RETURN DEMONSTRATION EVALUATION TOOL FOR

BAG TECHNIQUE

Name: _____________________________________ Grade: _____________

Time started:____________ Time ended:_________Date of RD:___________________

AREA FOR EVALUATION RATING COMMENTS

SKILLS (35%) 5 4 3 2 1 0
ASSESSMENT /PLANNING
1. Determine the procedure to be
performed.
1. Find a flat surface to place your
bag.
2. Determine all equipments
needed.
3. Wash hands.
4. Gather equipment needed.
IMPLEMENTATION
5. Pull out the paper lining and
plastic lining from the bag
6. Put the bag in one corner of the
lined surface at your
convenience.
7. Open the bag and take out hand
towel, soap dish and apron and
place them at one corner of the
work area.
8. Perform handwashing.
9. Put on apron correctly.
10. Pull out things needed for a
specific procedure and place it
on one corner of the working
area.
11. Place waste paper bag outside
the work area.
12. Close the bag and proceed with
specific nursing care treatment.
a. Benedict’s Test-Urine testing
for glucose determination
i. Put 5 ml of Benedict’s
solution into the test tube.
ii. Heat over flame
iii. Drop 3-5 gtts urine and boil
 iv. Leave the mixture to cool to
room temperature
v. Read and interpret result
vi. Record result
vii. Explain to the client the
significance of the findings
and give health teachings
b. Acetic Acid test for albumin
determination
i. Fill 2/3 of test tube or 5 ml
urine
ii. Heat the upper portion
of test tube with urine
without shaking until
boiling.
iii. If cloudness appears in
the heated portion, add 5
gtts one at a time of 10%
acetic acid and heat
again.
iv. Interpret characteristic
result.
v. Record result
vi. Explain to the client the
significance of the
findings and give health
teachings.
14. After completing nursing care or
treatment, clean and disinfect the
things used with alcohol.
15. Do handwashing again and open the
bag. Put back all articles in its proper
places.
16. Remove the apron and place it in the
bag.
17. Fold the paper and plastic lining
properly and place it back in the bag
and close the bag.
18. Make post visit conference and
make appointment for the next visit
EVALUATION
19. States outcome criteria for
evaluation.
20. Observe proper bag technique
21. Able to interpret and explain results
of procedure correctly to client.
KNOWLEDGE: (15%)
1. Gives rationale of the procedure.
2. Explains the elements and mechanics
of the procedure.
3. Knows the elements of nursing
process as applied.
4. States principles applied in the
procedure.
ATTITUDE: (10%)
1. Is well groomed.
2. Wears prescribed, neat, and clean
uniform.
3. Arrives on time for the RD.
4. Speaks to CI and client tactfully.
5. Minimizes use of energy, time, and
effort
6. Utilizes supplies efficiently.
7. Considers client’s safety, privacy, and
comfort.
8. Is well organized.
9. Keeps working area clean at all times.
10. Gives high value for aesthetics.

Comments: _______________________________________________________________
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Clinical Instructor’s signature: ____________________________________