Republic of the Philippines
TARLACSTATEUNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines
Tel.no.: 4931865 Fax: (045) 982-0110 website: www.tsu.edu.ph
______________________________________________________________________________________
Performance Evaluation Checklist
PROCEDURAL CHECKLIST FOR HOME VISIT PERFORMING THE BAG TECHNIQUE
Name of Student: ___________________________________________________
Year/Clinical Group: _________________________________________________
School Year: _______________ Term: _____ First Semester____ Second Semester ____ Summer ____
Date: ______________________________
Description:
Bag Technique is a tool by which the nurse, during her visit will enable her to perform a nursing procedure
with ease and deftness, to save time and effort, with the end view of rendering effective nursing care to clients. It
refers to the skill and knowledge in preparing and using the materials and equipment in the community health bag
in performing various nursing interventions at home.
Purposes:
1. To perform nursing procedures with ease and deftness.
2. To prevent contamination by observing proper aseptic technique thereby preventing, if not minimizing
infection.
3. To save time and effort with the end view of rendering effective nursing care to clients.
Procedure
ASSESSMENT
1. Gather all equipment needed. (PHN Bag & its contents & other
paraphernalia for Home Visit e.g., CHN Logbook)
2., Identify your client and gather all necessary data. (RHU family folder,
other members of the health team who handled the client, etc.)
3. Formulate your nursing objective and state the purpose of the visit.
4. Observe the patient and determine the health needs.
5.Always provide privacy whatever nursing procedure you will render to your
client.
PLANNING
1. Formulate your nursing objective for the home visit.
2. In planning for a home visit consider and give priority to the essential and
recognized needs of the individual and his family.
3. Planning in the delivery of care should involve the individual and family.
4. Planning should be flexible.
IMPLEMENTATION
1. Upon arriving at the client’s home, greet the client and introduce
yourself. Explain what you are going to do. Take the paper lining,
place the bag on the table or any flat surface lined with paper/plastic
lining, clean side out (folded part touching the table). Place the bag in
the left upper corner of the plastic or paper lining. Put the bag’s
handles or strap beneath the bag. The CHN bag should be 6 feet
away from the client
2. Ask for a basin of water or a dipper of water if faucet is not available.
Place these outside the working area.
3. Open the bag, take out the hand towel, soap dish and apron and
place them at one corner of the working area (within the confines of
the linen/plastic lining). Leave the plastic wrappers of the towel in a
soap dish in the bag. Close the bag after.
4. Do handwashing. Wipe, dry with towel.
5. Put on apron right side out and wrong side in with crease touching
the body, sliding the head into the neck strap. Neatly tie the straps at
the back.
6. Put out things most needed for the specific case being visited
(Pregnant client, Postpartum mother & the NB, School aged child,
Morbid case and they are your Family Case Load) e.g., thermometer,
kidney basin, cotton ball, waste paper bag), BP Apparatus etc. and
2
1
0
REMARKS
place at one corner of the working area with the plastic or paper
lining. Close the bag.
7. Place waste paper bag outside of working area.
8. Proceed to the specific nursing care or treatment. (This is very
dependent on the health situation and the client you will be visiting.)
9. After completing nursing care or treatment, clean, wash, dry and
sanitize with 70% alcohol the things used.
10. Do handwashing again.
11. Open the bag and put back all articles in their proper places.
12. Remove apron folding away from the body, with soiled folded
inwards, and the clean side out. Place it in a plastic bag and put in the
outside pocket of the PHN bag.
13. Clean and fold the linen/plastic lining, place it in a plastic bag and
close the bag.
14. Make post-visit conference on matters relevant to health care, taking
anecdotal notes preparatory to final reporting in your CHN logbook.
Take note of environmental factors which affect the clients/family
health.
15. Impart necessary health teachings in accordance with the health
problems identified.
16. Make appointment for the next visit (either home or clinic), taking
note of the date, time and purpose.
17. Do after care by keeping the area clean and return all used articles in
its proper places.
EVALUATION
18. Record all relevant findings, observations and health problems
identified about the client and members of the family during the
visit.
19. Include quality nurse-patient relationship.
20. Document all nursing care rendered and evaluate the effectiveness
of nursing care provided.
21. Refer to the RHU if there are aberration from the normal findings.
TOTAL SCORE:
Shown to me by:
_____________________________
Signature over Printed Name
Clinical Instructor
Shown to me:
___________________________
Signature over Printed Name
Student