Shadow Health Tina Jones Comprehensive Assessment: Key Findings and Documentation Tips

The Tina Jones Comprehensive Assessment in Shadow Health is one of the most detailed and interactive patient simulation exercises available on the platform, offering nursing students the opportunity to conduct a thorough health assessment. This simulation involves assessing a virtual patient named Tina Jones, a 22-year-old female who is seeking medical care for a variety of symptoms. The goal of this comprehensive assessment is to help students practice gathering subjective and objective data, developing care plans, and improving their clinical reasoning.

Key Findings in Tina Jones’ Comprehensive Assessment

In the Tina Jones comprehensive assessment, there are several key findings that students must identify. These findings involve both subjective data (what the patient reports) and objective data (what the clinician observes or measures). Some of the main findings include:

Subjective Data:
- Chief Complaint: Tina reports general fatigue, difficulty sleeping, and intermittent chest pain. She also mentions feeling anxious and stressed, which are critical symptoms that need further exploration.
- History of Present Illness: Tina describes her chest pain as being sharp and brief, occurring about twice a week for the past month. She has no history of heart disease but has a family history of hypertension.
- Lifestyle and Behaviors: She is a non-smoker, does not consume alcohol excessively, and is not on any medications. However, Tina is a college student who is under stress due to exams, which may contribute to her symptoms.
Objective Data:
- Vital Signs: Students will gather vital signs such as blood pressure, heart rate, respiratory rate, and temperature. These measurements will give students an idea of the patient’s general health status and whether any immediate concerns need to be addressed.
- Physical Examination: The simulation will involve assessing Tina’s skin, respiratory rate, cardiac function, and other aspects of her physical health. Any findings such as abnormal breath sounds or changes in heart rhythm are crucial.

Documentation Tips for Tina Jones’ Assessment

Accurate documentation is critical in nursing practice, and Shadow Health’s Tina Jones assessment provides an opportunity to practice this skill. Here are some documentation tips for the comprehensive health assessment:

Organize Data Systematically: Use a SOAP format (Subjective, Objective, Assessment, and Plan) to document the findings from Tina Jones’ assessment. This structure helps keep the information organized and ensures all aspects of the patient’s condition are addressed.
- Subjective Data: Document Tina’s own descriptions of her symptoms, including the severity, timing, and associated factors (e.g., stress).
- Objective Data: Include specific measurements like blood pressure, heart rate, and any abnormal findings from the physical exam.
- Assessment: Based on the data collected, summarize your findings, including potential diagnoses or differential diagnoses.
- Plan: Develop a care plan that addresses Tina’s symptoms, including further testing, lifestyle changes, and possible treatments.
Use Clear and Concise Language: When documenting findings, avoid jargon and focus on clarity. Be specific about measurements (e.g., “Blood pressure: 130/85 mmHg” rather than “slightly elevated blood pressure”). If Tina reports discomfort, use specific descriptors such as “sharp” or “dull” to convey the intensity and nature of her pain.
Avoid Assumptions: Stick to factual information provided by the patient and what you observe. Avoid making assumptions about Tina’s symptoms, and ensure that your documentation reflects only what is objectively observable or patient-reported.
Regularly Update Documentation: As the patient’s condition evolves, update the documentation accordingly. If Tina reports any new symptoms or if any test results come in, include them in the record.

In summary, Tina Jones’ comprehensive assessment is a valuable learning opportunity that requires careful observation, critical thinking, and precise documentation. By accurately documenting key findings and structuring them properly, students will enhance their clinical documentation skills, which are essential in real-world nursing practice.