Malaria

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MALARIA:

COMPILED

DEFINITION OF MALARIA:

1. It is an acute tropical protozoa infection caused by an infected female


anopheles mosquito bite found in hit and cold climate.

2. This is an acute tropical protozoa infection caused by plasmodium parasite.

MAIN PLASMODIUM SPECIES

Plasmodium falciparum

Plasmodium vivax

Plasmodium ovale

Plasmodium malariae

NB: In Zambia there are 250 species of mosquitoes and about


40 belong to the anopheles species . Three main vectors have
been identified and these are:

Anophelus fenestus

Anophelus gambiae

Erabiensis

MODE OF TRANSMISSION:

o Through bite by an infected anopheles mosquito

o Through blood transfusion i.e if the blood is contaminated by malaria


parasite

o Through transplacental mother to child.

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LIFE CYCLE OF MALARIA

The malaria parasite life cycle involves two hosts (mosquito and human being). The
sexual reproductive phase takes place in the mosquito while the asexual reproductive
phase occurs in the human half.

STAGE ONE: A female mosquito that has already fed on a blood meal from an
infected person bites another person and injects sporozoites which are found in its
saliva.

STAGE TWO: This is also known as the liver stage. The sporozoites rapidly enter the
liver cells and transform into tissue schizonts that reproduce asexually to generate
large numbers of merozoites. Note that in plasmodium vivax and plasmodium ovale a
dormant stage(hypnozoite) can persist in the liver and cause relapses by invading the
blood stream weeks or even years later.

STAGE THREE: After 5-20 days the merozoites rapture the liver cells and begin the
erythrocytic cycle (RBC cycle). During the cycle the merozoites invade the RBCs in the
peripheral blood system, where they feed and multiply further resulting into a large
increase of parasite population in the human host. The release of merozoites
produces the characteristic fever in the patient.

STAGE FOUR AND FIVE: After the asexual cycle, some merozoites develop into
gametocytes the sexual form which are ingested by the mosquito sucking blood.

STAGE SIX: In the mosquito gut, male and female gametes merge from the
gametocytes and fuse into zygote which migrate into the gut wall where they
produce the oocysts. Each oocyst generates approximately 1000 sporozoites. After 2
weeks the sporozoites migrate into the mosquitos salivary gland becoming highly
infective after 9 days and the cycle resumes.

CLINICAL FEATURE

1. irritability - This is because the child experiences

pain all over the body. This comes as a result of body


malaise, headache, myalgia etc.

2. Vomiting: - This is due to irritation of the Git


by the parasites.

3. Convulsions - This is a result of high


temperature.

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These convulsions are more common in children less
than 3 years.

4. Fever - This happens when red blood


cells burst.

This could be accompanied by slight chills. The fever


ranges between 390C to 410C.

5. Coughing - This comes as a result of severe


vomiting

6. Sweating - This comes as a result of sudden


fall in temperature

as the client begins to feel better.

7. Annorexia - This is due to vomiting

8. Diarrhoea - Due to Git disturbances. It can


also be due to

metabolic disturbances.

PATHOPHYSIOLOGY:

First a mosquito bite occurs and sporozoites are inoculated


into the hosts blood stream. These sporozoites migrate to
liver of the host for development and multiplication. This
process is called pre-erythrocytic schizogony.

Tissue schizous enlarges and divides to form thousand of


merozoits when merozoites are formed the liver tissue
ruptures and releases the merozoites into the blood stream

In the blood stream, the merozoites enter the red blood cells.
In the red blood cell the merozoites develops into ring forms
which grow in size, becoming trophozoites. These multiply and
divide into a number of small merozoites and form schizonts.

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The merozoites are released by rupture of the red cell
membrane and enter new young red cells. After a period,
some merozoites give rise to two sexually differentiated forms
of gametocytes (male and female) ready to be sucked by a
mosquito.

MANAGEMENT:

OBJECTIVES:

To eradicate the causative organism

To prevent complications such as anaemia

To reduce the temperature to normal

To treat the symptoms i.e fever, diarrhoea.

INVESTIGATIONS:

o History taking: Complete history should include common symptoms of


malaria , age, place of residence, recent travel history, treatment history,
history of recent blood transfusion and other illness. In children refuse to feed
or decreased activity should be noted.

o Laboratory diagnosis: use of microscope to confirm the presence of parasites


with aid of blood slide (BS). Rapid diagnostic test (RDT) is an immune-
chromatic test used to diagnose malaria. Cassettes and strips are used to
carry out the test, results are can be read in 10-15 minutes.

o Blood for haemoglobin to rule out anaemia.

TREATMENT FOR MALARIA

2. Quinine:

Dose: - Infants up to 1 year P.O.


250 mg daily

in divided dose for 5-7 days.

Child 1-3 years 400 mg


daily individed

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doses for 5-7 days. 3-6 years 650 Mg daily in
divided doses every 4-6 hours for 5-7 days. 6-12
years 1000 mg (1g) daily every 4-6 hours for 5-7
days.

Injection 10 mg/Kg body weight in 500 ml 5%


glucose over 4 hours every 8 hours.

Side effects: - Tinnitus, headache


abdominal pain,

nausea, visual disturbances, confusion,


hypersensitivity reactions, hypoglycaemia, renal
failure.

Nursing Implication - Give the drug with


glucose

- Give with a lot of water.

3. Fansidar:

Dose: - 5-10KgKg -
tablet

- 10-20 Kg - 1
tablet

- 20-30 Kg - 1
KG

- 30-45 Kg - 2
tablets

- >45Kg - 3
tablets

Side effects: - Dizziness, headache,


anorexia, glossitis,

general body malaise

Nursing Implication - Explain the side effects

- Encourage the client to do oral care frequently.

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PARACETAMOL:

Dose- 3 months - 1 year 60-120 mg, 1-5


years 120-250 mg,

6-12 years, 250-500 mg. These are given 6


hourly.

Side effects: - Liver damage on


prolonged use

Nursing Implication: - Avoid use for long time.

NURSING CARE:

OBJECTIVES:

To relieve symptoms

To maintain good nutritional and physiology body status

To prevent complications such as cerebral malaria

To educate patient on malaria preventive measures

To provide comfort for the patient.

RELIEF OF SYMPTOMS:

Admit the child in a general ward which is well ventilated for good
oxygenation The ward should be clean and have good lighting, make sure
that the cot is maintained dry as a wet bed is a source of discomfort. Create a
peaceful environment for rest by minimizing noise.

The child will be nursed according to stages i.e cold, hot and sweating stages.

During the cold stage, more bedding to prevent chilling the child. A heater be
provided if possible to reduce on rigors which cause severe muscle aching.

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During the hot stage, the windows will be opened to keep him/her
comfortable. Extra linen will be removed to reduce on heat. A fan may be
provided if possible, but it should not be directly to the child as it causes
hyperventilation to the child.

During the sweating stage, the child will continue on light covers. During this
stage, a child will be given a bath in order to keep him/her comfortable. Wet
linen will be removed and replaced with dry and clean linen.

OBSERVATION

Observations of vital signs will be done 2 hourly to assess the childs


condition. Temperature will be done to detect hypothermia or pyrexia.
Respiration will be done to monitor the condition of the respiratory system.
Pulse will be done to rule out cardiac involvement. Blood pressure will also
be done to rule out cardiovascular disorders.

The child will also be observed for convulsion. If present, report and carry the
orders. The weight will be monitored to assess progress and it also helps in
drug administration. Observe the feeding harbits as the child may tend not to
eat due to vomiting. Observing for any stool abnormalities for colour, smell,
constipation or diarrhoea. Observe for urine output to rule out kidney failure.

PSYCHOLOGICAL CARE:

Explain the condition of the child to the mother or care taker. Explain that
the condition will change as this is to allay anxiety. Allow the caretaker to
ventilate his/her views about the condition of the child.

Procedures and investigations to be carried out and will be explained to gain


co-orperation. Explain every thing possible being done to improve the
condition of the child.

NUTRITION AND FLUID:

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Encourage the mother to continue breast feeding the child if she/he is still
breast feeding. Iv fluids may be given as ordered to replace lost fluids and
electrolytes through vomiting and diarrhoea. Encourage mother/caretaker to
give the child adequate glucose to prevent hypoglycaemia. Proteins and
vitamins should be encouraged to provide energy and quick recovery. Avoid
irritating foods.

HYGIENE:

Bathing is one of the most important procedures to be done in order to


promote comfort. To prevent infectious. Oral care is important to stimulate
appetite. Frequent change of linen as soon as they are wet to promote
comfort.

REST AND SLEEP:

Provide a restful environment by minimizing noise, to promote sleep. Feed


the child and bath him/her to promote sleep and rest.

Prescribe drugs should be given to relieve pain and promote sleep and
comfort. Procedures should be timed in order to allow enough time for
resting.

ELIMINATION:

Monitor the voiding patterns of the child to detect kidney failure. Roughage
should be given to prevent constipation. Record the finding and report to the
in charge.

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IEC;

THE MOTHER OR CARETAKER WILL BE EDUCATED ON THE NEED TO SLEEP UNDER


TREATED MOSQUITO NETS.

1. The cause of malaria will be explained to the mother and the signs
and symptoms will be explained so that she is aware of these.

2. Teach the mother not to buy drugs from anywhere as drugs sold may
loose its potency.

3. Encourage the mother to continue giving drugs to the child if she/he is


to be discharged on drugs.

4. Encourage to report recurrencies of symptoms immediately

5. Encourage to bring the chid 4-5 days after completion of medication


for blood tests.

6. Cutting of long grass and clearing of the yard should also be


encouraged.

7. All stagnant water should be removed as this is a breeding place for


mosquito.

COMPLICATIONS:

1. Cerebral malaria

2. Anaemia

3. Splenomegally

4. Jaundice

5. Black water fever

6. Kidney failure.

***************************

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MARKING KEY

MALARIA:

(a) (i) Give the main causative organism.


4%

- Plasmodium Falciparum which is the most dangerous of the


four malaria parasites rapidly developing anaemia.

(ii) State 5 signs and symptoms.


15%

1. Headache due to parasitaemia, toxins and general


illness

2. Joints pains-parasitised RBCS attracts other RBCs leading to clumping and


blocking of capillaries.

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3. Fever accompanied by rigors and sweating when malaria parasite are
released from red blood cells into the blood stream after incubation period.
Fever is usually characterised by the cold, hot and sweating stages.

4. Rigors feeling of coldness, then hotness and finally sweating followed by a


feeling of wellness.

5. Vomiting-irritation of stomach by increased bile triggers transmission of


impulses that leads to vomiting.

(b) LIFE CYCLE IN MAN: 16%

2% 2%

Gametocytes form ready Infected mosquito bite.

To be sucked.

2%

2% Pre-
erythrocyte sporozoites and

Saliva are released in the

Blood stream of man.

Merozoites are released

Into the blood stream by

Rupture of RBC membrane to

enter new RBC.

2%

2% Sporozoites go
to the hosts liver

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Cells where development and multiplication

Takes place.

Trophozoites develop and divide into

Small merozoites and from mature schizonts.

2%

Tissue schizonts enlarge divide to form thousand

Of merozoites.

2%

Merozoites are released into the blood

Stream

First a mosquito bite occurs

Sporozoites are innoculated into the host's blood steam

Sporozoites go to the host's liver for development and multiplication known as


pre-erythrocytic schizogony

Tissue schizont enlarges and divides to form thousands of merozoites.

The liver tissue ruptures to release the merozoites into the blood stream.

In the blood stream the merozoites enter the Red Blood cells.

In the Red cell the merozoites develop into ringforms which grow in size,
becoming trophozoites.

These multiply and divide into a number of small merozoites and form mature
schizonts.

The merozoites are released by rupture of the red cell membrane and enter new
young red cells.

After a period some meroites give rise to two sexually differentiated forms of
gametocytes (male an female), ready to be sucked by a mosquito.

2% each phase with correct


explanation.

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(c) Describe management.

(i) Medical treatment 15%

1. Quinine: (Blood Schizontoicide)

Dose: Tablets: 600 mg 8 hourly for 5 to 7 days.

Intravenously 1200 mg in1000 mls of 10% dextrose to run in 4 hours stat, then
600 mg in 500 Ml 10% dextrose. 8 hourly to run in 4 hours by three (03) to six
(06) doses or 30 Mg/Kg body Weight followed by 10 Mg/Kg body weight quinine.

Side Effects:- 1. Vertigo

2. Headache

3. Confusion

4. Ataxia

5. Hypotension

6. Tachycardia

7. Tinnitus

8. Hypoglycaemia

9. Temporary deafness

Nursing Implications:

1. Check apical pulse rate and blood pressure before commencing treatment

2. Use cautiously in patients with hepatic or renal impairment

3. Give supplementay or extra glucose to prevent hypoglycaemia

4. Explain the possible side effects

2. Fansidar: (Antimetabolite)

Dose: 3 tablets/1500 mg stat as a single dose.

Side Effects:

1. Atrophic glossitis

2. Agranulocytosis

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3. Aplastic anaemia

4. Leukopenia

5. Thrombocytopaeni

6. Headache

Nursing Implications:

1. Use with caution in patients with hepatic or renal dysfunction

2. Administer supplementary iron tablets to prevent anaemia

3. Advise adequate fluids for effective drug excretion

3. Coaterm. Dose: 16 tables divided in 5 doses 4 Initial, 4


after 8 hrs, 4 after 24

hrs and 4 - 2nd day. Side effects: Being investigated. CIs:


Pregnant women

Side effects: being investigated. CIs:

Pregnant women

Weight below 10kg

4. Halofantrin Hydrochloride (Halfan) (Schizantoicide)

Dose: 500 mg (2 tablets) 8 hourly times 3 doses

Side Effects:

1 Abdominal pains

1. Diarrhoea

2. Puritis and skin rash

3. Ventricular dysarrythimias

Nursing Implications

1. Do not use in pregnancy or lactating mother and cardiac patients.

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2. Advise a fat containing diet for fast absorption

5. Paracetamol Tablets:

Dose: 1000 mg TDS oral x 3/7

6. Ferrous Sulphate

Side Effects:

Liver damage after prolonged use. Kidney damage after prolonged use.

Nursing Implication:

Give correct dose and for 3 days only.

NOTE: To describe at least 3 drugs. 1% for correct name

1% for correct dose

2% for 2 correct side effects

1% for appropriate nursing implication.

Total: = 15%.

Nursing Care (35%)

Objectives: 2%

1 1. To treat malaria by drug administration

2. To prevent complications such as cerebral malaria

3. To maintain good nutrition and physiological body status

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Environment: (2%)

- Suzwayo will be nursed in a well ventilated room


for good oxygenation since pyrexia disturbs
respiratory pattern. Suzwayo malaria being
recurrent Suzwayo may have low haemoglobin
level which demands for good ventilation and
enough oxygen.

- The bed should be maintained dry as a wet bed is


a source of discomfort.

- She will be nursed in the main ward with good


lighting but quiet to promote rest

Environment in cold stage (2%)

- During the cold stage, more blankets will be given


to him to prevent chilling as during this stage he
will have rigors and feels very cold.

- A heater may be put to keep him warm and to


reduce on rigors which causes severe muscle
aching thereafter.

- A warm drink will be encouraged such as a cup of


tea to keep her warm.

Environment in hot stage (2%)

- Windows will be opened to keep him comfortable


as he will not tolerate heat.

- If heat is conserved at this stage, the high


temperature can damage the hypothalamus.

- Temperature is reduced by removing extra


blankets.

- Provision of a fan but should not be direct as it


can hyperventilate the patient.

Environment in sweating stage (1%)

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- Patient continues on light bed covers

- Wet linen is changed as sweat can be


discomforting and it is good media for microbes.

Observations (12%)

- Vital signs observations are monitored 4 hourly to


monitor patient patient's condition.

- These are pulse, respiration, temperature and


blood press.

- If temperature is higher then 39o C then tepid


sponging be done and patient be covered in light
linen with fan on.

- Observe for side effects of drugs such as in,


hypoglycaemia in quinine administration.

- If established present, then commence Iv fluids


after doctor's orders.

- Prevent hypotension by giving a lot of oral fluids.

- Prevent hypoglycaemia by giving food rich in


carbohydrates.

- Observe general condition of the patient such as


mental stability and level of consciousness to
detect early complication such as cerebral
malaria.

- Watch for paroxysmal stages in order to provide


the appropriate care.

- Observe for delirium which may be due to


hyperpyrexiaa and not necessariy cerebral
malaria.

- Monitor elimination pattern such a adequate


urination since malaria may complicate to black
water fever and renal failure.

- Observe for hydration status especially in the


sweating stage when profuse sweating could lead
to dehydration.

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- If established, give a lot of fluid especially
intravenously. Give 12% for 12 points.

Nutrition: Cold Stage 1%

- Encourage patient to take warm fluids and foods


to keep him warm (Give 1%)

Hot stage (2%)

- Give cool drinks such as orange juice or any other


fruit juice

- This will cool down the body but will also provide
nutrition and hydration.

Sweating stage (2%)

- During this stage, the patient feels a lot better

- The patient can eat any kind of food as tolerated,


but encourage nutritious food rich in iron, vitamin
C and vitamin B 12 for build up of haemoglobin
and red cell count which was depleted by
haemolysis.

- Let the patient be given appetising food to


encourage him to eat.

Elimination:

Ensure patient is voiding to monitor kidney function


drug elimination and prevention of toxaemia.

- Prevent constipation by giving food with roughage


(Give 2%).

Hygiene: 2%

Sweating stage

- Let the patient have a bath of water of warmth


according to his choice to smooth him so he can
feel a lot better

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- Linen be changed if wet with sweat for comfort

- Mouth care is very vital as it prevents halitosis


and mouth ulcers especially due to hyperpyrexia.

Rest and Sleep (1%)

- Rest and sleep are encouraged in the sweating


stage

- This is promoted by a bath given feeding done,


and noise lessened.

Psychological care: 1%

- Explain the condition and paroxysms

- Explain drugs, effects, side effects and procedures


to gain cooperation.

Health Education 3%

- Not to take unprescribed chloroquine to avoid resistance of


parasite to chloroquine

- To complete all treatments to avoid


relapse

- To seek early treatment to avoid complications such as


cerebral malaria haemolytic anaemia etc.

- Preventive measures such as: use of IINS, use of insecticides


closing windows early, elimination of mosquito breeding places
by buring ditches, empty cans, cutting surrounding grass
shorts.

(d) State 5 complications.


15%

1. Cerebral malaria blocking of the capillaries with parasitized red cells


and necrotic lesions in the cerebral tissue are caused by stasis in the
cerebral circulation with anaerobic glycolysis and lactic acidosis.

2. Anaemia plasmodium falciparum attacks both young and mature red


cells but invades young cells to a greater extent.

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3. Renal failure may occurs in falciparum malaria usually caused by
extrarenal factors.

4. Jaundice due to increase in bilirubin caused by impairment in


bilirubin transport because of reticuloendothelial blockage and
disturbance of hepatocyte microvilli.

5. Blackwater fever there is dark black urine due to severe haemolysis


during an attach of malaria with massive intravascular haemolysis and
haemoglobinaemia and haemoglobinuria.

3 Marks each for any 5 = 15%

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