BIODATA OF PATIENT:NAME- PAUL RAHI AGE- 34 YEARS SEX- MALE UNIT NO.

- C- 7385124 WARD- 16 EDUCATION- GRADUATION OCCUPATION- LAB TECHNICIAN MARIETAL STATUS- MARRIED RELIGION- CHRISTIAN DIAGNOSIS- ALCOHOL DEPENDENCE DATE OF ADMISSION- 11-6-12 DOCTOR INCHARGE- DR. SANDEEP GOYAL CHIEF COMPLAINTS:34yr. Old Paul Rahi brought to hospital with chief complaints of: EPISODES OF SEIZURES since one day PALPITATION since one day RETROSTERNAL PAIN since 6days UNEASINESS since 1 week MULTIPLE EPISODES OF VOMITING since one day TREMORS since 2 weeks

PRESENT HISTORY:- patient was apparently well one week ago when he had episodes of seizure at home following with vomiting. The patient was brought to casuality. Patient was admitted in ward 23 then was transferred to ward 11 and then was reffered to psychiatric ward. PAST HISTORY:-

MEDICAL HISTORY:- No significant past medical history of DM, HTN, TB etc. SURGICAL HISTORY:- No significant history of accident and trauma in past PSYCHIATRY HISTORY:- Patient was drinking alcohol since 10yrs but start taking more since 1 yr approx 1 bottle daily start from morning. Then patient was taken to deaddiction centre mundian in 2009 and patient had abstinence of alcohol till 2011. Then due to family problems he again started taking alcohol.

FAMILY HISTORY:FAMILY TREE-

FATHER:- Mr. J. A. Rahi, 76 years old, retired employee of CMC blood bank, h/o asthma, hypertension; no h/o of any psychiatric illness; shares good bonding with the patient. MOTHER:- Mother died at the age of 52 years, in 2003, after 2-3 months of elder sons death; there was no h/o any psychiatric illness. She was close to the patient. Sister:- Rubina; 45 years old, graduate worked as teacher at Wylie school; no h/o any medical or psychiatric illness, good bonding with the patient. Brother:- Bobby Rahi; 34 years at the time of death; there was addiction of fortwin and alprex; and there was h/o Polydrug abuse . WIFE :- 28 years old ; had done graduation worked as teacher ; she have no history of any medical or psychiatric illness.

PERSONAL HISTORY:-

Prenatal & Birth history:- Mother was normal during birth of the child. Patient born by NV D premature at 7months. Breastfeeding was done at 6months. Early development:- He was normal during childhood achieved all milestones at appropriate time. Childhood history:- He was introvert, shy in nature had limited friends, but participation in social activities is appropriate. Neurotic traits:- No history of neurotic traits like bed wetting, nail biting etc. School history:- He was average at school time . studied till graduation. No history of frequent school change. Marital history:- He is married

PREMORBID HISTORY: Paul Rahi was introvert personality less talkative. Patient doesnt like to visit any relative . Interaction with new people is less. he makes few friends but social interaction is good. Patient is involved in religious activities. Patient is slow learner. Patient was having addiction of alcohol and tobacco chewing and he is non vegetarian. Patient likes to play out-door games like cricket, he also likes to listen music OCCUPATIONAL HISTORY:- Patient was working in his own lab as lab technician . History of frequent change in job is present. MARITAL HISTORY:- He is married. Married at age of 30 yrs. Marriage was arranged and patient had good relations with his wife. Had no children. OBSERVATION AND PHYSICAL EXAMINATION:- Thin built, short height moderate look and introvert. Physically patient doesnt has any abnormality. Maintain less eye contact and smile occasionally. Patient looks anxious due to family conflicts with father and wife is also not supporting him. Maintain hygiene and perform daily activities independently.

MEDICATION CHART:MEDICATION Tb. Dilatin Tb. Pantop Tb. Ativan Cap. Tramadol DOSE 100mg 40mg 2mg 40mg ROUTE Oral oral oral oral ACTION Anticonvulsants Antacid Anxiolytics Analgesic

T. Acamprosate

250mg

Oral

Anticraving

MENTAL STATUS EXAMINATION: General Apperance: Facial Expression : appropriate changes with change of subject Posture : slightly bend Mannerism : raising eyebrows, repated blinking Dress : patient dresses neatly appropriately according to season Hygiene : patients personal hygiene is maintained Physical Feature : looks appropriate to age , no physical deformity Motor Disturbance: motor retardation

Disorder of Speech & Thought:Retardation: slowing of speech Disorder of Thoughts: were absent. Disorder of Perception:- no hallucinations or illusions are present Disorder of Memory:a) Immediate: b) Recent: c) Remote: Orientation:a) Oriented to Persons and Place b) Disoriented to Time c) Insight:- Present present present present

d) Concentration:- Poor e) Judgement:- fair f) Sleep:- sleep is adequate for 6-8 hours

ALCOHOL DEPENDENCE Dependence: A compulsive or chronic requirement. The need is so strong as to generate distress (either physical or psychological) if left unfulfilled.

Substance Dependence Physical Dependence: Physical dependence on a substance is evidenced by a cluster of cognitive, behavioral And physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems. (APA 2000). Psychological Dependence:

An individual is considered to be psychologically dependent on a substance when there is an overwhelming desire to repeat the use of a particular drug in order to produce pleasure or avoid discomfort. Alcohol dependence is more common in males and has an onset in late second or early third decade. The course is usually insidious. Therefore is often an associated abuse or dependence of other drugs. If the onset occurs late in life especially after 40 yrs of age an underlying mood disorder should be looked for. PREDISPOSING FACTORS: Biological Factors: Genetics: children of alcoholics are three times more likely than other children to become alcoholics. Monozygotic twins have a higher rate than dizygotic. Biochemical Factors: second biological hypothesis relates to the possibility that alcohol may produce morphine like substance in brain that are responsible for alcohol addiction. Psychological Factors:

Developmental Influences: it focuses on a punitive superego and fixation at the oral stage of psychosexual development. Personality Factors: personality traits such as low self esteem, frequent depression, passivity, the inability to relax, inability to communicate effectively are common in individuals who abuses substance.

Socio cultural Factors: Social Learning: the effects of modeling, imitation, and identification on behavior can be observed from early childhood onward. Family appears to be important influence. Peers often exert great deal of influence and co-wokers in work setting. Conditioning: substance create a pleasurable experience that encourage the use to repeat it. it is the intrinsically reinforcing properties of addictive drugs that condition the individual to seek out their use again and again. Cultural and ethnic influences: Availabilty of drugs in community, and patterns of consumption based on cultural acceptance, and determing the availabilty of the substance. CAUSES IN PATIENT: 1. Personality factors 2. Social learning 3. Conditioning 4. Cultural and ethnic influence Complications: 1. Acute intoxication: There is generalized CNS depression with alcohol use increased in reaction time, slowed thinking, poor motor control and later ataxia and incoordination occur. there is progressive loss of self control with frank disinhibited behavior. 2. withdrawal syndrome: A. Early or Minor withdrawal: The severity of the early alcohol withdrawal symptoms varies with both the amount of consumption and duration of use. The earliest symptoms are insomnia, and vivid dreaming.

Within 48 hrs minor symptoms such as anxiety, tremors, anorexia, nausea, vomiting, insomnia, sweating and tachycardia appear. Of alcoholics in withdrawal 5 to 15% develop seizures. More than 90% of seizures occur between 6to 48hrs after cessation of drinking and are usually grandmal type. In Patient symptoms present: insomnia anxiety tremor anorexia, seizures

Late or Major Withdrawal (Delirium Tremens): Within in first five days of abstinence highest period of risk being between 72 to 96hrs. The signs and symptoms are delirim with severely imparied sensorium, marked autonomic hyperactivity (tachycardia, hypertension, tachypnoea fever, sweating) coarse tremors, vivid hallucinations (visual or tactile), changing levels of psychomotar activity. Nightmares and insomnia are common. Dehydration and electrolye imbalance. The condition is life threateing if not treated. 3. Alcoholic seizures (rum fits): Generalized tonic clonic seizures occur in about 10% of alcohol dependence patients usually 12 to 48 hrs after heavy bout of drinking. 4.Alcoholic hallucinosis: Alcoholic hallucinosis is characterized by the presence of hallucinations (auditory) during partial and complete abstinence following regular alcohol intake. 5. Neuropsychiatric complications of chronic alcohol use: a. wernickes enecephalopathy: deficiency of thiamine. . Korsakoffs psychosis: Gross memory disturbances with confabulation. Insight is often imparied. 5. Other complications: a. Alcoholic dementia

b. Cerebellar degeneration c. Peripheral neuropathy d. Central pontine myelinosis Treatment: 1. Behavior therapy 2. Psychotherapy 3. Group therapy 4. Deterrent agents 5. Anti- craving agents (Acamprosate, naltrexone and SSRIs) 6. Other medications (benodiazepines, antidepressants, antipsychotics, lithium, carbamazepine, and even narcotics have been tried. In patient: Individual psychotherapy was done to educate the patient for risk of taking alcohol use and asked him how he can control to avoid alcohol. 2. Group therapy 3. Cognitive therapy (Daily Record Dysfunctional Thoughts DRDT) 4. Benzodiazapines (Ativan) SOCRATS Scale was applied to check the motivation for quiting the alcohol Nursing Management: Assessment: History taking Mental status examination Mini-mental state examination Therapeutic sessions- 2 To find out the cause of addiction. To find out cause of relapse.

Nursing diagnosis: 1. Ineffective coping related to inadequate coping skills and weak ego as evidenced by use of substances as a coping mechanism. 2. Fluid volume deficit less then body requirement related to less intake of fluids. 3. Low self esteem related to failure to full fill role expectations. 4. Lack of effective interpersonal relationship related to alcohol use and irresponsible behavior patterns.

NURSING CARE PLAN:

S.No.

Nursing diagnosis
Ineffective coping related to inadequate coping skills and weak ego as evidenced by use of substances as a coping mechanism.

1.

Expected outcome Client will able to verbalize adaptive coping mechanisms to use, instead of substance abuse, in response to stress

planning
1.To set limit on manipulative behaviour.

Nsg Implementation 1. Set limit on manipulative behaviour. Told about consequences when limit are violated.

Rationale Because of weak ego and delayed development client is unable To establish own limit and had craving. Client may have substance from various sources while in treatment. Because gratification has been closely tied to oral needs it is unlikely that client is aware of more adaptive coping strategies.

Evaluation

2.To explore

Options available to overcome stress rather then to use substance

2. Explore options available to assist with stress rather then resorting to substance use. Practice these techniques.

Client will adopt various adaptive coping mechanism to over stress and delay the craving of substance.

3. To give positive reinforcement to respond stress with adaptive coping stragies

3.Give positive reinforcement for ability to delay gratification and respond to stress with adaptive coping strategies.

Because of weak ego client needs lots of positive feedback to enhance self esteem and promote ego development.
Fluid volume deficit less then body requirement related to less intake of fluids.

2.

Client will be free of signs and symptoms of dehydration

1.To give parenteral support if required. 2.To encourage the patient to take more fluids like lemon water , juices etc. 3.To maintained strict intake output chart.

1.Start IV fluids if required. 2.Encourage the patient to

take more fluids like lemon water, juices etc. 3.Maintained strict intake output chart.

To correct fluid and electrolyte imbalance.

Client will maintain adequate hydration status.

4.Assess the early signs of dehydration.

Low self esteem related to failure to full fill role expectations.

1.To encourage client to identify behaviours that have caused family problems. 2.To involve the client in Client will group to express provide feelings openly confrontation, and identify and give his roles positive towards reinforcement family. for participating

1.Encourage the client to identify behaviours that causes family problems. 2. Do not allow client to rationalize or blames problems to others. 3. Redirect the client to focus on his role functioning and expectation of family. 4. involve the patient in group activity and give positive reinforcement in group participation and sharing views.

Client will aware of his problems and role confusion. It will enhance the self esteem of client.

Self esteem will enhanced .

4.

Lack of effective interpersonal relationship related to alcohol use and irresponsible behavior patterns.

Client will able to maintained the effective interpersonal relationship.

1.To encourage the client to explore alternative ways for dealing with stress. 2. To help the client to develop skills in problem solving and implementing solutions.

1.Encourage the client to explore the alternative ways for dealing with stressors. 2. Help the client to develop the skills in problem solving approaches and implementing solutions. 3. Help the client to express his feelings in acceptable ways and give positive reinforcement. 4. Avoid discussion of unanswerable questions such as why the client uses substance.

Client will know about adaptive ways to overcome stressors. Client will able to maintained effective relationships.

Client enhance the effective interpersonal relationship.

PROGRESS REPORT:12TH

June : Patient was not oriented to time and place. Having loss of appetite. Having hand tremors and having slurred speech. 13th June: Patient is oriented to person and place not to time. Have slept well. Taking less fluids and oriented about disease condition.
14th

June Patient is oriented to time place and person. Slept well. Take adequate fluids. Know about disease condition and motivated to quit alcohol. DISCHARGE TEACHING: Deciding alternatives for stressful situations Risk of taking alcohol

Follow up Motivation enhancement therapy Assertive technique Support system Drug Compliance

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