, Head His academic
porasona chele dilen keno? down performance
Patient ‘6th semester e back peyechilam was poor
duto subject e.
Patient Didi ami akhn snan kore asi, ektu Nodding head
pore to block print er kaj suru hobe?
Nurse ‘Ha aaj tahole jao, kala bar kotha
hobe.

Summary of day 1

 The patient was cooperative. His attention and concentration easily aroused.
 His general appearance was good and sometimes he maintains eye to eye contact during
communication but he speaks in slow and monotonous voice.
 Some predisposing factors are elicited like the patient lost his father in childhood, failure
in life, poor academic performance.
 He answers all the questions but always with a blunt facial expression.

For day 2
 Date: 23. 03. 2022
 Time: 9:30 AM
 Duration: 45 Minutes
 Place of interaction: Male Psychiatric Ward, Pavlov Mental Hospital, Kolkata
 Description of Environment: Calm and quite environment where patient can share his
feelings freely with face-to-face communication.
 Reason for selecting the patient: To facilitated the changes of behavior.

Specific objectives:
 To determine the precipitating factors behind his illness
 To assess the patient’s perception about the problem
 To encourage to the adaptive behavior of the patient

Participants Conversation Technique Non-verbal Inference

used communication
Nurse Good morning Souvik babu, aaj Greeting Maintains eye
mon Kemon ache? contact
Patient ‘Good morning. Valo achi.’
Nurse Brakefast, medicine khawa Questioning Nodding head
hoyegeche nischoi?
Patient ‘Ha’
Nurse Achha apni kal block print e ki Reflecting Maintains eye Patient was
banalen? contact able to do the
Patient ‘Duto curtain print korechi’ activities by
own self
Nurse Bah, besh valo! Ajo hobe naki Giving
block print er kaj? recognition
Patient ‘Ha hobe, oi 11 ta nagad suru hobe’

Nurse Achha souvik apni to engineering Questioning

poten, to ki stream chilo apnar?
Patient ‘Mechanical.’

Nurse Kon college e porten? Questioning

Patient ‘Techno India te’
Nurse Otato private institution, to tomar Exploring Active listening
porasonar khoroch o tomar mamai
diten?
Patient ‘Na, amader barita bikri kore
deowa hoyechilo, to okhan thekei
porasonar khoroch maa dito’

Nurse Pora sona korte bujhi ekdom valo Focusing Head down Answer in slow
lagtona? rate and low
Patient ‘valo lagto, kintu mone rakhte Observation pitch
partemna, tai marks kome jeto’
Nurse ‘College ba hostel e ki kono Exploring Active listening
problem hoyechilo karor sathe?
Patient ‘na na sekom kichu hoini, ami
hostle e thaktamna, barite thaktam’
Nurse Tarpor 6th semester apni back Paraphrasing Head down, Patient feeling
peyechilen bole porasona chere observing sad.
dilen tai to? behaviour
Patient ‘Ha’
Nurse Accha apni porasona chere dewar Broad Maintains eye
por ki korten? opening contact
Patient ‘koyekta tution poratam, tarpor ekta
shopping mall e salesman er kaj
peyechilam’
Nurse Bah! Khub valo to, apnar valo lagto Reflecting Sad face, He had no job
ei kaj gulo korte? observation satisfaction
patient ‘Ha kharap lagtona, er theke r valo
kicu paini’
Nurse Tuition poano to valo kaj, ete upset Giving Nodding head,
howar to kicu nei. recognition listening
Patient ‘Ha valoi to’
Nurse Apni to bollen apni shopping mall Paraphrasing Nodding head
eo kaj korten eki sathe tai na?
Patient ‘Ha valoi to’
Nurse Kotobochor shopping mall e kaj Questioning Maintains eye
korechen? contact
Patient ‘5 bochor hobe’
Nurse Tapor chere dilen keno? Exploring Maintains eye Looking very
Patient ‘Lockdown er somoy orai chariye contact sad
dilo’
Nurse Tarpor r kono kaj khojar chesta Focusing Head down He sounds very
koren ni? low.
Patient ‘Ha korechilam, paini’
Nurse Achha, ami sunechilam apni naki Clarifying Nodding head
nesha korten khub. eta ki thik?
Patient ‘Ha’ Observing
Nurse Keno nesha korten? Exploring Active The patient
Patient ‘Barite bekar bose chilam, kono kaj Listening, became very
chilona, valo lagtona kichu, making depressed after
financial problem hochhilo barite observation losing his job
setar jonno jhamela legei thako,
barite thakte ichhe kortona, tai
bondhu der sathe majhe majhe
nesha kortam.’
Nurse Ki ki nesha korten? Reflecting Observation
Patient ‘Cigarette, bear, ganja’
Nurse Apnar to kono rojkar chilona, Focusing Head down Patient looking
Patient tahole nesha korar taka kothai very sad and
peten? feeling guild
‘Dhar kortam, churi kortam bari
theke kokhno kokhno’
Nurse Chakri ta chole jaowar pori apni Exploring
protom nesha kora suru korechilen
naki naki er ageo kokhno nesha
korten?
Patient ‘Age majhe majhe cigatette
khetam.’
Nurse Achha nesha korar por apnar Reflecting Active listening
kirokm feeling hoto?
‘valoi lagto, tai to addicted hoye
Patient porechilam. Barite bekar bose theke
upset thaktam sobsomy, to segulo
vule jetam nesha korar por’
Nurse Apni kotodin dhore erokm nesha Focusing
korchilen?
Patient ‘prai 5 – 6 mas’
Nurse Tarpor ki holo, ekhane kivabe elen Theme Active listening Patient had
ektu khule bolben? identification insight about
Patient ‘Barite jante parlo jokhn khub his problem
jhamela suru holo, maramari,
jhograjhati, gali galaj esob choltei
thako. Ami majhe majhe bari theke
beriye jatam. Tarpor ekdin kali
pujor somoy neshar ghore parar
kichu cheler sathe khub marpit
hoyechilo taka poisar bepar niyei,
to sei ghatanar porei mama amake
moonlight foundation e vorti kore
ase, okhane 4 mas treatment howar
por abar barite niye jaowa hoi
amake’. Barite kichudin takar por
khub osustha hoye porechilam.
Tarpor ekhane niye asa hoi.
Nurse Accha apni bollen apni barite giye Restating Nodding head
khub osustha hoye porechilen. Tai
Patient to?
‘Ha’
Nurse Thik kirokom problem hocchhilo Focusing Active listening
ektu khule bolben?
Patient ‘khabar khelei bomi hoye jeto,
khete ichhe kortona, sobsomoy
ghum peto, matha vari hoye thakto,
majhe majhe hat paa kanpto,
thikmoto kothao bolte partam na’

Nurse Barite giye ki abar nesha suru Pinpointing Nodding head Patient had
korechilen? poor treatment
Patient ‘na na. medicine er side effect er compliance.
jonnoi hoyto hoyechilo’
Nurse Achha apnar ki akhon r kono Clarifying Maintains eye Patient is
somossa ache? contact feeling attach
Patient ‘na, akhon r kichu nei, Dr. boleche with family
barir lok elei chere debe.
Nurse Achha Souvik babu aaj tahole asi
kal abar kotha hobe?
Patient ‘Ha didi’

Summary of day 2
 The patient was cooperative and spontaneously disclose his feeling and problem.
 The precipitating factor of his problem is elicited.
 Some predisposing factors are also found like loss of job, family conflict, peer pressure.
 Before admission to this hospital, he was previously treated in a deaddiction center.
  Now his condition is stable and he takes active participation in the ward activities and
other occupational activities offered by Anjali (NGO)

For day 3
 Date: 24. 03. 2022
 Time: 10:00 AM
 Duration: 30 Minutes
 Place of interaction: Male Psychiatric Ward, Pavlov Mental Hospital, Kolkata
 Description of Environment: Calm and quite environment where patient can share his
feelings freely with face-to-face communication.
 Reason for selecting the patient: To facilitated the changes of behavior.

Specific objectives:
 To restore the adaptive behaviour
 To help the patient to bring confidence into him
 To improve his communication skill
 To confront the patient to the reality

Participants Conversation Technique Non-verbal Inference

used communication
Nurse Good morning Souvik babu, Greeting Maintains eye His social
Kemon achen? contact, smiling judgement is
Patient ‘Good morning Didi. Valo achi.’ intact
Nurse Aaj sokal theke ki ki korlen? Broad
‘brakefast korlam, medicine opening
Patient khelam, tarpor snan korlam’
Nurse Aaj to block print er kaj nei, erpor Broad Maintains eye
ki korben? opening contact
Patient ‘Aaj Anjalir ekta meeting ache
seminar hall, tar jonno projector set
korte jabo ektu pore’
Nurse Bah! Apni to dekhchi ekhane onek Giving Smiling Willingly
kaj sikhe felechen? recognition participates in
Patient ‘Ha’ various
activities
Nurse Accha apni ager di bollen dr. Paraphrasing Head down He feels sad
boleche barirlok ele apnake chere
debe, to apar barir lok aseni dekha
korte?
Patient ‘Na. ekhane asar por maa ekbar
esechilo dekha korte, tarpor r keo
aseni.
Nurse Apni jogajog korar chesta koren ni Clarifying Maintains eye
tader sathe? contact
Patient ‘Ha Anjali ke bolechi ora contact
korbe boleche’
Nurse Achha apni kichu vebechen bari Broad Maintains eye Wish to take
diye ki korben? opening contact, active responsibility
Patient ‘Ha ekta kaj kujbo, tarpor barite listening
thakbo. Jodi bari theke keo nan iye
jai Anjali boleche amader koyekjon
ke home e pathabe.
Nurse Apnar erokm keno mone hochhe je Reflecting Making
bari theke keo niye jabena? observation
Patient ‘onekdin dhore to contact korar
chesta kora hochhe, keo to response
korchena.’
Nurse Se jai hok bari giye abar ager moto Pinpointing
nesha kora suru korben na to?
Patient ‘na na chere diyechi”
Nurse Achha ekhane apnar kotojoner Broad
sathe bondhutto hoyeche? opening
Patient ‘Onekei ache. Pronob, pintu ache,
milan dao ache.
Nurse Bah! Onek bondhu to. Achha Broad Maintains eye He willingly
ekhane saradin kivabe somoy opening contact given answer
katche apnar?
Patient ‘Sokal bela ghum theke uthe
khwadawa, snan sereni; tarpor jrdin
anjalite kaj thake sedin kori,
onnodin gulo konodin gardening er
jonnonjai noile karam kheli, golpo
kori, dupur bela Anjali te cinema
dekhi kono kono din’
Nurse Meditation, exercise egulo korano Clarifying Nodding head
hoina ekhane?
Patient ‘Ha Anjali te class hoi majhe
majhe, r didira jokhn korai tokokno
kori.
Nurse Majhe majhe sudhu class e korlei Giving Nodding head
hobena, keo na koraleo nijekei information
regular practice korar habit korte
hobe.
Patient ‘Ha’
Nurse Achha Souvik babu discharge er Suggesting, Active listening, He
por apni jekhanei jan home e ba sharing maintains eye demonstrates
nijer barite sekhane giye, ekhan perception contact understanding
theke jegulo sikhechen segulo vule about the fact
gele kintu cholbena, mone rakhte
hobe. Ei je ekhane jerokom
responsibility niye kaj koren, barite
giyeo segulo kore hobe. Protidin
ektu exercise korte hobe, thik
somoye khabar khete hobe, somoy
moto medicine o nite hobe, poriskar
porichhono thakte hobe, follow up
er jonno aste hobe periodical basis
e. Age je apni nesha gulo korte
segulo je valo jinis noi seta to apni
bujhte perechen, tahole oguloke
ekebarei bad dite hobe jibon theke,
tobei to sustho thakben tai na? r
sobsomoy sobkichute upset hoye
gele ba dukhho pele to cholbena;
amader sathe sobsomoy sotsi valo
hobe tar to kono mane nei, valo
kharap misiyei to jibon. Tahole
amader sobtakei accept korte hobe
r sevabei egiye jete hobe. Tobei to
amara valo thabo r onnokeo valo
rakhte parbo. Ki jegulo bollam
mone thakbe to?
Patient ‘Ha nischoi mone rakhbo’
Nurse Ha mone to rakhtei hobe, r korteo Greeting Nodding head Social
hobe nijeke. Jai hok Souvik babu judgement is
khub valo laglo apanar sathe kotha intact
bole. Valo thakben.
Patient ‘Ha didi. Thank you. Apnio valo
thakben’

Summary of day 2
 Patient’s general appearance was well groomed.
 He was very cooperative, spontaneously gives answers and able to express his real
feelings.
 He had insight about his problem
 He develops adaptive behaviour and voluntarily participate in various word activities.
 He esblished good relationship with others members in the word.
 Now he does not exhibit any abnormal symptoms.
 Now his condition is stable and he wishes to go home.
INTERVIEW TECHNIQUES USED
Verbal
i) Direct questioning
ii) Paraphrasing
iii) Restating
iv) Clarifying
v) Broad opening
vi) Focusing
vii) Pinpointing
viii) Reflecting
ix) Sharing perception
x) Suggesting
xi) Theme identification

Non verbal
i) Listening
ii) Nodding head
iii) Maintaining eye contact
iv) Head down
v) Observing
vi) Smiling
vii) Greeting

CONCLUSION
Interview skills for process recording are developed gradually. I was able to win the patient’s
confidence. The problem identified was Poly substance abuse with symptoms of depression.
Gradual and subsequent interaction will help the client to overcome his problem.