Far Eastern University
Institute of Nursing
1 semester AY 2009-2010
st
PERFORMANCE RATING SCALE
BAG TECHNIQUE and URINE TESTING
Name of Student: ______________________________________ Date: __________________
Section/ Group: ___________ Name of Clinical Instructor: ______________ Score: _________________
Directions: Please rate the student’s performance according to the following competencies:
0 – NOT OBSERVED (The activity was not demonstrated by the student)
1 – UNACCEPTABLE (The performance was incorrect and inefficient)
2 – NEEDS IMPROVEMENT (The task was performed correctly but with some difficulty)
3 – COMPETENT (The task was performed quickly, thoroughly, and precisely)
CRITERIA 3 2 1 0 REMARKS
I. ATTENDANCE/ ATTITUDE (10%)
1. Reports on time and attends to activities punctually
2. Displays proper grooming and wears complete uniform
3. Behaves appropriately towards teacher, classmates, & client(s)
4. Accepts constructive criticisms
II. ESTABLISHES A GOOD WORKING RELATIONSHIP WITH CLIENT (20%)
1. Greets client
2. Introduces self
3. States purpose of home visit
4. Sets contract with the client
5. Informs client of the procedure
6. Informs client of the results of the procedure (if appropriate)
7. Encourages client to verbalize thoughts and concerns
8. Appreciates client’s cooperation
III. BAG TECHNIQUE (40%)
1. Remove paper lining from the bag
2. Spread paper lining with clean side out (folded part touching the
surface) on a flat surface of table, chest or box or if none, use
the floor
3. Place bag on the upper left side of paper lining with the bag
opening facing the working area and the bag’s handles or strap
tucked carefully beneath the bag
4. Open the bag and take out the plastic lining.
5. Lay plastic lining over the paper lining with clean side out (folded
part out)
6. Bring out towel and soap with soap dish
7. Close the bag without locking and perform hand washing
8. After hand washing, put the soap and soap dish on the paper
lining (outside the plastic lining) with hand towel on top of the
soap dish.
9. Put on the apron observing proper technique.
10. Open the bag and remove articles needed for care making sure
that they are placed within the plastic lining.
11. Place a paper receptacle outside the work area.
12. Close the bag then complete care.
13. After completing nursing care, clean articles used. (Articles are
usually disinfected using alcohol including the top of the plastic
lining)
14. Close and discard the paper receptacle
15. Perform hand washing
16. After hand washing, open the bag and return all articles used
17. Return the soap and soap dish inside the bag last with the hand
towel under the soap dish
18. Take off and fold apron using proper technique and return to
bag.
19. Fold the plastic lining (clean-side-out) and return to bag
20. Close and lock the bag
21. Get the bag, fold the paper lining without touching the
contaminated side and discard.
IV. URINE TESTS (30%)
1. Prepares the needed materials.
Benedict’s test
2. Place 5cc Benedict’s solution in a clear test tube.
3. Heat the test tube.
4. Add 8 to 10 drops of urine and mix thoroughly.
5. Boil for at least 2 minutes and allow it to cool.
6. Interpret result correctly.
Heat and Acetic Acid Test
7. Fill the test tube with 2/3 full of clean, fresh urine.
8. Heat the upper portion of the test tube. (Lower portion is not
heated to serve as contrast).
9. Add 3 to 5 drops of acetic acid.
10. Re-heat the test tube, then allow it to cool
11. Interpret result correctly.
Grade Computation:
Final Grade = Summation of (Raw Score/Perfect Score X Percentage)
____________________________ ____________________________
Signature of Student Signature of Clinical Instructor
