Scribd
Upload
54 views2 pages

Patient Process Recording: Mood Disorder

Mr. Vassu, a 36-year-old male, was admitted with a mood disorder and psychosis, exhibiting symptoms such as euphoria, hyperactivity, and impaired judgment. During a 20-minute process recording, he displayed adequate verbal communication and maintained eye contact, while also showing signs of flight of ideas and delusions of grandiosity. The nurse aimed to establish rapport, assess mental status, and gather patient history.

Uploaded by

Adline
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
54 views2 pages

Patient Process Recording: Mood Disorder

Mr. Vassu, a 36-year-old male, was admitted with a mood disorder and psychosis, exhibiting symptoms such as euphoria, hyperactivity, and impaired judgment. During a 20-minute process recording, he displayed adequate verbal communication and maintained eye contact, while also showing signs of flight of ideas and delusions of grandiosity. The nurse aimed to establish rapport, assess mental status, and gather patient history.

Uploaded by

Adline
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

PROCESS RECORDING

PATIENT PROFLIE

Name of the patient : Mr. Vassu

Age : 36 years

Sex : male

Address :

Date of admission :

Diagnosis : Mood disorder with psychosis

Date of process recording :

Time :

Duration : 20 mts

DESCRIPTION OF PATIENT

Client was admitted with complaints of reduced sleep, increased psychomotor


activity, euphoria, increased talk etc. Now he is euphoric, hyperactive and had slurred speech
and impaired judgement.

OBJECTIVE

 To establish good rapport.


 To collect history and to assess mental status
 To identify signs and symptoms of illness.

Nurse’s response Patient’s response comments

Duration 15 mts

Hello, Good morning. Good morning Eye contact developed.


How are you? Fine.
Why are you lying in this bed Oh, I will go later. Verbal communication
adequate
constantly? Just go to outside
ward.
Irritated.
Are you happy here? I don’t like this place
Oh, you just leave that. Did you
take your breakfast? Yes. Pulab.
How was your sleep?
Eye contact.
Ok. When did you slept It was Ok.
Immediate and recent memory
yesterday? 8 o’ clock and woke up at
intact.
Who all are your family morning 5 o’clock.
members? Father, mother, one sister and
In which person you have more brother
Happy
preference? My cute sister.

Did she have any children?


Increased speech.
Yes, one son. She will bring Flight of ideas.
him in my home. I will play
with him. He is very cute and I
like him very much. He used to
call me as uncle. He also likes
me.
Doctor came for rounds and he
went by saying bye.

CONCLUSION

Client was very co-operative. Client had flight of ideas and delusion of grandiosity.

You might also like