Assignment 4 - Week 10- Comprehensive Case Study for David Jones

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Capella University *

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May 28, 2024

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Running Head: CASE STUDY Comprehensive Case Study for David Jones Robin A Peacock Capella University

2 CASE STUDY Abstract David Jones came to the Veteran’s Administration Clinic due to being referred by his family due to him having memory issues that are causing him and others to be unsafe. This paper is to show the client’s case study, diagnosis, treatment plan, evaluation, and client follow up plan for treatment. The case study includes why client is referred to Veteran’s Administration which includes, presenting problem, history of problem, previous counseling experience, medical history, culture, social class, and current functioning.

3 CASE STUDY Table of Contents Title Page .................................................................................................................................. 1 Abstract .................................................................................................................................... 2 Table of Contents … ................................................................................................................. 3 Introduction …………………………………………………………………………………...4 Engagement .............................................................................................................................. 5 Assessment Plan ....................................................................................................................... 7 Intervention Plan ........................................................................................................................ 9 Evaluation Plan .......................................................................................................................... 14 Client Follow up Plan .................................................................................................................. 15 Conclusion ……… ...................................................................................................................... 16 References ................................................................................................................................... 18

4 CASE STUDY Introduction David Jones is a 68-year-old Caucasian male that has been married for 42 years to his wife, Sarah. David has five siblings, which he is the youngest. David has three children: John, age 40, Pamela, age 38, and Elizabeth, age 36. He has grandchildren; it is not known how many grandchildren David has without more interviewing. David did not report any spirituality or religion at this time. David graduated in Rawlins, Wyoming for high school. Sarah and David attended high school in Rawlins, Wyoming together. David did not attend college since he worked as a Ranch Manager on the family farm after serving four years in the Army. Sarah completed her registered nursing degree during David’s time in the army. Sarah has not used her nursing degree due to helping David on the ranch and taking care of her family once they were married. John is currently married and has a family. He and his family live on the family ranch to able to be close to his parents. For the last eight years he has been taking care of the ranch. John has concerns for his Dad’s safety due to his Dad may be hurt or the animals as his dad is having issues remembering tasks relating to caring for the animals. It is unknown if Pamela is married or has children. She feels that her mother puts her father’s needs before her own, which causes problems between Pamela and her father. Her mom is unable to travel to visit with her sister and her family due to being unable to leave her father alone. Pamela is irritated with her father due to her mother unable to do anything by herself. Elizabeth as well as her family live in North Carolina. Her parents have been unable to meet their youngest grandchild due to David’s memory issues. David and Sarah have been to visit Elizabeth and her family only one time since Elizabeth’s child was born four years ago.

5 CASE STUDY David has routine medical care as he received an examination every year. David takes medication for high cholesterol to control his cholesterol but is otherwise healthy. David keeps his heart healthy by running on the treadmill. Engagement David’s family is concerned about his memory issues and David being unsafe at home to take care of himself at this time, so he has been referred to the Veteran’s Administration Clinic for a second time. David feels that the visit to the Veteran’s Administration clinic is unnecessary and has not been cooperative with the staff. David appears agitated currently due to being angry when he is unable to remember the questions he is being asked or putting together simple words according to Sarah. David is only able to drink and feels that drinking is the only thing he does not mess up. Sarah agrees with this assessment as she reports that drinking is the only thing he remembers to do. David’s stability is normal. David can maintain a conversation about himself and respond to questions when asked. David does not have any developmental or physical disabilities. David has had memory concerns developed in the last several years. David’s appearance appears well kept and has appropriate grooming. It has been reported by family members that they are concerned about David’s and Sarah’s safety at home when living on his ranch because David may harm himself or the animals. Sarah feels she is unable to leave him unattended due to these concerns. David feels that his family is overreacting and should not be worried about him. David has been having memory issues for four years or longer as he was a patient four years ago. David was a patient at the Veteran’s Administration Clinic four years ago and appeared with agitation and loss of memory. David admits to being unable to remember the days of the week, misplacing his keys, and overfeeding or not feeding the animals on the ranch. The

6 CASE STUDY records with the Veteran Administration Clinic show that he would forget to close the gate at the ranch and the livestock were not safe as they got out at the ranch property. David has had personality changes as he is easily agitated and keeping to himself more by not going to social events that he has attended in the past that were important to him and Sarah. He is unable to watch Jeopardy and Wheel of Fortune due to saying the same thing repeatedly, unable to stay still, put easy words together or remembering the question on the tv show. David was employed until he was 60 years old as a Ranch Manager that is family owned and managed. David stopped working at the ranch due to his memory issues that caused problems on the ranch. David’s support system includes his close immediate family, which includes wife, and two of his children, John and Pamela. Elizabeth is not able to provide any support daily as she lives in North Carolina. David’s culture is being a ranch manager as it has guided him through his whole life, even as a child. Three quarters of all Wyoming ranch managers are white according to the United States Census Bureau (2018). There are 95% of ranch managers are Caucasian in Wyoming according to the United States Census Bureau (2018). Home care is the preferred residential setting by patients of Alzheimer’s instead of residential memory care settings (Smith et al, 2022). Caregivers of Alzheimer patients can develop mental health issues due to the strain that caregiving of the patient. The family’s needs must be addressed in addition to David’s (Paul et al, 2019). An appropriate diagnosis for David Jones is major neurocognitive disorder with possible Alzheimer’s disease, mild with agitation. According to The Diagnostic and Statistical Manual of Mental Disorders, 5 th edition Text Revision (DSM-5-TR, American Psychiatric Association, 2022), this diagnosis is appropriate due to David having a decline in his cognitive function, as

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