SGRD COLLEGE OF NURSING ,VALLAH ASR

CASE STUDY
ON ALCOHOLISM
CLIENT-MR.AMRIK SINGH

SUBMITTED TO: DR.RAJESH KONNUR

HOD PSYCHIATRIC DEPT

SGRD CON VALLAH ASR

SUBMITTED BY: MONIKA JOSEPH

M.SC (N) 1ST YEAR

ROLL NO: 1118

SPECIALITY- PSYCHIATRIC NURSING

SGRD CON VALLAH, ASR

SUBMITTED ON: 07/03/2012

[THIS CASE STUDY HAS ENCLOSED THE BRIEF HISTORY OF MR.AMRIK SINGH
ADMITTED TO SGRD HOSPITAL PSYCHIATRIC WARD & DIAGNOSED AS ALCOHOL
DEPENDENCE.. INFORMANT IS HIS FATHER AND VARIOUS BOOKS ARE REFERRED FOR
COMPLETION OF CASE STUDY.]
 CASE STUDY
OF
Mr. Amrik Singh
WITH
ALCOHOL DEPENDENCE
IDENTIFICATION DATA

Name :- Mr.Amrik singh

Age :- 26 yrs
Sex :- Male
Address :- Puttligarh, Amritsar
Ward :- Psychiatric Ward
Religion :- Sikhism
Education :- 10th Std.
Marital Status :- Single
Occupation :- working in chicken shop
Income :- 36,000 Rs/Annually
Date of Admission :- 29/2/2012
Diagnosis :- Alcohol dependency
Language :- Punjabi
Reliability :- Reliable
Client information is provided by Mr.Rajinder singh (father)
He is staying with the client from last 26 years and father is
Very much concerned about the client. Client relationship
With his father is very good.
Informant
1. Patient
2. Father

PSYCHIATRIC HISTORY
COMPLAINTS AND THEIR DURATION
1. According to patient
Patient is regularly taking alcohol since 2003 daily around half bottle. He started taking alcohol
under peer pressure for first time in 2003. Gradually he developed habits of taking alcohol daily
in Peer Company. The after 3 months he increased the dose of alcohol consumption from half
bottle to full one bottle. At present in 2012 client is chronic alcoholic and used to consume 3-4
bottles a day. After taking alcohol quarrels with father and brother.
CHIEF COMPLAINTS:
 Uncontrolled anger
 Anorexia
 Insomnia
 Body aches

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. This time patient came
voluntarily for treatment.
HISTORY OF PRESENT ILLNESS
a) Onset :- Gradual
b) Precipitating factors :- Peer group pressure His friends use alcohol and
Cigarette. He is working in chicken shop and job
stress.
c) Course of the illness :- 8 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, Milestones achieved appropriately

2. Behavior during childhood

No history of sleep disturbances, no thumb sucking, no tics and mannerism, no history of
bed wetting late childhood, no sibling rivalry

3. Physical illness during childhood

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

4. School
Patient studied till 10th std. Relationship with peers and teachers normal. He was an
 average student and left school due to the lack of interest in studies.

5. Occupation
He is working in chicken shop as a helper form 2 years .

6. Sexual history
Not sexually active. No abnormalities reported.

7. Martial History
Unmarried

8. Use and abuse of alcohol, tobacco

He is using alcohol and tobacco since six years. Daily take half bottle of alcohol and 15-
20 cigarettes a day.

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

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 : Pleasant
- Eye contact : maintained
- Posture : normal
-Attitude towards examiner : co-operative
- Rapport : rapport maintained
- Motor behaviour : no abnormal motor behaviour like tics,
Mannerism, pacing, motor retardation
B. THOUGHT AND SPEECH:
1. Form of thought:
N. Why do you come here with your father?
P. 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
N. What is your problem?
P. 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:
N. How are you feeling now?
P. I am not ok.
- Affect: affect is normal

Inference: affect is congruent to mood.

D. PERCEPTION:
N. When you are alone, can you seeing anything that other person can’t see and hear?
P. No

Inference: No hallucinations and delusions

E. SENSORIUM AND COGNITION:

Consciousness: conscious, alert, oriented to time, place and person.
F. MEMORY
a. Immediate:
N. What I asked just now?
P. Anything you can see and hear more.

Inference: Immediate memory is intact.

b. Recent memory:
N. What you had in breakfast?
P. Yes

Inference: Recent memory is intact.

c. Remote memory:
N. When is your birthday?
P. 14th may 1985

Inference: Remote memory is intact.

G. ATTENTION AND CONCENTRATION:

N. How many days in a week and tell them?
P. 7 days, he says from Monday to Sunday
N. Subtract 100-5?
P 95

Reference: Attention is aroused and concentration is also sustained.

H. ORIENTATION:
N. What must be the time now?
P. It must be 10’o clock
N. Who brought you here?
P. I came along with my father.
N. Who is that lady wearing white saree?
P. She is a ward sister.
N. Where are you now?
 P. I am in NIMHANS hospital.
Inference: he is oriented to time, place, and person.

I. ABSTRACTION:
N. What is the different between the potato and stone?
P. Potato is eatable and stone is hard.
N. What is the similarity of banana and orange?
P. Both are fruits

Inference: Abstraction is good.

J. COMPREHENSION:
N. What will you do, if u misses the bus?
P. I’ll catch another bus.
N. What you will do if you feel cold?
P. I’ll wear sweater.

Inference: comprehension is good.

K. INTELLIGENCE:
N. What is the capital of India?
P. Delhi

Inference: Intelligent is good.

L. JUDGMENT:
- Personal judgment:
N. What are you planning to do after discharging from here?
P. I want to settle my life.
- Social judgment:
N. What will you do when you saw a person drowning?
P. I will call other people because I don’t know swimming
- Test judgment:
N. What you will you do if your ward is fire?
 P. I’ll pour water to stop the fire.
Inference: Judgment of the patient is good.

M. INSIGHT:
N. Why you are coming and staying here?
P. I have to stop alcohol drinking.

Inference: Insight is present.

Physical examination
General information:
A. GENERAL OBSERVATION:
Mr.Amrik singh is moderately built and healthy.
B. VITAL SIGNS:
a. Temperature : 98º degree
b. Pulse : 80/minutes
c. Respiration : 20/minutes
d. Blood pressure : 130/70 mm of hg

C. HEIGHT AND WEIGHT:

a. Height : 5.5”
b. 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. Palpation: No local swelling; 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/minutes

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 supra cardiac
dullness
d. Auscultation: S1 S2 auscultated. No abnormalities noted, pulse-80/minutes
M. ABDOMEN:
 a. Inspection: size and shape of the abdomen normal, no distension and tenderness.
b. Palpation: no abnormalities found. Firm musculature noted
c. Percussion: 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. Swelling/ oedema: no swelling or oedema
c. Muscles: no emaciate

Q. LOWER EXTREMITIES:
a. Deformities: no abnormality noted
b. Swelling/ oedema: absent
c. Muscles: not emaciated
d. Lymph nodes: not palpable
e. Joints: normal ROM

R. NERVOUS SYSTEM:
a. Higher function: conscious and oriented
b. Memory: immediate is impaired and recent, and remote is intact.
c. Orientation: patient is oriented to time, place and person
d. Insight and judgement: normal
PROCESS RECORDING
CONVERSATION COMMENTS
N: Good morning! Gait normal
P: Good morning, sister!

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

P: Yes, bread alone.

N: Today, you are looking fresher.

P: Yes, sister, I am better now. I want to get
discharged soon.

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

P: I am happy. and visual hallucination.

N: Was you father strict with you?

P: Yes, he was strict and used to beat me. Shows grief.

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

N: Do you satisfied in your job?

P: No, I don’t have job satisfaction. Patient has occupational stress.

N: What is your date of birth?

P: 14th may 1985 Remote memory intact.

N: Do you like your parents and brother? Patient is attached with his family.
P: Yes, I like my parents and brother
N: Why you are quarrelling with brother?
P: When I drink alcohol I will lose my control.
N: What is your plan after discharge?
P: I want to go for a good job or start a business. Willing to work after discharge.

N: Once you get discharged you must come for

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

N: Do you want to ask any question?

P: No, tomorrow I will talk to you sister.

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

answering my questions.
P: Bye! Sister.

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 Pharmacologic Dose Rout Action Side effects Nurses
al Name e responsibil
ity
T. Chlordiazepoxi Oral 15- Oral Anti- Nausea, vomiting, In
chlordiazepoxide de 100 mg IV and anxiety epigastric pain, injection
50-100 mg IV agent. diarrhea, should be
slowly impotence, given
impairment of deltoid and
driving skills, is gluteal
irritability. muscle.
T. Rantac Ranitidine Oral 150- Oral Histamine Headache,Dizzines Administer
300 mg IV H2receptor s,rarelyhepatitis,th correct
antagonist rombocytopenia,br dose
east symptoms,
hypersensitivity,co
nfusion,
T. BC BC 32.5mg oral Vitamin B Look for
and C Hypervitaminosis, side
complex G.I.Symptoms,yell effects,exp
supplemet. ow coloured urine. lain about
urine
colour
change
T. Liv 52 Sihymanin 140mg oral Liver Occasional See for
protectant laxative effects hypersensit
ivity.
T. Fluoxtine Fluoxtine 20mg oral Antidepres Nervousness,
sant insomnia, anxiety,
tremor, headache,
drowsiness, nausea
and drymouth.

DESCRIPTION OF DISEASE CONDITION

ALCOHOL DEPENDENCE
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
CLASSIFICATION OF ALCOHOLISM
STUDY
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.
Etiological Genetic factors Heritable

Factors Important, strong Environmental

Environmental influences
influences are are limited. Under

Contributory classification
Family history May be positive. Parental alcoholism and client comes
antisocial behavior under
usually present Type-1
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,
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).
Client was
 Biochemical factors (e.g. role of dopamine and non epinephrine in
influenced both
cocaine, ethanol and opiod dependence.
by psychological
and Social factors.
2. PSYCHOLOGICAL FACTORS
 Curiosity, need for novelty seeking.
 General rebelliousness and social non-conformity.
 Early use of alcohol and tobacco.
 Poor impulse control.
 Sensation – seeking (high)
 Low – self esteem (anomia)
 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.
He was also
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.
influenced by easy
 Cultural and ethnic factors.
availability and
 Pharmacological factors.
socioeconomic
 Ecological factors. factors

AVAILABILITY
 Alcohol is easily available and drinking is accepted as a norm in
functioning and social gathering.

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

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
include:
Physical examination. In case of client’s
History collection. physical
Neurological examination. examination, history,
Mental status examination. collection,
GGT (gamma glutyl transfarase) neurological
MCV (mean corpuscular volume) examination, MSE
and blood
GGT is raised to about 40 IU/L in 80% of alcohol dependant individuals. investigation
An increase in GGT of more than 50% in an abstinent individual signifies a done.
resumption of heavy drinking.
MCV is more than 92 fi (normal= 80-90 H) is 60% of alcohol dependent
Individuals.
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.
Client developed the
Dyspepsia
complication of
Vomiting
vomiting, muscle
Peptic ulcer
wastage and vitamin
Cancer
deficiency.
Esophageal varices
Mallory-weiss syndrome
Achlorohydria
Carcinoma stomach and esophagus.

LIVER
Fathy degeneration of the liver.
Alcoholic hepatitis
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 beriberi.
Alcoholic myopathy.
Risk for coronary artery disease.

D BLOOD
Folic acid deficiency anemia.
Decreased WBC production.
Anemia, thrombocytopenia, vilk factor deficiency, hemolytic anemia.

E MUSCLE
Peripheral muscle weakness and wasting of muscles.

F SKIN
Spider angiomas.
Acnerosacea
Palmar erythema
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. Client does not
Pseudo-cushing’s syndrome, hypogonadium, gynecomastia (in men). develop
Ammenorhea, infertility, decreased testosterone and increased LH levels. the reproductive
complications
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. Usually intoxication and
these patients have been drinking alcohol in large amounts on a regular basis withdrawal
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.

 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 Client developed the
the individual but his whole family. Loss of job, loss of income will make social complications
the Family condition miserable. There will be a role model reversal, i.e. the of work and family
breadwinner becomes an alcoholic and the wife takes the role of earning. problems.
Marital disharmony is a common complication.

 DRUNKEN DRIVING will lead to accidents.
 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. In case of client
i) Ruling out or diagnosing any physical disorder. behavior therapy,
ii) Ruling out or diagnosing any psychiatric disorder. psychotherapy,
iii) Assessment of motivation for treatment. group therapy are
iv) Assessment of social support system. carried out.
 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.
ii) Work spot
iii) Family
iv) Environment

 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
In case of clients’s
Detoxification is the process by which an alcohol dependent person recovers
assessment and
from the intoxicating effects of alcohol in a supervised way. It includes,
psychological
 Administration of minor transquilisers (anti-anxiety drugs like
methods of treatment
chlordiazepoxide or diazepam) to control anxiety, insomnia agitation
are carried out.
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 no liver damage), carbohydrate, vitamins C and B complex.
(especially vitamin B1, B6 and B12) preparation parenterally.
 Provide calm, safe environment.
 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.

6. PSYYCHOSOCIAL REHABILITAION
Rehabilitation is an integral part of multimodal treatment of alcohol Nursing care of
dependence. alcohol dependents
was given to Client.
NURSING CARE OF ALCOHOL DEPENDENTS
The nurse taking care of an alcoholic in a de-addiction ward should
Understand some basic concepts about the problem.
 Alcoholism is a chronic disorder.
 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 enhances 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.
Clients was engaged
CARE IN THE ACUTE STAGE in yoga / exercise /
(Immediately after admission during detoxification) play.
 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 since 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)
 To understand the alcoholic, it is important to look beyond the symptoms Nursing care during
and learn about the person. Later stage of
 These persons are in need of physical as well as social rehabilitation. hospitalization was
 Attention to their rest, diet, personal hygiene and appearance is given to the client.
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.

NURSES ROLE IN PREVENTION OF ALCOHOLIC ABUSE

 PRIMARY PREVENTION: Aim to avoid the appearance of new cases In nurse’s role in
of alcohol abuse by reducing the consumption of alcohol through heath prevention of alcohol
promotion, especially heath education. abuse tertiary
prevention was not
 SECONDARY PREVENTION: Attempts to detect cases early and to carried out.
treat them before serious complications cause disability.

 TERTIARY PREVENTION: Aim is to avoid further disabilities and to

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 withdrawal symptoms.
2. Impaired verbal communication related to slurred speech and side effects of medication.
3. Altered Nutritional level related to the anorexia.
4. Altered physical & psychological dependence related to withdrawal symptoms.
5. Ineffective coping related to depression secondary to withdrawal symptoms.
6. Insomnia related to emotional disturbances.
7. Knowledge deficit related to alcoholism, treatments and its effect
Nursing process
S.no Nursing Assessment Nursing Objectives Plan of Action Implementation Rationale Evaluation
Diagnosis
1. Subjective data: pt fear Anxiety related to To help the -to assess the -Assessment (physical To assess the baseline data Anxiety of the patient
about the body aches & withdrawal help to cope patient physically & or psychological) of the for further complications. has reduced.
recovery of addiction. symptoms up with the psychologically patient has done. -To help the patient in coping
Objective data: withdrawal -to help the patient - Detoxification has strategies.
The patient was anxious symptoms in Detoxification. done by the means of - It helps the patient to relax,
related to the -to provide quiet, close monitoring of the & decrease nervous system
withdrawal symptoms calm environment patient. irritability.
as evidenced by to the patient. - Quiet, calm - To reduce the irritability of
inquiries and -reassure the client environment is provided the patient.
uneasiness. with in a calm & to the patient. - To provide comfort & to
quiet tone of voice. - Reassurance is given make ease of the client &
- To treat the in a calm & quiet tone. helps in de-addiction.
client’s withdrawal
symptoms
symptomatically.
 - Client’s withdrawal
symptoms are treated
symptomatically.

2. Subjective data: Impaired verbal To make the -to assess the -Patient’s speech of -To assess baseline data for The speech pattern of
Patient complains that communication affective patient about the pattern is assessed. further complications. the patient is cleared.
he is unable to speak related to slurred verbal pattern of speech. -rate, volume and -To know the rate of affected
due to shaking voice. speech and side communicat - To assess the rate, clarity of speech is speech.
Objective data: effects of ions by volume & clarity of assessed by conducting -To know that cause of the
Impaired verbal reducing speech. nursing process with the slurred speech.
medication.
communication related (slurred -to compare the patient.
to slurred speech. speech ) the relationship of - Relationship of the
effect of slurred speech with slurred speech is
withdrawal the side effect of compared with the
symptoms prescribed prescribed medication -To make the clear speech of
medication. (sedatives) (it can be the patient & to maintain the
- To provide speech due to the side effect of effective communication
therapy to the the medication). skills
patient. - Speech therapy is
-to report the provided to the patient.
presented sign of -Presented signs of
slurred speech the slurred speech is
psychiatrist. reported to the
psychiatrist.

3. Subjective data: Imbalanced To improve -To assess the -Assessed the condition -To asses the baseline data Nutritional status of the
Patient complaints nutrition: less than the condition of the of the patient. for further complications client is improved.
about the weakness & body nutritional patient - To correct fluid &
weight loss. requirement/fluid status of the - To provide - Parenteral Support is electrolyte imbalance,
Objective data: volume deficit. patient. Parenteral support provided to the patient. hypoglycaemia and vitamins
Nutritional level is may be required deficit.
altered as evidenced by initially. - To facilitate the repair of
loss of weight, poor - To Encourage -Encouraged cessation damage to GI tract.
skin turgor, electrolyte cessation of of substance abuse. - These interventions are
imbalance. substance abuse necessary to maintain an
- To consult with - Consulted with ongoing nutritional
Dietician regarding dietician regarding the assessment.
the no: of calories no: of calories require
required based on based on body size &
body size & level of level of activity. -To assess the effectiveness
activity. of nursing interventions.
-To document
intake & output and - Documented the
calorie count and intake and output & -diseased liver may be
weight client daily. calorie count and incapable of properly
- Ensure that the weight client daily. metabolizing protein
amount of proteins resulting in an accumulation
in the diet is correct - Ensured the amount of of ammonia in the blood.
for the individual proteins in the diet is - To minimize the fluid
client condition. correct for the retention.
- To restrict the individualised client
sodium may be condition. -To encourage the intake &
needed. facilitates client’s
- To provide small - Restricted the sodium achievement of adequate
frequent feeding of in the diet. nutrition.
client’s favourite
foods. - Small frequent feeing
- Supplement of client favourite foods
nutritious meals is provided.
with multiple
 vitamin and mineral - Supplemented
tablets. nutritious meals with
multiple vitamin &
mineral tablet.
4. Subjected data: Altered physical To reduce -To assess the -Assessed the condition -To assess baseline data for Physical
Patient complaints of & psychological the condition of the of the client. further complications. &Psychological
body aches. dependence withdrawal patient. -To assess the present dependence is
Objected data: related to symptoms - To identify the -Identified the condition of the patient. improved.
Body aches are related withdrawal & help the withdrawal withdrawal symptoms
to withdrawal symptoms. patient in symptoms present t present in patient. -To provide comfort to the
symptoms of coping of in patient. patient and to treat the
de-addiction. withdrawal -To treat the -Treated the withdrawal symptoms.
symptoms. withdrawal symptoms -To reduce the pain & to
symptoms symptomatically. support the patient in
symptomatically. -Provided analgesics to withdrawal symptoms.
-To provide the patient as prescribed - To support the client in
analgesics to the by the physician withdrawal symptoms.
patient as prescribed (tab.Tramadol 10 mg
to the patient. bd). -To relieve anxiety of the
- To provide -Provided sedatives to patient.
sedatives to the the client (inj.serenace
client as prescribed 10mg od) as prescribed -To enhance the knowledge
by the client. by the physician. of the patient.
- To provide - Provided
psychological Psychological support
support to the client. to the client.
- To educate the -Educated the client
client knowledge knowledge about the
about the withdrawal symptoms
withdrawal of deaddiction.
 symptoms of de-
addiction.

5. Subjective data: The patient will Ineffective -To help the patient -Helped the patient to -motivation for change is patient has substituted
Patient complaints that I substitute healthy coping identify the identify the substance related to recognition of a healthy coping
am feeling aggressive, coping responses related to substance abusing abusing behaviour and problem that is upsetting to responses for substance
because I am not for substance withdrawal behaviour and its its consequences. the patient. abuse behaviour.
tolerating body aches. abusing symptoms consequences. -Identification of
Objective data: behaviour. -To help the patient -Helped the patient predisposing factor and
Patient is aggressive identifying the identifying the precipitating stressors must
due to inability to cope substance abuse substance abuse precede planning for more
up withdrawal problems. problems. adaptive behavioural
symptoms. -To involve the -Involved the patient in responses.
patient in describing describing situations
situations leads to leads to the substance
the substance abuse abuse behaviour.
behaviour.
-To offer support -Offered support
consistently & consistently &
expectations that the expectations that the
problem has the problems had the -Denial and rationalization
strength to strength to overcome are dysfunctional coping
overcome the the problem. mechanism that can interfere
problem. with recovery.
- To Encourage the -Encouraged the patient
patient to participate to participate in a
in a treatment treatment programme. -Socially isolated people who
program. use drugs to gain confidence
-To help the patient -helped the patient in social situations.
identify and adopt identify and adopt -substance abusing behaviour
 healthier coping healthier coping alienates significant others,
responses. responses. thus increasing the person’s
-To Identify & -identified & assessed isolation.
assess social social support systems
support systems that that are available to the
are available to the patients.
patients.
-To educate the -Educated the patient
patient and and significant others
significant others about the substance
about the substance abuse problems and
abuse problems and available resources.
available resources.

6. Subjective data To improve the Insomnia -To assess the -Assessed the pattern of -To assess the baseline data Sleeping pattern is
Patient complaints that sleeping pattern of related to pattern of sleep. sleep. for further complications. improved of the client.
he is unable to sleep at the patient emotional - To restrict the -Restricted the visitors Or
night from 1 week. disturbances visitors at the time at the time of sleep. -To enhance sleep at night. Insomnia is treated with
Objective Data: of sleep. -To reduce the body activity the following
Disturbed sleeping - To avoid day time -Avoided day time & to enhance the sleep. implemented
pattern is related to naps naps. interventions.
withdrawal symptoms -To avoid the -Avoided the
of deaddiction or consumption of consumption of
emotional disturbances. stimulant stimulants at night time. -To prepare the environment
supplements at to enhance the sleep
night like tea or psychologically.
coffee. -To enhance the sleep of the
-To provide calm & -Provided calm & quiet patient at night.
quiet environment environment to the
to the patient. patient. -To sedate the client & to
 -To Encourage the -Encouraged the patient enhance the sleep.
patient to take warm to take warm glass of
glass of milk before milk before going to
going to the bed. bed.
-To administer the -Administered the
sedatives to the sedatives (inj-serenace
patient as prescribed 10mg I/M) as
by the physician. prescribed the
physician.
7. Subjective data: Knowledge deficit Knowledge -To assess the -Assessed the previous -To assess the level of The knowledge is
Patient complaints that related to the deficit previous knowledge knowledge of the understanding of the patient. enhanced of client
what are the hazardous substance abuse related to of the patient. patient. -To enhance the knowledge regarding the substance
effect of substance and its treatment. substance -To provide -Provided knowledge of the Patient. abuse & its treatment.
abuse, advantage of abuse, knowledge regarding the diseased
treatment given to me. treatments regarding condition, its effect on
Objective data: and its (substance abuse ,its health.
Knowledge deficit effects hazardous
related to substance physical
abuse and of its ,environmental
treatment . ,social -To enhance the knowledge
,psychological of the patient regarding the
effect) -Provided knowledge treatment.
-To provide the regarding advantages of
knowledge the treatment given to
regarding the the patient. -To enhance the knowledge
treatment given to about the benefits of
the patient. compliance of regimen &
-To provide -Provided knowledge side effects of non
knowledge about about the compliance of compliance.
the compliance of
 treatment regimen. Treatment regimen.
-To provide proper -Proper time is provided
time to the patient to the patient to clear
to clear his enquires his doubts regarding the
& doubts regarding provided knowledge.
provided
knowledge.

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
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 Amrik singh 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

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

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