FNP_Standardized_Procedure_Worksheet_AP 601 (1)
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Chamberlain College of Nursing *
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NR 601
Subject
Medicine
Date
Dec 6, 2023
Type
docx
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8
Uploaded by apenaloza098
NR601 Standardized Procedure Worksheet
Name: Amy Penaloza
Carefully read the assignment guidelines and rubric and complete each section of the worksheet below.
1. Definition
A.
Disease or condition- Erectile Dysfunction in Older Adults
a.
ED is the inability to sustain an erection of cavernous smooth muscle in the penis during sexual intercourse (Hicks et al., 2021).
B.
Pathophysiology- a.
Erections are a neurovascular response that begins with a release of nitrous oxide and increased production of cGMP. cGMP triggers potassium channels and prevents calcium from entering the cells. Prostaglandin F2a and Norepinephrine activate receptors on cavernous smooth muscles causing relaxation. Dilation of arteries begins to occur leading to blood flow into the penile shaft. Compression of subtunical veins begins which decreases blood outflow. Stretching of the tunica begins which decreases venous outflow and Po2 increases to 100mmHg which causes an erection. The pressure continues to cause ischiocavernous muscle creating rigidity for sexual intercourse.
(Mirone et al., 2022) 0320 RB/KK
b.
Erectile dysfunction can be a result from a vascular, neurologic, endocrine, structural, psychologic, or structural cause. Medications and poor social habits such as smoking and high alcohol intake can also cause ED.
(Jackson et al., 2019)
C.
Incidence and prevalence
a.
Incidence-Approximately 600,000 new cases of Erectile Dysfunction reported annually in the United States. ED affects 50% of men above the age of 40 years old. (Sirikan Rojanasarot et al., 2023)
b.
Prevalence- i.
Men 40-49 12.4%
ii.
Men 50-69 46.6 %
iii.
8.3% (10,302,540 out of 124,318,519) of insured males received care for ED in 2022. iv.
Hispanic men 19.9%, Caucasian men 21.9%, African American men 24.4%. (Sirikan Rojanasarot et al., 2023)
2. Assessment
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A.
Symptoms
a.
Flaccid penis
b.
Reduced sexual drive.
c.
Trouble keeping an erection during sexual intercourse.
d.
Trouble initiating an erection.
e.
Premature ejaculation
f.
Delayed ejaculation
g.
Unable to produce an orgasm after stimulation. (Saramies et al., 2022)
B.
Physical Exam
a.
Visual inspection and palpation of genitalia. DRE is not required.
b.
BP, BMI, and waist circumference
c.
Visual inspection of decreased body hair and small testicle
d.
Observe for gynecomastia
e.
Bulbocavernosus reflex . Assess anal sphincter tone and genital reflexes. f.
Assessments-Cardiovascular assessment + for CVD, Arteriosclerosis, HTN, or PVD. Neurological assessment + for depression, anxiety, or performance anxiety. Genitourinary assessment + enlarge prostate. Endocrinological assessment + for Diabetes
g.
Assess for Penile plaques
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h.
Asses femoral and lower extremity pulses for blood flow to genitals. (Selvin et al., 2023)
C.
My practicing state is Florida. Physician collaboration is not required. 3. Diagnostic tests
A.
Testing
a.
Labs- hbA1C, lipid panel, CBC, BMP, TSH, Testosterone level
b.
Radiology- Doppler ultrasound, angiogram, cavernosogram, c.
International Index of Erectile Function (IIEF) Patient Questionnaire d.
Nocturnal erection test
e.
Injection Test
(Hsiao et al., 2019)
B.
Expected results
a.
Abnormal lab results include low testosterone levels, uncontrolled DM and CVD. b.
Abnormal radiological results reveal poor blood supply to penis or obstruction.
c.
Injection test can reveal short lasting erections
d.
Nocturnal Erection Test can report no erections or flaccid erections.
e.
Cavernosography can be positive for a venous leak.
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(Hsiao et al., 2019)
4. Management
A.
First-line medications
i.
Sildenafil (Viagra) 25mg qdaily. Max dose 100mg. Geriatric dose 25mg. Use as needed at least 1 hour up to 4 hours prior to the start of sexual intercourse. Take on an empty stomach for maximum effectiveness.
ii.
Contraindications- Do not nitroglycerin can cause fatal hypotension.
iii.
Side effects- prolong erections, sodium retention, hypotension, avoid grapefruit
(Mirone et al., 2022)
B.
Second-line medications
i.
Intraurethral alprostadil (Muse) Intraurethral suppository 125 ug pellets. Max dose 250ug. Administer 5 minutes to 50 minutes prior to the start of sexual intercourse. Recommendation is no more than 2 pellets in a 24hour period. ii.
Contraindications- Do not nitroglycerin can cause fatal hypotension.
iii.
Side effects- penile pain, dizziness, urethral bleeding, dysuria
(Mirone et al., 2022)
C.
Other treatments
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i.
Surgical intervention- Penile prosthesis can be considered for appropriate candidate.
ii.
Shockwave therapy- effective clinical procedure for men with erectile dysfunction that is caused by having vascular disease.
iii.
Improving lifestyle, treating anxiety and depression, healthy eating
habits, losing weight, addressing comorbidities.
iv.
Smoking Cessation can restore erectile function.
(Antonio et al., 2022) D. Follow-up
i.
Patient should notify provider if erection lasts longer than 4 hours. The provider will advise to seek immediate attention. ii.
If a patient that is not responding well to medications or has adverse side effects patient should stop using medication and check in for a follow up to discuss next course of action. iii.
After starting ED treatment, patients should follow up at the clinic 1-3 weeks. Assessment of quality and quantity of erections is needed as well as the patient’s satisfaction of erection achieved. (Antonio et al., 2022) E.
Referral
i.
Referral to urologist if patient does not respond to medications or treatment plan well. Patient can also request a surgical consult for surgical intervention by urologist. 0320 RB/KK
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References
Antonio, L., Wu, F. C. W., Moors, H., Matheï, C., Huhtaniemi, I. T., Rastrelli, G., Dejaeger, M., O’Neill, T. W., Pye, S. R., Forti, G., Maggi, M., Casanueva, F. F., Slowikowska-Hilczer, J., Punab, M., Tournoy, J., Vanderschueren, D., Forti, G., Petrone, L., Corona, G., & Rastrelli, G. (2022). Erectile dysfunction predicts mortality in middle-aged and older men
independent of their sex steroid status. Age and Ageing
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(4). https://doi.org/10.1093/ageing/afac094
Hicks, C. W., Wang, D., Windham, B. G., & Selvin, E. (2021). Association of Peripheral Neuropathy with Erectile Dysfunction in US Men. The American Journal of Medicine
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(2), 282–284. https://doi.org/10.1016/j.amjmed.2020.07.015
Hsiao, W., Ruth Ann Bertsch, Hung, Y.-Y., & Aaronson, D. S. (2019). Tighter Blood Pressure Control Is Associated with Lower Incidence of Erectile Dysfunction in Hypertensive Men. The Journal of Sexual Medicine
, 16
(3), 410–417. https://doi.org/10.1016/j.jsxm.2019.01.011
Jackson, S. E., Firth, J., Veronese, N., Stubbs, B., Koyanagi, A., Yang, L., & Smith, L. (2019). Decline in sexuality and wellbeing in older adults: A population-based study. Journal of Affective Disorders
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, 912–917. https://doi.org/10.1016/j.jad.2018.11.091
Mirone, V., Fusco, F., Cirillo, L., & Napolitano, L. (2022). Erectile Dysfunction: From Pathophysiology to Clinical Assessment. Practical Clinical Andrology
, 25–33. https://doi.org/10.1007/978-3-031-11701-5_3
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Saramies, J., Koiranen, M., Auvinen, J., Uusitalo, H., Hussi, E., Becker, S., Keinänen-
Kiukaanniemi, S., Tuomilehto, J., & Suija, K. (2022). A Natural History of Erectile Dysfunction in Elderly Men: A Population-Based, Twelve-Year Prospective Study. Journal of Clinical Medicine
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(8), 2146. https://doi.org/10.3390/jcm11082146
Selvin, E., Wang, D., Tang, O., Fang, M., Christenson, R. H., & McEvoy, J. W. (2023). Elevated Cardiac Biomarkers, Erectile Dysfunction, and Mortality in U.S. Men. JACC
, 2
(4), 100380–100380. https://doi.org/10.1016/j.jacadv.2023.100380
Sirikan Rojanasarot, Abimbola Onigbanjo Williams, Edwards, N., & Khera, M. (2023). Quantifying the number of US men with erectile dysfunction who are potential candidates for penile prosthesis implantation. Sexual Medicine
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(2). https://doi.org/10.1093/sexmed/qfad010
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