Angela I. Service Plan Notes

Service Initiation Date: 11/26/2019

NO DNR ON FILE

Last Date Reviewed: 01/15/2020

Location Notes: Client lives in The Commons in Huffman

Summary: Angela was in a car accident at age 17 that caused her to be a quadriplegic. She is now 37 years old and lives with her mother, Sandra, who is her primary caregiver. On 11/22/2019, Sandra was in a car accident and broke her arm. We are there to provide care while her mother recovers from her injury. We are there to help with her morning and evening routines. Angela and her mother will help all caregivers with her needs and will provide direction.

Allergies: Latex, Ultram, Mucomyst, singulair, augmenin, xulane

Stated Medical Condition

  • Quadriplegic

  • Periodic high CO2. (Client can feel symptoms of drowsiness and headache)

    • Uses I-Pap Machine

  • Muscle Spasms

  • Healing pressure sore on right rib cage.

  • Osteoporosis

    • Be careful when moving arms as they will come out of socket.

Is the client on hospice?: No

Is the client on home health?: No

Date of Birth: 2/15/1982

Height and Weight: 5’9” 118 lbs

Pets: 5 small dogs. They will bark when you first arrive but are harmless

Smoker: No

Dress Code: Blue scrubs with name tag

Is Cell Phone Use Allowed?: No

Is Sleeping Allowed?: No

Personal Care

  • See Service Plan and detailed list of ADL’s in the blue folder.

  • Medication Reminders: No. Mother will administer meds.

  • Toileting:

    • Client has a foley catheter. We will need to empty it routinely

    • Client has 2 BM’s per week. She says she can tell when she is having a BM. She uses a pad on the bed. For now, her mother will take care of BM but we will assist when Angela becomes comfortable with us.

  • Bathing:

    • Client gets a daily bed bath in the mornings and sometimes in the evening if needed due to BM or urine.

    • Wash hair once per week

  • Dressing:

    • She wears a shirt at night and pants and shirt during the day.

    • She will need full assistance with dressing.

  • Routine Skin and Hair:

    • Brush hair as part of morning and evening routine

    • She likes to have facial moisturizer applied in the morning.

  • Shaving and Oral Care:

    • Shave under arms and legs

    • Brush teeth morning and evening

  • Transfer:

    • Will need to be transferred from bed to chair.

      • Client will walk caregivers step by step to transfer to chair. They have a slide board but her and her mother are able to do it with one person without the board. Ask for the board if needed.

      • Client will be positioned on edge of bed. Hand under bottom and arm. Lift and slide to chair.

    • Will need to be positioned in her bed or chair if she becomes uncomfortable and to avoid pressure sores.

      • Until you are comfortable with positioning, ask for Sandra to confirm Angela is positioned correctly.

  • Walking: No

  • Exercising:

    • Range of motion exercises in the morning. She likes to do them outside if the weather is nice.

Housekeeping and Personal Services

  • Meal Preparation:

    • Sandra will make several meals during the week. We can reheat foods. They also order out.

  • Feeding:

    • Will need feeding assistance.

    • She likes to eat slowly.

    • No issues with swallowing.

  • Cleaning: See detailed list of cleaning tasks on Page 2 and 3 of Service Plan in the blue folder.

    • Keep area clean

  • Laundry:

    • Change and wash linens daily

  • Shopping:

  • Escort:

    • Client may need to be driven to doctor’s appointments. Please contact your supervisor to confirm you are an approved driver.

Likes and Dislikes

  • See Getting to Know You document in the blue folder. Please contribute regularly.

  • Like to eat her hamburgers right-side-up.

Notes

  • Emergency Contact Information found in the blue folder.

  • Client wakes up at 9am. After being groomed, she eats and then goes outside to enjoy their backyard.

  • Client goes back into her bed around 8pm.

  • Client wears air boots at night to avoid pressure sores.

Updates:

  • 1/15/2020 - Until you are comfortable with positioning, ask for Sandra to confirm Angela is positioned correctly in the bed and chair. She can get pressure sores if not in her chair correctly. She cannot sleep properly if not straight in her bed.

  • 1/15/2020 - Be careful when moving and positioning Angela’s arms. She has osteoporosis and her arm will come out of socket easily.