Malaria

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An acute infectious disease caused by protozoa of the genus
Plasmodium: P. falciparum, P. vivax, P. malariae, and P. ovale
Transmitted to humans by mosquito vectors
P. falciparum malaria the most severe form of the disease
Untreated primary attacks lasting from a week to a month or longer
Overview
Relapses occurring commonly, with sporadic disease recurrence
for several years
Hepatic parasites (P. vivax, P. ovale , and P. malariae ) possibly
persisting for years in the liver (responsible for the chronic carrier
state)
Plasmodium sporozoites are injected by the bite of a mosquito
vector.
The infective sporozoites migrate by blood circulation to parenchy-
mal cells of the liver; there they form cystlike structures containing
thousands of merozoites.
Overview-Pathophysiology
Upon release, each merozoite invades an erythrocyte and feeds
on hemoglobin.
Eventually, the erythrocyte ruptures, releasing heme (malaria pig-
ment), cell debris, and more merozoites, which, unless destroyed
by phagocytes, enter other erythrocytes.
Bite of female Anopheles mosquitoes
Overview-Causes
Blood transfusion or mother-to-fetus transmission (rare)
Malaria affects males and females of all ages equally.
Most cases in the United States result from travel to or migration
Overview-Incidence from an endemic area.
Approximately one-half of cases of malaria in the United States
are due to P. falciparum.
Renal failure
Liver failure
Heart failure
Pulmonary edema
Disseminated intravascular coagulation
Circulatory collapse
Overview-Complications
Severe normocytic anemia
Seizures
Hypoglycemia
Splenic rupture
Cerebral dysfunction
Death
Travel to endemic area
Recent blood transfusion
Malaise, arthralgias, myalgias
Assessment-History
Chills, fever
Headache, backache
Nausea and vomiting, diarrhea
Pale skin
Jaundice
Assessment-Physical Findings
Petechial rash
Hepatosplenomegaly (P. vivax and P. ovale )
Peripheral blood smears identify the parasites in red blood cells.
Complete blood count (CBC) shows decreased hemoglobin levels.
CBC shows possible decreased leukocyte count (as low as
3,000/¼L) and possible thrombocytopenia.
Diagnostic Test Results-Laboratory Urinalysis results are positive for protein and leukocytes.
Malarial thick and thin preparations via microscopy identify the
form the species and quantity of the parasite.
Liver function studies may be abnormal; lactic dehydrogenase
levels are elevated.

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Prothrombin time is prolonged (18 to 20 seconds).
Partial thromboplastin time is prolonged (60 to 100 seconds).
Plasma fibrinogen levels are reduced.
Diagnostic Test Results-P. falciparum malaria
CBC shows possible decreased leukocyte count (as low as
3,000/¼L). Leukocyte count (as low as 3,000/¼
L).
Rapid antigen capture enzyme identifies P. falciparum.
Symptomatic
Treatment-General
Exchange transfusions, if severe
Treatment-Diet Increased fluid intake
As tolerated
Bed rest during acute phase
Treatment-Activity
Avoidance of contact activities and exercise if splenomegaly is
present
I.V. fluids (if unable to take oral fluids)
Artemether and lumefantrine tablets or mefloquine in combina-
tion with doxycycline or artesunate to treat acute uncomplicated
malaria due to P. falciparum
Atovaquone-proguanil as the drug of choice for mild to moderate
P. falciparum; alternatively, quinine sulfate in combination with
doxycycline or clindamycin phosphate
Oral chloroquine or primaquine phosphate (for all forms except
Treatment-Medications those caused by chloroquine-resistant P. falciparum )
Atovaquone-proguanil or quinine sulfate plus doxycycline (for
malaria caused by P. falciparum )
Parenteral quinidine gluconate or I.V. clindamycin or oral quinidine
for severe disease (See Special considerations for antimalarial
drugs.)
Antipyretics such as acetaminophen or nonsteroidal anti-inflam-
matory drugs
Antiemetics
Activity intolerance
Acute pain
Anxiety
Decreased cardiac output
Deficient fluid volume
Fatigue
Nursing Considerations-Nursing Diagnoses
Hyperthermia
Impaired gas exchange
Impaired physical mobility
Impaired skin integrity
Risk for infection
Risk for injury
participate in self-care activities as tolerated
report decreased levels or absence of pain
acknowledge fears, feelings, and concerns about the current sit-
uation
maintain adequate cardiac output
demonstrate adequate fluid balance
Nursing Considerations-Expected Outcomes report an increased energy level
remain afebrile
maintain adequate ventilation and oxygenation
maintain joint mobility and range of motion (ROM)
maintain skin integrity
experience no further signs or symptoms of infection
remain free from injury and complications.

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Obtain a detailed patient history, including recent travel to endemic
areas.
Obtain malarial smears as ordered, for example, every 6 to 12
hours for three samplings.
Administer prescribed medications, including antimalarials, an-
tipyretics, and antiemetics as indicated; if the patient has a severe
infection, initiate I.V. access and prepare to administer quinidine
gluconate as a bolus dose and then as a continuous infusion until
oral therapy can be started.
Follow proper hand-washing and aseptic techniques as well as
standard precautions.
Provide for frequent rest periods; cluster nursing activities to pro-
Nursing Considerations-Nursing Interventions
mote rest.
Auscultate heart and lung sounds for changes.
Provide meticulous skin care. Encourage the patient to change
positions frequently and to perform or assist with ROM exercises.
Encourage the patient to verbalize concerns and fears. Provide
emotional support and explanations at the patient's level of un-
derstanding, and assist with positive coping strategies.
Evaluate symptom pattern, fever, type of malaria, and systemic
signs.
Encourage fluid intake; if patient has difficulty ingesting oral fluids,
expect to administer I.V. fluids.
Report all cases of malaria to local public health authorities.
Vital signs
Response to treatment
Fluid balance
Cardiopulmonary status
Nursing Considerations-Monitoring
Skin integrity
Energy level
Functional level
Coping strategies
Blood glucose monitoring
Blood pressure assessment
Contact precautions
IV bag preparation
IV bolus injection
IV catheter insertion
Nursing Considerations-Associated Nursing Procedures Neurologic assessment
Oral drug administration
Pulse assessment
Reportable diseases
Respiration assessment
Temperature assessment
Venipuncture
disorder, diagnosis, and treatment, including the need for compli-
ance with medication therapy to reduce the risk of relapse
prescribed medications, including drug names, dosages, ratio-
nales for use, schedule of administration, and duration of therapy
need to take artemether/lumefantrine, primaquine, or ato-
vaquone-proguanil with food
possible adverse effects associated with medications, such as
Patient Teaching-General tinnitus and visual disturbances with quinine, dizziness with ato-
vaquone-proguanil, and skin reactions with chloroquine or ato-
vaquone-proguanil
signs and symptoms of relapse and the need to notify a practition-
er if any occur
importance of adequate fluid intake
need for continued follow-up care to ensure complete resolution
of the infection.

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