HISTORY TAKING

IDENTIFICATION DATA

Name- : Master Akshay Shinde

Age - : 16 Yr

Sex- : Male

Bed no.- : 3

I.P.D no.- : 17012480

Ward- : Child Psychiatric ward

Education- : No formal education

Occupation : No occupation

Marital status : Single

Religion- : Hindu

Address- : Chiplun

Diagnosis- : Mental Retardation

Identification mark- : No identification mark

Date of admission- :

Date of assessment- :
2. Informant:

Name of the person Relation with the Adequacy Reliability

patient
1. Mrs. Nirali Mother Adequate Reliable

3.Presenting chief complaints

a). Psychiatric:

According to patient : Restlessness

According to informant: Aggressiveness.

Social: He doesn’t like to interact with others .

c). Interpersonal: He has poor interpersonal relationship

e). Biological: He is having complaints of loss of appetite, decreases sleep.

4.History of present illness

Duration: 3 days

Mode of onset: Acute

Course: Episodic

Intensity: Increasing
Precipitating factors: Fever

Description of present illness: Patient was well at the time of birth after 3 months of birth patient got malaria fever and after some
months patient got asthma that was not cure till now when the patient was of 2 year his mother noticed that he not started to walk and
speak also Now patient came with the history of fits before 3 days and have the history of abdominal pain, behavioural changes, the
Patient is taking treatment in the psychiatric ward of NIMHANS Hospital Banglore.

5. Treatment History:

Name of the Chemical Route Frequency Dosage Action

medication name
1.Tab. Consern Olanzapine Orally T.D.S 10mg Anti psychotic

2.Tab. Discern Discern Orally O.D 250mg Anti psychotic

3.Tab. Lorax lorazepam Orally H.S 2mg Sedative

6. Past psychiatric and medical history:

No. of previous episodes with onset and courses: Many times

Complete or incomplete remission: Incomplete remission

Duration: 1 month

Treatment details and its side effects Tab. olanzapine 10 mg

Tab. Lorax 2 mg

Past surgical history: No significant of surgical history

Past medical history: Patient has history of Asthma and jaundice.

7. Family history: No significant of any psychiatric illness in the family

Family Tree:

Key Points

Male

Female
 Dead patient

Dead patient

Mental
Name of Relation with Age/Sex Educati Occupation Marital Health status
the patient on status
family
member
Ikbaal ali Grand Father ----------- Illiterate ------ Married Dead
Reshma Grand Mother ----------- Illiterate ------ Married Dead
Jahagir Father ----------- Illitrate Farmer Married Dead
Nirali Mother 40yrs/F Illitrate Housewife Married Healthy
Sabu itself 16yrs/M Illitrate --------- Unmarried Mental Retardation
Rajia Sister 14yrs/M studying Student Unmarried Healthy
Personal History

Prenatal History

Antenatal period- Patient mother has no any infection in pregnancy but patient took no checkup, No vaccination.
Intranatal period- Normal Vaginal delivery no any other complication.
Birth- Full term Baby and cry after the birth
Birth defect- No
Postnatal Complication- Patient got malaria fever after 3 months of birth

Childhood history

Primary care giver- Mother

Feeding- Breastfeeding
Age of weaning- 6 months
Development Milestones- delayed
Behavior and emotional Problems- present
Illness during childhood- patient has a history of Asthma in childhood

Educational history
Age at beginning of formal education- At 6 yrs
Academic performance- Poor
Extra curricular achievements- poor
Relationship with peers and teachers- poor
School phobia- No school phobia
Look for conduct disorder- No any type of conduct disorder
Reason of termination of study- medical illness

Play history

Game played- Patient has no interest in game

Relationship with playmates- Helpful
Emotion problem during adolescence- No any type of emotional problem during adolescence

Occupation History:- No significant of any occupation

Sexual and marital history- Patient is Single

Premorbid personality

Interpersonal Relationship- Introvert

Family and social relationship- Poor
Use of leisure time- by watching television
Attitude to work and responsibility- Iresponsible
Religious ,Belief and moral attitude- Poor
Fantasy world- he did not have any fantasy world.

Habits
Eating pattern - Irregular
Elimination- Irregular
Sleep pattern- Irregular
Use of tobacco, drug and alcohol- Patient has history of taking tobacco daily,
 Mental Status Examination

General Appearance and behavior

Appearance: looking older
Facial expression: looks sad
Level of grooming: Well kept
Level of cleanliness: inadequate
Level of consciousness: drowsy
Mode of entry: General admission
Co-cooperativeness: Less Co-operative
Eye to eye contact: Not Maintained
Psychomotor activity: Decrease activity
Rapport: Poor Maintained
Gesturing: Normal
Posturing: Patient having no frank posture
Other movement: Patient remain sit some time for long period.
Hallucinatory behavior: Patient has visual hallucinatory behavior

 Speech
Initiation: Minimal
Reaction time: delayed
Rate: Slow
Productivity: Pressured
Volume: Decreased volume
Tone: Monotonus
Relevance: irrelevent
Coherence: Fully coherent
Inference: Patient having low volume of speech
Sample: Apka nam kya h. Apke ghar m kon kon h
Patient: Sabu, 2 behan bhai
Inference: No speech disorder is present but patient has alteration in speech.

 Mood and affect

Subjective:
Nurse : Apka man kaisa hai?
Patient: Pta nai
Objectives:
Patient looks sad
Inference: Affect is inappropriate with mood.

Thought:
Stream: Patient was not responding to question .
Form: Patient was not responding to question .

At content level:
Nurse : Kya apko lgta h ki koi apko marna chahta hai?
Patient: Nhi
Inference: Delusion of persecution is absent.

Nurse: Kya apko esa lgta ha ki log apke bare mai bat krte hai?
Patient:
Inference: Patient was not responding to question.

Nurse: Kya apko lgta ha k aap bhot mhan insan ho ?

Patient:
Inference: Patient was not responding to question.
Ideas:
Nurse: Kya apko esa lgta hai ki apki zindagi m kuch b nhi h, aap koi b kam nhi kr skte, koi apki mdd ni kr skta?
Patient:
Inference: Patient was not responding to question.

Obsessive Compulsive phenomena:

Nurse: Apke mnn m koi khyal bar bar to nhi ata?
Patient:
Inference: Patient was not responding to question.

Phobia:
Nurse: Kya apko kisi chij se drr lgta hai.
Patient: Nhi
Inference: Patient has no phobia

 Perception:
Illusion:
Nurse: Apko kabhi koi chij m kuch or to dikhai nhi deta?
Patient:
Inference: Patient was not responding to question.

Hallucination:
Nurse: Kya apko akele me koi awaz sunai deti hai?
Patient: Nhi
Inference: Auditory hallucination is not present
Nurse: Kya apko akele m koi dikhai deta h
Patient: haan hara rang
Inference: Visual hallucination is present.

Nurse: Kya apko esa lgta h ki apke shirr pr kuch reng rha hai?
Patient:
Inference: Patient was not responding to question.

Depersonalization:
Nurse: Apko esa lgta hai ki aap is duniya m ho hi nhi ?
Patient:
Inference: Patient was not responding to question

 Cognitive Function(Neuropsychiatric assessment)

Consciousness: Patient is not fully conscious.

Orientation:
Nurse: Ye apke pas kon khda h?
Patient: Ye meri maa h
Inference: Patient is oriented to person.
Nurse: Aap is time kha pe ho.?
Patient: Hospital
Inference: Patient is oriented to Place.

Nurse: Aaj kon si date h?

Patient: Pta ni
Inference: Patient is not oriented to time.

Attention
Nurse: Aap mujhe 1-8 tkk ginti sunao?.
Patient: 1------
Inference: Aroused with difficulty.

Concentration:
Nurse: Apke pas 20 rupee ho to usme se 3 rupee 5 bar km kro to kitne rh gye
Patient:
Inference: Patient was not responding to question.

Memory:
Immediate Memory:
Nurse: Teen pen dikhte hue puchti h ye kon se rang k h?
Patient: kala, lal, neela
Inference: Immediate memory is intact.

Recent Memory:
Nurse: Apne kl subah khane m ky khaya tha?
Patient:
Inference: Patient was not responding to question.

Remote memory:
Nurse: Hmara desh kb ajad hua tha?
Patient:
Inference: Patient was not responding to question.

Intelligence:
Nurse: Ek saal m kitne mhine hote h ?
Patient:
Inference: Patient was not responding to question
Arithmetic ability-
Nurse- 16x2 kitne hote h?
Patient-
Inference- Patient was not responding to question.

Abstraction:
Nurse: Iska mtlab btao- Pet m chuhe dodna?
Patient:
Nurse: Acha btao ki copy or dairy m kya smanta h?
Patient:
Nurse: Ankh or kann m kya antrr h?
Patient:
Inference: Patient was not responding to question.
Personal
Nurse: Yha se ghar jane k bad kya kroge?
Patient:
Inference: Personal judgment is intact.

Test:
Nurse: Agar do bche apes m ldd rhe ho to aap kya kroge?
Patient:
Inference: Test judgment is intact.

Social Judgment:
Nurse: Aapko agr raste me koi purse pda mile to aap kya kroge?/
Patient:
Inference: Patient was not responding to question

Insight:
Nurse: Aap yha p ku aye ho?
Patient: Pta ni
Inference: Insight(Grade 1) is absent

Physical examination
Appearance- Looking tired
Body built and nutrition- Nourished and healthy
Temp.- 98.6oc
Pulse- 84 beats/min
Respiration- 22 beats/min
B.P- 120/80 mm of Hg
Weight- 62 kg
Any physical abnormality- No any physical abnormality
Cvs- S1-S2 heard, murmer sound is not present
Respiration system- Respiration is normal, no wheezing sound
Abdomen- Soft, no any organomgely
Lymph nodes- No enlargement of lymphnodes
Level of consciousness- Patient is conscious.
Orientation- Patient is orient about time, place and person
Speech- Normal
Language- Hindi
Memory- Intact
Cranial nerve examination- Cranial nerve function is intact
 MENTAL RETARDATION
INTRODUCTION :

Mental retardation is a condition diagnosed before age 18, usually in infancy or prior to birth that includes general intellectual function
and lack of the skills necessary for daily living. When onset occurs at age 18 or after, it is called dementia, which can coexist with an
MR diagnosed.

Definition :

Mental retardation refers to significantly subaverage general intellectual functioning resulting in or associated with concurrent
impairments in adaptive behavior and manifested during the developmental period.

EPIDEMIOLOGY:

About 3% of the world population is estimated to be mentally retarded. In India 5 out of 1000 children are mentally retarded. MR is
more common in boys than girls. With severe and profound mental retardation mortality is high due to associated physical disease.

ETIOLOGY:

BOOK PICTURE PATIENT PICTURE

GENETIC FACTORS :
 Chromosomal abnormality : Present
 Down ‘s syndrome
 Turner’s syndrome.
 Cat-cry syndrome.
  Metabolic disorders :
 Phenylketonuria.
 Wilson’s disease.
 Galactosemia.

 Cranial malformation :
 Microcephaly. -
 Hydrocephaly

 Gross disease of brain :

 Neurofibromatosis. -
 Epilepsy.

 PRENATAL FACTORS :
 Infection :
Present
 Rubella.
 Cytomegalovirus.
 Syphilis
 Herpes simplex.

 Endocrine disorder :
 Hypothyroidism. -
 Diabetes mellitus.

 Physical damage and disorders :

 Injury. -
 Hypoxia.
 Radiation.
 Hypertension.
 Anemia.

 Intoxication :
  Lead. Present
 Certain drugs.
 Substance abuse.

 PERINATAL FACTORS :
 Birth asphyxia. -
 Prolonged or difficult birth.
 Prematurity.
 Instrumental delivery.

 POSTNATAL FACTORS :
-
 Infections like measles, meningitis.
 Accidents.
 Lead poisoning.

 ENVIRONMENTAL AND SOCIO- -

CULTURAL
FACTORS :
 Cultural deprivation.
 Low socio-economic status.
 Inadequate caretakers.
 Child abuse.

CLASSIFICATION AND TYPES OF MR :

Classification of mental retardation based on IQ :

 MILD RETARDATION (IQ 50-70) :

this is commonest type of mental retardation accounting for 85-90% of all cases. These individual have minimum
retardation in sensory-motor areas.
  MODERATE RETARDATION (35-50) :
About 10% of mentally retarded come under this group.

 SEVERE RETARDATION (20-35) :

Severe mental retardation is often recognized early in life with poor motor development and absent or markedly
delayed speech and communication skills.

 PROFOUND RETARDATION (IQ BELOW 20) :

This group accounts for 1-2% of all mentally retarded. The achievement of developmental milestones is
markedly delayed.they require constant care and supervision.

 UNSPECIFIED MENTAL RETARDATION

SIGNS AND SYMPTOMS :

BOOK PICTURE PATIENT PICTURE

-Deficiencies in cognitive functioning such as inability to  Before 3 days patient having episode of 1 fits.
follow Commands.  Reduced ability to learn
-Reduced ability to learn.  Difficulty in performing self care activites
-Expressive or receptive language problem.  Lack of curiosity
-Psychomotor skill deficit.  Delay developmental milestone
-Difficulty in performing self care activities.  Psychomotor skill deficit
-Neurologic impairement.
-Medical problems,such as seizures.
-Low self esteem and depression.
-Irritability when frustrated or upset.
-Acting out behavior.
-Lack of curiosity.
-Failure to achieve developmental milestones.
DIAGNOSTIC FINDINGS:

BOOK PICTURE PATIENT PICTURE

-History collection from parents and caretakers.  Done
-Physical examination.  Done
-Neurological examination.  Done
-Assessing milestones development.
-Investigation :
 Urine and blood examination for metabolic disorders.
 Culture for cytogenic and biochemical studies.
 Amniocentesis in infant chromosomal disorders.
 Chorionic villi sampling.
 Hearing and speech evaluation.
 EEG , especially if seizure are present.
 CT scan or MRI brain .
 Thyroid function test.
 Psychological test like Stanford binet intelligence scale

And Wechsler intelligence scale for children for categorizing. The child’s level of disability through psychological testing the

Mental age is estimated.

The intelligence quotient iis then determined using the formula :

MENTAL AGE

CHRONOLOGICAL AGE X 100

TREATMENT MODALITIES :

BOOK PICTURE PATIENT PICTURE

 Behavior management.  Monitor child developmental needs and problems.
o -Environmental supervision.  Programs that minimize speech, language, cognitive,
 Monitor child developmental needs and problems. psychomotor social, self-care and occupational skills.
 Programs that minimize speech, language, cognitive,  Patient is taking tab concern, discern, lorax.
psychomotor social, self-care and occupational skills.
 Ongoing evaluation for overlapping psychiatric disorders
such as depression, bipolar disorder.
 Family therapy to help parents develop coping skills and
dealwith guild or anger.
 Early intervention programs for children younger than age
3 with mental retardation :
o -provide day schools to train the child in basic
skill,
o such as bathing and feeding.
o -vocational training.

PREVENTION:

 Primary prevention :
 Preconception :
 Immunization for maternal rubella.
 Blood test for marriage licenses can identify the presence of venereal disease.
  During gestation :
 Prenatal care.
-adequate nutrition, fetal monitoring and protection from disease.
 Analysis of fetus for possible genetic disorder.
-by amniocentesis, fetoscopy, fetal biopsy and ultrasound.

 At delivery :
 Delivery conducted by expert doctors and staff especially in case of high risk pregnancy.
 Apgar scoring done at 1 and 5 min after birth of child.

 Childhood :
 Proper nutrition throughout the developmental period and particularly during the first 6 month after
birth.

 SECONDARY PREVENTION :
 Early detection and treatment of preventable disorder. For eg. Phenylketonuria and hypothyroidism.
 Psychiatric treatment for emotional and behavioral difficulties.

 TERTIARY PREVENTION :
This includes rehabilitation in vocational, physical and social areas according to the level of handicap. Rehabilitation is
aimed at reducing disability and providing optimal functioning in a child with MR.
 CARE AND REHABILITATION OF THE MENTALLY RETARDED :
 The prevention and early detection of mental handicap.
 Regular assessment of the mentally retarded person’s attainment and disabilities.
 Advice, support and practical measures for family.
 Provision for education, training,occupation or work appropriate for each handicapped person.
 Housing and social support to enable self care.
 Medical, nursing and other services for those who require them as outpatients,day patients, day patients or
inpatients.
 Psychiatric and psychological service

NURSING MANAGEMENT
LIST OF NURSING DIAGNOSIS :

 Risk for injury related to excessive exercise or potentially harmful behavior.

 Self care deficit related to cognitive impairement.

 Impaired social interaction related to disorganized thinking.

 Bowel incontinence and impaired urinary elimination related to weak bladder or bowel muscle tone.
 King’ s Nursing theory- nursing process

Assessment Perception, Communication, of Nurse and Client

Diagnosis Knowledge deficit about health care

Outcome goal and Planning Goal attainment is outcome goal. Setting goals and making decisions about how
to achieve the goals. This is part of transaction and again involves mutual
exchange with the client

Implementation It is a continuation of transaction

Evaluation Attainment of goal and the effectiveness of nursing care

 THEORY APPLICATION

NURSE PERCEPTION- - - - - - - - - - - - - - - - - - - - - - - - - - FEEDBACK- - - - - - - - - - - - - - - - - - - - - - - - - TRANSACTION

 Disorientation,
 Self care deficit
 Aggressive
 Altered thought process Risk for injury related to impaired judgment or disorientation .
 To collaborate with the client to identify anxious behavior as well
as their probable cause.

 To inform the client of available alternatives of dealing with anxiety

and agitation.
JUGDEMENT
 In an accepting non- threatening way, to encourage the client to
verbalize her feelings.
Impaired social interaction related to disorganized thinking.
Impaired social interaction related to disorganized thinking.
 Establish a working relationship by listening and responding to the
Altered thought process related to psychosis induced hallucination. client
 Collaborate with the client to develop a schedule of specific social
interaction or activities
 Identify any behavioral rules that the client may have learned from
Risk for injury related to impaired judgment or disorientation the family.

JUGDEMENT

Client seems to be angry with the attendants & complains of hearing of sounds.
ACTION

CLIENT PERCEPTION
 To collaborate with the client to identify anxious
 Physical immobility behavior as well as their probable cause.
 Aggressive behavior
 To inform the client of available alternatives of dealing
with anxiety and agitation.

 In an accepting non- threatening way, to encourage the

client to verbalize her feelings.
ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective data : Impaired social Help the client Establish a working Established a working To prepare for Social
Patient says that I interaction identify feelings relationship by relationship by future interaction is
have no interest related to that inhibit listening and listening and socialization. improved to
to talk anyone. disorganized social responding to the responding to the client some extent .
thinking. interaction. client. during conversation.
Collaborated with the
Collaborate with the client to develop a
client to develop a schedule of specific
schedule of specific social interaction or
Objective data : social interaction or activities by involving To improve the
Patient do not activities. group therapy. communication
interact with Identified any skill.
others. behavioral rules that
the client may have
Identify any learned from the family To help the nurse
behavioral rules that by involving family identify and
the client may have therapy. understand the
learned from the Refered the client to client’s
family. appropriate community dysfunctional
programs,support social behaviors.
groups & self help
lecture by explaining To reinforce
Refer the client to the importance of positive behavior.
appropriate group programe.
community programs, Encouraged the client
support groups & self and family to
help lecture. participate in ongoing
Encourage the client psychotherapy like To promote
and family to group therapy positive change
participate in ongoing for client and
psychotherapy family.
ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS

Subjective data : Risk for injury Maintain the safety Search the client and Searched the client To provide safety. Absence of
Patient says that I related to impaired of the client and client’s belongings and client’s injury to
feel angry judgment or others. upon admission to belongings upon himself and
sometime. disorientation . the unit. admission to the unit. others.

Provide a safe, quiet Provide isolation

environment for the room to the client. To reduce the
client. chance of injury.
Objective data :
Patient become Place sharp objects Placed sharp objects
angry sometime. out of reach of the out of reach of the
patient. patient like knife,
seizure, rope etc.
Encouraged the client To prevent injury.
Encourage the client to verbalize fear and
to verbalize fear and harmful impulse by
harmful impulses. maintaining good
IPR.
To help the
reorient the client.
If the client cannot Moved the client to a
comply with calm environment by
commands, move providing isolation
the client to a calm and reduced visitor Promoting
environment complaints
behavior.
ASSESSEMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS

Subjective data : Self care Client will able be Identify aspects of self Identified the aspects To know the base
Patient say that deficit related able to participate care that may be within of self care that may line data of the Self care deficit is
he is unable to to altered in aspects of self the client’s capabilities. be within the client’s patient. improved
do self care. physical care. capabilities.
mobility or
lack of Worked on one
maturity. Work on one aspects of aspects of self-care at enhance the self
Objective data : self-care at a time. a time by giving the esteem
Patient do not task like cutting of
self care. nails foot massageetc.

Provide simple, concrete

explanation. It encourages the
Provided simple, repetition of
concrete explanation. desirable
Offer positive feedback behaviors.
for efforts.
Offered positive
feedback for efforts. It will help the
Encourage patient to
independence Encouraged participate in self
independence. care.
ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS

Subjective data : Bowel Help the client Assess the client usual Assessed the client To reinforce the Reduced bowel and
Patient says that incontinence maintain adequate elimination pattern . usual elimination client ‘s usual urine incontinence.
my elimination and altered elimination pattern pattern . elimination pattern.
pattern is not urinary and avoid urinary and
good. elimination bowel complications. Encourage the client to To prevent
related to weak drink adequate amount of Encouraged the client constipation.
bladder or water during day time. to drink adequate
bowel muscle amount of water during
Objective data : tone. Administer stool softener day time.
Patient having and monitor the client To maintain
problem of bowel response. Administered stool elimination pattern.
and urine softener and monitor
incontinence. Help the client to maintain the client response.
the proper skin care. To preserve the
Helped the client to client skin
maintain the proper integrity.
Be accepting and skin care.
empathetic when the client
is incontinent. Client is accepted and To preserve self
empathetic when the esteem.
incontinent.
 HEALTH EDUCATION
Medication:-

-Advise the family member not to skip the dosage.(withdrawal symptoms) or double dosage

- Teach the family member about the side effects of Anti depressant Medication.

-Not consume other medication without doctor order.

Diet:-

-Instruct the client to avoid caffeinated food and drinks.

-Weight the client daily (wt loss)

-Offer the client frequent sips of water.

-Order food high in fibers

Hygiene:-

-Instruct the client and family member to maintain personal hygiene.

-Strict oral hygiene is very important sitting position

-Avoid smoking and tobacco

Follow-up:-

-Advise the patient and family member continue to take medication and regular follow-up

-Carry a card or other identification at all times

COURSE AND PROGNOSIS-

Master.Sabu is 16 Years male was admitted in Life Care Hospital Chiplun. He is diagnosed as a case of Mild Mental Retardation
.The condition of the client is improving gradually. The sign and symptoms are decreasing due to the proper therapeutic
regions.Initially the client was reluctant, exhibited aggressive behavior, gradually. He became co-operative.

CONCLUSION Mental illness refers to a wide range of mental health conditions — disorders that affect your mood, thinking and
behavior. Examples of mental illness include depression, anxiety disorders, schizophrenia, eating disorders and addictive behaviors.
Many people have mental health concerns from time to time. But a mental health concern becomes a mental illness when ongoing
signs and symptoms cause frequent stress and affect your ability to function.A mental illness can make you miserable and can cause
problems in your daily life, such as at school or work or in relationships. In most cases, symptoms can be managed with a combination
of medications and talk therapy (psychotherapy).

REFERENCES
Ahuja, n. (2011). shorttextbook of psychiatric nursing (6th ed., pp. 89-90). new delhi: jaypee publishers.
Kapoor, D. (2012). textbook of psychiatric nursing (1st ed., pp. 145)new delhi: jaypee publisher.
Sreevani, r. (2007). a guide to mental health & psychiatric nursing (3rd ed., pp. 162-166). new delhi: jaypee publishers.
What Is Mental Retardation?. (2017). Psychiatry.org. Retrieved 3 february 2018, from
https://www.psychiatry.org/patients-families/Mental Retardation
Mental illness - Symptoms and causes. (2018). Mayo Clinic. Retrieved 21 February 2018, from
https://www.mayoclinic.org/diseases-conditions/mental-illness/.../syc-20374968