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Alcohol Dependence Essay

Mr Shankappa has studied up to 9th standard ( incomlete) after which he had lost interest in studies & joined in his father’s business because of which his girlfreind left him. After this incidence patient started to consume alcohol, felt betrayed & could not stay in his hometown. So he ran away to Mumbai & worked their for an year, Came back & joined in a travel agency for 6 months. He was working as an autodriver during which he met with an accident, According to the informant: He was spotted by his brother in law when he is intoxicated on 28/10/09.

He was also noticed to have a physical injuries ( Patient reports that he met with an car accident). Last drink – 90 ml 12 pm 28/10/2009, was hospitalised & was rested for 2 months & left to Delhi for a Job, where he started consuming alcohol again & was brought back to Mangalore. HISTORY OF PRESENT ILLNESS: Patient was apparently normal around 12 year back when he discontinued in 9th standard & his love failed. He started to work in his father’s hotel . He would go to supply tea to nearby bar, where he started consuming alcohol. Parents were not aware of that till 3 years. Patient started to work in Vikram travels at the age of 17 years .

He use to come back home intoxicated with 2 – 3 bottles . He was not supporting their parents financially. He was beggging money of Rs 1000-2000 with the familiar persons & wouldn’t returns it. Patient is not going to work since 3 months , keeps telling that he is working in canteen. He often steals money from the hotel. One week back he left from home saying that he will go for a job , but he didn’t come back. According to the patient , he has studied up to 9th standard ( incomlete) after which he had lost interest in studies & joined in his father’s business because of which his girlfreind left him.

After this incidence patient started to consume alcohol, felt betrayed & could not stay in his hometown. So he ran away to Mumbai & worked there for a year, Came back & joined in a travel agency for 6 months. PAST HISTORY OF PSYCHIATRIC ILLNESS: On 29/10/10 patient was admitted with history of road traffic accident and patient was admitted on 17/10/2008 in a hospital with the complaints of alcoholism, increased talk, elevated self esteem, grandiosely ideas, assertive behaviour and irritability and diagnosed to have BPAD and alcoholic dependent syndrome with head injuries.

He was on antipsychotics and disulphuram therapy 250mg, 25/1/2009 history of drinking, vomiting, irrelevant talk, auditory and visual hallucinations fearfulness. Patients report he had an accident when he was driving the auto and hit by bus, he was not intoxicated, he sustained injury with loss of consciousness a passenger expired after which he is fearful he asked to he use to dream of incident and sleeplessness one year he use to hear voices of lady (survivor of accident) abusing him the case is still in the court Love failureWork tension Work tension Car accident Work tension.

Failure in 7th STD BPAD Work load ADS 19971999200220082009 At 14yrs16yrs19yrs24yrs25yrs LIFE CHART PAST HISTORY OF ILLNESS: Except he is having alcohol dependency & tobacco chewing since 3 years, he is not having any other significant history of illness. TREATMENT HISTORY: (NOT AVAILABLE) TREATMENT (PRESENT) Trade name| Generic name| Dosage| Frequency| Action| T. Valium| Benzodiazepam| 10mg| 1-1-4| Anxiolytic| Inj trineurosol| Thaiamin| 1cc| OD(5days)| Thiamine supplement| Cap benfomet| Benformet| 500mg| BD| Anticraving| T Rantac| Rantidine| 150mg| OD| H2 receptor| FAMILY HISTORY: Mr.

Ramachandra belongs to the nuclear family stays with the family and family has history of ADS in 1st and 2nd degree relatives and suicide in 2nd degree relatives and patient was the known case of alcoholic and tobacco chewing FAMILY GENOGRAM: PERSONAL HISTORY: Birth history: Mr Shan kappa was born by spontaneous full term normal vaginal delivery in a Govt hospital at Mangalore. There is no history of psychiatric illness of mother during pregnancy , there was no prenatal complications like convulsions, cyanosis or jaundice. No history of birth defects, he is the 4th child and expected one.

Childhood history: Mr shankappa was brought up by his mother. He was breast fed for 7 months . There is no delay in motor , language & social development . Developmental milestones are normal for the age. There is no history of thumb sucking , nail biting, head hanging in his childhood. Educational history: Mr Shankappa was started his education at the age of 5 years. He discontinued the studies at 9th standard as he was not interested. Play history: During his childhood days he liked to play with his childhood friends & neighbourhood children. His favourite play was cricket.

He was maintaining a good relationship with his peer group. Occupational history: According to the patient , he has studied up to 9th standard ( incomplete) after which he had lost interest in studies & joined in his father’s business because of which his girlfreind left him. Later he ran away to Mumbai & worked their for an year, Came back & joined in a travel agency for 6 months. He was working as an autodriver Marital & sexual history: Mr shankappa is married but claims to have sexual contact once out of which he has a son and he claims to be the father of that child. PRE-MORBID PERSONALITY: Interpersonal relationship:

Mr Shankappa is having a good interpersonal relationship with family , friends & able to make & sustain relationship, trust others, tolerate criticisms, took family responsibilities, preferred to be submissive. Pre-dominant mood: He is optimist and has cheerful attitude towards and self. Use of leisure time: Going out with friends, small picnic and movies(mostly love stories). Attitude to self & others: He is having good attitude towards self and feel he deserves more than what he is getting in life and he has good attitude towards others respects others values Attitude towards work & responsibility:

He is having a moderate level of decision making & taking responsibility skill. Religious beleifs & moral attitude: He beieves in god and Lord Krishna is his favourite god he goes to temple on every friday Fantasy life: He has a dream of starting his own travel agency one day Habits: He is having an habit of drinking alcohol since 12 years etc. Sleep: He is having sleep disturbance since 1yr due to hearing of voices. Physical examination: General appearance: Nourishment: well nourished Body built: athletic Health: healthy Activity: normal activity Posture Body curves: normal.

Gait: normal Skin condition Colour: wheatish Texture: dry Temperature: warm Lesions: none Head and face: Scalp: clean Face: no deformities seen Eyes: pupils equally reacting, wears spectacles Ear: normal and bilateral Nose: no structural deformity Mouth: no dentures hygiene is maintained Neck: normal range of motion and no enlargement of lymph nodes Chest Thorax: normal bilateral symmetrical expansion Breath sounds: normal, no wheezing or crepitation heard Heart: normal, no cardiac murmur, Heart rate 66 beats per second Respiration: rate—20 per minute, Blood pressure—11874mmHg.

Abdomen: normal bowel sounds, normal appetite, bowel and bladder movements normal Extremities: all joints have normal range of motion, power and tone adequate, no scars and wounds seen Genitals: no significant infections CNS: conscious oriented with normal speech MENTAL STATUS EXAMINATION GENERAL APPEARANCE & BEHAVIOUR: Mr Ramachandra nayak is moderately built & moderately nourished . he is having bruise marks over his nose and forehead. He maintains hygienic practices & is able to do self care activities. ATTITUDE TOWARDS EXAMINER: Mr Ramachandra nayak is co-operative to some extent & is interested in talking to me..

COMPREHENSION: It is intact, because he understood and answered to questions properly GAIT & POSTURE: Normal posture. He maintains straight & upright position , There are no deformities during walk. MOTOR ACTIVITY: Normal motor activity SOCIAL MANNERS & VERBAL BEHAVIOUR: Patient has appropriate social manners & and maintains good eye to eye contact RAPPORT: Rapport is established with some degree of difficulties. HALLUCINATORY BEHAVIOUR: Patient hears voices of women since accident incident. SPEECH: Mr Ramachandra nayak is able to speak and understand English, tulu, kannaka, Konkani, tamil, hindi, Malayalam..

1. RATE & QUALITY: He was able to speak in a spontaneous manner, productivity & rate of speech is high. There was no poverty or pressure of speech. 2. VOLUME & TONE: He has normal tone of speech and volume is low 3. FLOW & RHYTHM: Flow & rhythm of speech is smooth. No stuttering , stammering, circumstantialities & tangentiality, verbigeration, flight of ideas & clang associations are absent. MOOD & AFFECT: Q: How are feeling today? A: i am feeling good and happy Facial expression also shows that he is alright. Inference: Affect is appropriate to mood. THOUGHT: 1. STREAM & FLOW:

There is no poverty of thought, no thought block, no circumstantialities, speech is spontaneous & productivity is present. 2. CONTENT: The content of thought is “Bhajans & versus of Bhagavadgeetha, Calling out every woman as mother”. Ideas of grandiosity are present , no obsessions, no fear of death , no suicidal ideation is present . 3. PERCEPTION: He is not having any illusion , depersonalisation, derealisation , somatic phenomena are absent. He is having auditory hallucination. COGNITION: 1. ORIENTATION: Q: What is the date today? A: Today is 20/01/10 Q: Where are you now? A: My house Q: Who am I? A: You are a student studying nursing.

Inference: he is oriented to time, place & person. 2. ATTENTION: Patient could tell three digits forward & backward Inference: Intact. 3. CONCENTRATION: Asked him to subtract 3 from 50 consecutively. he was not able to do it correctly. Inference: Intact 4. MEMORY: Registration: Repeatedly i told five things by showing the pictures ( 3 times) . he was able to recollect all five things . Recent memory: Q: What you had for breakfast? A: today i had Poori and sagu Remote memory: Q: Do u remember the age when u did your schooling? A: It was in 1996 Inference: Immediate ,recent and remote memory is intact. 5. INTELLIGENCE:

Q: Who is the CM of Karnataka? A: It is Yediyurappa. Q: Which is the Distance between Bangalore and Mangalore? A: its nearly 350-380 kms Q: Which is the capital of Goa? A: Panaji Inference: Average. ABSTRACT THINKING: 1. SIMILARITIES & DIFFERENCES: Private travels and KSRTC * Both are comfortable * Both are fast * KSRTC buses are safer to travel * Private buses are cheap and more available 2. PROVERB TESTING: “All that gliters is not gold” It means one may look good outside but he may be bad inside Inference: Abstract thinking is present.. INSIGHT: Q: Why are you admitted her? A: As i am alcoholic and a problem to family.

Inference: Grade V. JUDGEMENT: * Social Q: What will u do during a road traffic accident? A: I will call ambulance using my Mobil * test Q: What will you do if u get 100 rupees on road? A: i will give it to a temple Inference: good FORMULATION: Mr Ramachandra nayak was admitted here on 28/10/09 with the complaints of road traffic accident , Alcohol dependant, Decreased sleep. During the time of mental status examination i found that he has mild impairment of memory and grandiose ideas. ALCOHOL DEPENDENCE SYNDROME Alcoholism refers to the use of alcoholic beverage to the point of causing damage to the individual, society or both.

Properties of Alcohol Alcohol is a clear colored liquid with a strong burning taste. The rate of absorptio into the blood stream is more rapid than elimination. Absorption of alcohol into the slower when food is present in stomach. A small amount is excreted throu urine and a small amount is exhaled. A concentration of 80 to 100 mg of alcohol of 100ml of blood is considered intoxication. A person with 200 mg to 250 mg will be toxic, sleep, confused and his thought process will be altered. If blood level is 300 mg/100 ml of blood the person may loose consciousness. A concentration of 5 mg /100 ml is fatal.

All the symptoms change according to the tolerance. Epidemiology The incidence of alcohol dependence is 2 %. In India 20 to 40 percent of subjects aged about-15 years are current users of alcohol and nearly ro “percent of them are regular exceessive users. Nearly 15 to 30 percent of patients are developing alcohol-related problems seeking admission in psychiatric hospitals. Medical and Social Complications of Alcohol Dependence: A. Medical Gastro- intestinal system: * Gastritis, peptic ulcer, reflux esophagitis, carcinoma of stomach and esophagus * Fatty liver, cirrhosis of liver, hepatitis, liver cell carcinoma * Acute and chronic pancreatitis.

* Malabsorption syndrome Cardiovascular system * Alcoholic cardiomyopathy * High risk for myocardial infarction CNS * Peripheral neuropathy * Epilepsy * Head injury * Cerebellar degeneration Miscellaneous * Vitamin deficiency disorder * Peripheral muscle weakness * Acne * Sexual dysfunction in males, failure of ovulation in females Damage to the fetus * Fetal alcohol syndrome (facial abnormality, low birthweight, low. intelligence), * Alcohol dependence is responsible for 3 percent of all cases of mental retarda tion * . B. Social * Marital disharmony * Occupational problems * Financial problems.

* Criminality * Accidents 1. Pychiatric Disorders due to Alcohol dependence A Acute intoxication: Acute intoxication develops during or shortly after alcohol ingestion. It is characterized by clinically significant maladaptive behavior or psychological changes, slurred speech, incoordination, unsteady ait, nystamus, irnpaired attention and memory. and finally resulting in stupor or coma. B Withdrawal syndrome: In persons who have been drinking heavily over a prolonged period of time, any rapid decrease in the amount of alcohol in the body is likely to produce withdrawal symptoms.

These are: * Simple withdrawal syndrome * Delirium tremens * Alcoholic seizures * Alcoholic hallucinosis SimpIe withdrawal syndrome:It is characterized by mild tremors, nausea, vomiting, weakness, irritability, insomnia and anxiety. Delirium tremens: – It occurs usually with in 2-4 days of complete or significant abstinence from heavy alcohol drinking. The course is short, with recovery occuring with in 3-7 days It is characterized by: * A dramatic and rapidly changing picture of disordered mental activity, with clouding of consciousness and disorientation in time and Place. * poor attention span.

* Vivid hallucinations which are usually visual; tactile hallucinations can also occur. * Severe-psycnomotor agitation, shouting and evident fear. * Grossly tremulous hands which sometimes pick up imaginary objects; truncal ataxia. * Autonomic disturbances such as sweating, fever, tachycardia, raised blood pressure, pupillary dilatation. * Dehydration with electrolyte imbalances. * Reversal of sleep-wake pattern or insomnia. * Blood tests reveal leucocytosis and impaired liver function. * Death may occur due to cardiovascular collapse, infection, hyperthermia or selfinflicted injury.

TREATMENT 1. A full assessment, including an appraisal of ‘current medical, psychological and social problems. 2. Goal setting: Setting up of short-term goals that deal with any accompanying problems in health, marriage, job and social adjustments; long-term goals can be set as treatment progresses, which are concerned with trying to change factors that precipitate or maintain excessive drinking, such as tensions in the family. 3 .. Treatment of withdrawal from alcohol a. Detoxification: Detoxification is the treatment for alcohol withdrawal symptoms. The drugs of choice are benzodiazepines.

The most commonly used drugs from this class are chlordiazepoxide 80-200 mg/ day and diazepam 40-80 mg/ day, in divided doses b. Others * For Vitamin B defeciency a preparation of vitamin B containing 100 mg of thiamine should be administered parenterally, twice daily for 3 to 5 days. This should be followed by oral administration of vitamin B for at least 6 months. * Administration of anticonvulsants as necessary, maintaining fluid and electrolyte balance, strict monitoring of vitals, level of consciousness and orientation. Close observation is essential. especially during the first five days. 4.

Alcohol deterrent therapy: Deterrent agents are those which are given to desensitize the individual to the effects of alcohol an maintain abstinence. The most commonly used drug is disulfiram (tetraethyl thiuram disulfide) or antabuse: Disulfirram : Disulfiram is used to ensure abstinence in the treatment of dependence. Its main effect is to produce rapidly and violently unpleasant reaction in person who ingests even a small amount alcohol while taking disulfiram. Mechanism of action: Disulfiram is aldehyde dehydrogenase inhibitor interferes with the metabolism of alcohol produces a marked increase in blood acetaldehyde levels.

The accumulation of acetaldehyde (to a level of 10 times more than which occurs in the normal metabolism alcohol) produces a wide array of unpleasant reactions called the disulfiram-ethanol reaction(DER), characterized by nausea, throbbing headache, vomiting, hypotension flushing, sweating, thirst, dyspnea, tachycardia, chest pain, vertigo, blurred vision and a sense of impending doom associated with severe anxiety. The reaction occurs immediately after the ingestion of even one alcoholic drink and may last up to 30 minutes.

Therapeutic indications: The primary indication for disulfiram use is as an aversive conditioning treatment for alcohol dependence. Side-effects: The adverse effects of disulfiram in the absence of alcohol consumption include fatigue, dermatitis, impotence, optic neuritis, mental changes, acute polyneuropathy and hepatic damage. With alcohol consumption the intensity of the disulfiram-alcohol reactions varies with each patient. In extreme cases it is marked by convulsions, respiratory depression, cardiovascular collapse, myocardial infarction and death.

Contraindications : * Pulmonary and cardiovascular disease. * Disulfiram should be used with caution in patients with nephritis, brain damage, hypothyroidism, diabetes, hepatic disease, seizures, poly-drug dependence or an abnormal electroencephalogram. * Patients at high risk of alcohol ingestion. Dosage-Disulfiram is supplied in tablets of 250 and 500 mg. The usual initial dose is 500 mg/ day orally for the first 2 weeks, followed . by a maintenance dosage of 250 mg/ day. the dosage should not exceed 500 mg/ day. Nurse’s responsibility:

* An informed consent should be taken before starting treatment. * Ensure that at least 12 hours have elapsed since the last ingestion of alcohol before administering the drug. * Patient must be instructed that ingestion of even the smallest amount of alcohol brings on a disulfiram-ethanol reaction with all its unpleasant effects; he should therefore be strictly warned not to take any alcohol whatever. * The patient should also be warned against ingestion of any alcohol-containing preparations such as cough syrups, drops of any kind, and alcohol-containing foods and sauces.

Advise not to use alcohol based aftershave lotions and advise against inhalation of paints, warnishes, etc. , containing alcohol. Any topical applications containing alcohol should also be avoided. * Caution patient to avoid taking CNS depressants or any O’IC (over-the-counter) medications during disulfiram therapy. * Instruct patient to avoid driving or other activities requiring alertness until response to drug is known. * Patients should be warned that the disulfiram-alcohol reaction may continue to occur for as long as 1 to 2 weeks after the last dose of disulfiram.

* Patients should carry identification cards describing the disulfiram-alcohol reaction and listing the name and the telephone number of the physician to be called. * Emphasize the importance of follow-up visits to the physician to monitor progress in long-term therapy. 5. Psychological treatment Motivational interviewing: This involves providing feedback to the patient on the personal risks that alcohol poses, together with a number of options for change. Group therapy: Group therapy enables the patients to observe their own problems mirrored in others and to work out better ways of coping with them.

Aversive conditioning: This therapy is based on classical conditioning. In alcoholism the behavior patterns are self-reinforcing and pleasurable, but are maladaptive for reasons outside the control of the client. In this technique the client is exposed to chernicallyinduced vomiting or shock when he takes alcohol. Cognitive therapy: This involves reduction in alcohol intake by identifying and modifying maladaptive thinking patterns. Cue exposure technique: This technique aims, through repeated exposure, to desensitize dmg abusers to drug effects, and thus improve their ability to remain abstinent.

Other therapies include assertiveness training, behavior counseling, supportive psychotherapy and individual psychotherapy. Alcoholics Anonymous (AA) his is a self-help organization founded in the USA by two alcoholic men, Dr. Bob Smith and. Bill Wilson, a stockbroker, on . 10th June 1935 It has since then spread to many countries. in the world -. AA considers alcoholism as a physical, mental and spiritual disease and a progressive one, which can be arrested but not cured. members attend group meetings usually twice a’ week on a long-term basis.

Each member is assigned a support person from whom he may seek help when the temptation to drink occurs. In crisis he can obtain immediate help by telephone. Once sobriety is achieved he is expected to help others. The organization works on the firm belief that abstinence must be complete. The only requirement for membership is a desire to stop drinking. There is no authority, but only a fellowship of imperfect alcoholics whose strength is formed out of weakness. Their primary purpose is to help each other stay sober, and help other alcoholics to achieve sobriety. Comparative study Book picture| | Patient picture|.

Complications of Alcohol Dependence | Medical:| | | * Gastro-intestinal| evident| | * CVS| Absent| | * CNS| Absent| | * Miscellaneous| Absent| | Social| Absent| Epidemiology| 20-40 % are >15 years| Present| | 10 % regular & excessive users| Present| Course| Chronic illness| Present,| | Incomplete remission| Present| | Episodic| Present| Psychiatric disorders due to alcoholic dependence| Acute intoxication| Present| | Withdrawal syndrome| Absent| | | Treatment| Full assessment| Done| | Goal setting| Done| | Treatment to withdrawal syndrome| No| | Alcohol deterrent therapy| Not prescribed| | Psychological treatment| Not provided|.

| Alcoholic anonymous| Not done| NURSING DIAGNOSIS; 1. Ineffective denial related to weak, underdeveloped ego evidenced by statements indicating no problem with substance abuse 2. Ineffective coping related to inadequate coping skills & weak ego evidenced by use of substances as a coping mechanism 3. Imbalanced nutrition less then body requirement / Deficient body fluid volume realted to use of substance instead of eating evidenced by loss of weight , pale conjunctiva & mucous membranes , poor skin turgors , electrolyte imbalance , anaemia ( and/or signs & symptoms of malnutrition & dehydration ) 4.

Impaired social interactions related to egocentric & narcissistic behaviour evidenced by inability to develop satisfying relationship & manipulation of others for own desires Nursing care plan with application of the theory of interpersonal relationship by Hildegard E Peplau Peplau emphasized that problems in the patient can be solved by prominent interpersonal relationship. According to Peplau there are our stages in the relationship. They are 1. Orientation During the orientation phase the individual has a felt need seeks professional assistance.

The nurse help the patient recognize and understand his problem and determine his need for help. 2. Identification phase The nurse identifies with those who can help him. The nurse explores the feelings of the patient to aid in coping with the undergoing illness as an experience the reorients feelingsand strengths positive forces satisfaction. 3. Exploitation During this phase the patient makes more demands than they did when they were seriously ill. They make many minor requests, or may use other attention getting techniques, depending on their individual needs.

the nurse use communication tools such as clarifying ,listening, accepting, teaching, and interpreting to offer services to the patient. The patient then takes advantage of the services offered based on his/her needs of interest. In this phase, the nurse aids the patient to use the services to help solve the problem 4. Resolution The patients needs have already been met by collaborative efforts between the patient and the nurse. The patient and the nurse now need to terminate the relationship and dissolve the links between them. Nurses roles Role of a stranger Role of a resource person.

Role of a teacher C Leadership Surrogate role D Counseling role A B Energy transformation 5. Ineffective denial 6. Ineffective coping 7. Imbalanced nutrition less then body requirement / Deficient body fluid volume, 8. Impaired social interactions Identification The nurses collects a detailed history and conducts a through physical and mental status examination to reveal the following problems the client faces: Frequent lying, Physical injuries, Stealing, Involvement in anti-social activities, Increased talk, High self esteem, Grandiosal ideas Assaultive & irritable behaviour.

The client responds to the treatment and nursing management and socialized more and involved in group activity Interventions are planned to accept his responsibility, develop coping patterns. Improved his communication and socializing skills . methods and requested family support Resolution Exploitation Orientation Evaluation Planning and implementation Diagnosis Assessment Sl no| ASSESSMENT| PROBLEM| OBJECTIVES| NURSING INTERVENTIONS| EVALUATION| 1| Client complains that he is feeling argued and gets anger if anybody speaks to him.

On observation, client appears restless and irritable| Ineffective denial related to weak, underdeveloped ego evidenced by statements indicating no problem with substance abuse| Client will demonstrate the acceptance of responsibility for own behaviour & acknowledge association between substance use & personal problems| -Make the client feel comfortable with your company. -Don’t argue or deny the belief. -Avoid laughing and physical contact. – Reinforce and focus on reality talk about real events and real hope. -Whispering or talking quietly near the client or friendly approach.

– Observe the clients signs & symptoms of hallucination. -Encourage the client to sleep for 6-8 hours minimum at night. -Provide a secure environment. -Ask him to take hot water bath before going to bed. -If possible have a cup of hot milk will induce sleep. -Prepare a clean and comfortable bed-Allow the client to read some books of his choice or a light music to hear. | Client demonstrates the acceptance of responsibility for own behaviour & acknowledges association| 2| Client complains that he has generalized body ache, heavy head, and feels like talking drug again.

Clients appear to be suffering from withdrawal symptoms. | Ineffective coping related to inadequate coping skills & weak ego evidenced by use of substances as a coping mechanism| Client will be able to verbalise adoptive coping mechanisms to use , instead of substance abuse , in response to stress | Observe the intensity of withdrawal symptoms. -Record vital signs and symptoms. -Give plenty of fluid to reduce constipation dehydration. -Change cloths of client of sticking due to excessive respiration. -Be with client and make him feel comfortable.

| Client is able to verbalise adoptive coping mechanisms| 3| Client complains of feeling tired lots of appetite on observation patient is restless| Imbalanced nutrition less then body requirement / Deficient body fluid volume realted to use of substance instead of eating evidenced by loss of weight , pale conjunctiva & mucous membranes , poor skin turgors , electrolyte imbalance , anaemia ( and/or signs & symptoms of malnutrition & dehydration )|.

Client will be free of signs & symptoms of malnutrition /dehydration| * Provide high protein, high calorie nutritious food, that can be consumed on the run provide 6-8 glasses of fluids perday * Maintain accurate record of intake output. * Weight the patient regularly. * Supplement diet with vitamins and minerals. * Walk or sit with patient while he eats. | Client exhibits no signs & symptoms of malnutrition| 4| Client complains of difficulty in talking to new person.

| Impaired social interactions related to egocentric & narcissistic behaviour evidenced by inability to develop satisfying relationship & manipulation of others for own desires| Client will interact appropriately with others| * Recognize the manipulative behaviours help to reduce the feelings or insecurity by increasing feelings of power & control * Set limits on manipulative behaviours. Explain what is expected & the consequences if limits are violated. Terms of limitations must be agreed on by all staff who will be working with the client *.

Ignore attempts by client to argue , bargain or charm his or her way out of the limit setting * Give positive reinforcements for non manipulative behaviours * Discuss consequences of client’s behaviour & how attempts are made to attribute them to others * Help client identify positive aspects about self , recognise accomplishments , and feel good about them| Social interaction was improved to some extent| Health education Regarding illness and medications.

* Explained regarding the nature of illness, also the fact that this is a long term disorder and that maintenance treatment therefore will require one or more medication may have be taken for long time. * Educated him regarding the medication, proper dose and time of administration.

* Explained regarding the expected side-effects and toxic effects of the prescribed medications as well as where to go in care of severe side effects. * Enlisted the signs and symptoms of relapse that may came, also explained the role of family members and others in preventing relapse. * Advised not to take any medication with out the advise not to stop drug abruptly with out psychiatric advise Personal hygiene * Educated the client the importance of bathing daily, brushing teeth daily, grooming, and wearing clean clothes, combing hair, cutting nails. Nutrition.

* Educated regarding importance of balanced diet. Regarding maintenance of adequate weight. Educated the intake of 3-4 liters of water per day. Educated the importance of fibers in diet. Physical activities which interest him. Regular weighing. Coping with illness * Educated the patient and family members regarding how to cope up with illness * Advised them to avoid situations which causes anxiety to client and provide calm and peaceful environment. * Encouraged client to take responsibilities. * Educated family members to encourage and appreciate even small tasks. * Explained the importance of follow up. Advised to abstain from alcohol and smoking.

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