PROCESS RECORDING OF
MR. SUDIP KUMAR MONDAL
SUFFERING FROM SUBSTANCE
USE DISORDER
SUBMITTED TO,
MADAM SEULI PAL
READER
W.B.GOVT COLLEGE OF NURSING
IPGME&R AND SSKM HOSPITAL
SUBMITTED BY,
GARGI GOSWAMI
2ND YEAR M.Sc. NURSING STUDENT
W.B.GOVT COLLEGE OF NURSING
IPGME&R AND SSKM HOSPITAL
Identification data of the patient:
Name : Sudip Kumar Mondal
Age : 39 years
Gender :Male
Address : Uttar Panchpara, P.O- Radha Dasi, P.S- Sakrail, Dist-Howrah
Marital status : Married
Religion : Hindu
Educational status : H.S passed
Occupation : Car driver
Family income : Rs.12000/month
Informant : Brother
Reliability : Reliable
Language known : Bengali
Registration no : IOPK/ RG2400017222
Ward : Male psychiatry Ward, IOP 2 nd floor
Diagnosis : Substance use disorder
Date of admission : 6.6.24
Chief complaints : According to Patient: “Amar ghum hoyna thikthak, hat kape”
According to informant:
Regular intake of alcohol for last 7 years
Intake of cannabis for last 7 years
Violent aggressive behavior for last 3 months
Wandering away tendency sine last 1 year
Place of process recording: 2 nd floor, Male psychiatry ward
Patient is sitting in his bed, room is well ventilated, environment is conducive and comfortable
for therapeutic nurse patient relationship, privacy is maintained, no destruction noise is present,
room is cleaned, well lighted, there is no one with the patient.
Objectives of process recording:
To develop a trustworthy and effective interpersonal nurse-patient relationship
To take history and mental status examination to assess the condition of patient
To gather information regarding family history, occupational history, marital history of
the patient
To identify patient’s problem and build up positive attitude to solve the problem
Day-1
Date and Content Inference Techniques
Time
18.06.24 at Nurse: Good morning Sudip babu, Ami SSKM Nodding of Greeting,
10:00 am- Nursing College r M.Sc. Nursing er chatrii. Ami head offering self
10:30 am apnar sathe ektu kotha bolte chai. Apnar kono
asubidha nei to?
Patient: Good morning, Na na madam, Amar kono
asubidha nei. Apnar ja janar ache bolun.
Nurse: Kal rate thik kore ghum hoyechilo? Aj Patient feels Making
kakhon ghum theke uthechen? drowsy observation,
exploring
Patient: Ratri bela valo ghum hoyni, 6:30 am e
uthechi. Ghum ghum pacche ekhono
Maintaining
Nurse: Aj sokale breakfast korechen? eye to eye Broad opening
contact
Patient: Hm korechi
Maintaining
Nurse: Aj sokale breakfast e ki kheyechen? Exploring
eye to eye
Patient: Aj Bread, egg, banana kheyechi contact
Date Content Inference Techniques
and
Time
Nurse: Apnar poribare k k ache? Open ended
questioning
Patient: Bou r 3 te baccha
Exploring
Nurse: Barir sobar sathe somporko kemon? Looking down
face
Patient: Valo na, amar prochur rag hoy, oder
mardhor kori
Nurse: Ekhane Kemon lagche? Exploring
Patient: Thik e lagche, Ekhane asar por nesha
korar r icche kore na
Nurse: Sudip babu, ekhane keno vorti Nodding his head Exploring
hoyechen bolte parben?
Patient: Ami nesha kori, barir lokkhe mardhor
kori, khub rag hoy, nesha theke beronor joono
vorti koreche ekhane
Nurse: Acha sudip babu apnar nesha korar Looking down his Broad opening
golpo ta ektu bolun to. Apni katodin dhore feet
nesha korten?
Patient: Ami gato 7 bachor dhore mod khai, r
tamak khetam tabe lock down er por theke
mod khaoya bere gache.
Focusing
Nurse: Dine katota poriman mod kheten?
Patient: Age kom khetam, lock down er por
theke dine 1-2 bottle to khawa hoyei jeto.
Date and Content Inference Techniques
Time
Nurse: Suraj babu, apni bolchen je apni mod Little bit irritated Restating and
khacchen 7 bachor dhore r tamak kheten Pinpointing
bollen tobe lockdown r por theke bere geche
khwa, ta apni keno mod khaoya suru
korechilen ba ki theke apni suru korechilen
eta ektu bolben?
Patient: Ami gari chalatam, sararat gari
chalate hoto tai alpo mod khetam bondhuder
sathe, kintu lockdown er por kaj chole jay,
takhon mod khaoyar poriman ta bere jay,
protidin 1-2 bottle moto khetam. Tarpor juya
kheltam bondhuder sathe, kintu ami sabsamay
here jetam, here jaoyar por abar khetam,
evabe bere gache
Exploring
He is looking anxious
Nurse: Accha first time kobe kheyechilen
mone ache?
Patient: First time kheyechilam jakhon class
XI e pori, bondhuder sathe
Exploring
Nurse: Accha first time kheye ki anuvuti Nodding his head
hoyechilo bolte parben?
Patient: Ha, khub valo legechilo tobe khaoyar
por prachur bomi hoyechilo
Nurse: Accha emon ki kakhono hoyeche je Exploring
apni tana kichuduner jonnyo mod khaoya
bondho korechen?
Patient: Na erokom hoyni
Date and Content Inference Techniques
Time
Nurse: Alcohol bade r ki kichu kheten? Nodding his head Open ended
questioning
Patient: Ha ganja khetam
Pinpointing
Nurse: Ganja katodin dhore nicchen? Maintaining eye to
eye contact
Patient: 7 years dhore
Looking down face Exploring
Nurse: Accha first jedin niyechilen sedin
kemon mone hoyechilo?
Patient: Khub valo legechilo, mone
hoyechilo kono chap nei, sab valo
Maintaing eye to eye Focusing
Nurse: Kakhono ki ganja khaoya kichudin contact
er jonnyo bondho korechen?
Patient: Ekdin bondho korechilam, kintu
ota bondho korle sarir kape, ghum hoyna r
khideo payna
Nurse: Apni ki juya khelechilen? Looking down face
Exploring
Patient: Ha
Nurse: Kobe theke eta start hoyeche? Feeling guilty
Exploring
Date and Content Inference Techniques
Time
Patient: Lockdown e kaj chole jaoyar por
bondhuder pallay pore suru hoy tarpor 2
bachor age 2 lakhs taka loss hoyeche,
tarpor theke khela bondho kore diyechi
Nurse: Thik ache, aj tahole ei porjonto Nodding his Bidding bye
thak. Ami abar kal asbo. Kal ese abar apnar head, leaning
sathe katha bolbo forward
Patient: Thik ache madam, Bye
Aj ke amra apni ekhane kiser jonnor bharti Summarizing
hoechen, karon ki chilo, bari niye, apnar
somosya niye kotha bolam, kal ke abar
asbo, aaro bisoy niye kotha bolbo.
Day- 2
Date and Content Inference Techniques
Time
19.06.24 at Nurse: Good morning, Sudip babu, Aj Nodding of head, Greeting
10:00 am-10: Kemon achen? Maintaining rapport
30 am
Patient: Good morning, madam, Aj valo
achi madam.
Clarifying
Nurse: Kal rate ghum hoyechilo valo?
Patient: Ha madam, kal rate motamoti
ghum hoyechilo.
Date and Content Inference Techniques
Time
Nurse: Apni kal bolchilen je apnar ganja and Patient is anxious, Restating
alcohol er nesha ache, ta egulo na khele apnar ki looking down face
kichu samosya hoy?
Patient: Ha, Amar thik moto ghum hocche na.
Amar khide pay na. Bukta byatha kore hat kape
Nurse: Apni bolechilen je lock down e apnar kaj Exploring
chole gache, tahole nesha korar jonnyo taka looking down feet
kothay peten?
Patient: Taka dhar kortam
Nurse: Mod khaoyar por ki barite kono jhamela Focusing
Looking down his
korechen kakhono?
feet
Patient: Ha mod khaoyar por bou k merechi
koyekbar, r ghorer jinis o vangchur korechi
Informing
Nurse: Accha aj ami apnake mod r ganja khele
sarir er ki ki khoti hoy seta bolbo
Patient: Thik ache madam
Nurse: Mod khele amader sarir e pressure bere Informing
Patient is nodding
jai, hritspondon bere jai, kidney r somosya, his head and active
peter somosya, saskosto aro onek kichur asonka listening and
thake tar sathe ghum kome jaoya, sritisokti lop agreeing
pawa, monojog kome jaoya, decision nite na
para eigulor sombhabona thake
Date and Content Inference Techniques
Time
Patient: Yes madam, apni thik e bolchen. Ei
jonnyoi ami charte chai
Nurse: Hospital e karor sathe bandhutto
He is nodding Exploring
hoyeche?
his head
Patient: Hmm hoyeche,golpo korechi, jante
perechi odero same somosya
Patient is
Nurse: Accha thik ache aj ja ja bollam mone Suggesting and
smiling
rakhben, diner bela ektu exercise, group activity bidding bye
gulo korar chesta korben, sobar sathe kotha
bolben, Ami abar kal asbo. Bye
Patient: Okay madam. Bye
Aj amra mod ganja khele kiki somosya hoy Summarizing
janlam kal eigulo theke beriye asar jonno amra
kiki korte pari, nijeke kivabe motivate korte pari
eigulo niye discuss korb kemon
Day 3
Date and Time Content Inference Techniques
20.06.24 at 10:00 Nurse: Good morning, Sudip babu, maintaining eye to Greeting,
am-10: 30 am Aj sakale ki ki kheyechen? eye contact exploring
Patient: Good morning mam. Aj
sakale ami cha, bread r dim
kheyechi.
Maintaining eye to Restating and
Nurse: Accha apni ager din bollen
eye contact exploring
je apni oneker sathe bondhutto
jamiyechen, golpo korechen, jante
perechen odero same somosya, apni
konodin group meeting attend
korechen?
Patient: Sevabe to ekhono konodin
attend korini
Patient is interested Suggesting
Nurse: Group therapy othoba group and taking initiative
meeting chesta korben attend korar,
okhane amra eke oporer jiboner
golpo suni, kivabe nesha charabo
seta niye alochona
Patient: Ok mam, ami chesta korbo
Patient is nodding his
Nurse: Nesha theke beriye asa ta Clarifying
head
apni nijer daitto mone koren to?
Date and Content Inference Techniques
Time
Patient: Hm
Nurse: Ekebarei charte prothom prothom He has very Suggesting
osubidha hobe kintu chesta korte hobe, menu positive mind and
plan korte hobe, ekta daily activity schedule is cooperative
korte hobe, plan korte hobe daily life style ke
sustho swabhabik rakhar, kokhon ki kaj korte
pari, kiki khabar khete pari, relaxation kivabe
korte pari eigulo to vabte hobe tai na?
Patient: Hm madam, chesta korbo. Ekhane je
sakale yoga r exercise hoy, ami roj kori.
Broad opening
Nurse: Apnar bari giye ki korar icche ache, He is optimistic
kichu vebechen? and has future plan
Patient: Ha, bari giye abar kaj kora suru Korte
hbe. Songsar chalate habe. R osudh khete hbe
thik moto.
He is maintaining Giving positive
Nurse: Bah khub valo chintavabna apnar. Bari eye to eye contact reinforcement and
giye o roj exercise korar chesta korben. Jadi clarifying
nesha korar icche hoy, takhon nijeke control
korar chesta korben, oi samay beshi kore jol
khaben, jore jore swas neben, barir loker sathe
samay kataben, gan sunben, exercise korben,
nijeke kaje involve korben.
Date and Time Content Inference Techniques
Patient: Thik ache madam.
Nurse: Accha bari giye jadi apnar kono Patient is smiling Pinpointing
bondho apnake mod khaoyar jonnyo jor
kore takhon apni ki korben?
Patient: Ami jabo na
Patient is nodding Informing
Nurse: Ami apnake assertiveness
his head
sekhabo, mane kivabe na bolben seta
Patient: Thik ache madam
Nurse: Jakhon keu bolbe chol ektu khai, Informing and
He listens
olpo khele kichu hobe na. Takhon clarifying
attentively about
sabsamay bolben je ‘ami khabo na, ota
assertiveness
khete anek samosya hoy’, ba ‘chol aj
techniques
amra pepsi ba cold drink khai’. ‘Amake
amar bacchader boro korte hobe’. ‘Ami
osob khabo na’. Sabsamay ‘I’ statement
use korben r na bolben.
Patient: Thik ache madam
Providing
Patient is information
Nurse: Bari jaoyar por osudh gulo thik
nodding his head
moto khaben, follow up e thik moto
asben, osudher dose kakhono miss
korben na.
Patient: Ekdam madam
Date and Time Content Inference Techniques
Nurse: Apnar sathe etogulo kotha Patient is Summarizing
bollam,(apni ki karone nesha suru smiling, bidding
korechilen, neshar jonno kiki khoti bye
hoyeche apnar, nesha theke beriye asben
kivbe) valo laglo. Aj ei porjonto thak.
Bye, Ami aschi. Valo thakben r poribare k
valo rakhben.
P: Accha madam
Summarization:
Mr. Sudip kumar Mondal, 39 years old married man, seems to be drowsy on 1st day, anxious,
looking down face due to long term illness, hospital environment etc, from the next day onwards
the patient is fully alert and was willing to engage in conversation. Patient is looking down his
feet, much concerned and worried about children and wife, anxious about the future, aggressive
towards the family members, sleeping difficulty, was worried regarding substance use. The
patient talks about his malpractices and agrees to follow how to overcome from those activities.
Patient is very much optimistic, active listening to the suggestions and wants to take initiative in
future. The patient is given motivation and information regarding attending group therapy, group
meeting, assertiveness training techniques, medication compliance and follow up. This process
recording has helped to identify patient problems as well as initiating interventions to address the
recent issues patient is dealing with. Further nursing interventions can be planned to address the
risk for violent or aggressive behavior, disturbed sleeping pattern, ineffective coping and low
self-esteem as well.
Gargi Goswami
20.06.24
Signature with date
