PROCESS RECORDING

I DEMOGRAPHIC DATA

Name : S D Mane

Rank: Civ

Age :57yrs

DOA : 14.11.2015

Diagnosis : Mania with Psychotic Symptoms

Sex : Male

Marital status : Married

Religion : Hindu

Occupation : Business

Address : Vill: Ramnagar, Distt- Maharanipatta, Vishakhapatnam

Socio Economic Status :Belongs to a low socio economic status

family. Main source of income is the client only.

Informant: Self, documents, unit personnel.

Information :

1. Self : Reliability fair

2. Old documents: Reliability good

ii) NURSING PROBLEMS IDENTIFIED
 Suspiciousness about fidelity of wife

 Exaggerated fear related to loss of job and future plans

 Changed physiological status related to palpitation

 Lowered self esteem related to loss of job

 Altered socialization related to loss of interest in surroundings

 Disturbed sleep pattern related to tension worry and feeling of

apprehension

 Low self concept related to disease condition.

 Altered nutrition less than body requirement related to

decreased appetite

 Altered body function related to loss of appetite.

 Impaired self image related to unemployment, lack of money,

decreased libido and lack of support from family members

 Risk of ineffective role performance due to lack of self

confidence.

 Interrupted family process related to incomplete sexual

intercourse.

 Ineffective individual coping related to changed self concept.

 Ineffective family coping related to unemployment, lack of

money and his psychiatric illness
iii) OBJECTIVES OF INTERACTIONS BASED ON THE PROBLEMS
IDENTIFIED & LEARNING NEEDS OF

CLIENT

 To help patient to overcome anxiety and prevent systemic

complication

 To protect the patient from self harm

 To help the patient to have adequate sleep and prevent

exhaustion

 To help the patient to develop effective coping.

 To maintain fluid and electrolyte imbalance

 To increase intake of food and improve nutritional status.

 To improve socialisation.

 To help patient to use his communication abilities and

overcome anxiety

 To enhance self concept.

 To improve family support

 To feel secure and have less anxiety.

 To provide protection.

 To assist in personal care.

 To improve sleep pattern.

 To divert patient’s attention from sickness.

 To encourage patient to lead a meaningful family & social life

 STUDENT

 To develop rapport with the patient.

 To provide therapeutic environment to the patient.

 To develop therapeutic nurse-patient relationship

 To develop skill in history taking & MSE of the patient.

 To exercise various techniques of therapeutic communication.

 To identify the various symptoms present in the patient.

 To develop skill in active listening & thereby diagnose &

assess the prognosis.

iv) PERSONAL HISTORY

Birth: 42 years of age, first order in siblings. Born by normal

delivery. Both prenatal & postnatal period was uneventful.

Milestones: Developmental milestones were normal. Started walking

by 01 yr and going to school at 05yrs. He was toilet trained at 03

yrs.

Schooling: Studied upto 10 +2.Average in studies. Use to maintain

control relations with schoolmates. No h/o pica, truancy, conducts

disorder or a school dropout.

Peer Influence: Used to maintain healthy relationship with peers and

others

Sexual History:
No h/o extra or premarital sexual exposure, no h/o STDs

Family History: Both parents expired, father died of MI, mother

suffered psychiatric illness at the age of 93 years.

Marital History: Got married in 2007, arranged non-consanguineous

marriage.
Wife had 02 abortions between the year 2008-2011 and still birth in
2011. No living issues

Occupational History: Joined army soon after passing out from

school, no punishment or awards

v) HISTORY OF ILLNESS

Presenting complaints

Admitted to the hospital on 2 oct 2015 with complaints of

 Tension, worry and feeling of apprehension
 Reduced sleep
 Palpitations since many
 Low mood years
 Loss of interest in surroundings
 Sexual dysfunction since one year

Present history of illness-

Client was apparently till 1993 when he joined army training centre
and was doing well
He use to play boxing and was representing his unit and was doing
well, but in one interdiv match he lost the game, and was very upset
and ashamed of this his unit people was very annoyed with his
performance and started telling him that he intentionally lost the
match, they start isolating him. Client felt ashamed of his loss, but
tried to participate in training activities as before

Client was slapped multiple times by JCO and officer of the platoon
after he was found guilty in a minor incident ( Client had disclosed
the details of a telegram to his friend which contained information
about his ailing mother)

Got injured, had bleeding from his ears and reduced hearing and
tinnitus was told to show to civil ENT specialist, ENT specialist
advised him operation if symptoms does not resolve in a week

On non-resolution of the symptoms, client reported to MH, where the

doctor identified the cause and told him to write a complaint and
the matter was taken up administratively. Client was discharged
after conservative management

Client started remaining fearful in unit. He gradually started

experiencing palpitation and hyperventilation for which he was
hospitalised multiple times

During one admission client complained of intense anxiety to the

doctor, he told that he would commit suicide than going back to unit
where he is constantly being harmed

Referred to CHAF Bangalore and diagnosed as ‘Anxiety State’ and

was treated with anti-anxiolytic and counselling responded poorly.
He was boarded out from the service in Nov 2013 with 20%
disability pension for next 02 years
He felt low and shameful as he lost his job, family members were
quite disappointed as he lost his job and they often use to taunt him
for loosing job and dependent on others. He use to feel dull with
lack of interest=t and loss of appetite. Occasionally use to feel
intense anxiety and palpitation and was relieved by Tab Librium

Started working in various security firms as supervisor but pay was

less and he kept on changing the job

first RSMB was carried out in 1995 at INHS Kalyani, where

specialist opinion was that his status had remain unchanged med
board assessed the disability to be 20% aggregated by medical
service

But accepted by PSA as <20%

During RSMB treatment changed from Tab Librium to Tab

Alprazolam

Initially he used to take 0.5 mg to 1mg of Tab Alprax to reduce his

symptoms of tremors and palpitation which he gradually increased
to 5mg by 1999 without any consultation

during the same time client suffered a financial loss in a fast food
outlet that he started and became dependent on his brother who
abuses him verbally for being unemployed in such incident client
felt intense anxiety and worthlessness and slashed his both forearm
and abdomen with knife and left home with an intention to die but
reported to the MH and was treated on OPD basis
He continued taking tab Alprax and increased the dose to 5.0mg a
day

In 2002 he was admitted in INHS Kalyani for second RSMB, he

stopped taking medicine on admission and developed intense
tremors of hands, Palpitation and felt unconscious in ward and
managed conservatively his disability was assessed RSMB was held
and decided to have 30% disability and was decided not have
further RSMB

Revised by accounts officer pension as <20%

2002-2009 continued working as security staff remained to be

symptomatic and increased the dose of Tab Alprax to 7.5 mg, got
married in 2007

In 2009 he consulted a civil hospital ‘The Mind Hospital’ in Orissa,

where he had reported to have thoughts that people are talking
about him, vague fear and tremors, he disclosed his habit of talking
Benzodiazepine

He was told that he has become dependent on Benzodiazepine and

was started on Tab Divalprox sodium, tab Olanzipine and tab
clonazepam he tolerated well these drug and use to go for review
every 6 months and is currently on same drug

a year back the client has been diagnosed as a case of diabetes and
hypertension and is taking medicine from ECHS hospital, gradually
he developed loss of erection and could not complete intercourse,
due to this the client used to remain low and feel helpless over the
past 9-10 months he reported feeling of passive suicidal ideas.

PROCESS RECORDING

 DAY 1
  DATE: 6.11.2015
 SETTING: BEDSIDE
 WARD: PSYCHIATRIC

Objectives to be attained

 To take consent for process recording.

 To develop therapeutic relationship with the patient.

 To identify his needs.

 To encourage the patient to verbalise his thoughts & feelings.

 To observe patient’s behaviour.

Participant Verbal & Non verbal Inference Technique used

communication
Nurse: Good morning kaise hai Client Open ended
aap? kya naam hai aapka becomes statement
alert and sits Broad opening
Client: Good morning madam on the bed
acha hoon madam, mera Gait normal
naam Ravi hai

Participant Verbal & Non verbal Inference Technique used

communication
Nurse Breakfast kiya aapne? Immediate Social
kya tha breakfast memory responding
mein? intact
Client:
Ji madam kar liya
breakfast wahi tha
madam puri thi sabji thi
aur chai

Nurse: Ghar mein apke kon kon Maintaining Social

hai? eye contact responding
Client:
Main aur wife hai Open ended
Nurse: question
Bache? Apke mata pita
Client: bhai behan Silence(non
verbal
Bache nahi hai. Do bhai communication
aur teen behan hai main by nodding
sabse chota hoon head)
Nurse: Kaha tak padhai kiya hai Maintaining Open ended
apne? eye contact question
Client:
12th pass hoon madam
Nurse: Aap yehan kab admit hue Immediate Self disclosure
the? Aapko kya memory
pareshani hai? intact
Client:
Madam main yehan do
tareekh ko admit hua tha
main RSMB ke liye admit
hua hoon.
Madam mujhe bahut
ghabrahat hoti hai, haath
kapte hai aur dil ki
dhadkan tej ho jaati hai
aur kuch dino se neend
aur bookh nai lag rahi hai

Participant Verbal & Non verbal Inference Technique used

communication
Nurse: Kal raat ko kaisi neend Client Validating
aayi apko? looking
Client: anxious and Observation
Madam neend theek se apprehensive
nai aati hai mujhe bahut
baar jagta hoon
Nurse: Aapko ye problem kab se Remote Direct
hai? memory questioning
Client intact
Madam ye problem toh Client
mujhe 1993 se hai looking down
regular medicine pe
hoon.

Nurse: Aapko ye problem 1993 Client Reflection

 se hai tabse aapko iski listening and
dawai chal rahi hai? nodding head Clarification
Client: Remote
Ji madam 1993 se main memory General lead
treatment le raha hoon. intact
Main is bimari ki wajah
Nurse: se board out ho gaya tha
nov 2013 mein.

Acha

Nurse: Ravi ji aap bahut jayda Client Purpose

tension lete hai aap kisi listening and
baat ko lekar pareshaan nodding head Advising
ho jaate hai aur uski
wajah se aapko neend
theek se nai aati, aap
sone se pehle poja kare
Client:
aur din mein bilkul bhi na
soye ho sake toh thoda
meditation kijeye.

Ji madam koshish
karunga

Participant Verbal & Non verbal Inference Technique used

communication
Nurse: Acha toh Ravi ji apne Summarizing
mujhe bataya ki aap 2 Client
oct ko admit hue the, nodding head Reassurance
aapka bimari 1993 mein
deduct hui thi aur iske
liye aap medicine le rahe
hai. Theek hai abhi round
ka samay ho gaya hai
Client: main aapse baad mein
baat karti hoon. Aapko
kuch poochna ho ya kuch
pareshani toh aap pooch
sakte hai.
 Ji madam jaruru. Thank
you madam

 DAY 2
 DATE: 20.08.2015
 SETTING: BEDSIDE
 WARD: PSY

Objectives to be attained:

 To develop therapeutic relationship with the patient.

 To identify his needs.

 To encourage the patient to socialise.

 To observe patient’s behaviour.

Participant Verbal & Non verbal Inference Technique used

communication
Nurse: Goodmorning Ravi ji Kaise Client Observation
hai aap? smiling Open- ended
Client: Theek hoon madam and questioning
answering
Nurse Breakfast kiya aapne? kya Immediate Social
tha breakfast memory responding
mein? intact
Client:
Ji madam kar liya
breakfast

Nurse: Kal raat ko kaisi neend Client Validating

aayi apko? looking
Client: anxious Observation
Madam neend theek se nai and
 aayi haikal bhi bahut baar apprehens Reflection
jaga hoon ive

Nurse: Hmm aapko dekh kar lag

raha hai apko neend nahi
aayi

Nurse: Kal aap mujhe apni bimari Client Linking

ke bare mein bata rahe the looking
kya aap mujhe shuru se anxious Pinpointing
batange ye problem kab
aur kaise shuru hui aapne Clarifying
iskliye kab report kiya
thoda detail mein General lead
bataayenge aap?

Client: Madam ji jaise ki maine

apko bataya tha ki ye
problem mujhe 1993 main
shuru hua tha main training
kar raha tha sabkuch bilkul
theek chal raha tha main
bahut kush tha apni job se,
unit ki taraf se main games
khelta tha lekin ek baar
main match mein haar gaya
aur uski wajah se unit wale
mujhse naraj ho gaye
mujse alag rehne lage,
mera unit ka JCO aur ek
officer ne thapad mara jiski
wajah se mere kaan mein
problem ho gaya main civil
mein check up karaya lekin
theek nai hua, phir maine
MH mein dikhaya aur unko
bataya ye sab kaise hua
uske baad mujhe unit se
bahut dar lagne laga, unit
ke naam se mujhe bahut
ghabrahat, darr, haat kapna
 aur dil ki dadkan badna
suru ho gaya aur main
behosh ho gaya, doctor ne
mujhe psychiatry ward
mwin refer kiya aur mera
medicine shuru kiya aur
phir mujhe board out kar
diya abhi main Rsmb ke
liye admit hua hoon.
Nurse: Family mein kisiko koi Client Linking
bimari listening
the Reflection
Client: Nai madam koi bimari nai question
hai Paraphrasing

Nurse: Koi bimari nai hai jaise Validating

diabetes, hypertension,
tuberculosis. Aapke father
ko ya mother ko, bhai
behan ko??
Client:
Nai madam abi tak toh aisa
kuch nai hai

Participant Verbal & Non verbal Inference Technique used

communication
Nurse: Aapko koi aur bimari iske Client Clarification
alawa? looking
Client: Ji madam pechle saal down and
mujhe pata chala hai ki answering
mujhe diabetes hai aur
hypertension bhi iske liye
medicine le raha hoon
Nurse: Aur koi bimari iske alwa? Client Pinpointing
hiding his
Client: Nahi sexual Conflict
problem
Nurse: Sahi mein koi aur bimari Reassuring
toh nai agar aap mujhe
batate hai toh main apki Clarifying
help kar sakti hoon.
Client:
madam aur koi problem nai
hai
Nurse: Achha ye batao aajkal Client Changing the
news main kya naya hai looks up subject

Client: Cricket chal raha hai india General Social

ka test match chal raha hai awarenes responding
s present
General lead
Nurse: Ok, good

Nurse: Ok Ravi ji aaj toh aapne Client Social

mujhe bahut kuch bataya nodding responding
apke bare mein, kal main head and
apko apki bimari ke bare listening Patronizing
mein bataungi aur agar
apko koi jankari chahiye
toh aap mujhse pooch
sakte hai
Client:
Ji madam

DAY 3; DATE: 21.08.2015; SETTING: BEDSIDE; WARD: PSY

Objectives to be attained:

 To develop therapeutic relationship with the patient.

 To identify his needs.
 To encourage the patient to socialise.
 To observe patient’s behaviour.
 Increase his self esteem.
 To encourage drug compliance & regular follow up.

Participant Verbal & Non verbal Inference Technique used

communication
Nurse: Goodmorning Ravi ji Client Observation
Kaise hai aap? smiling and Open- ended
Client: Theek hoon madam answering questioning
Nurse: Breakfast kiya aapne? Immediate Social
kya tha breakfast memory responding
Client: mein? intact

Ji madam kar liya

breakfast

Nurse: Kal raat ko kaisi neend Client Validating

aayi apko? looking
Client: anxious and Observation
Madam neend theek se apprehensive
nai aayi hai,Rkal bhi Reflection
bahut baar jaga hoon

Hmm aapko dekh kar

lag raha hai apko neend
nahi aayi

Nurse: Ravi ji main aaj apko Client Providing

apke bimari ke bare nodding head information
mein batane ja rahi and showing
hoon, kya aap janna interest in
chahenge? listening

Client: Ji haan madam.

Nurse: Anxiety waise thodi Client is Providing

bahut sab mein hoti hai, listening and information
lekin agar ye bahut showing
badh jaye aur aapke din interest
chariye ke kaam mein
effect karta hai toh
apko anxiety disorder ki
problem ho sakti hai
Karann
 Agar family mein
kisi ko hai
 bahut jayada
 stress lena
 kisi ka darr
 kisi ke saath agar
ache relations na
Client: ho
Ji madam mujhe bhi
bahut ghabrahat hoti
hai aur iski wajah se
mera kaam mein
mann nai lagta.
Nurse: Apko kya lagta hai apke Client is Focusing
case main kya Karann participating
ho sakte hai? in the Linking
conversation
Client: Mere family mein toh
nai hai, lekin mein apne Client
unit walo se darta tha looking sad
wo log mere saath bura while
bartaav karte the aur answering
ghar pe paiso ki
problem thi in sabki Client did not
wajah se main had good
pareshaan rehta tha, relationship
doctor ke paas gaya with his
unohne medicine likha, colleagues
us medicine se aaram
hota tha

Nurse: Toh aap medicine le Client Pinpointing

rahe the? nodding head
Client: Ji haan madam

Nurse: Aap kya dawa le rahe Client Clarification

the? knowing his
drug
Client Alprax ka jo tablet aata
hai na madam wahi le
raha tha doctor ne likha
tha

Nurse: Dekhiye jo apki dawa Client Validating

 hai wo toh aap lete listening and
rahe jaisa doctor ne nodding head Providing
apko bataya hai lekin information
uske saath saath apko
bhi apni taraf se koisis
karni hai apne
behaviour ko thodi
change karna chahiye
 Aap exercise,
yoga, pranayama,
meditation kar
sakte hai
 Khana samay se
khaye agar mann
nai karta toh thodi
hoda kar ke khaye
 son eke time aap
apne sar ka
massage kar
sakte hai, pooja
kar sakte hai isse
apko thodi shaanti
milegi aur
baichaini,
Client: ghabrahat kam ho
sakti hai
Madam main koshish
karunga
Nurse: Koshish karenge aap? Client Restating
nodding head
Client : Ji madam jarur karunga and is
positive in
accepting
the points
Nurse: Toh Ravi ji maine aaj
apko aaj apki bimari k
bare mein bataya aur
apko kya kya khyal
rakhna hai uske bare
mein bhi bataya.
III) INTERVIEW TECHNIQUE USED

 Observation
 Listening
 Direct questioning
 Exploring
 Enquiring
 Encouraging
 Listening
 Broad opening
 Restating
 Suggestion
 Supporting
 Appraising

IV) NATURE OF TERMINATION OF INTERACTION

Throughout the process recording the pre-requisites were kept

in mind like the physical setting, getting consent from the patient
&confidentiality. Keeping in mind the various techniques of
interview was adopted. The procedure covered period of 03 days.
The patient was encouraged to verbalise his thoughts & feeling.
These thoughts & feelings, patients verbal & non verbal behaviour
are analysed as evident from the process. It also includes nurse’s
thoughts& feelings at the end of the interaction & the plans made
for further interactions should be stated.

Therapeutic relationship was maintained throughout which

helped the patient in interaction, was composed & calm. The
objectives were met keeping in mind the various principles of
process recording. At times patient felt helpless as this job was an
important source of income for his family (he belongs to low socio
economic strata), so he was encouraged to maintain a positive
attitude. He has insight, but at the same time he worried n lost.

The interactive session was helpful in collecting history, MSE

& identifying the needs & rendering the need based care.

V) BIBLIOGRAPHY

 Bhatia M S,A Concise book on Psychiatric

Nursing,IIIedition,CBSpublishers,New Delhi;2005:pg no78-86
 KapoorBimla,Textbook of Psychiatric Nursing,VolI &II,I
edition,Kumarpublishers,New Delhi;2000:pg no 47-50

 Neeraja K P,Essentials of Mental health & Psychiatric

nursing,Vol I,I edition,Jaypeepublishers,New delhi;2008:pg
no90-92

 Practise Manual,Mental health Nursing,IGNOU

 Sreevani R,A guide to mental health & Psychiatric

nursing,IIIedition,Jaypeepublishers,New Delhi;2010:pg no91-
92
VI) EVALUATION CRITERIA

Sr Criteria Marks Allotted Marks Obtained

No
1 Format 05
2 Objectives 03
3 Setting 02
4 Therapeutic Techniques 10
used
5 Evaluation by the student 05
Total 25
 PROCESS RECORDING
ON
RECT BISWAJEET PRADHAN; AGE 21 YRS

sCHIZOPHRENIA

SUBMITTED TO SUBMITTED BY
LT COL MEENA CHACKO LT COL JOBI
CHACKO
PROFESSOR IIYR PBBSC (N)
CON, AFMC CON, AFMC

SUBMITTED ON
31.08.2015

PROCESS RECORDING
ON
SEP KALIDAS; AGE 20YRS
SCHIZOPHRENIA

SUBMITTED TO SUBMITTED BY
LT COL MEENA CHACKO LT COL JOBI
CHACKO
PROFESSOR IIYR PBBSC (N)
CON, AFMC CON, AFMC

SUBMITTED ON
31.08.2015
SUBMITTED TO SUBMITTED BY
Lt Col Jyoti P Shewale Capt Kavita Kumari
Lecturer IIYR PBBSC (N)
CON, AFMC CON, AFMC
 CHEATLE FORCEPS

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