CASE STUDY

OF
Mr. JOHNSON BABU
WITH
ALCOHOL DEPENDENCE
GENERAL INFORMATION

IDENTIFICATION DATA

Name :- J.P Johnson Babu

Address :-Manjunatha Chicken Center
2nd main Bapuji Nagar
Bangalore
Age :- 24 yrs
Sex :- Male
Ward :- De addiction centre
Address :- P1691
Religion :- Christian
Education :- 10th Std.
Martial Status :- Single
Occupation :- Non agriculture labor
Income :- 1000 Rs
Date of Admission :- 16/1/2010
Diagnosis :- Alcohol dependancy
Reliability :- Reliable
Language :- Hindi/ English/kannada
Informant
1. Patient
2. Father

COMPLAINTS AND THEIR DURATION

1. According to patient

Patient is regularly taking alcohol since 2003.Dailly around half litre. After taking alcohol
quarrels with father and brother. Uncontrolled anger, Decreased apetite and sleep.

2. According to Father

Patient is taking alcohol and cigarette daily with friends, shows anger towards father and
brother. Sleep is reduced and taking less food. Many time tried to hospitalize. Now he
 voluntarily came treatment.

HISTORY OF PRESENT ILLNESS

a) Onset :- gradual

b) Precipitating factors :- His friends use alcohol and cigarette. He is working in

chicken shop and job stress.

c) Course of the illness :- 6 years

d) Associate disturbance :- not taking food, decreased sleep and anger outbursts.

FAMILY HISTORY

HTN AND DM Healthy

49 years Healthy
44 years DM

26years 24years

No history of alcohol dependence and psychiatric diseases in family. History of diabetes

mellitus and hypertension present.

PERSONAL HISTORY

1. Birth and early development

Full term normal home delivery No pre and post natal complications. Normal growth and
development

2. Behavior during childhood

No h/o. sleep disturbances, no thumb sucking, no tics and mannerism, no h/o bed wetting, no
sibling rivalry

3. Physical illness during childhood

No history of ant major physical illness during childhood. No h/o epilepsy, head injury,
encephalitis during childhood.

4. School
Patient studied till 10th std. Relationship with peers and teachers normal. He was an average
student.

5. Occupation
He is non-agriculture labor. Running a poultry farm near Bangalore

6. Sexual history
Normal sexual history. No abnormalities reported.

7. Martial History
Not Married

8. Use and abuse of alcohol, tobacco

He is using alcohol and tobacco since six years. Daily take half litre of alcohol and 15-20
cigarette.

PREMORBID PERSONALITY

1. Social relations
Normal behavior toward family and friends

2. Intellectual activities
No significant intellectual activities noted.
3. Mood

Subjective – satisfied

Objective – looks cheerful

4. Character

a) Attitude to work and responsibility

Shows a responsibility towards home

b) Interpersonal relationship

Normal interpersonal relationship

5. Energy and initiative

He was active
 6. Fantasy life
Not reported

7. Habits
No habit of using tobacco and alcohol

MENTAL STATUS EXAMINATION:

A. General appearance and behaviour:

1. General appearance:

- Body built and physical experience: moderately built and healthy, young and wheatish in
complexion

- Grooming : well groomed

- Hygiene : maintained

- Dress : dress well and appropriate to season

- Facial expression : Pleasent

- Eye contact : maintained

- Posture : normal

2. Attitude towards examiner : co-operative

3. Rapport : rapport maintained

4. Motor behaviour : no abnormal motor behaviour like tics,

Mannerism, pacing, motor retardation

B. Thought and speech:

1. Form of thought:

Q. Why do you come here with your father?

A. I am using alcohol a lot and making problems .So to stop alcohol drinking I came here.

Inference: normal form of thought.

2. Content of thought
Q. what is your problems?

A. Alcohol drinking, smoking, anger towards father and brother.

Inference: Normal thought contents.

3. Speech:

- Evaluation of speech: appropriate volume, tone, speed

- Disorder of speech : no aphonia and others disorders

C. Mood and affect:

-Mood : Q. How are you feeling now?

A. I am not ok .

-Affect : affect is normal

Inference: affect is congruent to mood.

D. Perception:

Q. when you are alone, can you seeing anything that other person can’t see and hear?

A. No

Inference: No hallucinations and delusions

E. Sensorium and cognition:

Consciousness : conscious, alert, oriented to time, place and person.

F. Memory

a. Immediate: Q.what I asked just now?

A.Anything you can see and hear more.

Inference. Immediate memory is intact.

b. Recent memory: Q. what you had in breakfast?

A. yes

Inference: Recent memory is intact.

c. Remote memory: Q. when is your birthday?

 A. 14th may 1985

Inference: Remote memory is intact.

G. Attention and concentration:

Q. How many days in a week and tell them?

A. 7 days, he says from Monday to sunday

Q. Subtract 100-5?

A. 95

Reference: Attention is aroused and concentration is also sustained.

H. Orientation:

Q. what must be the time now?

A. it must be 10’o clock

Q. who brought you here?

A. I came along with my father.

Q. who is that lady wearing white saree?

A. she is a ward sister.

Q. Where are you now?

A. I am in NIMHANS hospital.

Inference: he is oriented to time, place, and person.

I. Abstraction:

Q. what is the different between the potato and stone?

A. Potato is eatable and stone is hard.

Q. What is the similarity of banana and orange?

A. both are fruits

Inference: Abstraction is good.

J. Comprehension:
Q. What will you do, if u miss the bus?

A. I’ll catch another bus.

Q. what you will do if you feel cold?

A. I’ll wear sweater.

Inference: comprehension is good.

k. Intelligence:

Q. What is the capital of India?

A. Delhi

Inference: Intelligent is good.

L. Judgment:

-Personal judgment:

Q. What are you planning to do after discharging from here?

A. I want to settle my life.

-Social judgment:

Q. What will you do when you saw a person drowning?

A. I will call other people because I don’t know swimming

-Test judgment:

Q. What you will you do if your ward is fire?

A. I’ll pour water to stop the fire.

Inference: Judgment of the patient is good.

M. Insight:

Q. Why you are coming and staying here?

A. I have to stop alcohol drinking.

Inference: Insight is present.

Physical examination
 1. General information:

A..GENERAL OBSERVATION:

Mr. J.P Johnson Babu is moderately built and healthy.

B. VITAL SIGNS:

a. Temperature : 98.6F

b. Pulse : 80/mt

c. Respiration : 20/mt

d. Blood pressure : 130/70mmof hg

C. HEIGHT AND WEIGHT:

Height : 5.5”

Weight : 48kg

D. SKIN AND MUCOUS MEMBRANE:

a. Skin colour : fair colour

b. Edema : absent

c. Moisture : the skin is generally moist and warm to touch.

d. Turgor : good , no ulcerations

E. HEAD:

a. Head and cranium: no scar.

b. Hair : black hair, no lice noted, no dandruff noted.

c. Movement of the head: normal ROM of the head and neck.

d. Forehead : no scar or lesion

F.EYES:

a.Expression: pleasant

b.Eye brows: equal, evenly distributed and no dandruff noted.

c.Eye lids: no lesion and scars, eye lashes are equally distributed

d.Lacrimation: clear fluid expressed, no discharges present.

e.Conjunctiva:appears pale and clear

G.EARS

a.Appearance: No masses or lesions present in the external ear.

b.No discharge

c.Hearing: is able to hear in both ears; Weber test-negative; Rinne test-positive

d.No lesions or mass.

H.NOSE:

a.Appearance: septum not deviated; no growth or lumps externally noted

b.Discharge: no discharge present

c.Patency: Both nostrils are patent

d.Sense of smell: good

I.MOUTH AND THROAT:

a.Lips, tongue: normal, no lesions or ulcers

b.Teeth: intact in the upper and in lower jaw

J.NECK:

a.Trachea is normal position, no palpable mass.

b.Lymph nodes: no palpable

K.CHEST AND RESPIRATORY SYSTEM:

a.Inspection: Size and shape is normal. Chest expansion equal in both the sides and
respirations are normal. b.Palsation: No local sweeling; no lymph node palpated
c.Percussion: No fluid collection

d. Auscultation: Breath sounds are loud, high pitch in both sides; no consolidations,
respiratory rate-20/mt

L.CARDIOVUSCULAR SYSTEM:

a.Inspection: size and shape of the chest is with the normal limits; no surgical scar

b.Palpation: carotid pulse and peripheral pulses are regular; normal sinus rhythm; rate-80/mt

c.Percussion: cardiac borders well within normal limits, no cardiac or supracardiac dullness

d.Auscultation: S1 S2 auscultated . No abnormalities noted, pulse-80/mt

M.ABDOMEN:

a.Inpection: size and shape of the abdomen normal, no distention and tenderness.

b.Palpation: no abnormalities found. Firm musculature noted

c.Perscussion: no ascitis and fluid collection.

d.auscultation: peristalsis heard in the right lower quadrant

N.BACK:

a.Spine and curvature: no abnormalities noted; no lymphs or lesions present

b.Movement: all movements are possible

c.Tenderness: no tenderness noted

O.GENITALIA:

Normal male genitalia; has no discharges

P.UPPER EXTREMITIES:

a.Deformity: no deformities noted

b.Sweeling/edema: no swelling or edema

c.Muscles: no emaciate
Q.LOWER EXTREMITIES:

a.Deformities: no abnormality noted

b.Swelling/edema: absent

c.Muscles: not emaciated

d.Lymph nodes: not palpable

e.Joints: normal ROM

R.NERVOUS SYSTEM:

a.Higher function: conscious and oriented

.Memory: immediate is impaired and recent, and remote is intact.

.Orientation: patient is oriented to time, place and person

.Insight and judgement: normal

CONVERSATION COMMENTS
Nurse: Good morning! Gait normal
Patient: Good morning, brother!

Nurse: Did you have your breakfast? Immediate memory intact.

Patient: yes, bread alone.

Nurse: Today, you are looking fresher.

Patient: Yes, brother, I am better now. I want to get
discharged soon.

Nurse: How is your mood today? Affect is appropriate, no auditory

Patient: I am happy. and visual hallucination.

Nurse: Was you father strict with you?

Patient: yes, he was strict and used to beat me. Shows grief.

Nurse: Do you think drinking alcohol is right? Realizes his mistake and analysis
Patient: No, it’s wrong and feels shame for this habit. his behavior.

Nurse: Do you satisfied in your job?

Patient: no, I don’t have job satisfaction. Patient has occupational stress.
 Nurse: What is your date of birth?
Patient: 14th may 1985 Remote memory intact.
Nurse: Do you like your parents and brother? Patient is attached with his family.
Patient: Yes, I like my parents and brother
Nurse: why you are quarrelling with brother?
Patient: When I drink alcohol I will lose my control.
Nurse: What is your plan after discharge?
Patient: I want to go for a good job or start a business. Willing to work after discharge.

Nurse: Once you get discharged you must come for

regular follow-up and continues taking the medicines Concentration is good.
till doctor says.
Patient: OK brother.

Nurse: Do you want to ask any question?

Patient: No, tomorrow I will talk to you brother.

Nurse: OK, we will stop here and thank you for

answering my questions.
Patient: Bye! Brother.

LAB INVESTIGATIONS

Sl Investigations Patient’s value Normal value Interence

No
1. Hemoglobin 11.2 gm % 13-18 gm% Slightly anemic
2. Total WBC count 6.600 cu mm 4,000-11,000 cu mm Normal
3. Polymorph 58% 60-70% Normal
4. Lymphocyte 36% 20-30% Normal
5. Eosinophil 4% 1-4% Normal
6. Serum creatinine 0.6 mg/dL 0.7-1.4 mg/dL Normal

MEDICATIONS

Drug Name Pharmacological Dose Route Action Side effects Nurses

Name responsibil
ity
T. Chlordiazepoxid Oral 15- Oral Anti- Nausea, In injection
chlordiazepoxid e 100 mg IV and IV anxiety vomiting, should be
e 50-100 mg agent. epigastric pain, given
slowly diarrhea, deltoid and
impotence, is gluteal
impairment of muscle.
 driving skills,
irritability.
T. Rantac Ranitidine Oral 150- Oral IV Histamine Headache,Dizzi Administer
300 mg H2recepto ness,rarelyhepati correct
r tis,thrombocyto dose
antagonist penia,breast
symptoms,
hypersensitivity,
confusion,
T. BC BC 32.5mg oral Vitamin B Look for
and C Hypervitaminosi side
complex s,G.I.Symptoms, effects,exp
supplemet yellow coloured lain about
. urine. urine
colour
change
T. Liv 52 sihymanin 140mg oral Liver Occasional See for
protectant laxative effects hypersensit
ivity.
T. Fluoxtine fluoxtine 20mg oral Antidepre Nervousness,
ssant insomnia,
anxiety, tremor,
headache,
drowsiness,
nausea and
drymouth.

CASE STUDY

INTRODUCTION

From time immemorial human beings have looked for substances to make life more
pleasurable and to avoid or decrease pain, discomfort and frustration. Despite definite
improvements in health care in most countries, problems related to drug and alcohol abuse
are increasing almost everywhere.

DEFINITION

Alcohol dependence was earlier called as “alcoholism”. Alcoholism is defined as a chronic

disease by repeated drinking that produces injury to the drunken health or to his social or
economic functioning.

EFFECT

Low to moderate consumption produces a feeling of well-being and reduced inhibitions. At

higher concentrations motor and intellectual functions are impaired, mood becomes very
labile and behavior characteristic of depression, euphoria and aggression are exhibited.
MEDICAL USE OF ALCOHOL

 As an ingredient in medicine in some pharmacological preparations like cough syrup,

tonics etc.
 As an antidote for methanol consumption.

Alcoholic beverages are widely used in many societies because of which their abuse potential
is often under estimated. Commonly used alcohol preparations are beer, wine, brandy,
whisky, rum, gin, arrack and toddy.

EPIDEMIOLOGY

 Epidemiological survey carried out in India reveal that 20 to 40 percent of subjects aged
above 15 are current users of alcohol and nearly 10 % of them are regular or excessive
users.
 Nearly 15 to 30 percent of patients seeking admission in psychiatric facilities are for
alcohol related problems.
 Among the acute medical admissions in a general hospital 10to 20 percent are due to
alcohol related problems.

BOOK STUDY PATIENT STUDY

TYPES
A. Alpha alcoholism
 Excessive and inappropriate drinking to relieve physical and for
emotional pain.
 No loss of control.
 Ability to abstain present.
B. Beta alcoholism
 Excessive and in appropriate drinking.
 Physical complications (e.g. Cirrhosis, gastritis, and neuritis) due to
cultural drinking patterns and poor nutrition.
 No dependence.
C. Gamma alcoholism
Also called as malignant alcoholism.
Client belongs to type
 Progressive course.
Delta alcoholism.
 Physical dependence with tolerance and withdrawal syndrome.
 Psychological dependence, with inability to control thinking.
D. Delta alcoholism
 Inability to abstain.
 Tolerance.
 Withdrawal symptoms.
 The amount of alcohol consumed can be controlled.
 Social disruption is minimal.
E. Epsilon
 Dipsomania (compulsive discharge)

BOOK STUDY PATIENT STUDY

CL ASSIFICATION OF ALCOHOLISM
Factors Type I Type II
Synonym Milieu limited Milieu – limited
Sex Both sexes Mostly in males greater
than 25 years .
Age of onset >25 years. <25 years. Under classification
Etiological Genetic factors Heritable client comes under
Type-1
Factors Important, strong Environmental influences
Environmental influences are
are limited.
Contributory
Family history May be positive. Parental alcoholism and
antisocial behavior usually
present
Loss of control Present No loss of control
Other features Psychological Drinking followed by
dependence and aggressive behavior,
guilt present spontaneous alcohol
seeking.
Pre-morbid Harm avoidance, Novelty seeking.
personality traits high reward
dependence
BOOK STUDY PATIENT
STUDY

ETIOLOGICAL FACTORS

 BIOLOGICAL FACTORS
 PSYCHOLOGICAL FACTORS
 SOCIAL FACTORS

1. BIOLOGICAL FACTORS

 Genetic vulnerability (family history of substance are disorder, eg, is type II

alcoholism).
 Co-morbid psychiatric disorder or personality disorder.
 Co-morbid medical disorders.
 Reinforcing effects of drugs (explains continuation of drugs)
 Withdrawal effects and caring. (Explain continuation of drugs).
 Biochemical factors (e.g. role of dopamine and non epinephrine in cocaine,
ethanol and opiod dependence.

2. PSYCHOLOGICAL FACTORS
 Curiosity, need for novelty seeking.
 General rebelliousness and social non-conformity. Client was
 Early use of alcohol and tobacco. influenced both
 Poor impulse control. by psychological
 Sensation – seeking (high) and
 Low – self esteem (anomia) Social factors.
 Concerns regarding personal autonomy.
 Poor stress management skills.
 Child hood trauma or loss.
 Relief from fatigue and for boredom.
 Escape from reality.
 Lack of interest in conventional goals.
 Psychological distress.
3. SOCIAL FACTORS
 Peer pressure (often more important than parental factors.)
 Modeling (imitating behavior of important other).
 Ease of availability of alcohol and drugs.
 Strictness of drug law enforcement.
 Intra-familiar conflicts.

OTHER CAUSES
 Interpersonal factors.
 Socioeconomic factors.
 Cultural and ethnic factors.
He was also
 Pharmacological factors.
 Ecological factors. influenced by
AVAILABILITY easy availability
 Alcohol is easily available and drinking is accepted as a norm in functioning and
and social gathering. socioeconomic
GENETIC FACTORS
factors
 Some excessive disorders have a family history of excessive drinking. There
is a genetic relation between alcoholism, depression and antisocial personality
disorder.

BIOCHEMICAL FACTORS

Several biochemical factors have been suggested including abnormality in

alcohol dehydrogenates in the neurotransmitter mechanism.

LEARNED BEHAIVOR

It has been suggested that learning processes may contribute in a more specific
way to the development of alcohol dependence through the repeated
experience
of withdrawal symptoms. Alcohol may act as a reinforce for further drinking.
Children especially boys tend to follow their parents drinking pattern. Some
people drink to get away from pain.

PERSONALITY FACTORS

Alcoholism is more common in anxiety, prone or cyclothymic personalities.

Drinking alcohol is also more common among antisocial personalities.
POOR COPING STRATERGIES
The person enable to face stress often resort to alcoholism. The disease
mechanism involved in alcoholism include denial, rationalization and
projection.

PSYCHIATRIC DISORDERS

Some patients with depressive disorders take to alcohol is the mistaken hope
that it will activate low mood. Persons suffering from anxiety disorders are
prone to take alcohol as an escape
SOCIAL CAUSES

Isolation, unemployment, loss, injustice and other social causes may lead to
Alcoholism

BOOK STUDY PATIENT STUDY

HIGH RISK GROUPS

Client has the same
Persons suffering from chronic physical illness, business executives, traveling process of
sales persons, industrial workers, urban slum dwellers, students in hostel, development of
military personnel etc are more prone to develop alcohol abuse. alcoholism.

PROCESS OF DEVELOPMENT OF ALCOHOLSM

EXPERIMENTAL
To begin with, persons start drinking alcohol due to pressure and curiosity.

RECREATIONAL
Gradually, whenever they meet in functions like marriages, hostel day or
college day, parties, conferences, they drink occasionally.

RELAXATIONAL
Further, whenever they want relaxation, on holidays and weak ends they start
enjoying their drink and continue to do so. Hence the frequency gradually
increases.

COMPULSIVE
Some people who started drinking occasionally, start drinking almost daily or
drinking heavily for a period of time for pleasure or to avoid the discomfort of
withdrawal symptoms.

STAGES

EARLY STAGE
INCREASED TOLERANCE: Needing more and more alcohol to experience
the same pleasure as experienced earlier.
BLACK OUTS: Inability to recollect incidents which happened under the
influence of alcohol.
PREOCCUPATION: Always thinking about how, when and where to drink.

MIDDLE STAGES

Loss of control over amount, time and occasion of drinking. Keeping away
from alcohol for sometime but going back to obsessive drinking after each
such abstinent period.

CHRONIC STAGE

Getting drunk ever on small amounts of alcohol. Willing to i.e., beg, borrow,
or steal to maintain supply to alcohol. Living to drink – alcohol takes priority
over family or job.

DIAGNOSTIC EVALUATION

Certain laboratory makers of alcohol dependence have been suggested. There In case of client’s
include: physical examination,
Physical examination. history, collection,
History collection. neurological
Neurological examination. examination, MSE and
Mental status examination. blood investigation
GGT (gamma glutyl transfarase) done.
MCV (mean corpuscular volume)

GGT is raised to about 40 IU/L in 80% of alcohol dependant individuals.

An increase in GGT of more than 50% in an abstinent individual signifies a
resumption of heavy drinking.
MCV is more than 92 fi (normal= 80-90 H) is 60% of alcohol dependent
Individuals.
BOOK STUDY PATIENT STUDY
OTHER LAB MARKETS
It includes,
Alkaline phosphatase.
AST
ALT
Uric acid
Blood triglycerides
CPK

COMPLICATIONS
I PHYSICAL OR MEDICAL COMPLICATIONS
A GASTRO-INTESTINAL SYSTEM
Gastritis.
Dyspepsia
Vomiting
Peptic ulcer
Cancer
Esophageal varices
Mallory-weiss syndrome
Achlorohydria
Carcinoma stomach and esophagus. Client developed the
complication of
LIVER vomiting, muscle
Fathy degeneration of the liver. wastage and vitamin
Alcoholic hepatitis deficiency.
Cirrhosis
Liver cell carcinoma
Liver failure
PANCREASE
Acute and chronic pancreatitis.

B CENTRAL NERVOUS SYSTEM

Peripheral neuropathy.
Delirium tremors.
Rum fits.
Alcoholic hallucinosis.
Alcoholic Jealousy
Wernicke- Korakoff psychosis
Alcoholic dementia.
Suicide
Cerebellar degeneration
Central posture myelinosis
Head injury and fractures.

C CARDIO VASCULAR
Alcoholic cardiomyopathy
High risk for myocardial infarction.
Cardiac beri-beri.
Alcoholic myopathy.
Risk for coronary artery disease.

D BLOOD
Folic acid deficiency aneamia.
Decreased WBC production.
Anemia, thrombocytopenia, vilk factor deficiency, hemolytic anemia.
BOOK STUDY PATIENT STUDY
E MUSCLE
Peripheral muscle weakness and wasting of muscles.

F SKIN Client does not

Spider angiomas. develop
Acnerosacea the reproductive
Palmar erythema complications
Rhinophyma
Spider revi
Parotid enlargement
Ascitis.

G NUTRITION
Protein malnutrition.
Vitamin deficiency disorders like pellagra and beri-beri.
H JOINTS
Gouts due to increase in uric acid level.

I REPRODUCTIVE SYSTEM
Sexual dysfunction in males.
Failure of ovulation in females.
Pseudo-cushing’s syndrome, hypogonadium, gynecomastia (in men).
Ammenorhea, infertility, decreased testosterone and increased LH levels.

J PREGNANCY
Fetal alcohol syndrome- fetal abnormalities like mental retardation and growth
deficiency.

BOOK STUDY PATIENT STUDY

II PSYCHIATRIC COMPLICATIONS

 PATHOLOGICAL INTOXICATION (Acute intoxication)

Maladaptive b ehavior effects, such as fighting, impaired judgement,
psysiological signs such as slurred speech, incoordination unsteady
gait, psychological changes such as mood changes, irritability, and
impaired attention.

WITHDRAWAL PHENOMENOM
The general withdrawal symptoms are – tremors, nausea and vomiting,
malacia, tachycardia, elevated BP, irritability, anorexia, insomnia, fits.

1. DELIRIUM TREMERS (DT) is a complicated withdrawal state. An

acute organic mental disorder and this should be treated as a psychiatric
emergency. DT is a short lived, but occasionally life-threatening, toxic,
confessional state with accompanying somatic disturbance. Prodoma
symptoms are insomnia, tremulousness and fear and occasionally
convulsions. The classical features are:
a) Clouding of conciousness and confusion.
b) Vivid visual hallucinations and illusions.
c) Marked tremors and fever. Client did not
d) Delusion, agitation, increased ANS activities. develop
any psychiatric
2. ALCOHOLIC SEIZURES (RUM FITS) complications of
Generalized toxic alcoholic seizures occur about 10 % of alcohol pathological
dependence patients, usually 12-48 hours after a heavy drinking. intoxication and
Usually these patients have been drinking alcohol in large amounts on withdrawal
a regular basis for many years. phenomenon.

3. ALCOHOLISM AND CRIMINALITY

Alcohol reduces inhibition and increases hostile behavior. Hence
alcoholics are more prone to violence and antisocial behavior.

4. ALCOHOLSIM AND SEX

 Alcohol increases the sexual desire but takes away the performance.
Alcoholic males suffer from sexual dysfunction.

5. ALCOHOL AMNESTIC DISORDER

Impairment is short and long term memory with disorientation and
confabulation.

6. ALCOHOLIC DEMENTIA
A chronic organic mental disorder due to long term alcohol drinking.
Irreversible impairment in memory, orientation, impulse control,
ability to solve problems etc may be there.

III NEUROPSYCHIATRIC COMPLICATIONS

1. WERINCKE’S ENCEPHALOPATHY
This is an acute reaction to severe thiamin deficiency the commonest cause
being chronic alcohol use. Characteristically, the onset occurs after a
period of persistent vomiting. The important clinical signs are.

 OCCULAR SIGNS
Coarse nystagmus and opthalmopligia with bilateral external rectus
paralysis occur early. Pupillary irregularities, retinal haemorhages and
papilladema can occur causing impairment of vision.

BOOK STUDY PATIENT STUDY

 HIGHER MENTAL FUNCTION DISTRUBANCE
Disorientation, confusion, recent memory disturbances, poor attention
span and distractibility are common. Apathy and ataxia are early
symptoms.Peripheral neuropathy and serious malnutrition are often co-
existent. Neuropathologically, neuronal degeneration and hemorrhage is
seen in thalamus, hypothalamus , mamillary bodies and mid brain.

2. KORSAKOFF’S PSYCHOSIS
As korsakof’s psychosis often follows wernicke’s encephalopathy, there
are together referred to as wernicke-kossakoff syndrome.Clinically,
korsakoff’s psychosis presents as an annestic syndrome,characterized by
gross memory disturbances with confabulation. In sight
is often impaired.

The neuropathological lesion is usually widespread, but the most consistent

changes are seen in bilateral dorsomedical nucleiof thalamus and
mammillary bodies. The changes are also seen in periventricular and
periaqueductal grey matter, cerebellum and parts of brain stem.
The cause is severe untreated thiamin deficiency secondary to chronic
alcohol use.

3. MARCHIAFAVA- BIGNAMI DISEASE

This is a rare disorder characterized by disorientation, epilepsy, ataxia,
dysarthria, hallucination, spastic limb paralysis and personality and
intellectual deterioration. There is a wide spread demyelination of corpus
collosum, optic tracts and cerebellar peuncles. The cause is probably some
 alchohol-related nutritional deficiency.

BOOK STUDY PATIENT STUDY

IV SOCIAL COMPLICATIONS
 WORK PROBLEMS: Decreased work performance, hence decreased
productivity due to chronic absence. As a result, the economy of the nation
suffers.
 FAMILY PROBLEMS: Alcoholism is a disease which not only affects the
individual but his whole family. Loss of job, loss of income will make the
Family condition miserable. There will be a role model reversal, i.e. the Client developed the
bread winner becomes an alcoholic and the wife takes the role of earning. social complications of
Marital disharmony is a common complication. work and family
 DRUNKEN DRIVING will lead to accidents. problems.
 Accidents.
 Marital disharmony.
 Divorce
 Occupational problem, with loss of productive man hours.
 Increased incidence of drug dependence.
 Criminality, occasionally.
 Financial difficulties.

IV OTHERS
 Alcoholic dementia.
 Cerebellar degeneration.
 Peripheral neuropathy

TREATMENT
Before starting any method of treatment, it is important to follow these steps.
i) Ruling out or diagnosing any physical disorder.
ii) Ruling out or diagnosing any psychiatric disorder.
iii) Assessment of motivation for treatment.
iv) Assessment of social support system.

BOOK STUDY PATIENT STUDY

v) Assessment of personality characteristics of the patient.
vi) Current and past social, interpersonal and occupational functioning.

The treatment can be broadly divided in to two types, which are often
interlinked. There are detoxification and treatment of alcohol dependence.
 ASSESSMENT OF THE PATIENT
i) His drinking pattern. In case of clients’s
ii) Work spot assessment and
iii) Family psychological methods
iv) Environment of treatment are
carried out.
 PHYSICAL METHODS
I) Detoxification
II) Disulfiram therapy.
 PSYCHOLOGICAL METHODS
I) Counselling
II) Individual and group psychotherapy.
III) Marital/ family therapy.
IV) Behavioral modification conversion therapy.
V) Relapse prevention therapy.

 Rehabilitation
 Alcoholic anonymous.

1.DETOXIFICATION
Detoxification is the process by which an alcohol dependent person
recovers from the intoxicating effects of alcohol in a supervised
way. It includes,

BOOK STUDY PATIENT STUDY

 Administration of minor transquilisers (anti-anxiety drugs like
chlordiazepoxide or diazepam) to control anxiety, insomnia agitation and
tremors.
 Assess fluid and electrolyte balance for rehydration-IV fluids are essential.
 Re-establish proper nutrition by giving a diet high is protein (when there is In case of clients
no liver damage), carbohydrate, vitamins C and B complex. (especially behavior therapy,
vitamin B1, B6 and B12) preparation parenterally. psychotherapy, group
 Provide calm, safe environment. therapy are carried out.
 Control nausea and vomiting.
 Administer anti-convulsant if there is withdrawal seizure.

1. DISULFIRAM (ANTABUSE) THERAPY

This drug produces intense head aches, severe flushing, extreme
nausea, vomiting, palpitations, hypotension, dyspnea and blurred vision
when
alcohol is consumed by the person.

2. BEHAIVOR THERAPY
The most commonly used behavior therapy is aversion therapy. Using
either a sub-thrushed electro shock or an emetic, like apomorphine.
 3. PSYCHOTHERAPY
Supportive psychotherapy and individual psychotherapy have been
used.
The patient should be educated about the risks of continuing alcohol
use, asked to resume personal responsibility for change and given a
choice of options for change.

4. GROUP THERAPY
Of particular importance is a voluntary self help group AA (alcoholics
anonymous) with branches all over the world and a membership in

BOOK STUDY PATIENT STUDY

Hundreds of thousands. Although the approach is partly religious in nature,
many patients desire benefits from group meetings.

5. DETERRENT AGENTS
The deterrent agents are also called sensitizing drugs.

CONTRAINDICATIONS
 First trimester of pregnancy.
 Coronary artery disease.
 Liver failure
 Chronic renal failure
 Peripheral neuropathy
 Muscle disease and history of psychosis in past.

OTHER DETERRENT AGENTS

 Citrated calcium carbonide (ccc)
 Metronidazole
 Nitrafezole
 Methyltetrazolethiol
 Animal charcoal.

6. ANTI-CRAVING AGENTS
A comprosate, naltrexme and SSRIs eg. Fluoxetine are among the
medications tried as anti-craving agents in alcohol dependence.
7. OTHER MEDICATIONS
A variety of other medications like benzodiazepines, anti-deprosants,
anti-psychotics, lithium, carbamazepine, narcotics have been tried.
There should be used only if there is a special indication for their use

BOOK STUDY PATIENT STUDY

8. PSYYCHOSOCIAL REHABILITAION
Rehabilitation is an integral part of multimodal treatment of alcohol
dependence.

NURSING CARE OF ALCOHOL DEPENDENTS Nursing care of

 The nurse taking care of an alcoholic in a deaddiction ward should alcohol dependents
understand some basic concepts about the problem. was given
 Alcoholism is a chronic disorder. to Client.
 It is a relapsing disorder.
 It is a disease affecting physical, mental and social well-being.
 Not only does the individual suffer but his family, work and community
also suffer.
 Accepting drinking as a problem by the patient is an important first step,
because most of the alcoholics deny that they are addicts. (denial).
 They are prone to pathological lying and manipulative behavior.
 The involvement of other significant persons especially the family
members enhance the recovery process.

The important five goals in the management of alcoholism include

1. Improving social relationships and supports.
2. Developing confidence and ability to change.
3. Identifying reasons to change.
4. Developing alternative activities.
5. Learning to prevent relapse.

CARE IN THE ACUTE STAGE(Immediately after admission during

detoxification)
 Patient to be kept in a quiet environment. Excessive stimuli increase the
patients agitation. Well lighted rooms help reduce fears and illusions.
 Safety precautions- careful observations of the patient’s behavior. Observe
for any signs of developing delirium tremors (DT).
 Be sure that the side rails are up when patient is in bed.

 Physical restraint may be necessary if patient is highly disturbed or

hyperactive.’
 Keep potentially harmful objects away from the room since the chance of
deliberate self harm is there.
 Keep the bed clean, dry and warm since some patients may be incontinent.
 Monitor vital signs every 15 minutes initially.
 Frequently orient the patient to reality and surroundings.

MEDICATION
 Follow medications as advised by doctor.
 Anti-anxiety drugs like chlordiazepoxide (Librium) and diazepam, if
necessary, parenterally given.
 Plenty of vitamins, especially Inj.B1, B6 land B12 and Tab B complex and
vitamin C.
 Antacids to relieve gastritis.
 Correct fluid and electrolyte in balanced by IV fluids.

NUTRITION
 Take care of the nutrition of the patient.
 Document intake, output and calorie content.
 Weight daily.
 Ensure that the patient receives small frequent feedings rather than large
meals.
 Ask family members to bring food that the patient enjoys.

Delirium tremors are an acute organic mental disturbance during the

withdrawal period of alcoholism. Watch for symptoms like confusion,
disorientation, tremor, illusion, hallucination, agitation and apprehension and
increased sweating, heart beat and pulse rate. Some patients may throw fit (run
fit). DT should be treated

as emergency sicne it may sometimes be fatal. IV fluids and IV diazepam,

keeping
the patient in quiet room , supplement with B complex vitamins and
reassurance as essential.

NURSING CARE DURING LATER STAGE OF HOSPITALIZATION:

(After detoxification is over) Nursing care during
 To understand the alcoholic, it is important to look beyond the symptoms later stage of
and learn about the person. hospitalization was
 These persons are in need of physical as well as social rehabilitation. given to the client.
 Attention to their rest, diet, personal hygiene and appearance is important.
 During the recovery and rehabilitation period the acceptance of the
patient by the nurse is essential. The nurse’s acceptance may encourage
the patient to socialize and participate in planned ward activities.
 The alcoholic patients have inferior feelings and low self esteem. lf the
nurse accepts him as an individual and cordially talks to him, the feelings
will be reduced.
 The nurse should be empathetic with the person but should not be over
sympathetic and be sure that they do not become dependent on her.
 The nurse has an important role in the care and rehabilitation of alcoholic
patients and their families. The wives should always be included in the
psychological therapy.
 It is important for the nurse to anticipate improvement instead of complete
care.
 Expression of kindness and being non judgmental , accepting him, being
consistent and understanding in approach all induce a formable
relationship which will help the recovery process.

BOOK STUDY PATIENT STUDY

NURSES ROLE IN PREVENTION OF ALCOHOLIC ABUSE
 PRIMARY PREVENTION: Aim to avoid the appearance of new cases of
alcohol abuse by reducing the consumption of alcohol through heath In nurse’s role in
promotion, especially heath education. prevention of alcohol
 SECONDARY PREVENTION: Attempts to detect cases early and to treat abuse tertiary
them before serious complications cause disability. prevention was not
 TERTIARY PREVENTION: Aim is to avoid further disabilities and to carried out.
reintegrate individuals in to society who have been harmed by severe
alcohol related problems.The nurse will be involved in all of the levels.
NURSING DIAGNOSIS

1. Anxiety related to irrational thoughts secondary to absence of support system.

2. Altered thought process related to unmet dependency needs.

3. Impaired verbal communication related to incoherent speech pattern and side effects of
medication.

4. Impaired concentration and attention related to alcohol intake.

5. Ineffective family coping related to depression secondary to alcohol dependence.

6. Insomnia related to emotional disturbances.

7. Knowledge deficit related to alcoholic dependence, treatments and its effects.

8. Potential for complications related to intake of anti-anxiety drugs.

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
feelings and 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
Leadership
Surrogate role C
Counseling role
D
A

Energy transformation
CLIENT EDUCATION

Help the patient to quit the plan

 Set a quit date-ideally

 Tell family and friend support
 Anticipate changes like alcohol withdrawal syndromes

Provide practical counseling

 Anticipate triggers and challenges in upcoming attempts

 Patient should consider limiting from alcohol while quiting

Help the patient to obtain extent of treatment, social support.

 Help the patient to develop social support for helping him quit the habit.

Recommend use of approved pharmacotherapy

FAMILY EDUCATION

 Help family members to recognize the danger situations and explain the chance of
relapse.
 Avoid others drinking in front of patient
 Remove all products of alcohol from the surro8unding prior to alcohol cessation
 Accomplish life styles that reduce stress.
 Improve quality of life or produce pressure learning cognitive and behavioral activities
to cope.

CONCLUSION

As a part of my clinical requirement I selected Mr.Johnson Babu with diagnosis of

alcohol dependence for my case presentation and by treatment his condition is improving. By
taking this case presentation I attained adequate knowledge about the disease condition and
its management in detail which will help me in caring such patients in future.
BIBLOGRAPHY

1. Ahuja.N.A Short Text Book of Psychiatry.5th edition. New Delhi. Jaypee

publishers;2002.p 37-44

2. Sreevani.R.A Guide to Mental and Psychiatric nursing.2nd edition. New Delhi. Jaypee
publishers.2007;p.129-134

3. Neeraja.K.P. Essentials of Mental Health and Psychiatric nursing.1st edition. New

Delhi. Jaypee publishers.2008;p.593-604

4. World Health Organisation.The ICD-10 Classification of mental and Behavioural

disorders.New Delhi.AITBS publishers.2007.p:75-76

5. Lalitha. K.Mental Health and Psychiatric nursing-An Indian Perspective.1 st

edition.Bangalore B.M.G book house.2007.p 517-518

6. Schultz.M.J.Videbeck.L.S.Lippincott Manual Of Psychiatric Nursing Care Plans.6th

ed.Philadelphia.lippincott publishers 2002.