JOSE RIZAL UNIVERSITY

College of Nursing and Health Sciences

Performance Checklist
Bag Technique & Home Visit

Name of Student: MAGADA, ALCENT JAMES N. Date: ___________

Year/Section/Group No.: BSN2 — 201N Grade: __________

Rate the student’s performance by checking the appropriate box using the following criteria:

5 - Excellent (Carries out procedure efficiently, systematically and independently/Personality

trait is observed at all times)
4 - Very Satisfactory (Carries out procedure efficiently and systematically but requires minimal
guidance and supervision/Personality trait is observed most of the time)
3 - Satisfactory (Carries out procedure efficiently and systematically but requires moderate
guidance and supervision/Personality trait is observed sometimes)
2 - Fair (Carries out procedure with close guidance and supervision/Personality trait is
seldom observed)
1 - Poor (Carries out procedure inefficiently and unsystematically/Personality trait is never
observed)

KNOWLEDGE - 30% 5 4 3 2 1 RATIONALE

1. State the objectives of this activity This is to reassure and

educate the patient with
the following steps and
procedures.

2. Use appropriate terms. Doing so grants clearness

and understanding.

3. State steps of the procedure in correct order This ensures complete and
proper gathering of
documentation.

4. Explain the rationale of every step. Doing so states the

reasons for conducting
each step, reassuring the
client.
SKILLS - 60%

5. Greet the client/patient, or the family member/s according to the To express respect to the
time of the day and establish rapport client.

6. State the purpose of the HV, allow the client /patient or the host This promotes a light
to feel at ease first before proceeding further. Introduce oneself environment; to have
and state reason for visit and procedure to be done. (Be sure to effective communication
seek client’s approval for the procedure to be performed.) with the client.

7. Inquire about health and welfare of client and other family This determines the
members, then ask about any health, and health related possible treatment for the
concerns/problems (You may align the case/assignment given client during the home visit.
by the Clinical instructor and discuss with them/family or to the
person involved.)

8. Locate or look for a convenient place for your CHN bag on the This prevents the
table or flat surface at least 6 feet away from the bedside, lined spreading of
paper/plastic lining, clean side out (folded part touching the microorganisms and the
table). Put bag’s handles/strap under the bag. (if home is very contamination of the
limited in space any convenient place could be, and bring out materials and the bag in
from the CHN bag the things needed for this care - as long as general.
proper procedure can be done in the said place) - then to be
followed by the bag technique as necessary or depending on
the need /procedure to be done or perform.

9. Ask for a basin of water and a glass of water if faucet is not This will be used for hand
available. Place these outside the work area. washing.

10. Open the bag, take the paper/plastic lining and spread over Doing so is to prepare for
work field or area (the clean side out). The paper lining, clean hand washing.
side out (folded part out).

11. Take out hand towel, soap dish and apron and place them at To prevent cross
one corner of the work area (within the confines of the contamination of infection
linen/plastic lining.) between the client and the
health care provider.

12. Do hand washing. Wipe hands dry with towel. Leave the plastic To prevent cross
wrappers of the towel and soap dish in the bag. contamination of infection
between the client and the
health care provider.

13. Put on apron right side out and wrong side with crease touching Same as the previous
the body, sliding the head into the neck strap. Neatly tie the procedure, but to also
straps at the back protect the front uniform of
the provider.

14. Put out things most needed for the specific case and place at To promote readiness and
one corner of the work area. And place waste paper bag outside have easier access to the
of the work area, close the bag required equipment.
15. Perform the nursing care/treatment, give the necessary. Advice To conduct the
or Health Teaching/Counseling based on the client’s need and nursing intervention and
condition. (You may also teach the family member/s, include the health education to the
them, since they are the ones with the client most of the times.). client together with the
other members of the
family.

16. After completing the nursing care or treatment, clean and To prevent cross
alcoholize the things used. contamination of infections
that may receive through
used or items exposed to
unclean environment.

17 Do hand washing again. To prevent infection that

can harm the healthcare
provider.

18. Open the bag and put back all articles in their proper places. To prepare for future use
and prevent from losing
them when put away
accordingly.

19. Render the Physical assessment as necessary/applicable. You Doing so educates the
may also consider- identifying household members and their client in terms the
health needs, and use of community resources. (If more than necessary health education
one member of the family is under health supervision and care, and treatment that may
start first with the well member to avoid transfer of infection.) help the them at home.

20. Remove the apron folding away from the body, with soiled side This prevents the
folded inwards and the clean side out. Place it in the bag. possibility of contamination
to any other articles or
equipment inside the bag.

21. Fold the linen/plastic lining; clean; place it in the bag and close Preparation for future
the bag usage; prevention of
contamination.

22. Record the findings, the date, your observation including the Doing provides an accurate
care or treatment, health teachings/ things done or rendered for evidence-based record that
reporting and documentation purposes can be used by the
provider for future nursing
interventions for the next
home visit.

23. You may also give specific instruction/s as in important health Doing so helps the client(s)
teachings or reminders, health counseling, and comfort be educated regarding
measures- so as to ensure appropriate nursing care, hence to their health and condition
minimize the sick in the family member, in case present. Also so they would know what
include measures/counseling for home safety & environmental to do at home or when in
hazard prevention. time of serious need of
professional assistance.
24. Set or make an appointment for the next Home Visit or Follow- This is to determine the
up visit to a Clinic, Health Center or a hospital as necessary. right schedule and data for
(Discuss any procedure /referral /consultation for any agency the next appointment.
visit as necessary.)

25 Summarize the teachings made or important reminders before To promote and effective
bidding goodbye and thank the Visit. (You may leave your health education or
telephone number/s for communication purposes as necessary.) teaching and reminders for
the client's own knowledge.

ATTITUDE - 10%

26. RESPONSIBLE: (complete equipment /paraphernalia)

27. DISPLAY OF COURTESY (acknowledge

criticism/suggestion/respect to Teacher)

28. with INTEGRITY (show skills with all honesty, competency, &
completely)