Title Evidence-Based Physical Examination
Subtitle Best Practices for Health and Well-Being Assessment
Author Kate Sustersic Gawlik, Bernadette Mazurek Melnyk, Alice M. Teall
ISBN 9780826164537
List price USD 95.00
Price outside India Available on Request
Original price
Binding Paperback
No of pages 800
Book size 229 X 280 mm
Publishing year 2021
Original publisher Springer Publishing Company
Published in India by .
Exclusive distributors .
Sales territory Bangladesh, India, Pakistan, Sri Lanka
Status New Arrival
About the book Send Enquiry
  
 

Description:

The first book to teach physical assessment techniques based on evidence and clinical relevance.

Grounded in an empirical approach to history-taking and physical assessment techniques, this text for healthcare clinicians and students focuses on patient well-being and health promotion. It is based on an analysis of current evidence, up-to-date guidelines, and best-practice recommendations. It underscores the evidence, acceptability, and clinical relevance behind physical assessment techniques.

Evidence-Based Physical Examination offers the unique perspective of teaching both a holistic and a scientific approach to assessment. Chapters are consistently structured for ease of use and include anatomy and physiology, key history questions and considerations, physical examination, laboratory considerations, imaging considerations, evidence-based practice recommendations, and differential diagnoses related to normal and abnormal findings. Case studies, clinical pearls, and key takeaways aid retention, while abundant illustrations, photographic images, and videos demonstrate history-taking and assessment techniques.

Key Features:

  • Delivers the evidence, acceptability, and clinical relevance behind history-taking and assessment techniques
  • Eschews “traditional” techniques that do not demonstrate evidence-based reliability
  • Focuses on the most current clinical guidelines and recommendations from resources such as the U.S. Preventive Services Task Force
  • Focuses on the use of modern technology for assessment
  • Aids retention through case studies, clinical pearls, and key takeaways
  • Demonstrates techniques with abundant illustrations, photographic images


Contents:

Contributors

Preface

Acknowledgments

List of Videos

Instructor Resource


Part I: Foundations Of Clinical Practice

Chapter 1. Approach to Evidence-Based Assessment of Health and Well Being (Kate Gawlik,
Bernadette Mazurek Melnyk, and Alice M. Teall) •
Systematic Approach to Advanced Health and Well-Being Assessment • The Importance of Evidence-Based Assessment • Moving to a Model of Prevention • The Seven Steps of Evidence-Based Practice • Step #0: Cultivate a Spirit of Inquiry Within an EBP Culture and Environment • Step #1: Formulate the Burning Clinical PICOT Question • Step #2: Search for the Best Evidence • Step #3: Critical Appraisal of Evidence • Step #4: Integrate the Evidence With Clinical Expertise and Patient/Family Preferences to Make the Best Clinical Decision • Step #5: Evaluate the Outcomes of the Practice Change Based on Evidence • Step #6: Disseminate the Outcomes of the Evidence- Based Practice Change • Evidence-Based Practice Resources • The U.S. Preventive Services Task Force Evidence-Based Prevention Recommendations • Evidence-Based Clinical Practice Guidelines • References

Chapter 2. Evidence-Based History taking Approach for Wellness Exams, Episodic Visits, and Chronic Care Management (Linda Quinlin and Kate Gawlik) • Wellness Exam, Episodic Visit, and Chronic Care Management • History Taking for the Wellness Exam • Key History Questions and Considerations • History of Present Illness • Past Medical History • Family History • Social History • Review of Systems • Physical Examination • Counselling • Unique Population Considerations for Examination • Evidence-Based Practice Considerations • Preventive Care Considerations • Case Study: Wellness Exam • The Episodic Visit • Key History Questions and Considerations • History of Present Illness • Past Medical History • Family History • Social History • Review of Systems • Physical Examination • Evidence-Based Practice Considerations • Case Study: Episodic Visit • The Chronic Care Management Visit • Key History Questions and Considerations • History of Present Illness • Past Medical, Family, and Social History • Review of Systems • Review of Systems, Past Medical History, Family History, and Social History • Preventive Care Considerations • Physical Examination • Laboratory Considerations • Evidence-Based Practice Considerations • Case Study: Chronic Care Management • References

Chapter 3. Approach To Implementing and Documenting Patient Centered, Culturally Sensitive Evidence -Based Assessment (Alice M. Teall and Kate Gawlik) • Health and Well-Being in the Context of Family, Community, and Culture • Family and Family Systems • Community, Disparities, and Population Health Culture, Cultural Identity, and Health Beliefs • Role of the Clinician in Assessing Health and Health Disparities • Clinician–Patient Partnership • Recognition of Barriers • Cultural Sensitivity • Evidence-Based Practice Considerations • Quadruple Aim and the Process of Cultural Humility • QSEN Competencies as a Foundation for Assessment • Documentation of an Evidence-Based Assessment of Health and Well-Being • General Guidelines for Documentation • Clinical Record as a Legal Document • Important Documentation Considerations • Clinical Documentation: Example • References

Chapter 4. Evidence-Based Assessment of Children and Adolescents (Rosie Zeno, Jennifer Kosla, and
Bernadette Mazurek Melnyk) •
Anatomic and Physiologic Variations in Children and Adolescents • Head, Eyes, Ears, Nose, and Throat • Chest • Abdomen • Puberty • Musculoskeletal • Developmental Approach to History Taking • History of Present Illness • Past Medical History • Family History • Social History • Developmental History • Preventive Care Considerations • Developmental Approach to Physical Examination • Inspection • Palpation • Percussion • Auscultation • Key Developmental Considerations • Adolescents • Key Diagnostic and Imaging Considerations • References

Chapter 5. Approach to the Physical Examination: General Survey and Assessment of  Vital Signs (Melissa Baker, Hollie Moots, Sinead Yarberry, Molly McAuley, and Kady Martini) • General Survey Approach to Physical Examination • Initial Steps to Determine Physiologic Stability • Components of a General Survey • Anatomy and Physiology • Body Temperature • Pulse Rate • Respiratory Rate • Blood Pressure • Pain • Life-Span Considerations for the Physical Examination • Key History Questions and Considerations • History of Present Illness • Example of Presenting Problem: Fever • Past Medical History • Family History • Social History • Review of Systems • Preventive Care Considerations • Differential Diagnoses • Physical Examination and Findings • Measurement of Temperature • Assessment of Pulse Rate • Assessment of Respiratory Rate • Blood Pressure Measurement • Assessment of Pain • Additional General Survey Assessments • Evidence-Based Practice Considerations • Normal and Abnormal Findings • Hypertension • Pain • Hypothermia and Hyperthermia • Shock • Case Study: Annual Well Exam • References

 

Part II: Evidence-Based Physical Examination and Assessment of Body Systems

Chapter 6. Evidence-Based Assessment of the Heart and Circulatory System (Kristie L. Flamm, Kate Gawlik,
Matt Granger, Allison Rusgo, Angela Blankenship, Audra Hanners, Kelly Casler, Joyce Karl, Mary Alice Momeyer, Samreen Raza, Martha Gulati, and Alice M. Teall) •
Anatomy and Physiology of the Heart and Circulatory System • The Pericardial and Cardiac Membrane • The Cardiac Chambers • Cardiac Circulation • The Cardiac Cycle and Heart Sounds • Cardiac Conduction • The Vascular System • Pediatric Anatomical and Physiological Considerations • Fetal Heart Development • Geriatric Anatomical and Physiological Considerations • Key History Questions and Considerations • History of Present Illness • Differential Diagnoses • Past Medical History • Family History • Social History • Review of Systems • Preventive Care Considerations • Physical Examination of the Heart and Circulatory System • Initial Observations • Approach to the Physical Examination • Cardiovascular Examination of the Patient: Seated Position • Cardiovascular Examination of the Patient: Supine Position • Peripheral Vascular Examination of the Patient: Supine Position • Cardiovascular and Peripheral Vascular Examination of the Patient: Special Maneuvers • Pediatric Cardiac Examination Considerations • Laboratory Considerations for the Heart and Circulatory System • Laboratory Tests to Assess for Cardiac Disorders and Cardiovascular Status • Laboratory Tests to Assess for Myocardial Injury and Myocardial Infarction • Laboratory Tests to Consider for Alternative Causes • Laboratory Tests to Assess for Selected Comorbid Conditions • Diagnostic Considerations for the Heart and Circulatory System • Ankle-Brachial Index • Electrocardiogram • Chest Radiograph • Echocardiogram • Stress Testing • Coronary Computed Tomography Angiography and Coronary Calcium Scoring • Coronary Angiography • Cardiovascular Magnetic Resonance Imaging • Cardiac Computed Tomography • Evidence-Based Practice Considerations for the Heart and Circulatory System • American College of Cardiology and the American Heart Association • United States Preventive Services Task Force Recommendations • Choosing Wisely® Recommendations • Abnormal Findings of the Heart and Circulatory System • Acute Coronary Syndrome • Abdominal Aortic Aneurysm • Atherosclerosis and Coronary Artery Disease • Atrial Septal Defect • Chronic Venous Insufficiency • Coarctation of the Aorta • Deep Vein Thrombosis • Heart Failure • Hypertension • Infective Endocarditis • Mitral Valve Prolapse • Pericarditis • Peripheral Artery Disease • Raynaud’s Phenomenon • Rheumatic Heart Disease • Tetralogy of Fallot • Ventricular Septal Defect • Case Study: Chest Pain • Case Study: Hypertension Follow-Up • References

Chapter 7. Evidence-Based Assessment of the Lungs and Respiratory System (Alice M. Teall, Oralea A. Pittman, and Vinciya Pandian) • Anatomy and Physiology of the Lungs and Respiratory System • Anatomic Structures of the Thorax • Anatomic Structures of the Lower Respiratory Tract • Physiology of Breathing/Respiration • Life-Span Differences and Considerations for the Lungs and Respiratory System • Key History Questions and Considerations for the Lungs and Respiratory System • Chief Concern • History of Present Illness • Past Medical History • Family History • Social History • Review of Systems • Physical Examination of the Lungs and Respiratory System • Initial Observations • Approach to the Physical Examination • Inspection • Palpation • Percussion • Auscultation • Pediatric Physical Examination Considerations • Geriatric Physical Examination Considerations • Laboratory Considerations for the Lungs and Respiratory Systems • Laboratory Tests to Assess for Respiratory Disorders and Respiratory Status • Testing to Monitor Lung Function • Pulmonary Function Tests/Spirometry • Imaging Considerations for the Lungs and Respiratory System • Radiography • Computed Tomography • Evidence-Based Considerations for the Lungs and Respiratory System • Abnormal Findings: Variations in Patterns of Breathing • Abnormal Findings: Common Respiratory Disorders • Acute Bronchitis • Asthma • Bronchiolitis • Chronic Obstructive Pulmonary Disease • Cystic Fibrosis • Influenza • Lung Cancer Screening • Obstructive Sleep Apnea • Pertussis • Pneumonia • Tuberculosis • Case Study: Shortness of Breath • Case Study: Cough and Fatigue • References

Chapter 8. Approach To Evidence-Based Assessment of Body Habitus Height, Weight, Body Mass Index, Nutrition (Emily Hill Guseman, Kate Gawlik, and Alice M. Teall) • Nutrition Physiology • Diet • Metabolism • Physical Activity • Life-Span Differences and Considerations in Anatomy and Physiology • Key History Questions and Considerations for Body Habitus • History of Present Illness • Past Medical History • Medications • Family History • Social History • Review of Systems • Preventive Care Considerations • Physical Examination of Body Habitus • Inspection • Special Tests • Life-Span Considerations for Physical Examination • Laboratory Considerations for Body Habitus • Evidence-Based Practice Considerations for Body Habitus • Abnormal Findings of Body Habitus • Malnutrition • Weight Gain • Weight Loss • Cachexia • Sarcopenia • Case Study: Wellness Visit • References

Chapter 9. Evidence-Based Assessment of Skin, Hair, and Nails (Lisa E. Ousley and Retha D. Gentry) • Anatomy and Physiology of Skin, Hair, and Nails • Life-Span Differences and Considerations in Anatomy and Physiology of Skin, Hair, and Nails • Key History Questions and Considerations for Skin, Hair, and Nails • History of Present Illness • Past Medical History • Family History • Social History • Preventive Care Considerations • Life-Span Considerations for History • Unique Population Considerations for History • Review of Systems • Physical Examination of Skin, Hair, and Nails • Total Body Skin Examination • Integrated Skin Exam • Lesion-Focused Examination • Life-Span Considerations for Physical Exam • Unique Population Considerations for Examination • Laboratory Considerations for Skin, Hair, and Nails • Lesion Cultures • Microscopy • Punch Biopsy • Evidence-Based Practice Considerations for Skin, Hair, and Nails • Abnormal Findings of Skin, Hair, and Nails • Acne • Actinic Keratosis • Bed Bugs • Cellulitis • Contact Dermatitis • Eczema • Epidermoid Cysts • Erythema Migrans • Folliculitis • Herpes Zoster (Shingles) • Melanoma • Nongenital Warts • Nonmelanoma Skin Cancer • Onychomycosis • Pityriasis Rosea • Psoriasis • Rosacea • Scabies • Tinea Corporis • Tinea Versicolor • Urticaria • Case Study: Acne • Case Study: Atypical Skin Lesions • References

Chapter 10. Evidence-Based Assessment of the Lymphatic System (Kate Gawlik and Alice M. Teall) • Anatomy and Physiology of the Lymphatic System • Fluid Balance • Lymphatic Organs and Tissues • Lymphocytes • Immune Function • Life-Span Differences and Considerations in Anatomy and Physiology of the Lymphatic System • Key History Questions and Considerations for the Lymphatic System • History of Present Illness • Past Medical History • Family History • Social History • Review of Systems • Preventive Care Considerations • Physical Examination • Inspection • Palpation • Laboratory Considerations for the Lymphatic System • Imaging Considerations for the Lymphatic System • Abnormal Findings of the Lymphatic System • Cat Scratch Disease (Fever) • HIV/AIDS • Lymphangitis • Lymphadenitis • Lymphedema • Lymphatic Filariasis (Elephantiasis) • Lymphoma • Mononucleosis • Sarcoidosis • Toxoplasmosis • Case Study: Fever, Sore Throat, Fatigue, and Lymphadenopathy • Case Study: Flu-Like Symptoms • References

Chapter 11. Evidence-Based Assessment of the Head and Neck (Alice M. Teall and Kate Gawlik) • Anatomy and Physiology of the Head and Neck • Skeletal Structure of the Head • Structures of the Neck • Structure and Function of the Thyroid and Parathyroid Glands • Life-Span Differences and Considerations • Key History Questions and Considerations for the Head and Neck • History of Present Illness • Past Medical History • Family History • Social History • Review of Systems • Preventive Care Considerations • Physical Examination of the Head and Neck • Inspection of Head, Face, and Neck • Palpation of Head and Neck • Percussion and Auscultation of Head and Neck • Pediatric Physical Examination Considerations • Laboratory Considerations for the Head and Neck • Assessment of Thyroid Function • Assessment of Parathyroid Function • Imaging Considerations for the Head and Neck • Headache or Head Injury • Discrete Thyroid Lesions (Nodules) • Evidence-Based Practice Considerations for the Head and Neck • Headache or Head Injury • Thyroid Disorders • Abnormal Findings of the Head and Neck • Headache • Head Injury or Trauma • Parathyroid Disorders • Thyroid Disorders • Pediatric Considerations • Craniofacial Disorders • Case Study: Recurrent Headaches • Case Study: Constellation of Symptoms and Comorbidities • References

Chapter 12. Evidence-Based Assessment of the Eye (John Melnyk, Rosie Zeno, and Alice M. Teall) • Anatomy and Physiology of the Eye • Accessory Structures of the Eye • Principal Structures of the Eye • Neurologic Components of the Ocular System • Key History Questions and Considerations for the Eye • History of Present Illness • Past Medical History • Family History • Social History • Review of Systems • Preventive Care Considerations • Physical Examination of the Eye • Inspection • Assessment of Corneal Light Reflex • Assessment of Pupillary Light Reflex, Accommodation, and Convergence • Visual Fields Testing • Testing Movement of the Extraocular Muscles • Assessment of the Red Reflex • Direct Ophthalmoscopy • Measurement of Visual Acuity • Intraocular Pressure Testing • Life-Span Considerations for the Eye • Pediatric Considerations • Pregnancy Considerations • Considerations for the Older Adult • Ocular Assessments Completed by Specialists • Testing of Color Vision • Assessment of Refraction • Dilated Fundoscopy • Laboratory Considerations for the Eye • Imaging Considerations for the Eye • Evidence-Based Considerations for the Eye • Abnormal Findings of the Eye • Cataracts • Conjunctivitis • Corneal Abrasion • Dacryostenosis and Dacryocystitis • Diplopia • Glaucoma • Macular Degeneration • Optic Neuritis and Retrobulbar Neuritis • Orbital and Periorbital Cellulitis • Pingueculum and Pterygium • Retinal Tears, Floaters, and Retinal Detachment • Retinopathy • Scleritis and Episcleritis • Strabismus • Sty • Subconjunctival Hemorrhage • Uveitis • Case Study: Eye Pain and Swelling • References

Chapter 13. Evidence-Based Assessment of the Ears, Nose, and Throat (Maria Colandrea and Eileen M. Raynor) • Anatomy and Physiology of Ears, Nose, and Throat • The Ear • The Nose • The Mouth and Pharynx • Lymphatic System • Key History Questions and Considerations for the Ears, Nose, and Throat • History of Present Illness • Past Medical History • Family History • Social History • Review of Systems • Preventive Care Considerations • Physical Examination of the Ears, Nose, and Throat • Inspection and Palpation of the Ear • Assessing Auditory Acuity • Assessing Air and Bone Conduction • Audiometry • Inspection and Palpation of the Nose and Sinuses • Inspection of the Mouth and Posterior Pharynx • Palpation of the Mouth and Jaw • Temporal Mandibular Joint • Life-Span Considerations for Physical Examination of the Ears, Nose, and Throat • Laboratory Considerations for the Ears, Nose, and Throat • Imaging Considerations for the Ears, Nose, and Throat • When to Image • When Not to Image • Evidence-Based Practice Considerations for the Ears, Nose, and Throat • Abnormal Findings of the Ears, Nose, and Throat • Abnormal Findings of the Ear • Abnormal Findings of the Nose • Abnormal Findings of the Throat • References

Chapter 14. Evidence-Based Assessment of the Nervous System (Leslie E. Simons) • Anatomy and Physiology of the Nervous System • Brain • Cerebrum • Cerebellum • Brainstem • Spinal Cord • Cranial Nerves • Motor Pathways • Sensory Pathways • Spinal Nerves • Spinal Reflexes • Life-Span Differences and Considerations in Anatomy and Physiology of the Nervous System • Key History Questions and Considerations • History of Present Illness • Past Medical History • Family History • Social History • Review of Systems • Preventative Care Considerations • Physical Examination of the Nervous System • Equipment • Inspection • Mental Status Examination • Cranial Nerves • Proprioception and Cerebellar Function • Reflexes • Sensory Function • Special Tests • Abnormal Findings of the Nervous System • Bell’s Palsy • Cerebral Palsy • Epilepsy • Hemorrhagic Stroke • Intracranial Tumor • Ischemic Stroke • Meningitis • Multiple Sclerosis • Myasthenia Gravis • Parkinson’s Disease • Peripheral Neuropathy • Trigeminal Neuralgia • Case Study: Facial Weakness and Drooping • Case Study: Jaw Pain • References

Chapter 15. Evidence-Based Assessment of the Musculoskeletal System (Zach Stutzman and Kate Gawlik) • Anatomy and Physiology of the Musculoskeletal System • Anatomy and Physiology of the Head and Spine • Anatomy and Physiology of the Upper Extremity • Anatomy and Physiology of the Lower Extremity • Life-Span Differences and Considerations in Anatomy and Physiology of the Musculoskeletal System • Key History Questions and Considerations for the Musculoskeletal System • History of Present Illness • Past Medical History • Family History • Social History • Review of Systems • Preventive Care Considerations • Life-Span Considerations for History • Physical Examination of the Musculoskeletal System • Inspection • Palpation • Range of Motion and Special Tests • Head • Cervical Spine • Thoracic/Lumbar Spine • Special Tests of the Lumbar Spine • Upper Extremities • Lower Extremities • Life-Span Considerations for Physical Examination • Imaging Considerations for the Musculoskeletal System • X-Ray • Magnetic Resonance Imaging • Ultrasound • Dual-Energy X-Ray Absorptiometry Scan • Evidence-Based Practice Considerations • Abnormal Findings of the Musculoskeletal System • Carpal Tunnel Syndrome • Nursemaid’s Elbow (Radial Head Subluxation) • Dupuytren’s Contracture • Rotator Cuff Tear • Lateral Epicondylitis • Osgood–Schlatter Disease • Osteoarthritis • Osteoporosis/Osteopenia • Rheumatoid Arthritis • Gout • De Quervain’s Syndrome • Case Study: Knee Pain, Swelling, and Instability • Case Study: Insidious Knee Pain and Limp • References

Chapter 16. Evidence-Based Assessment of the Abdominal, Gastrointestinal, and Urological Systems
(Leigh Small, Tammy Spencer, Rosario Medina, Kerry Z. Reed, Sandy Dudley, and Kate Gawlik) • Anatomy and Physiology • Landmarks, Musculature, and Contents of the Abdomen • Gastrointestinal Tract • Accessory Digestive Organs • Urinary System • Spleen • Life-Span Differences and Considerations in Anatomy and Physiology • Key History Questions and Considerations • History of Present Illness • Medical History for Gastrointestinal Concerns • Family History for Gastrointestinal Concerns • Social History for Gastrointestinal Concerns • Medical History for Urinary Concerns • Family History for Urinary Concerns • Social History for Urinary Concerns • Review of Systems for Gastrointestinal/Genitourinary Systems • Preventive Care Considerations Related to the Gastrointestinal System • Life-Span Considerations for History • Unique Population Consideration for History • Physical Examination • Preparation for the Examination • Inspection • Auscultation • Percussion • Palpation • Laboratory Considerations • Celiac Disease • Inflammatory Bowel Disease • Hepatitis • Pancreatitis • Urinary Tract Infection or Pyelonephritis • Imaging Considerations • Cholecystitis • Gastroesophageal Reflux Disease • Appendicitis • Hepatomegaly • Splenomegaly • Other Testing Considerations • Evidence-Based Preventive Practice Considerations • Abnormal Findings of the Gastrointestinal System • Constipation • Diarrhea • Nausea/Vomiting • Abnormal Findings Based on Location of Abdominal Pain • Right Upper Quadrant Pain: Duodenum, Liver, Gallbladder, Pancreas • Right Lower Quadrant Pain: Appendix, Ascending Colon • Left Upper Quadrant: Spleen, Stomach, Cardiac • Left Lower Quadrant Pain: Descending Colon • Periumbilical/Epigastric Pain: Stomach, Transverse Colon, Aorta • Abnormal Findings of the Urinary System • Lower Urinary Tract Infection • Pyelonephritis • Renal Colic (Urolithiasis, Ureterolithiasis) • Urinary Incontinence • Case Study: Epigastic Abdominal Pain • Case Study: Periumbilical Abdominal Pain • References

 

Part III: Evidence-Based Physical Examination and Assessment of Sexual and Reproductive Health

Chapter 17. Evidence-Based Assessment of the Breasts and Axillae (Brenda M. Gilmore and Brittany B. Hay) • Anatomy and Physiology of the Breasts and Axillae • Life-Span Differences and Considerations in Anatomy and Physiology of the Breasts and Axillae • Key History Questions and Considerations for the Breasts and Axillae • History of Present Illness • Past Medical History • Family History • Social History • Preventive Care Considerations • Life-Span and Unique Population Consideration for History • Breast Cancer Risk Assessment Tools • Physical Examination of the Breasts and Axillae • Inspection of the Breasts • Palpation of the Breasts and Axillae • Life-Span Consideration for Physical Examination of the Breasts and Axillae • Unique Population Considerations for Physical Examination of the Breasts and Axillae • Laboratory Considerations for the Breasts and Axillae • Genetic Testing for BRCA and Other Gene Mutations • Prolactin Levels • Imaging Considerations for the Breasts and Axillae • Mammography • Digital Breast Tomosynthesis • Ultrasound • Magnetic Resonance Imaging • Evidence-Based Practice Considerations for the Breasts and Axillae • Current Recommendations for Breast Cancer Screening • Abnormal Findings of the Breast and Axillae • Lymphadenopathy • Accessory Breast Tissue • Breast Mass • Malignant Mass • Breast Pain (Mastalgia) • Nipple Changes • Conditions Associated With Skin Changes of the Breast • Case Study: Bilateral Breast Pain • Case Study: Well-Woman Exam • References

Chapter 18. Evidence-Based Assessment of Sexual Orientation, Gender Identity, and Health
(Kathryn Tierney and Britta Shute) • Anatomy and Physiology • Sexual Orientation • Gender Identity • Life-Span Differences and Considerations in Anatomy and Physiology • Key History Questions and Considerations • Preventive Care Considerations • Physical Examination • Laboratory Considerations • Considerations Related to Sexual Orientation • Considerations Related to Gender Identity • Imaging Considerations • Considerations Related to Gender Identity • Evidence-Based Practice Considerations • Case Study: Rectal Pain • References

Chapter 19. Evidence-Based Assessment of Male Genitalia, Prostate, Rectum, and Anus (Rosie Zeno and
Alice M. Teall) •
Anatomy and Physiology of Male Genitalia • Male Pelvic Organs and Reproductive System • Anatomy of the Rectum and Anus • Structure and Function of the Prostate Gland • Life-Span Differences and Considerations • Key History Questions and Considerations for Male Genitalia, Prostate, Rectum, and Anus • History of Present Illness • Past Medical History • Family History • Social History • Review of Systems • Preventive Care Considerations • Life-Span and Population Considerations for History • Physical Examination of Male Genitalia, Prostate, Rectum, and Anus • Inspection • Palpation • Pediatric and Adolescent Considerations for Physical Examination • Laboratory Considerations for Male Genitalia, Prostate, Rectum, and Anus • Screening for Sexually Transmitted Infections • Testing for Prostate-Specific Antigen • Imaging Considerations for Male Genitalia, Prostate, Rectum, and Anus • Ultrasound • Evidence-Based Practice Considerations for Male Genitalia, Prostate, Rectum, and Anus • Testicular Cancer Screening • Prostate Cancer Screening • Common Abnormalities of the Male Genitalia, Prostate, Rectum, and Anus • Congenital or Developmental Abnormalities • Infection or Inflammatory Disorders • Other Abnormalities of Male Genitalia • Abnormalities of the Anus, Rectum, and Prostate • Case Study: Scrotal Pain • References

Chapter 20. Evidence-Based Assessment of the Female Genitourinary System (Sherry Bumpus and
Amber Carriveau) •
Anatomy and Physiology of the Female Genitourinary System • The Bony Pelvis • Pelvic Support • External Genitalia • Internal Structures of the Female Genitourinary System and Reproductive Systems • The Menstrual Cycle • Life-Span Differences and Considerations in Anatomy and Physiology • Key History Questions and Considerations for the Female Genitourinary System • History of Present Illness • Menstrual History • Gynecologic History • Obstetric History • Sexual History • Past Medical History • Family History • Social History • Preventive Care Considerations • Life-Span Considerations for History • Unique Population Considerations for History • Physical Examination of the Female Genitourinary System • Performing the Pelvic Examination • Inspection and Palpation of External Genitalia • Internal Inspection: Speculum Examination • Palpation: Bimanual Examination • Life-Span Considerations for Physical Examination • Special Population Considerations for Physical Examination • Laboratory Considerations for the Genitourinary System • Cervical Cytology • Wet Mount • Testing for Sexually Transmitted Infections • Human Papillomavirus Testing • Imaging Considerations for the Female Genitourinary System • Transvaginal and Transabdominal Pelvic Ultrasound • Evidence-Based Practice Considerations for the Female Genitourinary System • The Well-Woman Examination • Pelvic Examinations for Asymptomatic and Nonpregnant Adult Women • Cervical Cancer Screening and Human Papillomavirus Testing • Human Papillomavirus Vaccination • Assessment and Screening for Breast, Ovarian, and Endometrial Cancers • HIV Screening • Sexually Transmitted Infection Screening • Family Planning • Abnormal Findings of the Female Genitourinary System • Sexually Transmitted Infections • Vaginitis/Vaginosis • Vulvar/Vaginal/Urethral Lesions • Pelvic Support Issues • Genital Lesions/Masses: Malignant and Nonmalignant • Adnexal Masses • Menstrual Irregularities • Case Study: Abdominal Pain and Discharge • Case Study: Abdominal Pain and Bleeding • References

Chapter 21. Evidence-Based Obstetric Assessment (Emily Neiman) • Anatomy and Physiology • Breasts • Uterus • Cervix • Endocrine System • Cardiovascular System • Hematologic State • Respiratory System • Gastrointestinal System • Urinary System • Skeletal Structure and Function • Key History Questions and Considerations • History of Present Illness • Past Medical History • Family History • Social History • Review of Systems • Preventive Care Considerations • Unique Population Considerations for History • Physical Examination • Inspection • Palpation • Auscultation • Unique Population Considerations for Physical Examination • Laboratory Considerations • Initial Obstetric Lab Work • Gestational Diabetes Screening • Genetic Testing • Labs at 24–28 Weeks’ Gestation • Labs at 35–37 Weeks’ Gestation • Imaging Considerations • Evidence-Based Practice Considerations • Folic-Acid Supplementation • Gestational Diabetes Screening • Induction of Labor • Fetal Surveillance in Third Trimester • Management of Women at High Risk for Preterm Birth • Hypertensive Disorders • Abnormal Findings • Acute Cystitis Urinary Tract Infection • Asymptomatic Bacteriuria • Anemia in Pregnancy • Constipation in Pregnancy • First-Trimester Bleeding • Hypertensive Disorders • Thyroid Dysfunction • Hyperemesis Gravidarum • Pruritic Urticarial Papules and Plaques of Pregnancy • Gestational Thrombocytopenia • Case Study: Routine Prenatal Visit • Case Study: Problem Obstetric Visit • References

 

Part IV: Evidence-Based Physical Examination and Assessment of Mental Health

Chapter 22. Evidence-Based Assessment of Mental Health (Pamela Lusk and Bernadette Mazurek Melnyk) • Anatomy and Physiology • Key History Questions and Considerations • Assessment of Mental Status • Approach to Assessing Mental Status and Mental Health History • History of Present Illness • Family History • Past Medical History and Review of Systems • Social History • Strengths, Goals, and Interests • Preventive Care Considerations • Unique Population Considerations for History • Risk Assessment • Laboratory Considerations • Evidence-Based Practice Considerations • Evidence-Based Depression and Suicidality Screening • Evidence-Based Mental Health Screening Tools • Evidence-Based Screening Instruments Specific to Children/Teens • Findings in Common Mental Health Disorders • Anxiety and Anxiety Disorders • Trauma and Stressor-Related Disorders • Depression and Mood Disorders • Thought Disorders • Comorbid Mental Health Conditions • Special Considerations for Children and Adolescents • Anxiety • Attention Deficit Hyperactivity Disorder • Depression • The Write-Up for a Mental Health Assessment • Case Study: Adult Mental Health Assessment • Case Study: Pediatric Mental Health Assessment • References

Chapter 23. Evidence-Based Assessment of Substance Use Disorder (Alice M. Teall and Kate Gawlik) • Overview: Defining the Problem of Substance Use Disorder • Anatomy and Physiology of the Brain and Nervous System Involved in Substance Use Disorder • Neurons, Neurotransmitters, and Nervous System Involvement • Regions of the Brain Disrupted with Substance Use Disorder • Life-Span Considerations • Key History Questions and Considerations for Substance Use Disorder • Approach to Assessment of Substance Use: Screening, Brief Intervention, and Referral to Treatment • History of Present Illness • Past Medical History • Family History • Social History • Review of Systems • Preventive Care Considerations • Differential Diagnoses • Physical Examination for Substance Use Disorder • Laboratory Considerations for Substance Use Disorder • Imaging Considerations for Substance Use Disorders • Evidence-Based Practice Considerations for Substance Use Disorders • Abnormal/Common Findings Related to Substance Use Disorder • Substance and Non-Substance Addictive Behaviors • Impact on Families • Withdrawal Symptoms and Neonatal Abstinence Syndrome • Recovery • Case Study: Illicit Prescription Use • References

Chapter 24. Evidence-Based Assessment and Screening for Traumatic Experiences: Abuse, Neglect, and Intimate Partner Violence (Gail Hornor, Catherine Davis, Katharine Doughty, Catherine Huber, Rosie Zeno, and
Linda Quinlin) •
Trauma • Adverse Childhood Experiences • Abuse and Neglect of Children • Physical and Sexual Abuse • Emotional Abuse • Neglect • Intimate Partner Violence • Elderly and Disabled Adult Abuse • Key History Questions and Considerations • History of Present Illness • Past Medical History • Family History • Social History • Review of Systems • Preventive Care Considerations • Physical Examination • Physical Abuse • Sexual Abuse • Elder Abuse • Imaging and Laboratory Considerations • Additional Considerations • Evidence-Based Practice Considerations • Abnormal Findings • Abusive Head Trauma • Case Study: Well-Child Visit • Case Study: Vaginal Discharge and Pain • References

Chapter 25. Evidence-Based Therapeutic Communication and Motivational Interviewing in Health Assessment (Sharon Tucker, Debbie Sheikholeslami, and Haley Roberts) • Therapeutic Communication in the Context of Health Assessment • Therapeutic Communication, Motivational Interviewing, and Stages of Change • Key Skills and Considerations When Eliciting Patient History • Therapeutic Skills to Elicit Chief Concern and Reason for Visit • Eliciting the Past Medical History • Family Health History • Social History • Preventive Care Considerations • Physical Examination • Special Considerations for Communicating During the Physical Exam • Evidence-Based Practice Considerations • The 5 A’s Approach • Motivational Interviewing • Trauma-Informed Care • Case Study: Therapeutic Communication • References

 

Part V: Special Topics in Evidence-Based Assessment

Chapter 26. Evidence-Based History and Physical Examinations for Sports Participation Evaluation
(Marjorie A. Vogt) • Anatomy and Physiology of the Adolescent • Key History Questions and Considerations • History of Presenting Illness • Past Medical History • Family History • Social History • Review of Systems • Preventive Care Considerations • Physical Examination • Vital Signs • Inspection • Palpation • Auscultation • Contraindications and Restrictions for Sports Participation • Laboratory Considerations • Imaging Considerations • Evidence-Based Practice Considerations • Abnormal Findings • Hypertrophic Cardiomyopathy • Marfan Syndrome • Female Athlete Triad • Case Study: Pre-Participation Sports Evaluation • References

Chapter 27. Using Health Technology in Evidence-Based Assessment (Lisa K. Militello and Janna D. Stephens) • Health Technology in Evidence-Based Practice • Terminology Across Disciplines • Ethical and Legal Considerations • Evaluation of Evidence to Support Use of Health Technology • Variations in Approach to Evidence • Locating Health Technology Evidence • Keeping Pace With Evolving Health Technology • Case Study: How Technology Can Support Evidence-Based Assessment • Case Study: How Technology Can Support Evidence-Based Practice • Conclusion • References

Chapter 28. Evidence-Based Assessment of Personal Health and Well-Being for Clinicians: Key Strategies to Achieve Optimal Wellness (Bernadette Mazurek Melnyk, Kate Gawlik, and Alice M. Teall) • The Importance of Clinician Health and Well-Being • The National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience • Healthcare System Interventions • Key Questions for Self-Assessment of Clinician Health and Well-Being • Key Strategies for Optimizing Personal Health and Well-Being in the Nine Dimensions of Well-Being • Physical Wellness • Emotional Wellness • Financial Wellness • Social Wellness • Intellectual Wellness • Career Wellness • Creative Wellness • Environmental Wellness • Spiritual Wellness • Take Action to Improve Your Health and Well-Being Now: Bern’s Story • Acknowledgments • References

Chapter 29. Evidence-Based Health and Well-Being Assessment: Putting It all Together (Alice M. Teall and
Kate Gawlik) •
Introduction • Components of Advanced Assessment • Episodic/Acute Visit: Review History of Present Illness • Chronic Care Management Visit: Support Self-Management • Health History • Family History • Social History • Review of Systems: Focused, Extended, or Complete • Preventive Care Considerations • Physical Examination Components • General Survey • Mental Status • Head and Neck (Including Lymphatics) • Eyes • Ears • Nose • Mouth and Throat • Anterior, Posterior, and Lateral Chest • Cardiovascular and Peripheral Vascular • Abdomen • Musculoskeletal and Neurologic

 

Index

Components of Advanced Assessment and Physical Examination


About the Editors:

Kate Sustersic Gawlik, DNP, APRN-CNP, FAANP, is an assistant professor of clinical nursing at The Ohio State University. She is certified by the American Nurses Credentialing Center as an adult and family nurse practitioner. She has extensive background in primary care, with experience in family practice, college health, urgent care, and reproductive care. Her clinical interests are evidence-based practice, population health, preventive medicine, clinician well-being, health professionals’ education, wellness, and cardiovascular disease prevention. She has served as the project manager for the Million Hearts® initiatives at Ohio State’s College of Nursing since 2013. She leads and serves on multiple state and national workgroups targeted at improving cardiovascular population health.

Dr. Gawlik started her nursing career in 2006 and completed her MSc in nursing with a specialization as an adult/geriatric nurse practitioner in 2009 from The Ohio State University. She received an Abstract of Distinction at the Council for the Advancement of Nursing Science Conference in 2016 and the Editor’s Pick for 2017 Paper of the Year by the American Journal of Health Promotion for “An Epidemiological Study of Population Health Reveals Social Smoking as a Major Cardiovascular Risk Factor.” She was awarded the 2018 American Association of Nurse Practitioner State Award for Excellence for Ohio. She was inducted as a fellow into the American Association of Nurse Practitioners in June 2018.

Dr. Gawlik has been teaching nursing students since 2007. She has taught a variety of undergraduate, RN–BSN, and graduate nursing courses and serves as a clinical preceptor for advanced practice nursing students.

Bernadette Mazurek Melnyk, PhD, APRN-CNP, FAANP, FNAP, FAAN, is the vice president for health promotion, university chief wellness officer, and professor and dean of the College of Nursing at The Ohio State University. She is also a professor of pediatrics and psychiatry at Ohio State’s College of Medicine. In addition, she is the executive director of the Helene Fuld Health Trust National Institute for Evidence-Based Practice in Nursing and Healthcare. Dr. Melnyk earned her BSc in nursing from West Virginia University, her MSc with a specialization in nursing care of children and as a pediatric nurse practitioner from the University of Pittsburgh, and her PhD in clinical research from the University of Rochester where she also completed her post-master’s certifi cate as a psychiatric mental health nurse practitioner.

Dr. Melnyk is coeditor of six other books: Implementing the Evidence-Based Practice (EBP) Competencies in Healthcare: A Practical Guide for Improving Quality, Safety, and Outcomes; Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice (4th Edition), an American Journal of Nursing Research Book of the Year Award winner; Implementing EBP: Real World Success Stories; A Practical Guide to Child and Adolescent Mental Health Screening, Early Intervention and Health Promotion (2nd Edition); Intervention Research and Evidence-Based Quality Improvement: Designing, Conducting, Analyzing and Funding (2nd Edition), also an American Journal of Nursing Research Book of the Year Award winner; and Evidence-Based Leadership, Innovation and Entrepreneurship in Nursing and Healthcare.

Dr. Melnyk is an elected fellow of the National Academy of Medicine, the American Academy of Nursing, the National Academies of Practice, and the American Association of Nurse Practitioners. She served a 4-year term on the 16-member U.S. Preventive Services Task Force and the National Institutes of Health’s National Advisory Council for Nursing Research and was a board member of the National Guideline Clearinghouse and the National Quality Measures Clearinghouse (NGC/NQMC). She currently serves as a member of the National Quality Forum’s  (NQF) Behavioral Health Standing Committee.

Alice M. Teall, DNP, APRN-CNP, FAANP, is director of graduate health and wellness programming, director of innovative telehealth services, and an assistant professor of clinical nursing at The Ohio State University College of Nursing. An expert in nursing education, Dr. Teall was honored with The Ohio State University Provost Award for Distinguished Teaching by a Lecturer and with the Wright State University Presidential Award for Faculty Excellence. While serving as director of the online Family Nurse Practitioner program, she was chosen as The Ohio State College of Nursing Graduate Educator of the Year for 4 consecutive years.

Alice M. Teall began her nursing career as a diploma graduate of Miami Valley Hospital School of Nursing in 1983. She earned her BSc in nursing from Capital University, her MSc with a specialization as a Family Nurse Practitioner from Wright State University, and her DNP from The Ohio State University. She has certifications as a Family and Pediatric Nurse Practitioner and as an Integrative Nurse Coach. Her clinical expertise and areas of interest include adolescent health, primary care of at-risk youth and families, college health, and recovery from substance use disorder.


Target Audience:

This textbook is intended for a broad audience of health science students and clinicians, graduate & undergraduate nursing students, medical students, family/adult/pediatric/psychiatric nurse practitioners, acute care, primary care, or specialty care management, child mental health graduates, maternal–child health graduates, physician assistant graduates, pharmacy graduates, occupational therapy graduates, physical therapy graduates, respiratory therapy graduates who strive to exemplify excellence in evidence-based assessment and practice.

 

 
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