NURSING CARE PLAN

ON
Opioid Dependence
 HISTORY OF THE PATIENT
BIO-DATA OF THE PATIENT

Name of the patient – Amrit

Age- 24 years

Gender- Male

Religion- Hindu

Nationality- Indian

Ward- General Ward

Marital Status- Unmarried

Language-Punjabi, Hindi, English

D.O.A- 10/02/2020

Education- Diploma in Mechanical Engineering

DIAGNOSE: - F19. - Mental and behavioral disorders due to multiple drug use and use of
other psychoactive substances

INFORMANT: Mother and patient.

Reliability of informant: Information reliable. As it is given by mother and patient lives

with his mother from birth. Insight was present; so patient was a reliable source.

CHIEF COMPLAINTS: - At the time of admission at Hospital Chief Complaints:

ACCORDING TO THE PATIENT:

On the day of admission patient was very frustrated from his opioid dependence and life style
and wishes to stop the use of opioids.

Chief complaints are-

Irritation 3 days

Frustration x 5 days

Restlessness x 1 day

Body ache x 1 day

Disturbed sleep x 3 days

HISTORY OF PRESENT ILLNESS: -

● Patient came to the hospital with chief complaint of Irritation, frustration and also
willingness to deaddict for opioid use.
● According to patient, he tried to stop taking opioids many times but fail to do that
leads to increase in frustration and anger; irritation.
● After that he decided to talk with parents and they brought him to Civil Hospital,
Bareilly.

PAST HISTORY OF ILLNESS: -

MEDICAL:

Patient did not have any history of medical illness.

SURGICAL:

Patient did not have any surgical history.

PSYCHIATRIC:

According to patient when he joined diploma (Mechanical engineering) his friends were used
to take drugs on the backside of the college {GuruNanak Institute of Technology}

● According to him, he never used to go there.

● After completion of diploma, he got job in Hawkins Pressure Cooker Company.
● After eleven months, he left the job due to completion of contract and family start
putting pressure for job.
● Due to this he started staying out of home from morning till night and start taking
opioids.
● According to patient he tried to leave the opioids many times but failed.
● He decided to come alone to the hospital but with the suggestion of friends he came
along with mother.

FAMILY HISTORY: -

Patient belongs to a nuclear family. Out of his parents father uses to take alcohol. Father is
head of the family.The economic status is average. He has two sisters. Both are elder than
patient and both sisters are married.
FAMILY TREE:

SOCIAL BACKGROUND OF THE FAMILY

Type of family: - nuclear family

Social status:-poor family

Physical illness: - patient’s father used to take alcohol

Mental illness: - patient’s maternal grandmother was suffering from mental disorder and
patient’s emotional liability was good with his grandmother. Rest of the family members are
mentally normal in condition

PERSONAL HISTORY: -

1. Birth history

● Born withnormal vaginal delivery at Leela Vati hospital (Hoshiarpur).

● No any complications/ injury at the time of delivery.

● According to mother he cried immediately after the birth.

2. Childhood History:

● Primary caregiver: Mother and father

● Feeding: Breast feeding was given till the age of 1 year

● Age of weaning: weaning was started at the age of 7 months

● Developmental milestones: Normal developmental milestones

● Behavior and emotional problems: No history of behavioral and emotional

problems like thumb sucking, excessive temper tantrums, head-hanging, nail biting,
enuresis, night terrors, etc

● Illness during childhood: No any history of CNS infections, epilepsy, neurotic

disorders, malnutrition

● Physical illness during childhood: Patient did not have any psychiatric illness during
his childhood
3. SCHOOLHISTORY

● Age of beginning of formal education: Schooling was started at the age of 4 ½

years.

● Education level- Diploma in mechanical engineering after passing 10th.

● He is further going for studies in merchant navy.

● Academic performance:he was an average student

● Relationship with peers and teachers: he had good relationship with peers and
teachers

● School phobia: No any history school phobia is present

● Conduct disorder: No any history of conduct disorders.

4. WORK HISTORY

● Patient starts doing job in Hawkins Pressure Cooker Company after diploma
completion.

● Income /month- 10 thousand/month.

● Income was sufficient.

● Job shift –he did job in Hawkins Company for 11 months due to completion of
contract; otherwise no any significant reason for shift.

● Relationship with others- good relationship with other members of company.

5. SOCIAL HISTORY

● Attitude toward the society- good.

● Religious – occasionally used to visit gurudwara.

● Hobbies- basket ball playing and watching movies.

6. SEXUAL HISTORY:

● No H/O any sexual disorder.

7. MARITAL HISTORY:

● Patient is divorced.

PREVIOUS PERSONALITY: -

1. SOCIAL RELATIONS:

● Patient has conflict in relationship with his father because his father uses to take
alcohol and due to that parents of patient always use to do fight.

● He was a cheerful person and has many friends. His attitude to self and others was
good. He has self-confidence. He gets easily irritable and he is sensitive. He has good
decision making in facing problem and has good religious and moral beliefs.

2. INTELLECTUAL ACTIVITIES:

● Patient was good in studies and had a history of fair academics.

3. MOOD:

● Patient became irritable some time.

4. PERSONALITY CHARACTER

Ambitious – to continue the studies and deaddict himself fromopioids.

5. HABITS AND ADDICTIONS:

Smoking

● Age of start smoking- 17 years.

● Reason of start smoking- curiosity( self interest)
● Amount when he starts taking smoke- aprox 1-2 cigarettes/day.
● Where he used to take-outside the home.
● With whom he is used to take- alone or sometimes with friends.
● Age at which amount of cigarette increased- 19 years.
● Amount increased- 4-5 cigarettes/day or more.
● Amount of cigarette again increased in 2018.
● Amount increased- 7-8 cigarettes/day.
● Then 2020, he start taking opioids

Opioid history

● Age at which start taking opioids-22 years.

● Reason for starting- inability to get job.
● Amount –not specified but 2-3 times/day.
 ● Method of using- foil paper with the use of inhalation of fumes.
● Frequency of taking opioids decreased at-24 years.

VITAL SIGNS:

Date: 10/03/14 Time: 11:00AM

Sr. No. Vital signs Patient value Normal value Remarks

98.40 F(axillary
1. Temperature 97-990F Normal
Route)

2. Pulse 78/min. 60-100/ min. Normal

3. Respiration 18/ min. 16-24 / min. Normal

110/70-130/90
4. Blood pressure 120/80 mm/Hg Normal
mmHg

LAB INVESTIGATIONS:

Date:11-03-14
S.No. Test Name Patient Value Normal value Remarks

1. Hb 14.0 gm/dl 12-16 gm/dl Normal

2. TLC 9400/ cumm 4000-11000 /cumm Normal

3. Neutrophils 68% 40-75% Normal

4. Lymphocytes 29% 20-45% Normal

5. Monocytes 02% 2-8% Normal

6. Eosinophils 02% 1-6% Normal

7. Blood Urea 26.0 mg/dl 15-45 mg/dl Normal

8. S.creatinine 1.0 mg/dl 0.8-1.8 mg/dl Normal

9. Serum albumin 4.28 mg% 3.5-5.0 mg/L Normal

10. Direct bilirubin 0.2 mg% 00-04 mg% Normal

11. Total bilirubin 0.6 mg% 01-12 mg/ Normal

 12. SGOT 38 u/L 0-400 u/L Normal

13. SGPT 46 u/L 0-400 u/L Normal

TREATMENT

Pharmacological
S. No. Drug Dose Route Frequency Action
name

Antianxiety
Tab
1 Clonazepam 2 mg Orally TDS
Control (Benzodiazepines)

1mg
Antianxiety
2 Inj.lopez Lorazepam I/m SOS
(1/2ampu
(Benzodiazepines)
le)

Inj.Pantode Pantoprazole Proton pump

3 40 mg I/v BD
c sodium inhibitor.

H 2Blocker and
4 Tab. Aciloc Rantidine 150 mg Orally BD
ulcer healing drug.

Inj. Sedative/muscle
5. promethazine 25mg IM STAT
phenargan relaxant

MENTAL STATUS EXAMINATION

BIO-DATA OF THE PATIENT

Name of the patient – Amrit

Age- 24 years
Gender- Male
Religion- Sikh
Nationality- Indian
Ward- General Ward, Civil Hospital
Marital Status- Unmarried
Language- Hindi, English
D.O.A- 10/02/2020
Address- Udam Singh Nagar,
Education- Diploma in Mechanical Engineering

DIAGNOSE: - F19. - Mental and behavioural disorders due to multiple drug use and use of
other psychoactive substances

1. GENERAL APPEARANCE: -
a. Facial expression:Patient is facial expression are according to situation or consistent
with subject under discussion.

a. Posture: Patient is restless.

b. Mannerism: Patient lays his head down again and again while conversation.

c. Grooming and Dress: -Patient is wearing appropriate dress which is according to the
place and season. Hair was not combed.

d. Hygiene: -Hygienic condition of the patient is fair. Patient takes bath everyday and
also changes his clothes. His clothes are clean. Nails are also cut properly and are
clean.

e. Physique: -Patient is a young moderately body built and his hairs are white to some
extent.

f. Level of Eye Contact: -Patient sometimes maintained eye-to-eye contact throughout

the conversation.

2. MOTOR DISTURBANCES: -

a) Over activity or Hyperactivity: it is absent in my patient

b) Under activity or motor retardation: - Patient does not show shows motor
retardation.
 c) Stereotypy: it is absent in my patientas he was not repeating phrases or any other
activity all the times.

d) Negativism : It is absent in my patient

N: Ajay bed se uth kar bahar jao aur fir wapis bed pe ao.
P: Patients follow the commands.
Outcome: Negativism absent.

e) Compulsive movements:- it is absent in my patient

f) Echopraxia:- it is absent in my patient

g) Automatic obedience:-it is absent in my patient

h) Waxy flexibility:-it is absent in my patient.

3. SPEECH AND THOUGHT DISORDERS:-

A. DISORDER OF FORM OF THOUGHT:

I. Circumstantiality : It is absent in my patient. Patient reaches at goal without any

irrelevant talking.
What are you eating in breakfast?
Ans.: Aloo prantha with butter, tea.

II. Irrelevant: Patient answers the question appropriately so irrelevance is absent in the
patient.

III. Neologism: Patient answered question appropriately and not invent his own language
and new word for describing his sentence.

IV. Tangential thinking: Patient answer appropriately of every question and goal is
achieved.

V. Word salad - absent

VI. Preservation - absent

VII. Ambivalence - Absent in the patient..

EVALUATION OF SPEECH:

Intensity: patient voice is audible and not exceeding loud.

Pitch: pitch of the patient voice is normal.

Speed: patient speaks at normal rate of speech.

Spontaneity: spontaneous.

Reaction time: Reaction time is normal and answered appropriately most of the time.

B. DISORDER OF CONTENT OF THOUGHT:

DELUSIONS: Delusions are false beliefs are irrational not shared by persons of same age,
race and standard of education, which is held by conviction and which cannot be altered by
arguments and are persistent.

● Persecutory delusions - Absent in the patient.

● Delusion of reference - Absent in the patient.

● Delusion of influence - absent

● Delusion of sin and guilt - absent

● Hypochondrial delusion => absent

● Delusion of grandeur=>absent

● Nihilistic delusions => absent

PROGRESSION LEVEL:

OBESSIONN:

N:kya apko kabi esa laga k koi vicah apke man main bar bar aa raha hai jo apko khud
ko pta ho k yeh nahi anna chahiye aur jo apko tension de raha ho?

P: Nahi.

Inference: Patient himself does not recognize to be abnormal ideas.

PREOCCUPATION:

Observation: patient thought content does not centre on a particular idea.

Inference: patient is able to progress in thoughts

C. DISORDER OF RATE OF SPEECH:

● Pressure of speech: Pressure of speech is normal

 ● Flight of idea: - it is absent in the patient as the patient was not shifted his ideas from
one to another during conversation.

● Retardation=> absent

● Mutism=> absent

● Aphonia=> absent

● Thought block=>absent

● Clang association=> absent

4. DISORDER OF PERCEPTION: -

Hallucinations: May be defined as a sensory experience in the absence of a stimulus or an

object.

Auditory Hallucination: it is absent in the patient.

Visual Hallucination: it is absent in the patient.

Olfactory Hallucination: it is absent in the patient.

Tactile Hallucination: it is absent in the patient.

Somaic Hallucination: it is absent in the patient.

ILLUSIONS:

N: yeh mere hath me kya hai?

P: pen

Inference: Absent

5. DISTURBANCES IN AFFECT: -

a) Pleasurable affect: - it is absent in the patient.

b) Un-pleasurable affect: -there was no unpleasurable affect shown by the patient.

c) Aggression: Patient did not show aggression when he would said to sit down on bed or
take medicine
d) Mood swing: it is absent in the patient.

6. DISORDER OF MEMORY: -

Memory: Function by which information stored in the brain is later recalled to consciousness

a) Immediate memory
N: Main jo 5 chizo k naam bolunga use mere peeche bolna: pen, tea, mobile, table,
shirt.
P: pen, tea, mobile, table, shirt.
Inference: Immediate memory of the patient was intact.

b) Recent memory
N: What you have taken last night?
P.: Chapatti, rice and daal
Inference: Patient’s recent memory was also intact.
c) Remote memory
N: what was the name of your fast friend in childhood?
P: Sunil was my fast friend in childhood.
Inference: Patient’s remote memory was intact.

Disorders of Memory

Amnesia: Absent in my patient as patient was recalling all the events fully.

Para-amnesia: Absent in my patient as patient was able to recall the events fully.

Deja-vu: absent as patient did not show any over-familiarity.

James-vu: absent as patient did not show unfamiliarity to familiar people.

7. ORIENTATION: -

It is the ability to recognize the surroundings.

Time:

N. What is the day today?

P. Tuesday

Inference: Oriented to time

Place:
N: Where are you at present?

P: Hospital

Inference: oriented to place.

Persons:
N: yeh apke sath kon hai (pointing toward his mother)?
P: meri mummy hai.

Inference: Oriented to person.

8. INSIGHT

Q: How you came to the hospital, what happened on that day?

Ans: I used to take drugs and want to move away from them. For this reason only I talked to
my parents and they brought me to hospital.

Inference - intellectual insight was present in patient (level-5)

9. CONCENTRATION

N: Amrit suppose you have 100Rs and you have spent 7Rs then what amount is left
with you?

P: 93Rs.

N: now subtracts 7Rs from 93Rs?

P: 86 Rs. (after some time)

Inference - good concentration; as he was able to concentrate for long time period.

10. JUDGMENT

Test

N:agar kahi aag lag jaaye to kya krenge?

P: pani dalenge

Inference: test judgment intact.

Personal
N:hospital to ghar ja ke kya karoge?

P: apna kam pe javanga

Inference: personal judgment intact

11.INTELLIGENCE: -

N: India ka prime-minister kaun hain?

P: narendra Modi
N: India ki capital kya hai?
P: Nai delhi
Inference: Patient is intelligent and is having good general information.

13. SLEEP: patients sleeping pattern is impaired. He used to take sleep of 5-6 hrs and wake
up in mid night.

PHYSICAL EXAMINATION
HEAD TO TOE EXAMINATION:

● PHYSICAL EXAMINATION:

● BASIC PARAMETERS:

Sr. No. Vital signs Patient value Normal value Remarks

98.40 F(axillary
1. Temperature 97-990F Normal
Route)

2. Pulse 78/min. 60-100/ min. Normal

3. Respiration 18/ min. 16-24 / min. Normal

110/70-130/90
4. Blood pressure 120/80 mm/Hg Normal
mmHg

● GENERAL APPEAREANCE:
● Facial Expression: NOrmal
● Gait : Normal
● Posture : Normal
● Colour : Fair
● INTEGUMENTARY SYSTEM:
● OBSERVE FOR SKIN:

-Colour : normal skin colour

-Condition : pricking marks of syringes on arms
-Temperature : warmth
-Pigmentation : No any pigmentation is seen.
-Edema : No edema

● OBSERVE FOR NAIL:

-Color : Pallor in color

-Clubbing : absent
-Cyanosis : absent

● FACE:

-Symmetrical in size and no facial edema.

● HEAD:

-Hair : Normal, equally distributed and healthy hair

-Scalp : clean

● SPECIAL SENSES:
● EYES AND VISION:

-Eye brows, eye lashes: present, normal in condition, not infected

-Eye lids : normal
-Conjunctiva : pale red in color, not infected
-Sclera : normal
-Pupils : equally reacting to light
-Vision : field of vision is normal
-Eye ball movements : normal
-Use of goggles and : nil
- Symmetry : bilateral

● EARS AND HEARING:

-Shape of the external ear: normal

-Hearing : hearing acuity is normal
-Using of hearing aids : nil
-Other complaints : no history of infection, itching or discharge.

● NOSE AND SINUSES:

-Deformity, discharge : no deviated nasal septum

-Mucous membrane for color: normal pale red in color
-Allergies : no history of any allergy
-Obstruction : nil
-Epistaxis : absent
-Sinuses : normal in condition.

● MOUTH AND THROAT:

-Lips : No color changes in the lips, dry lips, no ulceration.

-Teeth : Teeth are present, normal in alignment
-Gums : Normal, red in color, no swelling
-Buccal mucosa : No discoloration and no ulceration
-Tongue : No lesions. Not deviated from midline,
In and out Tongue movement is present
-Sore throat : Absent
-Swallowing : normal, no difficulty.
-Tonsils : not enlarged, no inflammation/ pain
-Odor of breath : No foul smell
-Voice : normal, high pitch.

● NECK:

-Movements : present, no stiffness

-Pain : nil
-Jugular vein : not distended
-Lymphnodes : not enlarged, no inflammation.
-Thyroid gland : not enlarged

● RESPIRATORY SYSTEM (THORAX AND LUNGS):

-Shape of the chest - Normal in shape

-Movements - symmetrical movements
-Breath sound - normal
-Respiratory rate - 18 breathes/ minute
-No History of breathlessness, cough and pulmonary arterial hypertension.

● INSPECTION:

Abnormal breathing pattern

-Tachypnea : nill
-Bradypnea : nil
-Hyperapnea : nil
-Dyspnea : nil
-Cheyne stroke respiration: nil
-Orthopnea : nil
-Kussmaul’s respiration : nil

● PALPATION:

-Tracheal displacement : normal, trachea central in position

-Palpate for
Tenderness
Depression, : Normal
Bulging,
Crepitus,
Swelling, cardiac impulse
-Measurements
Vertical and horizontal chest movements: normal, symmetrical in movements
● AUSCULTATION:

- Crackles
- Wheeze : Wheezing sounds present.
- Strider
- Plural friction rub

● CARDIOVASCULAR:
● INSPECTION:

-Air - no dry or brittle air comes from nose.

-Eyes - sclera and conjunctiva normal
-Lips and tongue – pale in colour
-Jugular vein - Not distended
-Abdominal distension - nil
-Nails - no clubbing/ thickening. Capillary filling time is normal.
-Skin -colour and texture is normal
-Lower extremities - no edema

● PALPATION:

-Major arterial pulse - present

-Edema - absent
-Presence of thrills - absent

● AUSCULTATION:

-Systematically auscaltate:

- Aortic area
- Pulmonic area no abnormal sounds are identified
- Tricuspid area
 - Mitral area
-Heart rate and rhythm- 82/ minute
-Identify S1 and S2- present, normal
-Extra heart sounds if any
-S3 (ventricular gallop) - extra heart sound not identified.
-S4 (atrial gallop)
- Murmurs
● GASTROINTESTINAL SYSTEM:
● INSPECTION:

-Shape and symmetry- normal, abdominal distention absent, no scar or lesion stretch
Marks presents
-Abdominal girth - 50 cm
-Umbilicus - dimpled, no discharge / infection present

● PALPATION:

-Liver - no organomegaly were identified

-Spleen
-Pancreas

● PERCUSSION:
-No formation of gas or fluid collection in the abdomen

● AUSCULTATION;
-Bowel sound is clear

● GENITOURINARY SYSTEM:

● Normal urethra patency

-No history of Nocturia, Dysuria, Incontinence, Dribbling, Infection, Urgency, Hematuria.

● GENITO REPRODUCTIVE SYSTEM:

-No abnormal discharge present,

-No history of STD

● MUSCULOSKELETAL SYSTEM:

-Posture : normal
-Muscular pain/ cramps : nil
-Pain, swelling, redness of the joint: nil
-Ability to perform ADL : No, need of instruction every time to initiate the work
-Muscle strength : poor 3/5, voluntarily losing his strength.
-Back: No history scoliosis, khyphosis, lordosis, and injuries.
● NERVOUS SYSTEM:

-Patient is fully conscious and oriented

-Cognitive status- immediate, recent, remote memory is impaired
-Total cognitive level of functioning is poor
-Plantar reflex response is present
-Co ordination, equilibrium- no response
-Problems of speech- fast and high pitch, no abnormality in speech.
-GCS Glascoma scale score is 15 / 15 (E- 4, M- 6, and V- 5)

PHYSICAL SYMPTOMS

IN BOOK IN PATIENT

● akathisia (uncomfortable feeling of inner Absent

restlessness)

● blocked nose Absent

● bone pain Present

● chills (shivering) Absent

● cramps Present

● diarrhea Absent

● difficulty sleeping (insomnia) Absent

● dizziness Absent

● general feeling of being unwell (malaise) Present

● headaches Present

● hot flushes Absent

● hypoglycemia (low blood sugar) Absent

● itching Absent

● joint pain Absent

● muscle pain Present

● nausea Absent

● runny nose Absent

● skin rash or rashes Absent

● sweating Absent

● tachycardia (rapid heartbeat) Absent

● tinnitus Absent

● tiredness Present

● vomiting Present

● weakness Present

PSYCHOLOGICAL SYMPTOMS

In book In patient

● anxiety Present as assessed during communication

with the patient.

● cravings for the drug Present

● concentration problems Absent

● confusion Absent

● depression Absent

● dysphoria Absent

● euphoria Absent

● feeling agitated Absent

● feeling restless Absent

● feeling irritable Absent

● mood swings Absent

● suicide ideation Absent

Treatment
 In book In patient

Tab. Methadone Not given

Tab.Buprenorphine given

Tab.Naltrexone given

Clonidine Not given

THEORY IMPLICATION
PAPLAU’S INTERPERSONAL RELATIONS THEORY

PatientAmrit24 year’s male is suffering from opioid dependenceand is not able to maintain
Interpersonal relationship. And as a nurse I have to improve patient’s interpersonal
relationship so I implemented Hildegard paplau model.

Phases of interpersonal relationship

Identified four sequential phases in the interpersonal relationship:

1. Orientation
2. Identification
3. Exploitation 
4. Resolution
Interpersonal theory and nursing process

Both are sequential and focus on therapeutic relationship

Both use problem solving techniques for the nurse and patient to collaborate on, with the end
purpose of meeting the patient’s needs

Both use observation communication and recording as basic tools utilized by nursing

NURSING PROCESS INTERPERSONAL THEORY
Assessment Orientation
Data collection and analysis [continuous] Non continuous data collection 
May not be a felt need Felt need 
 Define needs
Nursing diagnosis  Identification
Planning Interdependent goal setting
Mutually set goals 
Implementation Exploitation
Plans initiated towards achievement of Patient actively seeking and drawing help 
mutually set goals Patient initiated
May be accomplished by patient , nurse or
family
Evaluation Resolution
Based on mutually expected behaviors  Occurs after other phases are completed
May led to termination and initiation of new successfully 
plans   Leads to termination a

Hildegard Paplau model:-

RESOLUTION

TERMINATION OF VISIT ON LAST

DAY BY TELLING TO THE PATIENT
AND ALL THE DISCHARGE CRITERIA
EXPLAINED TO PATIENT.

EXPLOITATION

FAMILY THERAPY, GROUP THERAPY,

RECREATIONAL THERAPY, MEDICATION,
PSYCHO-EDUCATION, TREATMENT COMPLAINCE.

IDENTIFICATION

CHIEF COMPLAINTS: - Irritation, Frustration, Restlessness, Body

ache , vomiting , Disturbed sleep

Patient identified for chief complaints and other health needs.

ORIENTATION

NURSING
NAME: - Amrit ,
MANAGEMENT
AGE:- 24 YEARS SEX:- MALE,

DIAGNOSIS- opioid dependence

ASSESSMENT:-

IPR Maintained with patient for a trustworthy relationship with patient.

 ● Personal history of the patient to collect base line data
● Identification data of the patient is collected
● Chief complaints of the patients have been recorded
● Patient is aggressive and anxious and impulsive
● His social interaction is reduced
● Poor nutritional pattern and impaired sleeping pattern

DIAGNOSIS:-

1. Imbalanced nutrition less than body requirements related to restlessness evidence

by weight loss and dietary pattern
2. Altered sleeping pattern related to restlessness as evidenced by sleeping hours of
the patient.
3. Decreased coping skills related to abuse of heroine as evidence by impulsive
behaviour and decreased capacity to do work.

SHORT TERM GOAL

1. To improve dietary pattern of the patient

2. To improve sleeping pattern of the patient
3. To stop drug abuse of patient

LONG TERM GOAL

1. To maintain effective therapeutic nurse -patient relationship.

2. To provide knowledge to the patient and relatives regarding disease condition
3. To maintain nutritional pattern to normal
4. To provide psychological support to patient.
 Nursing Expected
S. No Planning Implementation Rationale Evaluation
diagnose outcome

1 Imbalanced To improve Maintain accurate record of Record of the patient is Because these are important Nutritional
nutrition less nutritional intake, output and weight. maintained. nutritional assessment data. pattern
than body pattern improved to
requirements some extent
related to Provide favourite foods. Patient liked dishes given This encourages eating
restlessness to him digestion of food will
evidence by improve
weight loss and
dietary pattern.

This improves the nutritional

Patient do walking in status.
Advise patient to do corridor
walking daily.

To induce appetite.
Fruits given to patients
Provide supplement diet
with vitamins and minerals.

To provide good knowledge

Educate client about Psycho education given to
importance of balanced the patient
nutrition
 Nursing Expected
S. No Planning Implementation Rationale Evaluation
diagnose outcome

2 Altered sleeping To improve Assess the sleeping pattern Sleeping pattern of patient To collect base line data of Sleeping
pattern related sleeping of the patient is intermittent the patient pattern
to restlessness pattern of the improved to
as evidenced by patient some extent
sleeping hours Provide calm and quite Calm and quite To induce sleep
of the patient. environment to patient environment provided

limit stimuli to patients Entry of visitors limited

To avoid disturbance

Advice client to daily do Patient guided to do

meditation meditation To calm his mind

Give warm milk to patient Warm milk given to the

during bed time patient To induce sleep

Administer prescribed Inj, phenargen given.

medicines to patient
Sedative to induce sleep
 Nursing Expected
S. No Planning Implementation Rationale Evaluation
diagnose outcome

3. Decreased To improve Recognize the behaviour Behaviour of patient is Understanding the Skills will be
coping skills coping skills helps to reduce feelings of impulsive motivation behind the improved to
related to of the patient insecurity. behaviour may facilitate some extent
irritable and greater acceptance of the
aggressive individual.
behaviour as
evidence by
impulsive Lack of feedback may
behaviour. decrease this behaviour.
Ignore attempts by client to
argue, bargain, or charm his Ignored the patient’s
or her way out of the limit attempts.
setting.

Give positive reinforcement Positive reinforcement

for manipulative behaviour. enhances self esteem and
Positive reinforcement promotes repetition of
given through individual desirable behaviour.
therapy of the patient.
CONCLUSION
Patient name Amrit was admitted in psychiatric ward with diagnosis of opioid dependence ,
patient was having chief complaints of :,Irritation x 3 days, Frustration x 5 days, Restlessness
x 1 day, Body ache x 1 day, Disturbed sleep x 3 days. Patient was neat and clean and not
having any mannerism. He was oriented to time and day and having Sign and symptoms in
patient. Delusion of reference, Persecutory delusion, Incoherence, Circumstantiality,
Tangentiality, Pressure of speech, Flight of ideas, Disoriented, Immediate memory impaired,
Auditory hallucinations, visual hallucinations, Decreased sleep, Decreased appetite were
absent , his judgement was intact and his sleeping pattern was normal. Withdrawal
symptoms were present in first three days and after that patient was normal and stable.

HEALTH EDUCATION:

● Encourage the patient to take part is self care activities and daily living activities.

● Patient is encouraged to talk with others in slow speed and listen them attentatively. It
helps the patient to maintain social relationship within society.

● Patient’s family is encouraged to assess the patient in eating and providing a meal
according schedule (i.e. only 3 times meal in a day).

● Patient is encouraged to participate in meditation/Yoga. It helps the patient to be

calm.

● Patient and family members are educated about treatment compliance.

● Patient and family members are educated about

● Giving healthy diet

● Restrict entry of visitors

● Restrict water intake at night

● Medicine on time

● Good attitude/behavior of family members

● Psycho-education
BIBLIOGRAPHY:
BOOKS:
1. Neerja KP. Essentials of Mental Health Nursing. 1st edition. New Delhi: Jaypee
Brothers Medical Publishers (P) Ltd; 2008.
2. Sadock BJ. et al. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral
Sciences/Clinical Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins;
2003.
3. Sharma Pawan. Essentials of Mental Health Nursing. 1st edition. Haryana: Jaypee
Brothers Medical Publishers (P) Ltd; 2003.
4. Sreevani R. A Guide to Mental Health and Psychiatric Nursing. 3 rd edition. New
Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2010.
5. Stuart Gail w. Principles and Practice of Psychiatric Nursing. 9th edition. Noida:
Elsvier; 2009.
6. Townsend Mary C. Psychiatry Mental Health Nursing Concepts of Care. 4 th edition.
Philadelphia: F. A. Davis Publishers; 2003.