Process recording
Identification data of patient:-
Name: Mr. Animesh
Age: 33year
Gender: male
Education: Engineer
Occupation: Analysist
Religion: Hindu
Date of admission- 24-2-2025
Diagnosis: Alcohol Dependence Syndrome
History of present illness
Patient was maintaining well and free of any psychoactive substance use around 12 years back. He used to live with his grandparents
as his father died when he was 3 yrs old and his mother went to marry someone else. Since then his grandparents used to take care but
in 1995 his grandfather also died. So grandmother used to take care of him and his younger brother also. He was regular in his college
Around 2nd year of his college he was introduced to alcohol by his friends and also of his own curiosity he tried it for the first time.
Initially he felt nauseated and didn’t like the taste but after some time he felt lifted up and excited so he started to take it frequently 3-4
times a month. Then he continued this for years. After few years his grandmother also expired and then he started to live with uncle
and younger brother also with another uncle. His drinking increased to 1-2 times per week thinking of what will happen to him. Then
after his graduation he started searching for job to complete his alcohol demand. He got the jobs both in Delhi and Panipat but he used
to be irregular and also many times he used to have argument with other colleagues. Sometimes he used to consume alcohol during
office hours too. During this time he used to be irritated decreased interaction with others and most of the times he would be
preoccupied with alcohol. Then in 2009 he got amount of 8 lakh from inherited property of which he bought a flat for himself. He
gave room of the flat on rent . he used to get the money from rent and also from his job which he used for alcohol. He also started to
drink 4-5 bottles of beer/ day and 1-2 whiskey though he was aware of the side effects. He maintained this behaviour for years till
2013. Now he didn’t have money for alcohol because he was unemployed and also his money decreased so he sold his flat for 14
lakhs. Now he used to spent the money rashlessly as he used to drink 8-10 bottles per day and travelled to Bangkok, Thailand and
other places in India also. He used to think that nobody cared about him and then drink more. He used to think that his younger
brother is more cared by everyone and nobody thinks of him . So he started thinking that there is no benefit of living because no one
loves me and so he tried to harm himself by knife. Because of his drinking habit he had a fight with his brother and he asked him to
leave the house, so he said he would end his life. His brother complained in the police station that his brother wants to kill himself and
he will not be responsible for anything. So then patient started to live with his aunty, she asked him to get treatment and she brought
him toNIMHANS
Introduction to patient about orientation phase-
I went to introduced myself to Animesh on 24/02/25. I introduced myself as a M.sc student nurse who would like to help him get out
of his drug taking behavior and depressive state. I also told him that everything is kept confidential and hence we could discuss on all
matters quite openly. He easily accepted this contract and we decided to start our interview on 24/02/25. I also told my patient that our
relationship time duration of IPR is only for short period i.e., with in the period of hospital stay and would try to achieve maximum of
our objective of evaluate them.
Aims and objectives of IPR-
For patient
To establish therapeutic IPR
To socialize effectively
To ventilate the feelings
To learn healthy coping mechanisms
To engage in diversional activity
To maintain the normal nutritional, bowel and sleep pattern
To discuss about the medication, its effects and side-effects.
To participate in discussing the problems
To prepare for discharge from ward termination of IPR
For nurse
To develop adequate skills in communication
To develop skills in establishing and maintaining IPR with the patient, assessing problems, finding out solution and attaining
the objectives, set for the patient
To learn how to deal with the patient more effectively
To judge my own self, my anxiety, fear and emotions
Interview-I
Date-24/02/25
Patient sleeping pattern- 11:00 pm- 6 am, no complaint of disturbance
Place- Interview room
Time- 10.00 am
Specific objectives: To establish therapeutic IPR with the patient.
Nurse Patient Therapeutic technique Inference
Verbal Nonverbal Verbal Nonverbal
Good morning Smiling Good morning (smiling, shaking his Greeting Checking social
Anuj head) judgment
Kaise ho Thik hu Looking at nurse Exploring
To assess the mood
Aaj Man kaisa Placing the hand over Thik hi hai…. Looks sad Exploring of the patient
hai the shoulder Checking willingness
for interview
Kal maine Soft tone of voice Ji sister ji Nodding his head Seeking clarification
aapko
Patient is ready to
interview ke
bare me bataya share his problem
tha na. aapko
yad hai..
Aaj hum aapke Looking at the patient Theek hai Looking at nurse Seeking clarification
or aapke
To know about his
nashe ke bare
mein bat substance abuse and
karenge
pattern of a substance
Aap kaha se Looking at the patient Ghaziabad Uttar Looking at nurse Listening abuse
ho? Pradesh se.
To gather the
Aapke ghar me Mai to apni bua ke
kaun kaun hai? sath rehta hu. Mere information of the
papa bachpan me
patient
expire ho gye the aur
mummy ne dusre se
shadi kari li.
Sister mai sharab
Aap kis cheez Looking at the patient Looks sad & down Theme identification
bahut peeta hu.
ka nasha karte
Thoda depression
ho
bhi hai
Kab se hai? Looking at the patient Sister depression to Looking at nurse Clarifying To know about his
Sharab pina mujhe ab 1-2 mahine
substance abuse
shuru karne se se hua hai jisme ki
pehle ya bad maine aapko nujsan
me pahuchane ki
koshish bhi kari hai
Sharab kb se College ke second
Looking at the patient Looking at nurse Listening To know about his
pite ho year se
substance abuse
Khud se piya Maine khud se bhi
Looking at the patient Looking at nurse To know about his
tha ya kisine piya tha aur dosto ne
pilaya tha. bhi bola to pi liya. substance abuse
Kabhi chodne Looking at the patient Ni sister Looking at nurse Listening To know about
ki koshish ki
relapse
hai
Chalo tiik hai..
Looking at the patient Looking at nurse
aaj humne Ok sister
aapke nashe ke To prepare for next
bare me bat
interview
kiya hai ab kal
hum aapki
family aur
daily routine
ke bare me bat
karenge.
Summary: Animesh was co-operative throughout the interview. He was ready to talk with me and ready to answer all the questions
and willing to continue the interview next day.
Introspection: I was able to understand what the patient is telling during the interview. I was able to conduct the interview
confidentially. I was able to establish therapeutic relationship.
Plan for the next interview: I planned to discuss about family members and his daily routine tomorrow.
Evaluation: I was able to maintain therapeutic IPR. My patient was supportive and co-operative throughout the interview.
TEERTHANKER MAHAVEER COLLEGE OF NURSING
Teerthanker Mahaveer University, Moradabad
Process Recording
On
Alcohol Dependence Syndrome
Submitted to
Mr. M.G Vishwas
Asst Professor
Dept of Psychiatric Nursing Submitted by
TMCON, TMU
Ms. Hina Singh
I Msc Nursing
Date of submission Dept of Psychiatric Nursing
TMCON, TMU
4-2-25
