CASE STUDY

Identification data:
Name: Mr. Mahadevappa
Age/Sex: 40 y/male
Address: No-55, 5th cross, 1st main,
Doddabasthi, Mysore road,
Bangalore.
Education: 8th std
Occupation: Coolie
Income: 1,500/month
Marital Status: Married
Religion: Hindu
IP No NIMHANS

Informant: Patient and his wife, is adequate and reliable

Chief complaints:
History of alcohol consumption since 20 years
Cigarette smoking – 16 years
Occasional use of other drugs like Cannabis
Irritability, irrelevant talk, decreased sleep and reduced intake of food since 4 months
Talking to self

History of Present Illness:

Patient was apparently alright 20 years back when he started to take alcohol due to peer
influence. Beginning he use to consume only alcohol about 90 ml/day but frequency is increased as day
passed. Last drink is 15 days back and it was about 360 ml. Patient started to smoke cigarettes 16 years
back and initially he use to smoke 2-3 cigarettes per day, gradually number of cigarettes per day
increased and before admitting here number of cigarettes per day was 10-15. History of occasional use
of other drugs like cannabis is present. He was having craving, tolerance when he stops to take alcohol.
Patient is having complaints of sleeplessness, shaking of hands and lack of control since 3 years and
early morning drinking since 4 years. Patient is suspicious about his wife that she is having affairs with
other person.
Precipitating factors – nil
Predisposing factors – nil
Biological functioning – decreased appetite and sleeping pattern and reduced personal hygiene
Occupational functioning – patient is not regular for his duty
Treatment history:
Mr. Mahadevappa is taking treatment for last 3 years for the same complaints. He had been
admitted in Govt hospital 2 years back for the complaints of pneumonia and took treatment for that. He
is presently receiving drugs like;
Inj. Lorazepam 2 mg 1-0-1
Tab. Risperidon 3 mg 1–0–1
Tab.Inac 50 mg 1-0-1

Past Psychiatric and Medical History:

Mr. Mahadevappa was admitted in Govt hospital for the complaints of pneumonia and he took
treatment for that, now he is alright. He is taking treatment for Substance use disorder sing 3 years and
for similar complaints he was admitted in same hospital 3 years back. No history of head injury,
convulsion and HIV.

Family History:
Patient is living with his wife and 4 children. History of substance use in the family is present.
His father was heavy drinker of alcohol. No other history of psychiatric disorders in the family.

Personal History:
Perinatal history: not known
Childhood history:
Educational history:
He had studied up to 8th standard. His academic performance was average. His extracurricular
achievements were poor. His relationship with his friends and his teachers was good. Reason for
termination of school was poor economic condition of the family.

Play history: He used to play all types of games. His relationship with his friends was good.

Emotional problems during adolescence: no history of running away from home and emotional
problems during adolescence.
Occupational history:
He started to go to work at the age of 16 years as a coolie. He was satisfied with his work and job
was appropriate to him.
Sexual history:
Appearances of secondary sexual characters are at the age of 13 years. No abnormalities
associated with puberty.

Marital history: His marriage was arranged. His relationship with his wife was good and he is having 4
children.
Premorbid personality:
He was an extrovert in nature. He maintained good relationship with his family members and his
friends. He was having good attitude towards him and others. He uses to spend his leisure time with
friends. He believes in god and other religious activities.
Habits: appetite – decreased
Normal bowel and bladder movements

Mental status examination

 General appearance and Behaviour
Mr.Mahadevappa, 40 years old male looks appropriate to his age; he is moderately built and under
nourished. Patient is conscious, well kempt and oriented to place person and time. He came willingly to
hospital and he is cooperative, eye to eye contact established but not maintained, rapport established.
Psychomotor activities are decreased. He is maintaining normal posture and gesture. Abnormal
movements like extra pyramidal symptoms, tremors are present. No catatonic phenomena.

 Speech:
 Initiation of speech is spontaneous, reaction time is delayed, rate of speech is slow, productivity
is elaborate reply and volume is normal. Speaks in monotonous tone and is relevant. Stream is normal
and coherent. No speech disorders are present.

 Mood:
Subjective: patient tells that I am not fine
Objective: patient is dull, anxious,sad
Predominant mood state is irritable

 Thought:
Stream of thought is normal and content is adequate, ideas of worthlessness, and guilt are
present. No thought disorders like aliniation; thought withdrawal and thought broadcast are present.

 Perception: He is having tactile hallucination. Ex- sensation of crawling of insects on the

body

 Cognitive functions:
Consciousness – conscious
Orientation – oriented to time, place and person
Attention – arousal with difficulty, not able to sustain, able to do calculations like 20-1, and he recalls
the names of week days and months of the years.
Memory:
His immediate and recent memory is intact and remote memory is altered.
Intelligence;
His general information is poor and arithmetic ability is poor, not able to interpret the
abstraction.
Insight:
He is aware of his abnormal behaviour and willing to take treatment.
Judgement:
Personal and social judgements are intact.

Diagnostic formulation:
‘Substance use disorder complicated withdrawal with seizures.’
 Physical examination:
General appearance:
Mr. Mahadevappa, is conscious, moderately built and nourished.
Vital signs:
Temp: 98.6` F
Pulse rate: 68/min
Respiration rate; 18/min
BP: 130/90 mm of Hg
Body built: moderately built
Posture: normal
Hygiene: adequate
Look: anxious

SUBJECTIVE DATA OBJECTIVE DATA

Vision Eye lashes are equally distributed

Patient said that “I can see you properly” Eye brows are normal
Pupils are equally reacting to light
No discharges from the eyes
Vision is normal

Hearing Ears are equal in size and shape

Patient said “I can hear you properly” No colour change present
Renni’s test and Weber’s test are positive
No discharges from the ears
Not using any hearing aids

Speech and orientation

Patient say’s that “I don’t have any difficulty
while speaking”
Respiratory system
“I don’t have any breathing difficulty”
He is able to talk
He is oriented to time, place and person
Inspection :
Respiratory rate :18/min
Chest normal symmetry and shape
No marks or scars over the chest
No pallor, cyanosis or nodules

Palpation :
Trachea is centrally placed
Respiratory movements are normal
Tactile fremitus is normal on both sides
Chest expansion – 2 cm
Percussion:
Resonance sound throughout lung field.
Auscultation;
 Normal breath sounds heard
Circulatory system
Patient say’s that “I don’t have chest pain” Temperature : 37` c
Pulse : 68/min
BP: 130/90 mm of Hg
Inspection :
No cyanosis on lips and extremities
No clubbing of fingers
Palpation:
Peripheral pulses are palpable
Auscultation:
S1 and S2 heard, no murmurs

Lymphatic system
Patient reported that “I am not having any enlarged Lymph nodes are not palpable and not enlarged
gland’s” Thyroid glands are not enlarged

Gastrointestinal system Inspection:

Patient says that “I not have pain in abdomen, my Patient is moderately built and nourished
appetite is decreased and elimination pattern is Weight 61 Kg
normal” Height : 167 cm
Dental hygiene : yellowish discolouration of
teeth’s
No tonsil enlargement
Tongue is coated
No abdominal enlargement, no scars or marks on
abdomen,
Auscultation:
Bowel sounds heard on auscultation
Percussion:
Tympanic sounds on stomach and dull sounds on
liver and spleen heard on percussion.
Palpation:
No tenderness, organomegally found on palpation

Urinary system Urine colour is pale yellow, normal specific

“Patient reported that I don’t have painful gravity, no signs of urinary tract infections and
micturation” bladder distention.

Musculoskeletal system Inspection:

Patient says that “ I have body pain” No scoliosis, kyphosis, lordosis
No swelling on joints
No abrasions
Mild tremors of hands present
he is able to walk
Gait is normal
Palpation:
No swelling, ROM is normal
Muscle strength is normal
cranial nerves are intact

Integumentary system
Patient says that “I don’t have any rashes on my
body but I feel insect crawling sensation on my
body”
Percussion:
sensory and motor system is having adequate
function
all reflexes are normal, no use of supportive
devices
No Rashes, Pustules, ulcers
skin is normal, adequate warmth is present
nails are in normal shape and size

Rest and sleep Drooping of eyelids present

Patient says that “I am not sleeping adequately”
Reproductive system
Patient says “I am not having any problem in the
genital area”
The patient is having the disturbances in sleep,
sleeping duration is 5-6 hrs/day
No abnormalities found on examination

Psychosocial aspect
Patient says that I will go to home after completion He is interacting with health team members in an
of the treatment acceptable way. Relatives and neighbours are
visiting him. He is cooperative with them and
health team members.

Investigation:
Investigation Patient value Normal value remarks
Glucose 104 mg/dl 60-100 mg/dl Normal
Urea 10 mg/dl 10-35 mg/dl Normal
Creatine 0.9 mg/dl 0.6 – 1.4 mg/dl Normal
Pottassium 3.7 meq/l 3.5 – 5.5 m Eq/l Normal
Sodium 140 M Eq/l 135 – 145 m Eq/l Normal
Chloride 107 M Eq/l 95 -106 m Eq/l Slight increased
Haemoglobin 10.8 gm/dl 13 – 17 gm/dl Low
 Drug Dose, route Action Indication Contraindication Side effects Nursing action
and frequency
3 mg Antipsychotic drug  Short term  Hypersensitivity CNS:  Monitor BP regularly
Tab. Oral It blocks dopamine therapy for  Cardio vascular Neuroleptic malignant  Watch for Tardive
Risperidon 1-0-1 and serotonin in syndrome,
schizophrenia disease dyskinesia
receptors as well as  hallucinations,
delaying  Cerebro  Monitor for symptoms of
parkinson’s syndrome,
alpha, alpha 2, H1 response in long vascular hyperglycemia
tremors, fatigue, pain,
receptor in CNS, term therapy for diseases  Advise to take plenty of
CVS: tachycardia,
relives signs and schizophrenia  Dehydration, fluids
chest pain, othostatic
symptoms of  monotherapy or hypovolemia,  Avoid activities that require
hypotension
psychosis. combination with seizures altertness
ENT: rhinitis,
Lithium or sinusitis.  Wear protective clothing in
valporate for sunlight
short term  Monitor weight
treatment

2 mg, 0-0-1, Sedative and  Anxiety disorders  hypersensitivity  Sedation,  Monitor liver, kidney and
oral tranquilisers  Depressive dizziness, haematopoietic function
Tab.
Mechanism of action symptoms weakness and studies periodically in
Lorazepam
is by enhancing  Pre surgical unsteadiness patient receiving repeated
GABA transmission medication  Disorientation, or prolonged therapy.
in the brain depression,  Be alert for adverse
nausea, change reactions and drug
in appetite interactions.
  Headache  Warn patient to avoid
 Sleep hazardous activities until
disturbance the drugs CNS effects are
known.
 Tell patient to drink alcohol
or smoke during therapy
Tab. Inac 50 mg, 1-0-1 Non steroidal anti  All types of pain  Gastric ulcers  Nausea and  Administer the drug after
(Diclofenac inflammatory drug  Hypersensitivity vomiting meal only
Sodium) It inhibits the  Headache  Monitor the vital signs
synthesis of  Epigastric  Advise to take plenty of
prostaglandlins the burning fluids
mediators of the pain
Nursing diagnosis:
1. Risk for injury related to acute intoxication evidenced by confusion, disorientation
2. Impaired sensory perception related to withdrawal symptoms as evidenced by tactile hallucinations
3. Ineffective denial related to weak ego evidenced by statements indicating no problem with substance
use
4. Ineffective coping related to inadequate coping skills and weak ego evidenced by use of substances
as coping mechanism
5. Anxiety related to management of disease
6. Ineffective family coping related to impairment of adaptive behaviour and problem solving abilities
7. Imbalanced nutrition less than body requirement related to decreased intake of food
8. Disturbed sleep pattern related to withdrawal symptoms
 Assessment Diagnosis Plan of action Intervention Implementation Evaluation
Subjective data: “Risk for injury Patient will not  Monitor clients health status Clients health status Patient did not harm
harm self monitored himself
Patient says “I am related to acute  Place the client in a room Client is placed near to
having tremors and intoxication near to nurses station nurses station
abnormal movements” evidenced by  Institute seizure precautions All the precautions
confusion,  Reorient the client time, taken to prevent and
care during seizures
Objective data; disorientation” place and person
Fearfulness  Keep all the harmful All harmful substances
kept out of reach of
Tremors and EPS are substances out of reach of patient
present client
 Close observation should be Close observation is
done
done
Subjective data: “Ineffective coping Client will be able  Set limits on manipulative Conveyed acceptance Client expressed that
Patient says “I am not related to inadequate to verbalize behaviour. alter he is able to cope
able to cope with daily coping skills and adaptive coping  Explore options available to Patient is explained with the situation
routines” weak ego as mechanisms to use, assist with stress rather than about options available
evidenced by use of instead of substance resorting to substance use. to reduce stress
Objective data; substances as coping abuse, in response Practice these techniques
Fearfulness mechanism” to stress.  Give positive reinforcement
Watching around for ability to delay
gratification and respond to Reinforced and focused
stress with adaptive coping on reality
strategies.
 Laughing and
whispering is avoided
Subjective data: “Ineffective denial ‘client will  Develop trust. Convey an Spoke with client and Client demonstrated the
Patient says ‘ I have to related to weak, demonstrate attitude of acceptance. developed trust acceptance of
take substances to underdeveloped ego acceptance of Ensure that client responsibility for own
reduce my tensions’ as evidenced by responsibility for understands it is not the behaviours.
statements own behaviour and person but the behaviour
Objective data: indicating no acknowledge that is unacceptable.
Depressed problem with association between  Correct any misconceptions, Misconceptions of the
Sitting alone substance use” substance use and such as, “I don’t have a client are clarified
personal problems’ drinking problem. I can quit
any time I want to”. Do this
in a matter of fact,
nonjudgmental manner.
 Identify recent maladaptive
behaviours or situations that
have occurred in the client’s
life, and discuss how use of
substances may be a
contributing factor.
 Do not allow client to Client is explained to
rationalize or blame others accept the behaviours
for behaviours associated and don’t rationalize or
with substance use. blame others
Subjective data: ‘Anxiety related to Patient gets relief  Reassess the level of anxiety Reassessed the level of Clients anxiety level is
Patient says ‘ I am management of from anxiety as to get the base line data anxiety decreased to some
fearing about my life’ disease’ evidenced by facial extent
expression and  Explain about the disease Explained about the
Objective data; verbalization’ management and disease disease management
Patient is asking so condition. It helps to reduce and disease condition.
much doubts the anxiety and improve the
Pulse rate increased knowledge
Palpitations
sweating  Develop good IPR with the Developed good IPR
client it helps to achieve the with the client by
talking with him.
 cooperation of the patient
Encouraged the patient
 Encourage the patient to ask to ask his doubts.
his doubts to reduce the
level of anxiety Provided psychological
 Provide psychological support to the client
support to get relaxation
Provided relaxation
 Provide relaxation techniques.
techniques to reduce the
anxiety.

Subjective data: ‘Imbalanced Client will be free  Encourage cessation of Client is encouraged to Clients nutritional status
Client says ‘I am nutrition: less than of signs/symptoms substance use quit the substance use is improved to some
feeling weak’ body requirements of malnutrition  Consult dietitian. Determine extent
related to use of the number of calories
substances instead required based on body size
Objective data: of eating as and level of activity.
Client looks, evidenced by loss of  Document intake, output Intake and output record
Weak weight. and calorie count, and in maintained
Hb% is 10.8 gm/dl weigh client daily.
Less weight compare to  Ask client to take small and Client is told to take
height frequent diet small and frequent diet
 Provide the food according
to like of the client
 Supplement nutritious meals
with multiple vitamin and
mineral tablet
Subjective data: ‘Disturbed sleep ‘Client maintains  Reassess the sleep pattern to Reassessed the sleep Client’s sleep pattern is
Patient says ‘I didn’t pattern related to adequate sleep get the base line data pattern improved to some
slept during night’ depressed mood and pattern during night extent
fears evidenced by as evidenced by  Encourage the patient to Encouraged the patient Sleep hrs-8-9 hrs
Objective data: difficulty falling a facial expression avoid the day time sleep to to avoid the day time
Droopy eyes sleep’ and verbalization’ promote night sleep sleep
Facial expression
Sleeping hrs – 5-6  Encourage the patient to Encouraged him to
hrs/day engage in some activities engage in some
before sleep to promote the activities before sleep
sleep
 Provide calm and quiet Provided calm and quiet
environment to promote the environment
sleep
 Provide a glass of warm Advised the family
milk before going for sleep. members regarding the
Tryptophan in milk induces same.
sleep
Subjective data: Ineffective family Family will identify  Identify level of family Reassessed the family Family members
Family members more adaptive functioning. Assess functioning and understood the disease
coping related to
verbalises that ‘he is coping strategies communication pattern relationships. condition.
become irritable to us impairment of for dealing with interpersonal relationships
and we are in confusion clients illness and between members role
adaptive behaviour
state’ treatment regimen expectation problem solving
Objective data: and problem solving skill and availability of
Family members failed outside support system
abilities
to identify the adequate  Provide information for the Provided information
coping strategies family about the client’s for the family members
illness. What will be
required in the treatment
regimen and long term
prognosis
 Practice with family Practiced with family
member’s ways in which to members
respond to bizarre behaviour
and communication patterns
and in the event that the
client becomes violent.
Health Education:

Regarding illness and medications

 Educated his to stop the substance use behaviour involve in other activities
 Educated him and family members 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 come, also explained the role of family
members and others in preventing relapse.
 Advised not to take any other medication without the advise not to stop drug abruptly without
psychiatric advise

Personal hygiene
 Educated the client the importance of bathing daily, brushing teeth daily, grooming, wearing
clean clothes, combing hair, cutting nails.

Nutrition
 Educated client to take high nutritious diet containing all types of nutrients
 Educated regarding importance of balanced diet. Regarding maintenance of adequate weight.
 Educated the intake of 3-4 litres 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 cause 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.

Summary and Conclusion:

Mr.Mahadevappa admitted to the hospital with complaints of History of alcohol consumption
since 20 years, Cigarette smoking – 16 years, Occasional use of other drugs like Cannabis, Irritability,
irrelevant talk, decreased sleep and reduced intake of food, Talking to self since 4 months. After all the
medical and nursing management to the client, his condition is improved to some extent.

Self evaluation:
After taking this case for providing nursing care I understood about this psychiatric disorder
and also how to care a patient with Substance use disorder with withdrawal symptoms.
Bibliography

1. Mary C.Townsend “Essential of psychiatric mental health nursing”2nd ed, F.A.Davis,

Philadelphia, 2002.
2. Gail W Stuart ‘principles and practice of psychiatric Nursing” 8th ed, Elsevier, New Delhi: 2005.
3. Kapoor B, Text book of psychiatric nursing. Delhi: Kumar publishing house: 2008.

4. Niraj Ahuja, “A short text book of Psychiatry” 6th edition-2007, Jaypee brothers, New Delhi.

5. R. Sreevani, “A guide to mental health and psychiatric nursing”, 2004, 1 st edition, jaypee
brothers, New Delhi.
 MAYO COLLEGE OF NURSING
BHOPAL(M. P.)

CASE STUDY ON- SUBSTANCE ABUSE

DISORDER

SUBJECT- MENTAL HEALTH NURSING

SUBMITTED TO SUBMMITED BY
Mr. FREDDY MRS. ABHILASHA
PROFESSOR MSC (N) 2ND YEAR

DATE OF SUBMISSION /08/2019