Plan of Care & Instructions • Effective 05-11-2020
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Effective: 3/25/2026
Ioana is a 98-year-old woman who receives 24-hour care. She has a daughter (DTR) who is a doctor and stops by periodically to check on her. She has standing appointments on Monday and Wednesday at 12:45 PM at her daughter's office for infusion treatments—please coordinate transportation for those days.
Ioana is alert but not reliably oriented. She understands English and used to speak it fluently, but now speaks mostly Romanian. Communication can be challenging at times. She doesn't remember names very well, but she knows the people she knows and the people she likes. She doesn't like a lot of fuss made over her and rarely complains. While she can make her needs known, she may not tell you if she is uncomfortable or if something is bothering her—please be observant of non-verbal cues.
Ioana will get out of bed or out of her chair the moment you leave the room. She is fast, so you must be attentive at all times. She has a baby monitor and bed alarm in place. Be mindful that she may try to get up when you're not looking. This is an extreme fall risk client—never allow her to walk or transfer without full physical contact.
Ioana naps throughout the day, but please try to keep her engaged and limit naps to 2 hours or less. To keep her engaged, offer snacks throughout the day, do simple exercises together, open the blinds to let in natural light, and open the door if the weather is nice—she loves fresh air. If weather permits, consider sitting outside together. At bedtime, please encourage her to stay up until 9:00 PM if possible.
We monitor input and output for this client. Be sure to track and document all food intake, fluid intake, and output (urination, bowel movements) thoroughly during your shift.
Prepare and serve meals and snacks. Ensure meals are appropriate, timely, and safely provided. Support adequate food and fluid intake throughout the day.
Maintain a clean and safe living environment, including bedroom care, laundry, and keeping walkways clear of hazards.
Full assistance with upper body dressing. Assist with clothing selection and dressing as needed.
Provide full hands-on assistance with walking and transfers. Maintain physical contact at all times when client is standing or walking.
Full assistance with bed mobility including turning, repositioning, and getting in and out of bed as needed.
Assist with meals as needed, including setup, cueing, and hands-on assistance to ensure adequate intake. Encourage fluids throughout care.
Full assistance with bladder incontinence care. Monitor output and maintain hygiene. Report any concerns to the office.
Full assistance with bathing including setup, undressing, washing, drying, and dressing. Monitor water temperature for safety and comfort.
Full assistance with dressing, grooming, and personal hygiene including hair care, oral care, nail care, and skin care as needed throughout the day.
Keep client's personal items organized and within reach. Ensure belongings are maintained and accessible.
Full assistance with shower including setup, undressing, shower or bath transfer, washing, drying, and dressing. Monitor water temperature for safety and comfort.
Full assistance with bowel incontinence care. Monitor bowel function and maintain hygiene. Report any concerns to the office.
Provide medication reminders at scheduled times. Ensure medications are taken as prescribed. Document any refusals or concerns.
Assist with hygiene including toileting as needed. Monitor bowel and bladder function during care. Ensure client is clean and comfortable.
Provide ongoing supervision for safety. Maintain awareness of client's location and safety at all times during care. Monitor for unsafe behaviors and ensure the environment remains safe.
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Call the office without delay for:
Emergency Protocol
In case of emergency, call 911 first, then call the office immediately.