Treatment Plan for James Jensen

James Jensen is a 55-year-old artist. He is on VA disability benefits and cannot work. He has two grown children and was recently divorced after 20 years of marriage. He was diagnosed with bipolar disorder after an incident of drunk driving 10 years ago. He has since joined Alcoholics Anonymous and treats his bipolar with medication. The divorce has caused him to sink into a depression.He  lives  alone  in  the  home  where  he  raised  his  children  with  his  ex-wife.  He  is  independent in all ADLs, including driving and community mobility at an ambulatory level. He has lost interest in his artwork and is gaining weight rapidly from inactivity. He loves the outdoors, especially hiking and fishing, but has recently lacked the motivation to go. He has a few close friends in the arts community, and his children visit him often.James  saw  his  therapist  for  a  routine  medication  check.  The  doctor  is  concerned  with his weight gain and depressed state and is increasing cognitive behavioral therapy and adjusting his antidepressant. He has referred James to you, a CTRS at the outpatient mental  health  VA  facility,  to  help  him  reach  his  goals.  James’  provider  shares  the  following information from his most recent visit:

Significant  past  medical  history:  Disability  discharge  VA  due  to  mental  health.  Patient has a history of alcohol abuse. Mood stabilized with medication. Patient has a tendency to self-medicate. Lithium used as requires patient to complete routine blood work.

Medications: Lithium 600 mg orally in the morning and at nighttime. Lurasidone (Latuda) 40 mg orally once a day.

Cognition/perception:   Current  depressive  state  due  to  social  situation.  Vacillates  between mania and depression. Maintained with medication. Patient reports high level of sadness and lack of motivation. Patient tends to stop medication when mood elevates.

Physical Examination: WNL”

Client  Goals

1.Increase social supports

2.Learn techniques to cope with stress

3.Increase exercise to maintain healthy weight

1. Create  a  treatment  plan  for  James  Jensen,  using  evidence-based  practice  to  guide  your  decision  on  appropriate  interventions  following  the  DENT  problem-solving  method

 

a. Define the problem: Clearly identify and articulate the specific problem or challenge that needs to be addressed. This involves understanding the current situation, desired outcomes, and any constraints or limitations (1 paragraph)

b.Explore possible solutions: Generate a range of potential solutions or approaches to solving the problem. Encourage creative thinking and consider different perspectives or alternative options.(1 paragraph)

c. Narrow down options: Evaluate the potential solutions and select the most feasible and effective ones. Consider the advantages, disadvantages, and potential risks associated with each option.(1 paragraph)

d. Take action: Implement the chosen solution or solutions. Develop a plan, allocate resources, and set specific goals and timelines for execution. (1 paragraph)

2.What assessment would be most appropriate for you to give to James?  (1 paragraph: Question 2 and Question 3)

3.What factors must be considered when planning James’ intervention?

4.What is your PICO question?  (1 paragraph: Question 4 and Question 5)

5.What outcomes do you anticipate from your treatment plan?

6.How will you evaluate the outcomes of your treatment plan?  (1 paragraph: Question 6 and Question 7)

7.What contraindications should you consider in James’ treatment? (1 paragraph)

8.What  recreational  activities  would  be  appropriate  considering  James’  interests,  goals, and current functioning level?” 1 paragraph)

 treatment plan for James Jensen

 

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