Social Case Study

SOCIAL CASE STUDY REPORT
I. IDENTIFYING INFORMATION
Name : Aling Nena

Age : 60 years old
Birthday :
Civil Status : Married
Highest Educ. Attainment: Highschool level
Gender : Female
Religion : Catholic
Recent Address :
Provincial Address :
Source of Information :
II. FAMILY COMPOSITION
Educational
Name Age Status Relationship Occupation Income
Attainment
Php
College
67 M Spouse Farmer 30,000.00/
Level
annum
Php
Vocational
39 M Son Laborer 3,000.00/
Course
month
Daughter-in- College
46 M Unemployed None
law level
III. PROBLEM PRESENTED
Based on the medical records stated by the doctors and nurses, and the
information gathered from tha client’s daughter-in-law, Petra, Aling Nena suffered from
Cerebrovascular hemorrhage and was admitted at Community Hospital. The client was
advised to take maintenance medications, regular physical therapy and lifestyle
modification.
IV. BACKGROUND INFORMATION
a. CLIENT
The patient is identified as Aling Nena, 60 years of age, female, married

and a resident of ________. She graduated from high school and a native of
Cagayan. Aling Nena is a plain housewife and attends the needs of her family.
She usually cooks the family’s meal while her husband is in the farm. The other
household chores are designated to her son and daughter-in-law since she is old
enough for the other chores.
As written in her medical records, her family has a history of
hypertension, diabetes mellitus, cancer, chronic obstructive pulmonary disease
specifically pulmonary emphysema and heart disease. Her mother was diagnosed
with heart disease and stroke was her caused of death. Her father was a cigarette
smoker that can consume one pack of cigarette daily, and a diabetic who latter
suffered from amputated lower limbs. Her father’s caused of death was caused by
complications of diabetes.
During her 40’s, she was diagnosed with hypertension and Diabetes
Mellitus II. She was also advised to take maintenance medications like losartan,
metoprolol and metformin to be taken in regular basis. But due to non importance
of her health status, Aling Nena wasn’t able to take her medications on a regular
manner.
On the year 2009, Aling Nena suffered from mild stroke. She was rushed
and confined at Memorial Regional Hospital for almost 2 weeks. She undergone
several laboratory examinations and evaluation and then she was discharged and
advised to undergo continuous medications.
Aling Nena lifestyle was inactive. She did not do exercises nor simple
morning walks and jogging. Her daily routine includes cooking meals and
cleaning their room. In addition, Aling Nena also take regular afternoon naps after
eating their lunch.
b. FAMILY
Aling Nena is married to Mang Jose, 65 years old, who works as a farmer
earning Php 30,000.00 per annum. The couple has one child, Juan, 39 years of
age, who is residing with them together with his wife, Daryo, 46 years of age. The
couple’s only child, Ponce, is engaged in labor works earning Php 3,000.00 a
month in irregular basis. Petra, their daughter-in-law, is a college graduate but
currently unemployed and assists her in-laws.
c. ENVIRONMENT
According to the informant, Petra, Aling Nena was a native of Cagayan.

The town is rich in agricultural resources and the family’s source of income is
from farming. Other agricultural resources include hog raising/ piggery and
poultry. Moreover, factories and industrial businesses are also present. The mode
of transportation in the municipality include tricycle, jeepneys, buses and private
vehicles.
The family’s house was built in semi-concrete and wooden structures. The
couple Nena and Jose, who are already in their late adulthood ages, are being
taken cared of their only child, Daryo together with his wife, Petra. Their house is
situated near the farmland and town plaza which is accessible to variety stores and
establishments, church, and the municipal hall.
V. ASSESSMENT
This is a case of a 60 years old client who was diagnosed with Cerebrovascular
Hemorrhage. She was rushed at Community Hospital due to numbness of one side of the
body and severe headache accompanied by vomitting and fatigue. Upon admission, the
patient’s blood pressure was 190/110. She was then confined at the hospital for almost a
week and undergone several laboratory examinations and evaluations. After a week of
staying in the hospital, her attending physician advised her to take maintenance
medications, regular physical therapy and advised for a lifestyle modification.
VI. INTERVENTION PLAN
The main goal of this case study is for the betterment of the health status and
wellness of Aling Nena, and to improve her overall being.
Specific Responsible
Activity Time Frame Expected output
Objectives person
To refer to
30 minutes to 1 Regain her
dietician for Give/offer her Dietician/
hour, 3 times a previous
suggested food nutrionist
day nutritional status
nutition intake
To educate and
explain the Check her 15 minutes to 30 Attending Recover from her
course and medical minutes, 2 times physician/ Nurse illness/ modify
treatment of her condition a day on duty her lifestyle
illness
Mobilize the
To refer to a 1 hour, once a Physical
Light exercises affected body
physical therapist week therapist
parts
To establish Small talk 30 minutes to 1 Social worker Gather relevant
rapport and information and
gather hour, daily gain trust to each
information other
Raise the
awareness of the
Provision of
family of the
other services to Counselling Within one week Social worker
availability of
the family
resources in the
community
VII. RECOMMENDATION
In view of the above findings, undersigned hereby recommends the client avail
financial/ medical assistance from the office of ________________________________.
Prepared by:
_________________________
Social Worker Practitioner
Noted by:
_______________________________________
School Supervisor
______________________________________
Head Social Worker

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SOCIAL CASE STUDY REPORT

Name : Aling Nena

II. FAMILY COMPOSITION

IV. BACKGROUND INFORMATION

The patient is identified as Aling Nena, 60 years of age, female, married

According to the informant, Petra, Aling Nena was a native of Cagayan.

VI. INTERVENTION PLAN

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