DEMOGRAPHIC DATA:
1. NAME : Mr. Suresh Raut
2. AGE : 56 Years
3. SEX : Male
4. EDUCATION : Post Graduate (M.Com)
5. MARITAL STATUS : Married
6. RELIGION : Hindu
7. OCCUPATION : Business
8. INCOME : 50,000 per month
9. ADDRESS : Manewada, Nagpur
10. DATE OF ADMISSION : 02.03.2024
11. CONSULTANT : Dr. Pawan Adatia
12. DIAGNOSIS : Bipolar Disorder
13. INFORMANT : Patient’s wife
14. INFORMATION : Adequate
PROCESS RECORDING
Sr.no Nurse Patient Remark
Verbal Non- verbal Verbal Non- verbal
Greeting the
1. Good morning Mr. Suresh With smile & Maintaining eye Good morning looking towards me, with patient is
contact. necessary for
no look.
good
conversation.
I Msc. psychiatric Nursing Still maintaining eye contact
2. Ha jarur
student; I want to talk and asking soberly showing excitement and Introduction to
with you for few minutes if willingness to talk. self is
you are willing and therapeutic
comfortable. technique and
asking
permission will
maintain
client’s
importance.
To maintain a
How are you? How is your face to face interaction , Madam jee ‘’I am ok and I Increased pressure of therapeutic and
3. mood ? have good mood. speech, with high level of healthy
looking at
him. energy interaction.
Mr. Suresh can you tell me
4. Asking open end questions to Yes, I will tell you. This is Patient is
where are you? Who is the determine the free responses of hospital, My wife is with me Replying with oriented to Time,
person with you and What the patient. and now it will confidence. Person and Place
approximately the time is. be approximately 11 a.m.
(Replying with confidence)
Open ended question My wife brought me here, I Patient has grade
5. OK…Tell me why are you was ill. Anger towards his Wife 3rd insight.
here, who brought you here. for bringing him.
Do you think there was any
reason for bringing you here?
Gate way of India is in
Asking calmly and maintaining Immediate memory
Mumbai Replying energetically
Gate way of India is in eye contact is intact.
6. Mumbai, you have to repeat it and confidently
after 5 mins?
Recent memory
Replying energetically is intact.
Upma.
7. Asking calmly and maintaining
and confidently
What you had in breakfast? eye contact
Remote Memory is
Asking calmly and maintaining 22 February 1992 Replying energetically Intact
8. When is your wedding eye contact and confidently
anniversary?
9. Asking calmly and maintaining Replying energetically Personal judgment is
What will you do after going eye contact I will look after my business intact
and confidently
back home?
Asking calmly and maintaining I will tell him not to smoke Replying energetically Social judgment is
10. If you were in a movie theater eye contact here and confidently intact
and smelled smoke, what
would you do? Test judgment is also
. I will Post it in Post-box. Replying energetically
Asking calmly and maintaining intact.
11. eye contact. and confidently
If you found a stamped,
addressed envelope on the
street, what would you do with Ending
Your welcome communication
With Smile With Smile
12. it?
Thanks for your cooperation
SUMMERY
My patient Mr. Suresh Raut . Male 56 years old admitted in Astha hospital . After admission history
collection, physical examination, mental health examination and process recording is done he is diagnosed
to have bipolar disorder. With proper pharmacological treatment and supportive therapies patients symptoms
is been reduced now. And being discharged with follow up advice.
MKSSS SN COLLEGE OF NURSING
FOR WOMEN, NAGPUR
SUBJECT- MENTAL HEALTH
NURSING -I
PROCESS RECORDING ON-
BIPOLAR DISORDER
SUBMITTED TO- SUBMITTED BY-
Mrs. Vandana S Thangavel Ms. Rupali S Kharabe
Associate Professor M.Sc. 1st year
MKSSS SN College of MKSSS SN College of
Nursing For Women. Nursing For Women.
SUBMITTED ON –
22/03/2024
