University of Cebu

College of Nursing
Banilad Campus
Name: Angeline M. Taghap Grade:
Year and Section: BSN 2 B Date:

Bag Technique

Definition:
Bag Technique is a tool making use of a public health bag through which the nurse, during
his/her home visit, can perform nursing procedures with ease and deftness, saving time and effort
with the end in view of rendering effective care.

Purpose:
To render effective nursing care to clients and/or members of the family during home visit.

Equipment Needed: Medicines:

 Paper Lining  Betadine
Sterile cord tie 70% Alcohol
 Zephiran Solution
 Extra paper for making bag for waste material Acetic Acid
 Plastic/Linen lining Apron  Hydrogen Peroxide Hydrogen peroxide
 Alcohol Lamp Tape measure  Benedict’s Solution [Antibiotic]
 Hand towel in plastic bag Soap in a soap  Opthalmic
dish Ointment
 Baby’s Scale 2 test tubes
 Thermometer in Case [1 Oral and 1 Rectal]
 1 Pair of rubber gloves test tube holder
 Syringes [5ml and 2ml] Adhesive Plaster
Legend
 Dressing [OS, Cotton balls] 1 – Excellent
 Sterile Dressing [OS, Cotton balls] 2 – Very Satisfactory
 2 pairs of forceps [Curved and Straight] 3 – Satisfactory
 2 pairs of scissors [1 Surgical and 1 bandage] 4 – Needs Improvement
5 - Poor
 Hypodermic needles [G19, 22, 23, 25]

STEPS RATIONALE 1 2 3 4 5
PROCEDURE
1. Upon arriving at the client’s home, place the To insure the safeness of the client and also it looks neat.
bag on the table or any flat surface lined with
paper lining, clean side out (folded part
touching
the table). Put bag’s handles or strap
beneath the bag.
2. Ask for a basin of water if faucet is not To be used for hand washing.
available. Place these outside the work area.
3. Open the bag, take the linen/plastic lining To make ensure the sterility of the place where you
and spread over work field might put your equipment.
or area. The paper lining, clean side out (folder
part out).
4. Take out hand towel, soap dish and apron Prepare the materials that is necessary for hand
and place them at one corner of the work area washing.
(withing the confines of the linen/plastic
lining.)
5. Do handwashing. Wipe and dry with towel. To prevent spreading microbes to the client.
Leave the plastic
wrappers of the towel in in soap dish in the
bag.
6. Put on apron right side out and wrong This helps to protect the nurse’s uniform from liquid
side with cease touching the body, sliding infection.
the head into the neck strap. Neatly tie the
straps at the back.
 7. Put out things most needed for the specific Organize things so that it can save time.
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. It helps to promote proper sanitation within the work
place.
9. Close the bag. For safety and avoid unnecessary loss of the important
things.
10. Proceed to the specific nursing care or Getting and giving care to a client helps to feel
treatment (e.g., TPR taking, comfortable.
Urinalysis, or wound dressing).
11. After completing nursing care or treatment, To sterilize the equipment that was used for the
clean and alcoholize the procedure.
things used.
12. Do hand washing again. To maintain the cleanliness.

13. Open the bag and put back all articles in Always do the after right after the procedure was done.
their proper places.
14. Remove apron folding away from the body, To avoid contaminating the uniform of the nurse.
with soiled side folded
inwards, and the clean side out. Place it in the
bag.
15. Fold the linen/plastic lining. If clean, place After care is a must.
it in the bag and close the
bag.
16. Make post-visit conference on The data that was collected is going to be used for
matters relevant to health care, taking comparison to the prior data.
anecdotal notes preparatory to final
reporting.
17. Make appointment for the next visit (either For follow up check up.
home or clinic).
POST-PROCEDURE ACTIVITY

18. After care of materials. Separate the soiled materials from clean materials and
to check if there is missing equipment.
19. Get the bag from the table, fold the paper Get the lining to throw it away.
lining and place in
between the flaps of the bag. Close bag.
20. Record all relevant findings about Used as reference data in the future.
client and family. Take note of
environmental factors which affect their
health. Include quality of
nurse-patient relationship and nursing care
provided.
ATTIDUE OF THE STUDENT:

21. Accept constructive suggestions and It helps to improve the student’s performance.
criticisms.
22. Assumes accountability. To be aware and become more responsible.

Source:
Pañares-Reyala, Jean, Community Health Nursing Services in the Philippines, 9 edition. Manila: Community Health Nursing
th

Section, national League of Philippine Government Nurses, Inc., 2000, pp.54-58).

Scoring: 1 x =
2 x =
3 x =
4 x =
Total divided by no. of items =
Comments:

LILIBETH C DE LA PEÑA, MAN, RPH RN

Students Clinical Instructor
Signature over Printed Name Signature over Printed Name
 University of Cebu
College of Nursing
Banilad Campus
Name: Grade:
Year and Section: Date:

Wound Care

Definition:
The application of dry material such as absorbent gauze to protect or cover the wound or
lesions.

Purpose: Legend
To protect the healing wound from trauma or bacterial invasion. 1 – Excellent
2 – Very Satisfactory
Equipment Needed: 3 – Satisfactory
4 – Needs Improvement
 Clean examination Gloves 5 - Poor
 Container for proper disposal of soiled dressing
 Sterile 4x4 gauze pad
 Betadine paint and cleanser
 Plaster

STEPS RATIONALE 1 2 3 4 5
PROCEDURE
1. Wash hands. To prevent spreading microbes.
2. Prepare materials. To save time.
3. Provide privacy To gain the client’s trust and give accurate information. It
also gives comfortability of the client.
4. Explain procedure to the client. To understand the procedure and to be aware of what is
happening.
5. Wash hands. To prevent spreading microbes.
6. Apply clean gloves. It promotes infection control and protect from body
fluids.
7. /remove old, soiled dressing and place in Removing the soiled dressing avoids further developing
appropriate receptacle. infections to the wound.

8. Apply new set of gloves. To maintain the sterility.

9. Assess the appearance of the undressed Check the wound if there is redness, swelling, bleeding,
wound bed for healing. skin breakdown, and the size of the wound.
10. Cleanse the wound with normal saline It cleanses the bacteria surrounding the wound.
solution.
11. Cleanse the wound with betadine cleanser. To clean the wound.
12. Cleanse the wound with betadine paint. It helps to maintain cleansing the wound site.
13. Remove used gloves. To avoid spreading the microbes that was harbored
during dressing the wound.
14. Wash hands. For hygiene.
15. Apply new pair of gloves. It helps to promote infection control.

16. Grasping the edges, apply the new dressing To protect the wound and help for healing.
on the wound.
17. Approximate, cute, and apply plaster on To ensure the bandage won’t fall off.
dressing.
 18. Remove gloves and dispose properly. To avoid spreading the microbes that was harbored
during dressing the wound.
19. Conduct client and family education about To perform how to dress the wound properly without
the dressing. the nurse assistance.
20. Do after care. So that the area is clean.

21. Wash hands. To prevent spreading microbes.

22. Do proper documentation Used as reference data in the future,

Scoring: 1 x =
2 x =
3 x =
4 x =
Total divided by no. of items =

Comments:

LILIBETH C DE LA PEÑA, MAN, RPH RN

Students Clinical Instructor
Signature over Printed Name Signature over Printed Name
 University of Cebu
College of Nursing
Banilad Campus
Name: Grade:
Year and Section: Date:

Testing Urine for Sugar

Purpose:
 To check urine for presence of sugar, acetone, bacteria, and other urinary products.
 To aid in diagnosis
 To determine the condition of the patient.
 To determine effectiveness of therapy.

Equipment Needed:
 2 Test tubes Alcohol lamp
 Benedicts Solution
 Container of urine
 Tissue Clean Gloves
Legend
 Denatured alcohol 1 – Excellent
 Acetic Acid Colored Chart 2 – Very Satisfactory
3 – Satisfactory
 Waste receptacle Test tube holder 4 – Needs Improvement
 Match or lighter Small glass 5 - Poor
 3 Droppers

STEPS RATIONALE 1 2 3 4 5
PROCEDURE
1. Assemble all equipment. It will be use for the testing procedure.
2. Wash hands. To prevent spreading microbes.

3. Explain procedure to the patient and To understand the procedure and to feel comfort. Also
explain proper collection of urine. to build thrust to the nurse.
4. Explain procedure to the client. To understand the procedure and to be aware of what is
happening
5. Don clean gloves. To prevent contamination.
6. Apply clean gloves. To prevent contamination.

Benedict’s Test

1. Place 5 cc of Benedict’s solution in a test It is use to detect glucose in the urine.

tube.
2. Add 8 drops of urine. It is part of the procedure.

3.Heat the button of the test tube until boiling When heating the test tube, the content of the tube
point. becomes turbid due to the precipitation.
4. Read the result and compare with the color To guide and to know the correct corresponding/
chart. meaning of the color.
B. Acetic Acid Test
1. Place 5 cc of the urine and place it on a test To detect of albumin of the patient.
tube.
2. Heat the test tube on the upper half. Reagent that was used will make a reaction through
heat.
 3. Add 3 drops of acetic acid once it boils. To determine the chemical reaction.

4. Heat again until boiling point. Reagent that was used will make a reaction through
heat.
5. Read and compare the result with the color To guide and to know the correct corresponding/
chart. meaning of the color.
AFTER CARE

1. Explain result to the patient. Inform the patient about the result so that they will
know if there’s follow up check up needed.
2. Place used instrument in the pouch for soiled To prevent spreading contamination.
instruments, place
soiled articles outside the bag.
3. Return clean equipment inside the bag. For security.

4.Wash hands. To prevent spreading contamination.

5. Return clean equipment inside the bag. For security.

6. Document findings. Used as reference data in the future.

Scoring: 1 x =
2 x =
3 x =
4 x =
Total divided by no. of items =

Comments:

LILIBETH C DE LA PEÑA, MAN, RPH RN

Students Clinical Instructor
Signature over Printed Name Signature over Printed Name
 University of Cebu
College of Nursing
Banilad Campus
Name: Grade:
Year and Section: Date:

Leopold’s Maneuver

Legend
Purpose: 1 – Excellent
2 – Very Satisfactory
Equipment Needed: 3 – Satisfactory
4 – Needs Improvement
5 - Poor

STEPS RATIONALE 1 2 3 4 5
PROCEDURE
1. Wash hands. To prevent spreading contamination.
2.Encourage the patient to empty the bladder. To acquire accurate result.

3. Compute the following: To determine when is her due date, and her past
a. OB Score pregnancy.
b. EDC
c. AOG
Physical Assessment First Maneuver

1.Position the patient It is important that your patient feel comfortable in her
position and situation.
2. Stand at the side of the bed, facing the It help to determine where is the place that you will
mother. assess.
3 Palpate the uterine fundus with warm hands. Warm your hands before touching the patient’s uterine
fundus so that she would feel comfortable.

4. Determine which part of the baby’s body lies It determine if there is no bulges and abnormalities
on the upper fundus according to its: detected.
a) Relative consistency
b) Shape
c) Mobility.
Physical Assessment Second Maneuver

1. Place the palmar surface of both hands on It ensures accurate findings.

either side of the abdomen
2. Apply a gentle but deep pressure in one Gently apply pressure on the abdomen so that you could
side of the abdomen. feel the position of the baby.

3. Palpate the opposite side from the top to To determine where or what is the position of the baby
the lower segment of the uterus in a slightly as of now.
circular motion.
4. Determine which side of the uterus is the To know how many weeks the patient has been t.
long axis of the fetus located.
5. Check the Fetal Heart rate To check if it alive.
Physical Assessment Third Maneuver

1. Grasp the lower uterine segment with It determines the engagement of the fetus.
thumb and fingers.
2. Identify the presenting part. So that you’d know where to put your finger.
 3. Determine the mobility of the presenting The presenting part is notengaged if it is not movable.It
part. is not yet engaged if it is still movable.
Physical Assessment Fourth Maneuver

1. Stand to the side facing the patient’s feet. To position properly your body and fingers. And acquire
correct findings.

2. Place the tips of the first three fingers on Brow correspond to the side that contained the elbows
both sides of the midline about two and knees.
inches from the inguinal ligament.
3. Apply pressure downward and in the Brow correspond to the side that contained the elbows
direction of the birth canal. and knees.
4. Confirm the presenting part. The fetus should be in proper position.

ATTIDUE OF THE STUDENT:

1. Accept constructive suggestions and It helps to improve the student’s performance.

criticisms.
2. Assumes accountability. To be aware and become more responsible.

Scoring: 1 x =
2 x =
3 x =
4 x =
Total divided by no. of items =

Comments:

LILIBETH C DE LA PEÑA, MAN, RPH RN

Students Clinical Instructor
Signature over Printed Name Signature over Printed Name
 NGT FEEDING

Name: Angeline M. Taghap Grade:__________________

Year and Section: BSN 2 B Date:___________________

DEFINITION:
Enteral feeding is a method of supplying nutrients directly into the gastrointestinal tract.

EQUIPMENT NEEDED:

NGT
Medicine Cup Legend:
Asepto Syringe
Tissue/Towel 1- Excellent
Stethoscope
Kidney Basin 2- Very Satisfactory
Clean Gloves
Plaster 3- Satisfactory
Glass of Warm Water
Calibrated Glass
Prepared Formula 4- Needs Improvement

5- Poor

PROCEDURE RATIONALE 1 2 3 4 5
ASSESSMENT:

Prior to NGT feeding ensure that the tube is located in the

stomach. Coughing, vomiting and movement can move the
tube out of the correct position. The position of the tube
must be checked:

 Prior to each feed

 Before each medication
 Before putting anything down the tube
 If the patient has vomited

Perform the following observations and obtain a gastric

aspirate to establish tube position.

 Ensure taping is secure

 Observe and document the position marker on
NGT/OGT – compare to initial measurements.
 Observe Patient for any signs of respiratory
distress
Procedure:
To prevent spreading microbes in the
1. Wash hands.
NGT tube.
2. Prepare materials. To save ample of time.
To establish patient confidence and
3. Provide privacy
respect privacy.
So that the patient is aware to the
4. Explain procedure to the client.
procedures that will be made.
5. Wash hands To prevent spreading microbes.
To maintain sterility of the NGT tube
6. Apply clean gloves. and avoid spreading microbes to the
said equipment.
To have enough and balance nutrients
8. Measure the correct amount of formula and warm it to on the NGT that will be administered.
the desired temperature Cold formula might cause discomfort
in the stomach of the patient.
Patients should be in comfortable
9. Elevate the patient’s bed to a high- or semi-Fowler’s
position and it would be easier to the
position
nurse also.
10. Place protective sheet under tubing to protect bedding To avoid getting soiled the linen and
and clothes. clothes.
For introduction and it would be
11. Remove cap or plug from the feeding tube.
easier to maneuver the NGT.
12. Check tube patency and placement
Always assess correct placement of
NGT tube to reduce the risk of
 Observing mark on NG tube
aspiration.
 pH testing
 Use the asepto syringe to inject 10-15 mL of air
pH testing will determine if there is
while auscultating with stethoscope listen for
acidic content from the formula.
bubbling or gurgling sound.
 Aspirate stomach contents. Note amount of Bubbling or gurgling indicates that the
residual withdrawn and inject gastric fluid back end of the tube is in the stomach.
into tube. DO NOT discard this fluid. If residual is
greater than 100 mL or twice the hourly rate of
feeding, call physician. DO NOT administer feeding.
To hold the NGT tube properly and
13. Clamp the tube and attach the tube to the asepto
attach the tube to the syringe for the
syringe.
introduction of formula.
It helps to clear and lubricated the
14. Flush with 50ml-60 ml water or as recommended
passage of the formula.
15. Pour the formula into the asepto syringe and unclamp
To enter in the GIT
the tube
Putting pressure or forcing the
16. Allow the formula to flow in by gravity formula entering to the GIT might
cause discomfort to the patient.
17. During the feeding, keep the bottom of the syringe no It control the amount of formula that
higher than 6 inches above the patients stomach. is administered.
18. Continue adding formula into the syringe until the
To complete the prescribe formula.
prescribed amount is given.
19. If there are medications to be given, do not mix the
medication into the feeding, take note if the medication is
Mixing the medication and the
to be given before or after the feeding, crushed the
formula might alternate the effect.
medication and mix it with water in the medicine cup,
pour the medication into the asepto syringe.
20. When the syringe is empty, flush the tube with the
It cleans the tube.
prescribed amount of warm water.
To prevent discomfort and entering
21. Clamp the tube.
the air.
22. Leave patient in high- or semi-Fowler's position for at
It minimizes the risk of aspiration of
least 30 minutes and observe after for vomiting or any
the patient.
other unusualities.
23. Discard soiled supplies in appropriate containers. To promote clean environment.
POST-PROCEDURE ACTIVITY
24. After care of materials. Cleanse reusable equipment
and rinse. Allow to airdry and wrap in clean towel to be To prevent spreading microbes.
used at next feeding
25. Proper Documentation: `

a) Verification of proper tube placement.

b) Amount of aspirated stomach content.
c) Feeding solution and amount. It is necessary to have proper
d) Medications administered. documentation to avoid errors.
e) Amount of water administered.
f) Patient's response to procedure.
g) Instructions given to patient/caregiver.
h) h. Communication with physician, when necessary.
ATTIDUE OF THE STUDENT:
It helps to improve the student’s
26. Accept constructive suggestions and criticisms
performance
To be aware and become more
27. Assumes accountability
responsible.
Reference:
https://www.vnhcsb.org/media/data/papers/pdf/031_2.
12.3.pdf

Students
Signature over Printed Name
LILIBETH C DE LA PEÑA, MAN, RPH RN