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unit7resp.docx Peer Response Instructions: Review the plans posted by your peers from your advanced practice nursing role perspective (educator, leader or nurse practitioner).  From this mindset, reflect upon a discussion you would like to have with your colleagues about their plan. · For example - if you are a nurse educator (clinical or academic) what are your thoughts about the patient education provided in the plan, or do you want to comment on or add to the education provided?   · If you a nurse leader what are your thoughts about the risk profile or cost effectiveness of the plan? · If you are a nurse practitioner did your peer develop a plan that aligns with evidence-based practice and current clinical guidelines? Etc. Please be sure to validate your opinions and ideas with citations and references in APA format.  Lucas Parenti Aug 20 4:44pm Reply from Lucas Parenti Diagnosis The 52-year-old male has a past medical history and symptoms that points to erectile dysfunction as the diagnosis. The reduced ability to maintain and achieve an erection are key symptoms for erectile dysfunction (Leslie & Sooriyamoorthy, 2024) The patient's poorly controlled type 2 diabetes mellitus with an A1C of 8.2%, hypertension, obesity, sedentary lifestyle, and hyperlipidemia have been shown to be risk factors for erectile dysfunction.   Management and Rationale The patient will need a comprehensive approach by implementing lifestyle changes and pharmacologic therapy as warranted. The first line treatment in erectile dysfunction is phosphodiesterase type-5 inhibitors that play a role in increasing the blood flow to the penis during sexual activity. Sildenafil, also known as Viagra, is a common prescription medication for patients experiencing ED (Burnett et al., 2018). The patient should also have blood work done for testosterone levels as low testosterone can have a negative impact on the patient's erectile dysfunction  (Leslie & Sooriyamoorthy, 2024). As noted by Bhasin et al. (2018), managing the patient's weight, improving proper glycemic control, and increasing physical activity are important modifiable risk factors for ED.   Prescription The patient will start taking Sildenafil 50mg orally one hour prior to sexual activity. The patient should not take this more than time per day and to take on an empty stomach. The patient will need to be educated on allowing the medication to take effect within 30-60 minutes. The patient will have ordered labs for monitoring total testosterone, CBC, TSH, HbA1C, and CMP to follow up on the diabetes control as well as evaluate further on the patient's fatigue.     Patient Education The patient will be educated on ED and that it is a treatable condition and common that is influenced by nerves, hormones, and the patient's past medical history as it is not uncommon with men that have diabetes and hypertension. The patient will be educated on sildenafil, the newly prescribed medication and the importance of when to take it. Certain side effects can include headaches, mild visual changes, and nasal congestion (Leslie & Sooriyamoorthy, 2024). The patient will also be educated on lifestyle modifications such as walking 30 minutes per day, implementing proper dietary habits, and glycemic control.   Follow-Up Plan The patient will follow up within 4 weeks to evaluate sildenafil and adjust the dose as needed. Labs will be reviewed, and an endocrinologist will need to be referred if the testosterone is low. The patient will also need a dietician referral to help make healthy eating habits.   References   Bhasin, S., Cunningham, G. R., Hayes, F. J., et al. (2018). Testosterone therapy in men with hypogonadism: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 103(5), 1715–1744.  https://doi.org/10.1210/jc.2018-00229Links to an external site. Burnett, A. L., Nehra, A., Breau, R. H., et al. (2018). Erectile dysfunction: AUA guideline. The Journal of Urology, 200(3), 633–641.  https://doi.org/10.1016/j.juro.2018.05.004Links to an external site. Leslie, S. W., & Sooriyamoorthy, T. (2024, January 9).  Erectile dysfunction. StatPearls.  https://www.ncbi.nlm.nih.gov/books/NBK562253/Links to an external site. · Reply to post from Lucas Parenti Reply · Mark as Unread Mark as Unread Mariam Lomashvili Aug 20 3:53pm Reply from Mariam Lomashvili Diagnosis The most likely diagnosis for this 52-year-old male is erectile dysfunction (ED), predominantly vasculogenic, in the context of multiple cardiometabolic risk factors. His type 2 diabetes (A1C 8.2%), hypertension, hyperlipidemia, obesity (BMI 32), and sedentary lifestyle all contribute to endothelial dysfunction and impaired nitric oxide signaling, which are key mechanisms of ED. The diminished peripheral pulses further suggest vascular disease. Importantly, the patient maintains normal libido, making hypoactive sexual desire disorder less likely. The presence of mild nocturia could point toward lower urinary tract symptoms (LUTS) or benign prostatic hyperplasia (BPH), which may influence therapeutic decision-making. Diabetes is strongly associated with ED, and better glycemic control has been shown to improve outcomes (Defeudis et al., 2022; Wang et al., 2023). Management and Rationale Initial evaluation should include laboratory studies such as fasting glucose, repeat A1C, morning total testosterone, lipid panel, and renal function tests. If testosterone is low, further hormonal evaluation with luteinizing hormone, follicle-stimulating hormone, and prolactin would be warranted. Screening for depression, obstructive sleep apnea, and atherosclerotic cardiovascular disease (ASCVD) is also important, given that ED can serve as an early marker of vascular disease (Wang et al., 2023). Additionally, prostate-specific antigen (PSA) testing may be considered in the setting of nocturia after shared decision-making. The first-line treatment for this patient is a phosphodiesterase-5 inhibitor (PDE5i). PDE5 inhibitors are effective in improving erectile function, including in men with diabetes, though response rates may be lower compared to the general population. Tadalafil is a particularly suitable option in this case because daily dosing of 5 mg not only improves erectile function but also reduces LUTS associated with BPH, thereby addressing both of the patient’s concerns (Defeudis et al., 2022; Wang et al., 2023). If the patient prefers an on-demand regimen instead of daily therapy, sildenafil 50 mg to 100 mg as needed 30–60 minutes before sexual activity is an alternative. Both options are safe with his current medications, though caution should always be taken to avoid concurrent nitrate use. Lifestyle and cardiometabolic optimization are also essential. Structured exercise, weight reduction, a Mediterranean-style diet, and improved sleep can enhance erectile function and improve glycemic control. Targeting an A1C closer to 7%, ensuring blood pressure control, and optimizing lipid management are important for both sexual and cardiovascular health (Defeudis et al., 2022). Prescription The prescription for this patient would be: 1. Tadalafil 5 mg orally once daily. Take one tablet by mouth at the same time each day, with or without food. Do not exceed one tablet in 24 hours. Dispense 30 tablets. Refills: 2. If the patient prefers on-demand dosing instead of daily therapy: 1. Sildenafil 50 mg orally as needed. Take one tablet by mouth 30–60 minutes prior to sexual activity. May increase to 100 mg or decrease to 25 mg based on response and tolerability. Do not exceed one dose in 24 hours. Avoid taking with high-fat meals. Dispense 6–10 tablets. Refills: 2. Patient Education Patient education should emphasize that PDE5 inhibitors require sexual stimulation to be effective. The patient should be informed about common side effects, including headache, flushing, nasal congestion, dyspepsia, and—specifically with tadalafil—back pain or myalgias. He should be instructed to seek urgent medical attention for chest pain, sudden vision or hearing changes, or an erection lasting longer than four hours. Equally important is counseling on lifestyle changes. The patient should aim for at least 150 minutes of moderate aerobic activity per week, combined with resistance training twice weekly. Weight reduction of 5–10% can significantly improve both glycemic control and erectile function. Alcohol should be limited, and tobacco should be avoided. Sleep hygiene should also be addressed. Patients should also be cautioned against using over-the-counter “male enhancement” supplements, as many of these products are adulterated or lack reliable efficacy data (Petre et al., 2023). Follow-up and Referral The patient should follow up in 4–6 weeks to evaluate the effectiveness and tolerability of the prescribed PDE5 inhibitor, review adherence to lifestyle modifications, and assess laboratory results such as A1C and testosterone. If the initial therapy proves ineffective, options include dose titration, switching PDE5 inhibitors, or adding second-line interventions such as vacuum erection devices or alprostadil. If laboratory evaluation reveals hypogonadism, referral to endocrinology would be indicated for further management. Referral to urology should also be considered if the patient fails first-line therapies. Finally, given the diminished peripheral pulses and known cardiometabolic disease, a referral to cardiology may be warranted to evaluate for systemic vascular disease, since ED is often an early indicator of cardiovascular pathology (Wang et al., 2023). References Defeudis, G., Mazzilli, R., Tenuta, M., Rossini, G., Zamponi, V., Olana, S., Faggiano, A., Pozzilli, P., Isidori, A. M., & Gianfrilli, D. (2022). Erectile dysfunction and diabetes: A melting pot of circumstances and treatments.  Diabetes/Metabolism Research and Reviews,  38(2), e3494.  https://doi.org/10.1002/dmrr.3494Links to an external site. Feng, H., Peng, W., Deng, Z., Liu, J., & Wang, T. (2023). Erectile dysfunction and exosome therapy.  Frontiers in Endocrinology,  14, 1123383.  https://doi.org/10.3389/fendo.2023.1123383Links to an external site. Petre, G. C., Francini-Pesenti, F., Vitagliano, A., Grande, G., Ferlin, A., & Garolla, A. (2023). Dietary supplements for erectile dysfunction: Analysis of marketed products, systematic review, meta-analysis and rational use.  Nutrients,  15(17), 3677.  https://doi.org/10.3390/nu15173677Links to an external site. Wang, C.-M., Wu, B.-R., Xiang, P., Xiao, J., & Hu, X.-C. (2023). Management of male erectile dysfunction: From the past to the future.  Frontiers in Endocrinology,  14, 1148834.  https://doi.org/10.3389/fendo.2023.1148834