Petra D. Service Plan Notes

Client Admission Date: 1/30/2020

NO DNR ON FILE

Last Date Reviewed: 1/30/2020

Location Notes: Lives with 27-year-old son, Eric, and his wife, Holly. Also has two kids, 16 and 17 years old. Her primary caregiver is Demetria who works Mon-Fri, 7a-3p.

Summary: Petra was in a car accident 8 years ago and her spinal cord was severed. She requires daily caregiver help.

Allergies: None

Stated Medical Condition

  • Parapalegic

  • Diabetic

  • Frequent UTI

  • Pressure sore on left buttocks

Is the client on hospice?: No

Is the client on home health?: Yes. Silver Spring Home Health

Date of Birth: 3/4/1971

Height and Weight: 5’4” 220lbs

Pets: One small dog. Friendly.

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: Yes

    • Pills are in organizer

    • Insulin injections 3 times per day

  • Toileting:

    • Superpubic catheter that needs to be emptied.

    • Digital stimulation bowel movements.

  • Bathing:

    • Bed bath daily

    • Showers when requested by client

      • Bring change of clothes as you may get wet during shower.

      • Uses shower chair

    • Wash hair daily or every other day

    • Alternate bathing between day and evening shifts

  • Dressing:

    • Dress lower body in the bed

    • Dress upper body in the chair

  • Routine Skin and Hair:

    • Apply lotion after bathing once she is in her chair

  • Shaving and Oral Care:

    • Shaves under arms and uses cream for legs

    • She has a teeth brushing routine using multiple cups to drink from and spit.

      • Will need to be cleaned regularly

  • Transfer:

    • Uses a hoyer. Family or client will direct each caregiver how to use the hoyer.

    • Hoyer Lift Video (actual procedure dictated by client)

  • Walking:

  • Exercising:

    • Range of motion directed by client

Housekeeping and Personal Services

  • Meal Preparation:

    • Cook full meals

    • Warm up prepared foods

    • Pick up restaurant food

    • On a low carb, low sugar diet

  • Feeding:

    • Requires feeding assistance

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

  • Laundry: Yes

  • Shopping:

    • She will ask you to run errands for her. Use your personal vehicle and add mileage and destination to TSheets

  • Escort:

    • You will drive her handicap van. Please make sure you are an approved driver.

Likes and Dislikes

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

Notes

  • Emergency Contact Information found in the blue folder.

  • Insulin injections and digital bowel stimulation are two approved health maintenance activities (HMA) that will be be performed by our staff. Our nurse regularly assesses the client, and if approved, HMA’s can be performed by our staff under the direction, training and supervision of the client.

Updates:

  • No Updates