Nursing Care of Malaria

Nursing Care Plan for Malaria Patients.

Malaria is a relatively common condition caused by parasitic infection by the Plasmodium protozoans, generally acquired from the bite of a mosquito. The disease is widespread throughout the tropical and subtropical regions, including much of Latin America and Asia, however, the vast majority of reported cases – approximately 90% – occur in Sub-Saharan Africa.

The disease remains very prevalent in these regions with 216 million cases of malaria reported globally in 20161, resulting in an estimated 731,000 deaths2.

The Malaria parasites belong to the Plasmodium (phylum Apicomplexa) genus. Infection in humans is generally caused by infection by P. malariae, P. ovale, P. knowles, P. vivax and P. falciparum34. The vast majority of infections are reported to be caused by P. falciparum, accounting for approximately 75% of cases5.

Signs and Symptoms

Onset of symptoms varies greatly, some patients may remain asymptomatic for up to 25 days after infection, while others may manifest in as little as 1 week6. Some cases have been reported to remain asymptomatic for a period of years, however, these cases remain very sparse.
Initial manifestations of Malaria are similar to flu-like symptoms and include fever, headache, shivering, joint pain, vomiting, convulsions and haemolytic anaemia. Severe cases may present with acute respiratory distress.
Progression of the disease can lead to liver and renal failure7. Additional symptoms include severe headache, low blood sugar, haemoglobin in the urine, spontaneous bleeding, coagulopathy and shock8.
Patients with cerebral Malaria can exhibit neurological symptoms including abnormal posturing, nystagmus, conjugate gaze palsy, opisthotonus, seizures, decorticate and decerebrate posturing and coma7.

Transmission

Transmission of the Malaria disease is dependant on the female Anopheles mosquito, which acts as a definitive host and transmits the parasite in the form of a motile sporozoite into a vertebrate host (such as a human) where the parasite can travel through the blood to multiply and complete its life cycle9.
There have been reported cases of transmitted malaria infections from blood transfusions10, although these remain rare. Transmission through exposure to other body fluids is considered unlikely.
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Pathophysiology

Malaria infection involves two distinct phases, the exoerythrocytic phase, which occurs in the liver, and the erythrocytic phase, which involves red blood cells (RBC’s). The primary portal of infection is through the bite of a mosquito which serves as a reservoir for sporozoites which are present in an infected mosquitos saliva. When an infected mosquito pierces the skin of a human, these sporozoites are released into the bloodstream where they migrate to the liver and infect hepatocytes and multiply asexually. Infected patients will remain asymptomatic during this time, lasting between a week and one month6. Although the liver is a key host for the parasite, liver dysfunction is not common and usually occurs in patients with additional liver conditions, such as viral hepatitis11.

As the parasite matures in the red blood cell, it will cause the cell to swell and eventually lyse, releasing the newly multiplied parasites into the bloodstream where they can infect additional red blood cells.
The malaria parasite classically results in paroxysm, a two-day cycle of sudden coldness, followed by shivering, and then profuse sweating (diaphoresis) in actively infected patients12 (tertian fever). In P. vivax and P. ovale infections, this cycle occurs over three days (quartan fever)12.
Malaria parasites can cause acute respiratory distress in up to 25% of adult patients, and 40% of children13  thought to be caused by respiratory compensation of metabolic acidosis, noncardiogenic pulmonary oedema, pneumonia and severe anaemia.


Immune Response

Electron Micrograph of red blood cell displaying adhesion proteins. Source: Wikimedia

The parasite is relatively invisible to the body’s immune system and able to evade detection as it resides within the cells of the liver and red-blood cells. The parasite actively prevents host red-blood cells from destruction in the spleen by displaying adhesion proteins to stick to the blood vessel walls.

Genetic Resistance

The prevalence of the disease in low socio-economic combined with high levels of mortality and morbidity has resulted in genetic pressure on the human genome favouring those with genetic factors such as sickle cell traits, a glucose-6-phosphate dehydrogenase deficiency and the absence of Duffy antigens on red blood cells.
Medical Management
Malaria is commonly treated with a combination of anti-fever and targeted anti-malarial medications. Infection with lesser strains, such as P. vivax, P. ovale and P. malariae frequently do not require hospitalisation14.
The standard treatment for simple or uncomplicated malaria is the use of artemisinins in combination with other anti-malarial medications, known as antemisinin-combination therapy, or ACT15.
Common drugs used in the treatment of Malaria include;

  • Amodiaquine
  • lumefantrine
  • mefloquine
  • sulfadoxine/pyrimethamine
  • dihydroartemisinin
  • piperaquine

The WHO recommends a combination of quinine and clindamycin in early pregnancies (first trimester) and regular ACT therapy for later stage pregnancies (second an third trimester).
A vaccine is currently being trialled in several countries in an attempt to combat the disease16.

Physical Assessment

Assess the patient’s level of consciousness and monitor vital signs and urine output. Assess for evidence of shock and evidence of an enlarged spleen or liver, as well as anaemia, which could indicate active or previous malaria infection.

Look for signs of bleeding and prepare for blood transfusion if patient shows excessive bleeding. Monitor blood glucose and evaluate the patients nervous system for level of consciousness hourly.

Nursing Diagnosis & Care Plan

Nursing Assessments
– Assess the patient’s airway and breath sounds for signs of respiratory distress, or shortness of breath.
– Monitor vital signs
– Assess skin colour, turgor, peripheral pulse and capillary refill.

Nursoing Interventions
– Administer oxygen is SpO2 below 92%.
– Ventilate the room and ensure air can circulate.
– Place the patient in a semi-fowlers position.
– Discourage the patient from undertaking any high exertion activities.

Nursing Assessments
• Monitor vital signs, particularly body temperature.

Nursing Interventions
• Administer antipyretic medications as ordered.
• Ensure patient is appropriately dressed for the environment. Remove blankets or clothing is necessary.
• Maintain fluid balance to combat dehydration.

Nursing Assessments
• Monitor fluid balance (fluid balance chart)
• Assess for dehydration

Nursing Interventions
• Anticipate fluid loss through sweat associated with fever.
• Administer parenteral fluids as appropriate.

Nursing Assessments
• Assess GO tract for regular bowel sounds.
• Measure patients weight.

Nursing interventions
• Provide food as tolerated
• Provide oral hygiene
• Encourage bed rest or reduced activity
• Administer PRN anti-emetic medications

Nursing Assessments
• Assess the patient’s knowledge of the disease, its processes and risks

Nursing Interventions
• Discuss the importance of adhering to the treatment plan.
• Review and explain medication with patient or and/or carer
• Review disease process with patient
•Supply patient with reading material or documentation if appropriate

1.
WHO . World Malaria Report 2017. WHO; 2017.
2.
GBD 2015. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1459-1544. [PubMed]
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Collins W. Plasmodium knowlesi: a malaria parasite of monkeys and humans. Annu Rev Entomol. 2012;57:107-121. [PubMed]
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Mueller I, Zimmerman P, Reeder J. Plasmodium malariae and Plasmodium ovale–the “bashful” malaria parasites. Trends Parasitol. 2007;23(6):278-283. [PubMed]
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Nadjm B, Behrens R. Malaria: an update for physicians. Infect Dis Clin North Am. 2012;26(2):243-259. [PubMed]
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Bartoloni A, Zammarchi L. Clinical aspects of uncomplicated and severe malaria. Mediterr J Hematol Infect Dis. 2012;4(1):e2012026. [PubMed]
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Rijken M, McGready R, Boel M, et al. Malaria in pregnancy in the Asia-Pacific region. Lancet Infect Dis. 2012;12(1):75-88. [PubMed]
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Schlagenhauf-Lawlor P. Travelers’ Malaria. PMPH-USA; 2008.
10.
Owusu-Ofori A, Parry C, Bates I. Transfusion-transmitted malaria in countries where malaria is endemic: a review of the literature from sub-Saharan Africa. Clin Infect Dis. 2010;51(10):1192-1198. [PubMed]
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Bhalla A, Suri V, Singh V. Malarial hepatopathy. J Postgrad Med. 2006;52(4):315-320. [PubMed]
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Ferri F. Protozoal infections. In: Ferri’s Color Atlas and Text of Clinical Medicine. Elsevier Health Sciences; 2009:1159.
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Korenromp E, Williams B, de V, et al. Malaria attributable to the HIV-1 epidemic, sub-Saharan Africa. Emerg Infect Dis. 2005;11(9):1410-1419. [PubMed]
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Waters N, Edstein M. 8-Aminoquinolines: Primaquine and Tafenoquine. In: Treatment and Prevention of Malaria: Antimalarial Drug Chemistry, Action and Use. Springer; 2012:69-93.
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Kokwaro G. Ongoing challenges in the management of malaria. Malar J. 2009;8 Suppl 1:S2. [PubMed]
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Walsh F. Malaria Vaccine gets “green light.” BBC News Online. http://www.bbc.com/news/health-33641939.

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