Evidence-Based Physical Examination

Kate Sustersic Gawlik, DNP, APRN-CNP, FAANP, FNAP is an associate 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, parental burnout, 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 and improving student health and wellness. 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. In 2015, she graduated with her DNP and a post-master's certificate as a family nurse practitioner from The Ohio State University. Dr. Gawlik was awarded the Outstanding Faculty Award in 2013 and the Outstanding Leadership Award in 2017 at 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 and into the National Academies of Practice in March 2021. She received the 2022 American Association of Colleges of Nursing Innovations Award. 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. Her passion lies in teaching in the online platform, both in synchronous and asynchronous classrooms. She has been teaching solely online since 2012. Dr. Gawlik developed an online educational module on cardiovascular population health that is used nationally and internationally. The educational module has led to the cardiovascular screening of over 100,000 people. Her educational interests include the development of new and innovative teaching modalities and pedagogies for online teaching with a focus on advanced assessment, evidence-based practice, and health promotion courses. Bernadette Mazurek Melnyk, PhD, APRN-CNP, FAANP, FNAP, FAA, is the Vice President for Health Promotion, University Chief Wellness Officer, and Helene Fuld Health Trust Professor of Evidence-Based Practice and Dean of the College of Nursing at The Ohio State University. She also is a Professor of Pediatrics and Psychiatry at the College of Medicine and Executive Director of the Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare. Dr. Melnyk is a nationally and internationally recognized expert in evidence-based practice, intervention research, child and adolescent mental health, and health and wellness. She is both a pediatric nurse practitioner and psychiatric mental health nurse practitioner, and co-editor of eight books, including Evidence-Based Physical Examination: Best Practices for Health and Well-Being Assessment; Evidence-Based Physical Examination Handbook; Implementing the Evidence-Based Practice (EBP) Competencies in Healthcare: A Practical Guide for Improving Quality, Safety, and Outcomes; Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice (4th Edition); Implementing EBP: Real World Success Stories; A Practical Guide to Child and Adolescent Mental Health Screening, Early Intervention and Health Promotion (3rd Edition); Intervention Research and Evidence-Based Quality Improvement: Designing, Conducting, Analyzing and Funding (2nd Edition); and Evidence-Based Leadership, Innovation and Entrepreneurship in Nursing and Healthcare. Dr. Melnyk has over 33 million dollars of sponsored funding from federal agencies and foundations and has authored over 450 publications. She 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, and serves as Editor of the journal Worldviews on Evidence-based Nursing. Dr. Melnyk served a 4-year term on the United States Preventive Services Task Force and recently served on the mental health standing committee of the National Quality Forum. She is a currently a member of the board of directors for the National Forum for Heart Disease and Stroke Prevention and a member of the National Academy of Medicine's Action Collaborative on Clinician Well-being and Resilience. She has received numerous national and international awards, including being named an edge-runner three times by the American Academy of Nursing. Alice M. Teall, DNP, APRN-CNP, FAANP, FNAP, is an Associate Clinical Professor and Director of Graduate Health and Wellness Programming at The Ohio State University. An expert in nursing education, Dr. Teall was honored with the Innovations in Professional Nursing Education Award from the American Association of Colleges of Nursing, the Provost Award for Distinguished Teaching from Ohio State, and the Presidential Award for Faculty Excellence from Wright State University. While serving as director of the online Family Nurse Practitioner program at The Ohio State University, she was chosen as College of Nursing Graduate Educator of the Year for 4 consecutive years. Dr. Teall is coeditor of five textbooks, including Evidence-Based Physical Examination Handbook and Assessment and Diagnosis Review for APRN Certification Exams. Alice M. Teall began her nursing career as a diploma graduate of Miami Valley Hospital School of Nursing in 1983. She earned her BS in Nursing from Capital University, her MS with a specialization as a Family Nurse Practitioner from Wright State University, and her DNP from Ohio State. She has certifications as a Family and Pediatric Nurse Practitioner and as an Integrative Nurse Coach. Her areas of clinical expertise include adolescent health, primary care of at-risk youth and families, college health, and recovery from substance use disorder. Dr. Teall is a Fellow of the American Academy of Nurse Practitioners and the National Academies of Practice. An experienced educator, Alice M. Teall has taught assessment online and on campus for students across nursing programs, including LPN, traditional undergraduate, RN--BSN completion, accelerated graduate entry, traditional master's, BS-to-DNP, post-master's, and doctoral programs. Dr. Teall has published and presented nationally about the effective use of classrooms as engaged and collaborative communities of inquiry, where active learning, timely feedback, diversity of thought, and support for self-care and wellness are norms. Her contributions to advanced practice education include innovative use of synchronous web-conferencing, incorporation of wellness coaching techniques in clinical practice, and preparation for the use of telehealth to improve access to quality care and effectively address population health.

Contributors


Preface


Acknowledgments


List of Videos


ConnectTM Resources


Part I: Foundations of Clinical Practice


Ch 1: Approach to Evidence-Based Assessment of Health and Well-Being


Ch 2: Evidence-Based Assessment of Clinician Well-Being


Ch 3: Evidence-Based History Taking, Approach to Patient Visits, and Documentation


Ch 4: Evidence-Based, Culturally Sensitive, Therapeutic Communication


Ch 5: Evidence-Based Assessment of Children and Adolescents


Ch 6: Evidence-Based Assessment of the Older Adult


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


Ch 7: Evidence-Based General Survey Including Assessment of Vital Signs


Ch 8: Evidence-Based Assessment of Body Habitus, Body Mass Index, and Nutrition


Ch 9: Evidence-Based Assessment of the Cardiovascular System


Ch 10: Evidence-Based Assessment of the Vascular System


Ch 11: Evidence-Based Assessment of the Lungs and Respiratory System


Ch 12: Evidence-Based Assessment of Skin, Hair, and Nails


Ch 13: Evidence-Based Assessment of the Lymphatic System


Ch 14: Evidence-Based Assessment of the Head and Neck


Ch 15: Evidence-Based Assessment of the Eyes


Ch 16: Evidence-Based Assessment of the Ears, Nose, and Throat


Ch 17: Evidence-Based Assessment of the Nervous System


Ch 18: Evidence-Based Assessment of the Musculoskeletal System


Ch 19: Evidence-Based Assessment of the Abdominal, Gastrointestinal, and Urological Systems


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


Ch 20: Evidence-Based Assessment of Sexual Orientation and Gender Identity


Ch 21: Evidence-Based Assessment of the Breasts and Axillae


Ch 22: Evidence-Based Assessment of Male Genitalia, Prostate, Rectum, and Anus


Ch 23: Evidence-Based Assessment of the Female Genitourinary System


Ch 24: Evidence-Based Obstetric Assessment


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


Ch 25: Evidence-Based Assessment of Mental Health


Ch 26: Evidence-Based Assessment of Substance Use Disorder


Ch 27: Evidence-Based Assessment and Screening for Traumatic Experiences: Abuse, Neglect, and Intimate Partner Violence


Part V: Special Topics in Evidence-Based Assessment


Ch 28: Evidence-Based Assessments for Medical Clearance


Ch 29: Evidence-Based Assessments Using Telehealth Technologies


Ch 30: Evidence-Based Health and Well-Being Assessment: Putting It All Together


Index


Components of Advanced Assessment and Physical Examination Inside back cover