ST.

MICHAEL’S COLLEGE
Iligan City
COLLEGE OF NURSING

Name: ______________________________________________ Date : ____________

Clinical Instructor: ____________________________________ Grade: ____________

HOME VISIT
Concept:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________

Objectives:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________

Performed

PROCEDURE RATIONALE Ye No
s
Assessment:
• Should make use of all available
information about the patient and his family
through family records.

• Should consider and give priority to the

essential needs of the individual and his
family.

• Delivery of care should involve the

individual and family.
Planning;
Assemble the equipment and bring it near
the working area.
 __________________
 __________________
 __________________
 __________________
 __________________
 __________________
 __________________
 __________________
Implementation:
• Greet the patient and introduce yourself.
•State the purpose of the visit

• Observe the patient and determine the

 ST. MICHAEL’S COLLEGE
Iligan City
COLLEGE OF NURSING

health needs.
• Put the bag in a convenient place and then
proceed to perform the bag technique.

• Perform the nursing care needed and give

health teachings.

Evaluation:
• Record all important date, observation and
care rendered.

• Make appointment for a return visit.

 ST. MICHAEL’S COLLEGE
Iligan City
COLLEGE OF NURSING

Name: ______________________________________________ Date : ____________

Clinical Instructor: ____________________________________ Grade: ____________

BAG TECHNIQUE
Concept:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________

Objectives:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________

Performed
PROCEDURE RATIONALE
Yes No

Assessment:
● Assess the surroundings.
●Check and secure a suitable area for the
procedure.
Planning;
Gather all the necessary equipment needed
for the procedure.
● ____________________
● ____________________
● ____________________
● ____________________
● ____________________
Implementation:
1. Upon arriving at the client’s home, place
the bag on the table or any flat surface lined
with paper lining, clean side out (folded part
touching the table). Put the bag’s handles or
strap beneath the bag.

2. Ask for a basin of water and a glass of

water if faucet is not available. Place these
outside the work area.

3. Open the bag, take the linen/plastic lining

and spread over work field or area. The paper
lining, clean side out (folded part out).
 ST. MICHAEL’S COLLEGE
Iligan City
COLLEGE OF NURSING

4. Take out hand towel, soap dish and apron

and the place them at one corner of the work
area (within the confines of the linen/plastic
lining).

5. Do handwashing. Wipe, dry with towel.

Leave the plastic wrappers of the towel in a
soap dish in the bag.

6. Put on apron right side out and wrong side

with crease touching the body, sliding the
head into the neck strap. Neatly tie the straps
at the back.
7. Put out things most needed for the specific
case (e.g.) thermometer, kidney basin, cotton
ball, waste paper bag) and place at one
corner of the work area.

8. Place waste paper bag outside of work

area.

9. Close the bag.

10. Proceed to the specific nursing care or

treatment.

11. After completing nursing care or

treatment, clean and alcoholize the things
used.

12. Do handwashing again.

13. Open the bag and put back all articles in

their proper places.

14. Remove apron folding away from the

body, with soiled side folded inwards, and the
clean side out. Place it in the bag.

15. Fold the linen/plastic lining, clean; place it

in the bag and close the bag.

16. Make post-visit conference on matters

relevant to health care, taking anecdotal
 ST. MICHAEL’S COLLEGE
Iligan City
COLLEGE OF NURSING

notes preparatory to final reporting.

17. Make appointment for the next visit (either

home or clinic), taking note of the date, time
and purpose.

Evaluation:
• Documentation