CASE PRESENTATION

I . Bio data of patient

 Name: Amar Singh s/o Dalip Singh

 Age: 61 years
 Gender: male
 Religion: sikh
 Address: VPO bhagpur gagra , Moga
 Education: Illiterate
 Occupation: cycle shopkeeper
 Marital status: married
 Languages known: Punjabi
 Monthly income: 50000/-
 Date of Admission: 28/11/18
 CRF: PFDGG1001118423RN
 Mobile no. : 09914687915
 Diagnosis: Insomnia
 Reason for admission : Treatment and evaluation purpose
 Informant:
 Patient’s son
 Reliability of Informant: reliable

1. CHIEF COMPLAINTS:
According to patients :
 Decreased sleep
 Sadness
 Low mood X 10-15 days
 Episodes of pain and heart burn
 Loss of concentration
 Irritability
 Generalized body ache
 Constipation
According to informant :
A. Multiple complaints for body pain
B. Disturbance of sleep X 6 days
C. Low mood
D. Decreased sleep
b. Significance/relevance to the concept:
Insomnia or sleeplessness, is a disorder characterized by an inability to fall asleep or to stay
asleep for a desired duration. Insomnia is generally seen as both a sign and a symptom that can

1
accompany several sleep, medical, and psychiatric disorders characterized by a persistent
difficulty falling asleep. Insomnia is typically followed by functional impairment while awake.
Insomnia can occur at any age, but it is particularly common in the elderly. Indeed, any history
of persistent insomnia augments the lifetime risk of major depression. It is unclear whether the
insomnia represents a prodrome, shared genetic vulnerability, or a causative process promoting
depressive symptoms. Nevertheless, this association emphasizes the need for early recognition
and treatment of insomnia, and an evaluation for potential psychiatric disorders.
2. HISTORY OF PRESENT ILLNESS:
 Duration : 6 months
 Mode of onset: Progressive
 Course of illness: Progressive
 Predisposing factors : medical illness
 Aggravating factors : seasonal change
3. PAST HEALTH HISTORY
 Medical history:
 No H/O hypertension, Diabetes mellitus , Asthma, or any other medical illness.
 No h/o neurological disorders
 No h/o convulsions
 No h/o unconsciousness
 No h/o HIV, visceral disorders
 No h/o drug allergies
 H/o Pulmonary Tuberculosis
 H/o peptic ulcer
 h/o weight loss
 Surgical history: Not available
 Psychiatric history :
h/o alcohol intake
h/o intake of tab. Tramadol abuse 6 months ago
Sadness of mood
Pervasive and persistent sad mood
Decreased interest in other pleasurable activities
Lost around fro 10-15 days 6 months ago
No h/o suicidal ideation
No h/o big talks /over expenditure
No h/o head injury /seizures
No h/o hearing of voices
No h/o helplessness , worthlessness
o Hospitalization : In GGS hospital , Faridkot
o Nature of treatment : Drug therapy
o Improvement : Not significantly

2
 4. FAMILY HISTORY
Sr Members Relation with Education occupation Health status
.no Patient
1 Amar singh Patient Illiterate Cycle shop Ill
keeper
2 Jaimal kaur Wife Illiterate Housewife Hypertensive

3 Kartar singh Son Graduate Lives in Dubai Good

4 Jaspreet singh Son Graduate Private job Good

5. Kulwinder Daughter Undergraduate Student Good

kaur

 Type of family : joint

 Birth order : 1st in order
 Psychiatry history: h/o alcohol use in father and family
 Medical history: No significant history
 Surgical history: No significant history

Current housing conditions :

i. Home circumstances: conflicts with family

ii. Per capita income : 6250 rs. per month
iii. Socioeconomic status : upper Middle class family
iv. Head of the family : patient
v. Current attitude of family members towards illness : Cooperative
vi. Communication pattern in family : not satisfactory
vii. Cultural and religious view : Sikh religion
viii. Ethnicity : Punjabi
ix. Social support systems available : From relatives

3
FAMILY TREE

Father mother

patient brother

Son daughter son

6. PERSONAL HISTORY
a) BIRTH & DEVELOPMENT
 Antenatal period:
o Any febrile illness : no history
o Physical illness : no history
o Medications / drugs use : no history
o Trauma to abdomen : no history
o Immunization : no history available
 Natal period:
o Birth : full term
o Wanted : yes
o Type of delivery : normal vaginal delivery
o Birth cry : no history
4
 o Birth defects : no
o Postnatal complications : no
b) CHILDHOOD HISTORY :
o Primary caregiver : mother
o Feeding : breast feed
o Age at weaning : no history
o Developmental milestones : normal
o Age and ease of toilet training : no history
o Behavioural and emotional problems :
i. Thumb sucking : no history
ii. Temper tantrums : no history
iii. Tics and head banging : no history
iv. Night terror : no history
v. Fears : no history
vi. Bed wetting : no history
vii. Nail biting : no history
viii. Stuttering : no history
ix. Enuresis: no history
x. Encopresis: no history
c) Somnambulism : no history
EDUCATIONAL HISTORY :
o Age at beginning of formal education : illiterate
o Age of finishing formal education : N/A
o Relationship with peers and teachers : N/A
o School phobia : N/A
o Truancy , non attendance : N/A
o Learning disabilities : N/A
o Reason for termination of studies : N/A
o Bullying at school : N/A
d) PLAY HISTORY :
o Games played : No history available
o Relationship with mates : No history available

e) ADOLESCENCE:
Emotional problems during adolescence :
o Running away from home : NO
o Delinquency : NO
o Smoking : NO
o Drug abuse : NO
o Any other : NO SIGNIFICANT HISTORY AVAILABLE

5
 f) PUBERTY:
o Age at appearance of secondary sexual characteristics : 15 YEARS
o Anxiety related to puberty changes : YES
o Age at menarche : N/A
o Reaction to menarche : N/A
o Regularities of menstrual cycle : N/A
o Abnormalities : N/A
g) OBSTETRICAL HISTORY :
o Any abnormalities associated with delivery / puerperium/ pregnancy : N/A
o Number of children : N/A
o Termination of pregnancy : N/A
h) OCCUPATIONAL HISTORY :
o Age at starting work : 14 YEARS
o Jobs : cycle shopkeeper
o Reasons for change : NO CHANGE IN THE JOB
o Current job satisfaction : NO INTEREST IN WORK
i) SEXUAL HISTORY :
o Type of marriage : ARRANGE
o Duration of marriage : 32 YEARS
o Interpersonal relationship with in laws: SATISFACTORY
o Relationship with wife : cordial
o Relationship with children : cordial
j) SUBSTANCE ABUSE: history of alcohol consumption
k) PRE-MORBID PERSONALITY
i. Interpersonal relationships:
o Interpersonal relationships with family : satisfactory
o Interpersonal relationships with friends : Good
o Type of personality : introverted
o Making social relationships : good
ii. Use of leisure time :
o Hobbies : watching TV
o Interests : listening music , gossiping
o Intellectual activities : no
o Energetic : no
o Sedentary : yes
iii. Predominant mood :
o Happy and cheerful
o Despondant
o Reaction to stressful events : overt reaction to stress
iv. Attitude towards self and others :

6
 o
Self confidence level : high
o
Self criticism : yes
o
Self consciousness : yes
o
Thoughts for others : thoughtful
o
Self appraisal of activities : less
o
General attitude towards others : sympathetic , loving and caring
v. Attitude to work and responsibilities
o Decision making : less
o Acceptance of responsibility : no acceptance
o Flexibility : no
o Foresight : impaired
o Religious beliefs : faith in god
o Fantasy life : wants a happy life
o Day dreams : no
vi. Habits :
o Eating pattern : irregular
o Elimination : irregular
o Sleep : irregular 3 hours /day
o Use of drugs / tobacco / alcohol: yes
 VITAL SIGNS

s. no. Vital signs Normal value Patient value Remarks

1 Temperature 98.6 F 98 F Normal
2 Pulse 72-100/min 82/min Normal
3 Respiration 20-24/ min 18 /min Normal
4 B.P 120/80mm hg 146/80mm hg Prehypertension

INVESTIGATION

Investigations Normal Values Patient’s Values Remarks

Bilirubin
 Total 0.0-0.2 mg / dl 0.25 mg /dl Normal
 Direct 0.2-1.2 mg / dl 0.10 mg/dl Normal

SGOT 40 U/L 38 U/L Normal

SGPT 40 U/L 43 U/L Normal
Total protein 3.5-5.3 g/dl 6.9 g/dl Normal
Albumin 3.5-5.3 g/dl 4.0 g/dl Normal
Random sugar 80-120 mg/dl 116mg/dl Normal
Urea 15-45 mg/dl 21 mg/dl Normal
Creatinine 0.6-1.3 mg/dl 0.64 mg /dl Normal
Uric acid 3.5-7.2 mg /dl 4.9 mg/dl Normal
135-158 mmol/dl 142 mmol/dl Normal
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 Sodium 3.8-5.6 mmol/dl 4.5 mmol/dl Normal
Potassium 1.1 – 1.3 mmol/dl 1.2 mmol/dl Normal
Calcium
MEDICATION

Name the Composition Dosage Route Frequency Action

drugs
Tab. Lupirtin Flupirtine, Paracetamol 1 mg Oral BD Analgesic
P
Tab. Clozex Clonazepam 0.5 mg Oral OD Anticonvulsant
MD
Tab. Rabirox Levosulpiride, Rabeprazol 75 ng Oral BD Antipsychotic
L e
Tab. Doxflo Doxofylline 400 mg Oral BD Potent
bronchodilator
Tab. Niplar Vitamin D3 derivative 500 mg Oral SOS Elemental
calcium and
Vitamin D3
Dualin Levosalbutamol, Ipratropi 1.25 mg Inhalation TDS Broncho
respules um dilator
Eugel Cefuroxime 2 Oral TDS Broad -
tablespoon spectrum
antibiotic

Nursing care provided to patient

Day 1 1) Rapport established with the patient.

2) Vital signs are monitored.
3) Administration of medication.
Day 2 1) Co-operation of patient gained.
2) Establishment of good IPR with Patient.
3) Assessment regarding personal hygiene done.
4) History collection is done including biodata, illness and other all
aspects.
5) Preparation of nursing care plan according to patient’s needs.
Day 3 1) Mental status examination is conducted.

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 2) Behavioural therapy is given to patient.
3) Patient is assisted in self care activities.
4) Medical assistance is taken from the physician from GGS hospital ,
Faridkot.

MENTAL STATUS EXAMINATION

I. APPEARANCE

1. GROOMING AND DRESS

Inference:
Patient is wearing appropriate dress which is according to the place and season. Hair
are also combed. He is well groomed

2. HYGIENE

Inference:
Hygienic condition of the patient is good . Patient takes bath after 2 days and also
changes his clothes. Nails are clean.

3. PHYSIQUE

Inference:
Patient has normal body physique

4. POSTURE

Inference:
Patient is having an open posture.

5. FACIAL EXPRESSIONS

Inference:
Facial expressions of the patient are anxious . They are appropriate according to the
talk of the patient.

6. LEVEL OF EYE CONTACT

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 Inference:
Patient not maintains eye-to-eye contact throughout the conversation.

7. RAPPORT
N: Sat Sri akal Bapu ji ……
P: Sat sri akal
N:Bapu ji, mai tuhade nal gal kar sakdi ha ….
P: yes
Inference:
A good rapport is maintained with the patient. She took part in the conversation well
and responded to all the questions asked to her.

II. MOTOR ACTIVITY

Inference:
Patient is able to sit still. His psychomotor activity is decreased . Unusual gestures or
mannerisms are not present.

III. SPEECH

Inference:
Patient spoke in Punjabi language. Rate of speech is normal and in normal tone.
IV. EMOTIONS

1. MOOD
N: Kiwe ho tuc ?
P: hanji thik ha ..bas nind hi nhi aundi….
Inference:
Patient ‘s mood is good.

2. AFFECT

Inference:
Patient’s emotional response is appropriate.

V. THOUGHT

1. FORMATION LEVEL

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 N: tuc kis vajah to ethe admit ho ?
P: nind nhi aundi…..
Inference:
Normal formation level

2. CONTENT LEVEL

N: Tuhanu nind aundi hai ?

P: nhi… mainu bilkul v nind nhi aundi …
N: Tuhanu darr lagda hai
P: nhi…

Inference:
Delusions are present . Phobias are absent.

3. PROGRESSION LEVEL

N: ik hi khyal mann vich baar baar aunda hai ?

P: nhi…
Inference:
Progression level of thought is intact .

VI. PERCEPTION

N: Tuhanu lagda hai tuhanu koi bhula reha hai … par othe phir v koi majood nhi
hunda ?
P: Nahi.
N: Tuhanu lagda hai ki tuhanu koi dikhayi dinda hai … jo gujar chukka hai…
P: Nahi aisa bhi kuch nahi tha
Inference:
Patient is not having any kind of visual and auditory kind of hallucinations.
Perception in patient is intact.

VII. SENSORIUM AND COGNITIVE ABILITY

1. LEVEL OF ALERTNESS/CONSCIOUSNESS

Inference:
Patient is alert and conscious. He is actively listening to all the questions and is also
giving appropriate answers.

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2. ORIENTATION
N: tuc ethe kad aye?
P: parso ka aye c..
N: tuc kitho de rehn wale ho?
P: mai Fazilka da rehn wala ha.
N: ajj ki din hai ?
P: pta nhi.
N: tuc iss time kithe ho?
P: hasptal
N: tuc iss time kehre hospital ho ?
P: pta nhi
N: tuhade kol koun khada hai ?
P: mere kol mera munda khada hai.
Inference:
Patient is oriented with person but not to place and time .

3. MEMORY

a) Immediate memory

N: bapu ji , mai tuhanu hune ki puchya c ?

P: ki tuhade kol koun khada hai.
Inference:
Immediate memory of the patient is intact .

b) Recent memory

N: bapu ji , sawere khana khada tuc ?

P: ha khada c …
N: tuc dwai kadpo lyi c ?
P: mai sawere lyi c …
Inference:
Patient’s recent memory is also intact.

c) Remote memory

N: Tuc saah di bimari da ilaaj kitho karwaya c ?

P: Faridkot wale hasptal vicho .
Inference:

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 Patient’s remote memory is intact.

4. CONCENTRATION AND ATTENTION

N: Bapu ji , 10+10 ki hunde han ?

P: 20
Inference:
Patient is having sustained concentration and attention.

5. INFORMATION AND INTELLIGENCE

N: Punjab vich kinne dariya ne ?

P: 5
N: Punjab da much mantra koun hai ?
P: Capt. Amrinder Singh

Inference:
Patient general information level is good .

6. ABSTRACT THINKING

N: khana kyu khana chahida hai ?

P: jeonde rehn lyi
Inference:
Abstract thinking of the patient is good.

7. JUDGMENT

a) Social

N: Jekar tuhade kise rishtedar nu paiseya di jarurat hai ta tuck i karoge?

P: mai usdi jinni ho sake madad karn di kosish karunga …

Inference:
Patient has logical social judgment.

b) Personal

N: sanu sareya de naal kiwe rehhna chahida hai ?

P: sanu sab nal pyar nal milke rehnma chahida hai ….

13
 Inference:
Personal judgment of the patient is appropriate.

VIII. INSIGHT

N: tuhanu lagda hai ki tuhanu koi bimari hai?

P: Hanji mainu nind na aun di bimari hai ……
N: Tuhanu lagda hai ki eh ik mansik bimari hai ?
P: Nhi
Inference:
Patient is having grade IV insight as she accepts her illness.

IX. GENERAL ATTITUDE

Inference:
General attitude of the patient is normal and appropriate. Patient is very co-operative.

X. SPECIAL POINTS

N: Ajj sawere khana khada tuc?

P: Hanji…..
N: Bhukh thik tarike nal lagdi hai tuhanu ?
P: Hanji …thik hi lagdi hai….
N: Nind thik aundi hai tuhanu ?
P: Nind di bhut takleef hai….
N: Kabaz di oroblem hai tuhanu ?
P: Hanji hai …..

Inference:
Patient’s appetite, bowel, bladder and sleep pattern is disturbed

XI. PSYCHOSOCIAL FACTORS

1. STRESSORS

N: Tuhanu kise cheez di pareshani hai ?

P: Na pareshani ta koi ni haigi … bas nind di hi takleef hai ….

Inference:

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 He is worried about his illness.

2. COPING SKILLS

N: Tuc apni tension dur karn lyi ki karde ho ?

P: Kujh nhi bas TV dekhda ha ate parivar de nal gallan karda ha

Inference:
His coping skills are accurate

3. RELATIONSHIPS

N: Tuhade rishtedaran de nal tuhade sambandh kiwe ne ?

P: Vadia ne ….
N: Ki tuhanu oh change lagde ne ?
P: Hanji oh sab bhut shayita karde ne
N: Tuc ghar vich ladayi ta nhi karde ?
P: Nhi ….

Inference
Patient has good relationship with his relatives and family .

4. SOCIO CULTURAL

N: Tuc samaj de kanoon to tang ho ?

P: Nhi …
Inference
Patient follows the rules of society.
5. SPIRITUAL
N: Tuc path karde ho ?
P: Nhi
N: Tuc gurudware jande ho ?
P: Hanji kadi kadi….
N: Tuc rabb vich yakeen karde ho ?
P: Hanji … karda ha
Inference:
Patient is spiritual and believes in god.
SUMMARY : In MSE , it has been found that patient ‘s personal hygiene is maintained .
Psychomotor activity is decreased . but thought and speech are normal . There are no

15
 hallucinations and delusions . Patient is sad and affect is congruent. Grade IV insight is present .
General attitude is good and patient is cooperative.

Review of systems:

AREA TECHNI NORMS FINDINGS ANALYSIS

QUE and
INTERPRETA
TION
A. SKULL
1. Size, Inspection Normo cephalic and symmetrical Rounded Normal
shape and Palpation with frontal, and occipital Normo
symmetry prominences unsymmetrical cephalic and
of the parietal lobes); Smooth skull symmetrical
skull contour with frontal,
and occipital
prominences
unsymmetrical
parietal lobes);
Smooth skull
contour
2.Presence Palpation Rough , not uniform consistence; Has Abnormal
of Inspection presence of nodules or masses tenderness ,
nodules, masses and
masses, nodules
and
depression
3. Facial Inspection Symmetric or slightly asymmetric Symmetrical Normal
Features Palpation facial features; palpebral fissure and palpebral
equal in size; symmetric fissure equal
nasolabial in size,
nasolabial
folds are
symmetrical
4.Presence Inspection edema and hollowness Has Abnormal,
of edema Hollowness Volume
and deficiency of fat
hollownes within the orbit
s in the (the space
eye inside of the

16
 bony eye
socket).
B. HAIR
1.Evennes Inspection Not evenly distributed Evenly Abnormal
s of Palpation distributed
growth, with patches
thick of hair loss;
ness, or thick hair
thinness of
hair
2. Texture Inspection Dandruff in the hair Rough hair Abnormal
and Palpation
oiliness
over the
scalp
3.Presence Inspection No infection and infestation No infection Normal
of Palpation and infestation
infection
and
infestation
C. FACE
Facial Inspection asymmetric facial features; Asymmetrical Abnormal
features, palpebral fissures equal in size; facial features
symmetry symmetric nasolabial folds while talking
of facial or elevating
movement the eyebrow.
Equal
palpebral
fissure,
symmetrical
nasolabial
folds.
D. EYES
i. Eyebrows
Hair Inspection Symmetrical and in line with each Symmetrical Normal
distributio other; maybe black, brown or and aligned
n, blond depending on race; evenly with each
alignment, distributed other; black;
skin evenly

17
quality distributed.
and Movements
movement are
symmetrical.
ii. Eyelashes
Evenness Inspection Evenly distributed; turned outward Turned Normal
of Palpation outward
distributio eyelashes; hair
n and equally
direction distributed
of curl
iii. Eyelids
Surface Inspection Upper eyelids cover the small Not able to Abnormal
characteris portion of the iris, cornea, and close the eyes
tics and sclera when eyes are open; eyelids and has the
position meet completely when the eyes ability to
(in are closed; symmetrical blink.
relation to
the
cornea,
ability to
blink, and
frequency
of
blinking)
iv. Conjunctiva
1. Color, Inspection Pinkish or red in color; with Pale color; Abnormal
texture, Palpation presence of small capillaries; smooth in
and the moist; no foreign bodies; no ulcers texture
presence
of lesions
in the
bulbar
conjunctiv
a
2. Color, Inspection Pinkish or red in color; with Pale Abnormal , pale
texture, Palpation presence of small capillaries; conjunctiva
and the moist; no foreign bodies; no ulcers may be related
presence to the low RBC

18
of lesions level of the
in the patient.
palpebral
conjunctiv
a
v. Sclera
Color and Inspection Yellow in color; some capillaries Yellow sclera Abnormal
clarity maybe visible with some
visible
capillaries,
anicteric
sclera.
vi. Cornea
Clarity Inspection No irregularities on the surface; Clear and Normal
and looks smooth; clear or transparent smooth in
texture texture
vii. Iris
Shape and Inspection Anterior chamber is transparent; Dark brown in Normal
color no noted visible materials; color color;
depends on the person’s race transparent
anterior
chamber
Viii. Pupils
1. Color, Inspection Color depends on the person’s Pupil size is Normal
shape, and race; size ranges from 3-7 mm, 3mm.
symmetry and are equal in size; equally
of size round
2. Light Inspection Constrict briskly/sluggishly when Dilates when Normal
reaction light is directed to the eye, both looking at far
and directly and consensual objects and
accommo constricts
dation when looking
at near
objects.
Constricts
when there is
light.
ix. Visual Acuity
1. Near Inspection Able to see clearly Normal vision Normal

19
vision
x. Lacrimal Gland
Palpability Palpation No edema or tenderness over No tenderness Normal
and lacrimal gland and edema
tenderness noted.
of the
lacrimal
gland
xi. Extra ocular Muscles
Eye Inspection Both eyes coordinated, move in Moves in Normal
alignment unison, with parallel alignment Unison
and
coordinati
on
xii. Visual Fields
Peripheral Inspection When looking straight ahead, Can see Normal
visual client can see objects in the objects in the
fields periphery periphery.
E. EARS
i. Auricles
1. Color, Inspection Color same as facial skin; Same color as Normal
symmetry symmetrical; auricle aligned with the facial skin;
of size, outer canthus of eye, about 10 tip of auricle
and degrees from vertical aligned at the
position outer canthus
of the eye.
2. Texture, Palpation Mobile, firm, and not tender; Smooth in Normal
elasticity pinna recoils after it is folded texture,
and areas flexible and
of elastic pinna;
tenderness no tenderness
ii. Hearing acuity tests
1. Client’s Inspection Normal voice tones audible Can hear Normal
response normal volume
to normal tones or words.
voice
tones
F. NOSE
1.Any Inspection Symmetric and straight; no Symmetric and Abnormal,

20
deviations discharge or flaring; Uniform straight; Nasal flaring
in shape, color Uniform color suggests airway
size, or with nasal obstruction.
color and flaring. Nasal discharge
flaring or shows the
discharge presence of
from the mucus
nares secretions in the
air tract.
2. Nasal Inspection Nasal septum intact and in Nasal septum Normal
septum Palpation midline intact and in
(between midline
the nasal
chambers)
3. Patency Inspection Air moves freely as the client Only left nares Abnormal, not
of both breathes through the nares is patent. Right patent right
nasal nares is with nares show the
cavities secretion. presence of
mucus
secretions and
would suggest
there is an
infection in the
respiratory
system.
4. Palpation Not tender; no lesions Nor tenderness Normal
Tendernes nor lesions.
s, masses,
and
displacem
ents of
bone and
cartilage
G. SINUSES
Identificat Inspection Not tender Not painful Normal
ion of the when palpated
sinuses
and for
tenderness
H. MOUTH
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i. Lips
Symmetry Inspection Uniform pink color; soft, moist, Pink in color, Abnormal, May
of Palpation smooth texture; symmetry of dry and suggest cellular
contour, contour; ability to purse lips cracked lips dehydration.
color and
texture
ii. Buccal Mucosa
Color, Inspection Uniform pink color; moist, Pink color and Abnormal, May
moisture, smooth, soft, glistening, and dry. suggests
texture, elastic texture dehydration.
and the
presence
of lesions
iii. Teeth
Color, Inspection 32 adult teeth; smooth, white, Has 31 adult Abnormal, most
number shiny tooth enamel; smooth, teeth. The unpleasant
and intact dentures patient has odors are
condition yellowish known to arise
and teeth. Have bad from proteins
presence breath. Have trapped in the
of tooth decay in mouth which
dentures the lower right are processed
second molars. by oral bacteria.
The most
common
location for
mouth-related
halitosis is the
tongue.
iv. Gums
Color and Inspection Pink gums; no retraction Pink gums; has Abnormal
condition visible
retractions
v. Tongue/floor of the mouth
1. Color Inspection pink color; moist; slightly rough; Pink and moist. Normal
and thin whitish coating; moves Tongue moves
texture of freely; no tenderness freely and no
the mouth pain felt.
floor and

22
frenulum.
2.Position, Inspection Central position; pink color; Located and Normal
color and smooth tongue base with positioned in
texture, prominent veins the center.
movement
and base
of the
tongue
3. Any Palpation Smooth with no palpable nodules, No tenderness Normal
nodules, Inspection lumps, or excoriated areas nor masses
lumps, or
excoriated
areas
vi. Palates And Uvula
1. Color, Inspection Light pink, smooth, soft palate; The hard palate Normal
shape, Palpation lighter pink hard palate , more has a lighter
texture irregular texture color than the
and the soft palate; has
presence quite rough
of bony texture
prominenc
es
2. Position Inspection Positioned in midline of soft Positioned at Normal
of the palate the center of
uvula and the oropharynx
mobility
(while
examining
the
palates)
vii. Oropharynx And Tonsils
1. Color Inspection Pink and smooth posterior wall Dry, pinkish in Abnormal, May
and color. suggests
texture dehydration.
2. Size, Inspection Pink and smooth; no discharge; of Has no Normal
color, and normal size discharge;
discharge pinkish
of the
tonsils

23
3. Gag Inspection Present Present Normal
reflex
I. THORAX
i. Anterior thorax
1. Inspection Quiet, rhythmic, and effortless Difficulty of Abnormal,
Breathing respirations breathing labored
patterns breathing is a
common
manifestation
affecting clients
with cardiac
and pulmonary
disorders. It is
related to
obstructed
airway. It also
related to the
decreased size
of the lungs due
to PTB.
2.Tempera Palpation Skin intact; uniform temperature; Has an intact Normal
ture, chest wall intact; no tenderness; skin; has equal
tenderness no masses warmth on
, masses both sides. No
masses.
3. Auscultati Bronchovesicular and vesicular Has crackles Abnormal,
Anterior on breath sounds sounds on the crackles are
thorax upper thorax & audible when
auscultatio lower thorax there is a
n sudden opening
of small
airways that
contain fluid. It
is usually heard
during
inspiration.
ii. Posterior thorax
1. Shape, Inspection Antero posterior to transverse Has an antero Normal
symmetry, Palpation diameter in ratio 1:2; Chest posterior to

24
and symmetric transverse
compariso diameter ratio
n of of 1:2,
anteropost elliptical in
erior shape and
thorax to symmetrical
transverse chest
diameter
2. Spinal Inspection Spine vertically aligned Has a vertical Normal
alignment alignment
3.Tempera Palpation Skin intact; uniform temperature; No masses nor Normal
ture, chest wall intact; no tenderness; tenderness; has
tenderness no masses equal warmth
, and on each side
masses
7. Auscultati Vesicular and Broncho vesicular Has crackles Abnormal, the
Posterior on breath sounds heard on the condition is
thorax anterior and related to the
auscultatio middle part of decreased size
n right and left of the right lung
lungs. and poor
Diminished inspiratory
lung sound on effort due to
the posterior pain.
right lung.
J. CARDIOVASCULAR
i. Aortic Auscultati No pulsations No pulsations Normal
and on felt
pulmonic
areas
ii. Auscultati No pulsations; no lift or heave No pulsations Normal
Tricuspid on of lifts
area
iii. Apical Auscultati Pulsations visible in 50% of Has full Normal
area on adults and palpable in most PMI pulsation
in fifth LICS at or medial to MCL
iv. Auscultati Aortic pulsations Has pulsation Normal
Epigastri on
c area

25
v.Cardiov Auscultati S1: Usually heard at all sites Has full and Normal
ascular on Usually louder at the apical area rapid pulsation.
areas S2: Usually heard at all sites 84 bpm
auscultati Usually louder at the base of heart /minute.
on Systole: silent Sounds on the Normal
aortic and
pulmonic
areas; has a lub
sound on the
apex and dub
sounds on the Normal
tricuspid area.
Blood pressure
is 90/70
vi. Carotid arteries
1. Carotid Palpation Symmetric pulse volumes; full Has weak Abnormal,
artery pulsations, thrusting quality; pulsation. decreased
palpation quality remains same when the Symmetrical amount of
client breathes, turns head, and pulse. blood volume
changes from sitting to supine passing the
position; elastic arterial wall artery.
K. AXILLAE
1. Axillary, Inspectio No tenderness, masses, or nodules Have no Abnormal, The
subclavicul n masses and apocrine glands
ar, and nodules. located in the
supraclavic Presence of a axillae
ular lymph foul smelling produces sweat.
nodes odor. The secretion of
these glands is
odorless, but
when
decomposed or
acted upon by
bacteria in the
skin, it takes on
a musky,
unpleasant
odor.
L. ABDOMEN
1. Skin Inspectio Unblemished skin; uniform color Uniform color Normal
26
integrity n and has no
blemishes
2. Inspectio Flat, rounded(convex), or Has a concave Normal
Abdominal n scaphoid(concave) abdomen.
contour
3. Inspectio No evidence of enlargement of No Normal
Enlargeme n liver or spleen enlargement of
nt of liver the spleen and
or spleen liver seen
4.Symmetr Inspectio Symmetric contour Has a Normal
y of n symmetrical
contour abdominal
contour
5. Inspectio Symmetric movements caused by Abdominal Normal
Abdominal n respiration; visible peristalsis in movements
movements very lean people; aortic pulsations noted when
associated in thin persons at epigastric area inhaling.
with
respirations
, peristalsis
or aortic
pulsations
6. Vascular Inspectio No visible vascular Has no blood Normal
pattern n vessels
K. MUSCULOSKELETAL SYSTEM
i. Muscles
1. Muscle Inspection Proportionate to the body; even in Proportionate Normal
size and both sides to the body;
compar- even in both
ison on sides
the other
side
2. Fasci - Inspection No fasciculation and tremors Has no Normal
culation fasciculation
and and tremors
tremors in
the
muscles
3. Muscle Palpation Even and firm muscle tone Weak muscle Abnormal,

27
tonicity tone possibly related
to the amount
of food that
patient is
eating. Possible
exhaustion
experienced by
the patient
when she
coughs.

4. Muscle Palpation Has equal muscular strength on Weak muscle Abnormal,

strength both sides strength possibly related
to the amount
of food that
patient is
eating. Possible
exhaustion
experienced by
the patient
when she
coughs.

ii. Joints
1. Joint Inspection swelling, warmth, redness, pain, Edema is Abnormal
swelling crepitus present, pain
when moved.
III.Extre- Inspection swelling, warmth, redness, pain. Edema is Abnormal
Meties , Palpation present, pain
when moved
Neurologic Assessment:

Category Normal Actual Findings Analysis and

Findings interpretation
Mental Status
 Level of Alert Conscious Normal
Consciousn
ess
 Orientation Oriented Oriented to time place and Normal
person
28
  Language Coherent Coherent Normal
test
 Recall Not able to Able to state what happened Normal
remember to his in the past.

Cranial Normal Patient Interpretation

Nerves
CN I Olfactory Able to smell and Able to identify the scent of Normal
recognize stimuli the medicine
CN II Optic Able to read,2 mm [pupil Pupil size is 2 mm, not able Abnormal
size] to read,
CN III, IV, VI (+) Extra occular Pupils react to light. There Normal
Occulo motor Movement (EOM); is constriction and
Trochlear Lateral Upward and consensual accommodation.
Abducens downward; pupils Able to move the eyes in
reactive to light. any direction in unison.
CN V Able to feel and clearly Able to feel my finger on Normal
Trigeminal identify stimulus, with her face while covering his
bilateral facial sensation. eyes.
With active corneal
reflex.
CN VII Facial (+) Corneal reflex , Facial (+) Facial symmetry Normal
asymmetry
CN VIII Able to hear , but cannot Can hear but cannot walk. Abnormal
Vestibulo- maintain balance
cochlear
CN IX, X (-) gag reflex, uvula at Absent gag reflex, not able Abnormal
Glossopharyng the center to swallow and to identify
eal the taste of the food
Vagus
CN XI Soft palate , rises Not able to identify the taste Abnormal
Accessory of the food
(Spinal)
CN XII Able to shrug shoulders Cannot shrug shoulders Abnormal
Hypoglossal against resistance and to against resistance and turn
turn the head side and the head from right to right.
against resistance. Not able to protrude the
Able to move tongue tongue and move it side to

29
 from side to side side.
Muscle MNT Grading System:
Strength

Left Arm (+5) Active motion +2 inactive motion against Abnormal,

against full resistance some resistance.

Right Arm (+5) Active motion +2 inactive motion against Possible

against full resistance some resistance. exhaustion
experienced by the
patient when she
coughs.
Left Leg (+5) Active motion +4 active motion against Abnormal
against full resistance some resistance.
Right Leg (+5) Active motion
against full +4 active motion against Abnormal
Resistance some resistance.
Environment

 Room temperature : Normal , adequate

 Lightning : adequate

Safety :

 Violations of medical asepsis: Absent

 Violations of safety measures: Absent

Activities of daily living :

Feeding – able to perform

Dressing – able to perform
Combing – not able to perform
Brushing – able to perform
Bathing – able to perform
Transferring – able to perform

VI. LAB INVESTIGATIONS:

Serum Biochemistry test

30
Sr.no. Investigation In patient Normal value
1. Hemoglobin 9 gm. % 12-14 gm.%
2. RBC 98 mg/dl 153mg/ml
3. UREA 18.34 mg/dl 15-45mg/dl
4. WBC 8000/cumm 4000-11000/cumm
5. S. creat. 0.85mg/dl 0.7-1.5mg/dl
6. SGPT 15 IU/L 0-55IU/L
7. SGOT 32 IU/L 5-40 IU/L
8. S. Alkpo4 68U/L <50-150U/L
9. S. Bilirubin 0.7mg/dl 0.2-1.2mg/dl
10. Blood Sugar (Fasting ) 96 mg/dl 70-110mg/dl
11. Na+ 137 mcg/dl 135-155 mcg/dl
12. K+ 4.8 mcg/dl 3.5-5.5 mcg/dl
13. Cl 101 mcg/dl 98-107/dl
14. T. Bilirubin 1.4 mg% 0.8-1.1mg%
15. D. Bilirubin 0.6 mg% 0.1-0.4 mg%
16. Blood urea 43 mg% 15-45mg %
17. S. creatinine 0.9 mg% 0.5 -1.3 mg %
18. ALP 76 IU/L 60-150 IU/L
LIPID PROFILE :

Investigation In patient Normal value

Cholesterol 130 mg/dL 150-200 mg/dL
Triglycerides 150 mg/dL 40-140 mg/dL
High density lipid 27 mg/dL 35-170 mg/dL
Low density lipid 57 mg/dL 65-170 mg/dL
Very low density lipid 26 mg/dL 5-35 mg/dL
X-RAY CHEST:

Both cp angles appear clear

Heart size &aorta appear within normal limits
Rest of bony thorax under vision appear normal.

PTI/ INR :

Investigation In patient Normal value

PT Time 13 sec 10-14 sec
Control Time 13 sec 11 to 13.5 sec
Index 100% 9.5-13.5 sec

31
INR 110 < 1.1

PROCESS RECORDING

BIO –DATA OF THE PATIENT

 Name: Amar Singh s/o Dalip Singh

 Age: 61 years
 Gender: male
 Religion: sikh
 Address: VPO bhagpur gagra , Moga
 Education: illiterate
 Occupation: cycle shopkeeper
 Marital status: married
 Languages known: Punjabi
 Date of Admission: 28/11/18
BRIEF HISTORY OF PATIENT:

Patient was admitted to psychiatry ward , GGS hospital , Faridkot with the chief complaints of

According to patients :
 Decreased sleep
 Sadness
 Low mood X 10-15 days
 Episodes of pain and heart burn
 Loss of concentration
 Irritability
 Generalized body ache
 Constipation
According to informant :
E. Multiple complaints for body pain
F. Disturbance of sleep X 6 days
G. Low mood
H. Decreased sleep
PROCESS RECORDING

Objectives for the patient:

1. To establish rapport and therapeutic IPR.

2. To socialize effectively.
3. To ventilate his feelings.
4. To identify the problems.

32
 5. To learn healthy coping mechanisms.

Objectives for the nurse:

1. To develop adequate communication skill.

2. To develop confidence in maintaining therapeutic relationship.
3. To develop skill in acknowledging the problems of the patient.
4. To assist the patient in dealing with his personal problems.
5. To assist the patient in developing positive coping mechanisms.
6. To procure skill in evaluating the pre-set objectives in order to assess the effectiveness of
therapeutic IPR.
7. To judge self in dealing with anxiety, fear and sentiments while progressing through the
therapeutic IPR.

33
S.no Particip Conversation Therapeutic Inference Communica
ants techniques tion
1. 1 Nurse Sat sri akal bapu ji …. Giving Initiation of Verbal
. recognition communicatio
Patient Sasri kal …. n
2. 2 Nurse Ki mai tuhade nal gal kar sakdi Giving Initiation of Verbal
. ha ? recognition communicatio
Patient n
Hanji
3. Nurse Bapu ji tuhda na ki hai ? Giving Initiation of Verbal
recognition communicatio
Patient Mera na amar singh hai n
4. Nurse Tuhadi umar ki hai Exploring Maintain eye Verbal
to eye contact
Patient Meri umar 60 saal hai
5. Nurse Tuc kithe rehnde ho ? Questioning Responding Verbal
spontaneously
Patient Asi Moga de rehn wale ha …
6. 4 Nurse Tuc ethe kyu aye ho? Questioning Responding Verbal
. spontaneously
Patient Mainu nind nhi aundi …
7. Nurse Tuhanu hor koi takleef hai ? Linking Answer Verbal
adequately
Patient Ha … saah di problem hai ….
8. Nurse Bapu ji .. kadi ilaaj karwaya hai? Exploring Maintain eye Verbal
to eye contact
Patient Hanji Faridkot to hi karwaya c
9. 5 Nurse Tuhanu ethe aya kinne din hoya ? Linking Answer Verbal
. adequately
Patient Hanji ethe aya 2 din hoye ne
10. 6 Nurse Tuhanu eh takleef kad to hai ? Theme Answer Verbal
. identification adequately &
Patient Mainu ess takleef hoyw nu 6 mahine made
hoye ne eye to
eye
contact.
11. 7 Nurse Tuhanu ethe koun leke aya ? Open general Answers Verbal
. lead adequately
Patient Mainu mere munde leke aye ne
12. 9 Nurse Tuc koi golian ta nhi khande c ? Questioning Answers Verbal
. adequately.
Patient Ha tramadol diyan golian khanda c
13. 1 Nurse Tyuc ghar vich ki karde ho ? Open general Maintains eye Verbal
0 lead to eye contact
. Patient Mai kujh nhi karda

14. 1 Nurse Tuhanu koi tension ta nhi hai Reinforcing Answered Verbal
1 the patient sadly
. Patient Nhi offering

34
 general lead

15. 1 Nurse Hor koi problem hai ? Asking divert Answers Verbal
2 question adequately
. Patient Na bas ..a hi aa

16. 1 Nurse Kise hor nu eh takleef hai Encouraging Answers Verbal

4 description of adequately
. Patient Nhi thought
17. Nurse Tuhanu koi awaazan sunayi ta nhi
dindia … ya kujh dikhayi ta nhi
dinda
Patient Nhi
18. 1 Nurse Vehle time ki karde ho ? Encouraging Answers Verbal
5 ventilation of adequately
. Patient Kujh nhi gallan mardi ha … feelings.

19. 1 Nurse Tuhanu lagda hai ki es nal tuhade Encouraging Answers Verbal
7 parivar nu pareshani hundi hai description of adequately
. Patient Han… thought
20. 1 Nurse Koi fark mehsoos hoya Divert Answers Verbal
9 questioning adequately
. Patient Hanji thoda hai .. about his
thinking
process
21. 2 Nurse Thik hai … dwai time sir lende ho Linking with Answers Verbal
0 reality adequately
.
Patient Hanji
22. 2 Nurse Psychoeducation: Suggestion Linking and Verbal
1  Samai de nal dwai leni hai accepting my
.  Apne mann nu vyasat rakhna suggestion
hai
 Steam leni hai din vich 3 war
 Khana time te khana hai
 Je koi takleef hoyi ta doctor
nu jarur dasna hai
 Apne sareer di safai da
dhyan rakhna hai ate ale
duale da v
Patient Thik hai ji
23. Nurse Chalo kal milde ha …apna dhyan Informing Termination Verbal
rakheyo and of the
terminating interview is
the interview done in normal
Patient Thik hai beta way and is
accepted by
the patient.

35
Description of
the disease

36
 INSOMNIA
According to guidelines from a physician group, insomnia is defined as difficulty falling
asleep or staying asleep, even when a person has the chance to do so. People with insomnia
can feel dissatisfied with their sleep and usually experience one or more of the
following symptoms: fatigue, low energy, difficulty concentrating, mood disturbances, and
decreased performance in work or at school. The National Institutes of Health estimates
that roughly 30 percent of the general population complains of sleep disruption, and
approximately 10 percent have associated symptoms of daytime functional.

Prevalence

• About 30 percent of adults have symptoms of insomnia

• About 10 percent of adults have insomnia that is severe enough to cause daytime
consequences
• Less than 10 percent of adults are likely to have chronic insomnia

INSOMNIA TYPES & CAUSES

SR.NO. IN BOOK IN PATIENT

1) Adjustment insomnia (caused by a source of Present
stress and tends to last for only a few days or
weeks)
2) Behavioral insomnia of childhood (when a Absent
child associates falling asleep with an action
(being held or rocked), object (bottle) or
setting (parents’ bed))
3) Idiopathic insomnia (An insomnia that begins Absent
in childhood and is lifelong, it cannot be
explained by other causes.)
4) Inadequate sleep hygiene (caused by bad sleep Absent
habits that keep you awake or bring disorder
to your sleep schedule)
5) Insomnia due to drug or substance, medical Present (overuse of tramadol and
condition, or mental disorder(associated more alprazolam)
often with a psychiatric disorder, such as
depression, than with any other medical
condition)
6) Paradoxical insomnia(A complaint of severe Absent
insomnia occurs even though there is no
objective evidence of a sleep disturbance)
7) Psychophysiological insomnia(A complaint of Present
insomnia occurs along with an excessive
amount of anxiety and worry regarding sleep
and sleeplessness)

RISK GROUPS

Sr.no. Content In book In patient

1) A high rate of insomnia is seen in Present Present

37
 middle-aged and older adults.
Although your individual sleep need
does not change as you age, physical
problems can make it more difficult to
sleep well.
2) Women are more likely than men to Present Absent
develop insomnia.
3) People who have a medical or Present Present
psychiatric illness, including Respiratory
depression, are at risk for insomnia. problem previous
history of TB
and peptic ulcer
4) People who use medications may Present Present
experience insomnia as a side-effect. Previous history
of use of
tramadol and
alprazolam

PROGNOSIS

The lowest mortality was seen in individuals who slept between six and a half and seven and
a half hours per night. Even sleeping only 4.5 hours per night is associated with very little
increase in mortality. Thus, mild to moderate insomnia for most people is associated with
increased longevity and severe insomnia is associated only with a very small effect on
mortality. It is unclear why sleeping longer than 7.5 hours is associated with excess mortality.

MECHANISM OF INSOMNIA

 Cortisol : Cortisol is the stress hormone in humans, but it is also the awakening
hormone. Analyzing saliva samples taken in the morning has shown that patients with
insomnia wake up with significantly lower cortisol levels when compared to a control
group with regular sleeping patterns. Persons with lower levels of cortisol upon
awakening also have poorer memory consolidation in comparison to those with
normal levels of cortisol. A larger amount of cortisol released in the evening occurs in
primary insomnia.
 Estrogen : Many postmenopausal women have reported changes in sleep patterns
since entering menopause that reflect symptoms of insomnia. This could occur
because of the lower levels of estrogen. It can cause hot flashes, change in stress
reactions, or overall change in the sleep cycle, which all could contribute to insomnia.
Estrogen treatment as well as estrogen-progesterone combination supplements as a
hormone replacement therapy can help regulate menopausal women’s sleep cycle
again.
 Progesterone : Low levels of progesterone throughout the female menstruation cycle,
but primarily near the end of the luteal phase, have also been known to correlate with
insomnia as well as aggressive behaviour, irritability, and depressed mood in women.
Around 67% of women have problems with insomnia right before or during their

38
 menstrual cycle.[50] Lower levels of progesterone can, like estrogen, correlate with
insomnia in menopausal women. A common misperception is that the amount of sleep
required decreases as a person ages. The ability to sleep for long periods, rather than
the need for sleep, appears to be lost as people get older. Some elderly insomniacs
toss and turn in bed and occasionally fall off the bed at night, diminishing the amount
of sleep they receive.

CLINICAL MANIFESTATIOS

Sr.no. IN BOOK IN PATIENT

1. Difficulty falling asleep at night Present
2. Trouble getting back to sleep when waking Present
up during the night
3. Waking up too early in the morning Present
4. Not feeling well-rested after a night's sleep Present
5. Daytime downiness, fatigue, tiredness or Present
sleepiness
6. Irritability, depression or anxiety Present
7. Difficulty paying attention, focusing on Absent
tasks or remembering
8. Increased errors or accidents Absent
9. On-going worries about sleep Present
10. Relying on sleeping pills or alcohol to fall Present
asleep.

DIAGNOSIS

IN BOOK IN PATIENT
i) Sleep log: A sleep log is a simple diary Not done
that keeps track of details about sleep. In a
sleep log, record details like bedtime, wake
up time, how sleepy one feels at various
times during the day, and more. A sleep log
can also help the doctor figure out what
might be causing insomnia
ii) Sleep inventory: A sleep inventory is an Done
extensive questionnaire that gathers
information about personal health, medical
history, and sleep patterns.
iii) Blood tests: Doctor may perform certain Done
blood tests to rule out medical conditions
such as thyroid problems, which can disrupt
sleep in some people
iv) Sleep study: Doctor may suggest to do an Done
overnight sleep study, or poly somnography,
to gather information about the night time
sleep. In this exam, one sleeps overnight in a
lab set up with a comfortable bed. During the

39
exam the patient will be connected to an
EEG, which monitors the stages of sleep. A
sleep study also measures things like oxygen
levels, body movements, and heart and
breathing patterns. A sleep study is a non-
invasive test.
COMPLICATIONS

IN BOOK IN PATIENT
Lower performance on the job or at school PRESENT
Slowed reaction time while driving and a PRESENT
higher risk of accidents
Mental health disorders, such as depression, PRESENT
anxiety disorder or substance abuse
Increased risk and severity of long-term ABSENT
diseases or conditions, such as high blood
pressure and heart disease.

TREATMENT

IN BOOK IN PATIENT
 COGNITIVE BEHAVIORAL
THERAPY (CBT): CBT can have
beneficial effects that last well beyond
the end of treatment. It involves
combinations of the following therapies:
i. Cognitive therapy: Changing No
attitudes and beliefs that hinder your
sleep
ii. Relaxation training: Relaxing your Yes
mind and body
iii. Sleep hygiene training: Correcting
Yes
bad habits that contribute to poor
sleep
iv. Sleep restriction: Severely limiting
and then gradually increasing your Yes
time in bed
v. Stimulus control: Going to bed only
when sleepy, waking at the same Yes
time daily, leaving the bed when
unable to sleep, avoiding naps, using
the bed only for sleep and sex
 OVER-THE-COUNTER No
PRODUCTS: Most of these sleep aids
contain antihistamine. They can help you
sleep better, but they also may cause
severe daytime sleepiness. Other
products, including herbal supplements,
have little evidence to support their
effectiveness.
 PRESCRIPTION SLEEPING

40
 PILLS: Yes
i) Eszopiclone (Lunesta) No
ii) Ramelteon (Rozerem) No
iii) Zaleplon (Sonata) No
iv) Zolpidem (Ambien, Edluar,
Intermezzo, Zolpimist)

NURSING CARE PLAN

NURSING ASSESSMENT

 Vital signs are monitored.

 On MSE, it is found that patient shows depressive and decreased psychomotor
activity.
 Nutritional status of patient is assessed.
 Low self esteem in patient
 Collection of detailed history.
 Personal hygiene is assessed.

NURSING DIAGNOSIS

 Insomnia related to anxiety (as evidenced by difficulty falling and remaining asleep,
fatigue, and irritability)
 Ineffective airway clearance related to poor cough effort possibly evidence by
abnormal breath sounds and dyspnea.
 Altered role performance related to the need to perform rituals, evidenced by inability
to fulfill usual patterns of responsibility.
 Chronic low self esteem related to lack of positive feedback evidenced by inability to
tolerate being alone

Short Term Goals:-

 To improve coping mechanisms of patient .

 To enhance role performance in family .
 To promote coping skills.
 To promote the self esteem.
 To make patient self dependent.

Long Term Goals:-

 To rehabilitate the patient.

 To prevent further complications.
 To assist the patient in early recovery

41
Nursing Expected Planning Implementation Rationale Evaluation
Diagnosis Outcome
Insomnia Patient will  Determine the  The client’s sleep and  The amount of sleep an Patient has
related to demonstrat client’s sleep and activity pattern is individual needs varies demonstrated ability
overuse of e ability to activity pattern. determined . with lifestyle, health, to
sedatives as ■ Sleeps  Encourage patient  The patient is and age. ■ Sleeps through the
evidenced by through the to establish a encouraged to establish a  Rituals and routines night consistently
difficulty night bedtime routine to bedtime routine to induce comfort, ■ Feels rejuvenated
falling and consistently facilitate transition facilitate transition from relaxation, and sleep. after sleep
remaining ■ Feels from wakefulness wakefulness to sleep.  Stress interferes with a ■ No dependence on
asleep, rejuvenated to sleep.  The patient is person’s ability to relax, sleep aids
fatigue, and after sleep  Encourage him to encouraged to eliminate rest, and sleep.
irritability ■ No eliminate stressful stressful situations before Knowledge of causative
dependence situations before bedtime. factors can enable the
on sleep aids bedtime.  The patient is instructed client to begin to
Instruct patient and about factors (e.g., control factors that
significant others physiologic, psychologic, inhibit sleep.
about factors (e.g., lifestyle, frequent work  Knowledge of factors
physiologic, shift changes, that affect sleep enables
psychologic, excessively long work the client to implement
lifestyle, frequent hours, and other changes in lifestyle and
work shift changes, environmental factors) pre bedtime activities.
excessively long that contribute to sleep  Milk and protein foods
work hours, and pattern disturbances. contain tryptophan, a
other  Family comfort precursor of serotonin,
environmental measures, sleep which is thought to
factors) that promoting techniques, induce and maintain
contribute to sleep and lifestyle changes that sleep. Stimulants should
pattern can contribute to optimal be avoided because they
disturbances. sleep are discussed . inhibit sleep
 Discuss with  The bedtime food and  Anxiety is a feeling
patient and his beverage intake for items 1aroused by a vague,

42
 family comfort that facilitate or interfere nonspecific threat.
measures, sleep with sleep are monitored Identifying the client’s
promoting . perspective will
techniques, and  The patient is assisted to facilitate planning for
lifestyle changes use coping responses that identification of specific
that can contribute have been successful in emotions such as anger
to optimal sleep. the past. or helplessness,
 Monitor bedtime  The patient’s perspective distorted perceptions,
food and beverage of a stressful situation. and unrealistic fears.
intake for items  Encouraged verbalization  Maladaptive coping
that facilitate or of feelings, perceptions, mechanisms are
interfere with and fears. characterized by an
sleep.  Determined the client’s inability to make
 Assist him to use decision-making ability. decisions and choices.
coping responses
that have been
successful in the
past.
 Create an
atmosphere to
facilitate trust.
Seek to understand
patient’s
perspective of a
stressful situation.
 Encourage
verbalization of
feelings,
perceptions .
Determine the
client’s decision-
making ability.

43
Ineffective The client  Assessed  The respiratory rate of  Diminished breath The client able to
airway will be able respiratory rate. patient is assessed after sounds may reflect display patency of
clearance to:  Noted chest every 1 hour atelectasis. airway as manifested
related to  Sustain movement; use of  The chest movement;  Rhonchi and wheezes by:
poor cough respiratory accessory muscles use of accessory muscles indicate accumulation
effort rate within during respiration. during respiration are of secretions and  Client’s respiratory
possibly normal  Auscultated breath noted . inability to clear rate is within normal
evidence by range sounds; noted areas  The Auscultation of airways, which may range
abnormal  Display with presence of breath sounds; noted lead to use of accessory
breath sounds decreasing adventitious areas with presence of muscles and increased  Secretions decreased.
and dyspnea. amount of sounds. adventitious sounds is work of breathing.
secretion.  Documented done .  Expectoration may be Client’s restlessness
 Allay respiratory  The Documentation of difficult when was alleviated and
restless- secretions: respiratory secretions: secretions are very thick remained calm.
ness. character and character and amount of as a result of infection
amount of sputum. sputum is done . or inadequate hydration.
 Maintained patient  Blood tinged or frankly
on moderate high  The patient is bloody sputum results
back rest. maintained on moderate from tissue breakdown
 Checked for high back rest. in the lungs and may
obstructions: require further
accumulation of  The obstructions: evaluation and
secretions. accumulation of intervention.
 Take medications secretions are noted.  Positioning helps
as ordered by the maximize lung
physician.  The medications expansion and
prescribed are deflax , decreases respiratory
niplar and respules of effort. Maximal
salbutamol . ventilation may open
atelectatic areas and
promote movement of
secretions into larger

44
 airways for
expectoration.
 Prevents obstruction
and aspiration.
Suctioning may be
necessary if client is
unable to expectorate
secretions.
 High fluid intake helps
thin secretions, making
them easier to
expectorate. Prevents
drying of mucous
membranes and helps
thin secretions.

Altered role Patient will o Determine o Determining  This is important Patient is able to
performance be able to patient's patient's previous assessment data for resume role-related
related to the resume previous role within the formulating an responsibilities in
need to role within family and the appropriate plan of care.
role-related family .
perform the family extent to which  Identifying specific

45
rituals, responsibilit and the this role is altered stressors, as well as
evidenced by ies. extent to by the illness. adaptive and
inability to which this Identify roles of maladaptive responses
fulfill usual role is other family within the system, is
patterns of altered by members. necessary before
responsibility. the illness. o Encouraging assistance can be
Identify patient to discuss provided in an effort to
roles of conflicts evident facilitate change.
other within the family  Planning and rehearsal
family system. Identify of potential role
members. how patient and transitions can reduce
b) other family anxiety.
Encourage members have  Positive reinforcement
patient to responded to this enhances self-esteem
discuss conflict. and promotes repetition
conflicts o Exploration of of desired behaviors.
evident available options
within the for changes or
family adjustments in
system. role is done.
Identify Practice through
how patient role play.
and other o To Patient
family positive
members reinforcement for
have ability to resume
responded role
to this responsibilities
conflict. by decreasing
o Explore need for
available ritualistic
options for behaviors is

46
 changes or given .
adjustments
in role.
Practice
through
role play.
o Give
patient lots
of positive
reinforceme
nt for
ability to
resume role
responsibili
ties by
decreasing
need for
ritualistic
behaviors.

47
Chronic low Client will  Assess the self o Client has very low self  Assessment Client’s self
self esteem demonstrate concept of esteem. provides the esteem is
related to increased client. o Psychological support baseline data. enhanced . so
lack of self esteem  Provide is provided to client.  It will enhance that she is
positive and psychological o Inaccuracies in self the self esteem able to do her
feedback perception support to perception are of client. work by her
evidenced by of himself as client. discussed with client.  Client may not own and she
inability to a  Discuss o Client is motivated to see positive don’t need to
tolerate being worthwhile inaccuracies in enlist the weaknesses aspects of self depend on
alone. person self perception and strengths that others see. others.
with client. o Positive feedback is  It will help the
 Instruct the provided to client, when client develop
client to she has explored her internal self
prepare a list feelings. worth.
of weaknesses  It will help the
and strengths. client to learn
 Provide new coping
positive behaviour.
feedback to
client.

DISCHARGE PLAN

Patient not yet discharged and receiving treatments.

HEALTH EDUCATION
1) PERSONAL HYGIENE:
 Patient is taught about importance of personal hygiene of patient.

48
  She is advised to perform her self care activities independently.
 She is asked to perform hygiene practices daily.
2) DIET:
 Patient is taught about the importance of balanced diet.
 She is taught about foods that are contraindicated during taking particular medications.
3) EXERCISES:
 She is taught perform active and passive exercises.
 She is asked to assist patient to carry out activities of daily life.
4) ENVIRONMENT:-
 Environment should be calm and safe for the patient.
 Attendant is asked to remove all the hazardous objects.
5) MEDICATIONS:-
 Patient is advised to take medication regularly.
 Patient is advised to inform immediately whenever any unusual symptoms appears.
 She is advised not to discontinue medicine by their own.
Bibliography:
 Ahuja Niraj. A short Textbook of Psychiatry. 7th ed. Jaypee Brothers.
 Lalitha K. Mental Health and Psychiatric Nursing.1st ed. VMG Book House.
 Sadock BJ, sadock VA. Kaplan &Sadock’s Synopsis of psychiatry. 10th ed. Lippincott.
 Mary CT. Psychiatric Mental Health Nursing. 4th ed. F.A. Davis
American Academy of Sleep Medicine:
https://aasm.org/resources/factsheets/insomnia.pdf

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