Content

CONTENT

INTRODUCTION…………………………………..2

PATIENT’S BACKGROUND……………………..3

CLINICAL FEATURES…………………………….4

PHYSICAL ASSESSMENT…………………………5

INVESTIGATION…………………………….6 & 7

TREATMENT………………………………….8 - 10

NURSING CARE PLAN………………….…11-15

HEALTH EDUCATION…………….…………..16

SUMMARY……….……………………….…….…17

CONCLUSION…………………………………...18

REFFERENCE………………………….………….19

APPENDIX………………………………………..20

INTRODUCTION1

I choose MALARIA DISEASE for my case study.I get this topic when I was at Male Ward Kudat Hospital.When the patient with malaria disease is admitted in male ward,I am interested to find out about the disease.

Malaria is a public health problem in Malaysia even though malaria control activities over the last few decades has greatly reduced the incidence of malaria.It still occurs in the hinterland and less developed parts of the coutry and accounts for the considerable number of cases at the clinics and admissions to hospitals.

Malaria occurs when the causative agent is a parasite belonging to the genus Plasmodium.Malaria caused by one of the four Plasmodium species,namely Plasmodium Falciparum,Plasmodium Vivax,Plasmodium Ovale,Plasmodium Malariae.Malaria is a vector borne disease transmitted to man by the bite of an infected female ANOPHELINE Mosquito.The basic life cycle of all the malaria parasites is the same.It comprises a sexual phase with multiplication in the mosquito (sporogony) an asexual phase with multipication in the human (schizogony).

The human phase has several component:

Invasion of liver cells by sporozoites. Multiplication in the liver (pre-erythrocytic schizogony). Red cell development cycle (erythrocytic schizogony).

The clinical symptoms are caused by the rupture of the mature blood schizonts releasing the merozites and toxic product of the parasites metabolism incubation period is about 12 days for Plasmodium Falciparum,14 days for Plasmodium Vivax and Plasmodium Ovale and 30 days for Plasmodium Malariae.

PATIENT’S BACKGROUND

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D is male,19 years old.He was born 10 JULY 1991.He is Malaysian and his race is Rungus.He lives in Kampung Sikuati,Kudat.

D is single and have four siblings.He is a younger brother in his family.He do not have job yet but he followed his mother and mother to their farm.His mother and father are farmer.

PAST MEDICAL HISTORY

Previously he is always complain having fever and feel hot skin.He told that last 2009 he feel the same situation and he got Malaria PF++.3 days ago he was fever but did not come to hospital.

PRESENT MEDICAL HISTORY

D was admitted on 11 MARCH 2010 at 3.00pm to Male ward by Doctor Prabakaran Dhanaraj via Accident & Emergency unit and escorted by PPK Jebrail use wheel chair because D was very weak at the time.He complain of fever with chills and rigour for three days.He is vomiting and also bodyache with joint pain.On the date of admissions, his body weight is 53.9 kg.his vital sign is taken and the results is 116/74mmHg for blood pressure,78 for pulse rate,26 respiration rate,97% saturation and 38.5 Degree Celsius for body temperature.He also told that his bowel open was loose stool for two times and the characteristic is watery yellowish stool today.He is very weak,but stable and pink.

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CLINICAL FEATURES

The clinical features of Malaria very in severity depending on the species of parasite present,the immunity status of the patient and the intensity of the infection.The typical infection has three distinct stages,the cold stage,the hot stage and sweating stage.These a followed by an afebrils period in which the patient feels greatly relieved.

In the cold stage the onset is with lassitude,headache,nausea and chilly sensation follow by rigours.The temperature rises rapidly from 39 degree celsius to 41 degree celsius.Headache is often severe and commonly there is vomiting.This stage can last up to 3 hours.

In the hot stage,the patient feels hot and the skin is hot and dry to touch.Headache is intense but nausea commonly dizinishes.This stage can last up to 6 hours.

The sweating stage follows the hot stage and continues for and hour and so.After the primary attack of fever,there is an afebrile interval of 48 hours to 72 hours and this is followed by other attacks similar to the first.

Falciparum malaria may present a varied clinical picture including fever,chills,sweats and headache and may progress to icterus,coagulation defects,shock,renal and liver failure,acute encephalopathy and coma.

PHYSICAL ASSESSMENT4

INVESTIGATION1. FULL BLOOD COUNT (FBC)

-To see if any abnormalities in the blood.

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Result-11.03.2010-WBC 5.2,HB 13.9,HCT 44.8,PLATELET 36. -12.03.2010-WBC 4.7,HB 13.3,HCT 42.8,PLATELET 27. -13.03.2010-WBC 5.4,PLATELET 68. -14.03.2010-WBC 5.7,PLATELET 102. -15.03.2010-WBC 5.8,PLATELET 122. -16.03.2010-FBC RESULT NORMAL. -17.03.2010-FBC RESULT NORMAL.

2. BLOOD SPECIMENT MALARIA PARASITE (BSMP) -Test designed to discover abnormalities in a sample of patient’s blood for bacteria to determine. Result-11.03.2010-20,000 UL (PF++++) -12.03.2010-10,000 UL (PF++++) -13.03.2010-(PF++) -14.03.2010-(PF++) -15.03.2010-NEGATIVE TIMES 1 (NO MALARIA PARASITE SEEN) Noted to Doctor Euphrasia. -16.03.2010-NEGATIVE TIMES 2 (NO MALARIA PARASITE SEEN). -17.03.2010-NEGATIVE TIMES 3 (NO MALARIA PARASITE SEEN).

3. DENGUE SEROLOGY -To see if any dengue parasite that cause his fever. Result-NO DENGUE PARASITE SEEN.

4. GLUCOSE-6-PHOSPHATE DEHYDROGENESE (G6PD)-To detect leads of the breakdown of red blood cells.It also important before use of Primaquine. Result-NORMAL.

5. BLOOD UREA SERUM ELECTROLYTE (BUSE)-To know balance electrolyte in the body. Result-NORMAL.

6. OTHERS: PH :3.6 BUSE UREA :5 HESS TEST :NEGATIVE CULTURE & SENSITIVITY :NORMAL

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TREATMENTThe medication that given by doctor to D is:

1. Paracetamol 1gm QID - 6am,12pm,6pm,12midnight.

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2. Intravenous maxolon 10mg TDS - 6am,2pm,10pm.3. Tablet choroquine III/II for three days in a week.4. Tablet primaquine II/II for one week.5. Intravenous Quinine infusion 10mg/1kg over 4mg TDS (530mg) –

6am,2pm,10pm.After three days,and patient able to tolerate orally,the Intravenous Quinine is change to Tablet Quinine.

REGIME RADICAL TREATMENT OF MALARIA FALCIPARUM AND MALARIAE:

DAYAGE GROUP (YEAR)

<1 1-4 5-9 10-14 >151 Chl. ½ tablet

Pri. ¼ tabletChl. 1 tabletPri. ½ tablet

Chl. ½ tabletPri.1 tablet

Chl.1 ½ tabletPri. ½ tablet

Chl. 3 tabletPri. 2 tablet

2 Chl. ½ tabletPri. ¼ tablet

Chl.1 tabletPri. ½ tablet

Chl. 1 ½ tabletPri.1 tablet

Chl.2 tabletPri.1 ½ tablet

Chl.3 tabletPri.2 tablet

3 Chl. ½ tabletPri. ¼ tablet

Chl.1 tabletPri. ½ tablet

Chl.1 ½ tabletPri. 1 tablet

Chl.2 tabletPri.1 ½ tablet

Chl.3 tabletPri.2 tablet

NOTES:

CHLOROQUINE (Chl.) 10mg base per kg body weight on 1st and 2nd day and 5mg on 3rd day.

PRIMAQUINE (Pri.) 0.25 mg base per kg body weight daily for 14 days. FANSIDAR (Fan.) should be given 3 tablets additional if suspicious of

Chloroquine. QUININE SULPHATE 10mg per kg base per kg body weight 3 times daily if

patient show no improvement.

MANAGEMENT OF SEVERE AND COMPLICATED PLASMODIUM FALCIPARUM MALARIA

Severe Falciparum malaria is caused by the presence of high density of asexual forms of Plasmodium Falciparum in the patient’s blood.Patients need urgent special management including parenteral chemotherapy.However, in areas of high malarial

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endemicity clinical suspicion alone,should prompt a therapeutic trial with an approriate antimalarial drug even if the blood smears are negative.

MANIFESTATION OF SEVERE AND COMPLICATED FALCIPARUM MALARIA

Falciparum malaria can give rise to a number of severe manifestation and complication that have been described and recognised.When other disease have been excluded the presence of one or more of the following features is sufficient for the diagnosis of severe falciparum malaria.More commonly these manifestation combinely occur in the same patient.

Hyperthermia. Hyperparasitaemia (when the density of asexual forms of P.Falciparumin the

peripheral blood exceeds 5% of erythrocytes is more than 25000 parasite per ul at normal red cell count).In some cases of severe malaria a blood film may be negative.

Cerebral Malaria (when there is any manifestation of cerebral dysfunction in a patient with malaria).

Severe Anaemia (when haematocrit is less than 20%,haemoglobin less than 7.0g/dll).

Fluid,electrolyte or acid-base disturbances. Renal failure is defined as urine output of less than 400ml in 24hours and serum

creatinine is more than 265umol/1 or 3/dl and fails to improve after rehydration. Hypoglycaemia (when blood glucose concideration is less than 2.2 umol). Vomiting.

The presence of any one or combination of the above manifestation in a patient with malaria constitutes a serious life threatening condition which will need prompt attention and immediate treatment.

MANAGEMENT OF SEVERE AND COMPLICATED PLASMODIUM FALCIPARUM MALARIA

GENERAL AND SUPPORTIVE CARE:

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1. Review of data on the following six aspects is mandatory before choosing a treatment regime for malaria patient.

Level of Consciousness. Blood Pressure. Parasite Density. Haematocrit or Hb %. Blood Sugar. State of Hydration and renal function profile BUSE,creatinine.

2. Frequent monitoring of blood glucose levels is important. Sudden loss of consciousness or change in the condition of a malarial patient receiving quinine should be considered to be due to hypoglycemia until proven otherwise.

3. Fluid intake and output chart must be maintained accurately. Hydration status and urine output should be monitored constantly. Appearance of black urine should be noted. The amount of fluid of given as blood, bicarbonate, 50% dextrose as a vehicle for quinine and dopamine drip, should be included in the fluid balance calculations. Renal failure should be managed appropriately.

4. High body temperatures should be treated with vigorous rapid sponging and fanning. Paracetamol may be administered by mouth, nasogastric tube or as suppositories (15mg/kg).

SPECIFIC ANTIMALARIAL CHEMOTHERAPHY:

1. Quinine dihydrochloride 10mg/kg/dose in 5% dextrose over 4hour are given intravenously every 8hours until the patient is able to swallow tablets.

2. Once the patient is able to swallow, parenteral quinine therapy can be up to 7days.

NURSING CARE PLAN10

1. NURSING DIAGNOSIS: Fever Related to Disease Process.GOAL:Maintain body temperature at the normal range.NURSING INTERVENTION:

1. Assess patient general condition.2. Start malaria on protocol.3. Doing tepid sponging if patient increase body temperature.4. Encourage patient to use thin clothing.5. Nurse patient under fan.6. Provide good ventilation.7. Allow patient orally intake as tolerated.8. Use mosquito net to patient’s bed.9. Give medication as doctor order:

Serve antipyretic/antibiotic as prescribed. Paracetamol 1gm (QID) 3 times a day at 6pm,12md,6pm,12am. Intravenous drip 2.5l/day (5 pint) all NS. Intravenous maxolon 10mg (TDS) 6am, 2pm, 10pm.

10.Ask the mother to stay with patient to make sure the patient is comfortable.

11.Make sure patient take all the medication given.12.Monitoring vital signs especially the patient body temperature.13.Ensure a pleasant environment & facilitate proper position.14. Inform doctor regarding abnormal CSF result.

EVALUATION-Patient stay in comfortable position.-Patient taken medication as given.-Vital Sign-11/03/2010 at 6pm:

Blood Pressure:119/54 Pulse Rate:78/min Respiration Rate:22 Temperature:37.8 degree celcius Pain Score:2

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2. NURSING DIAGNOSIS: Knowledge Deficit Related to Drugs Compliance.GOAL:Patient will verbalize increase knowledge on drugs compliance.NURSING INTERVENTION:

1. Assess patient’s knowledge on drugs compliance.2. Explain to patient and his family members the importance of drugs

compliance.3. Explain the effects and side effects of the drugs.4. Explain the effects and side effects of alcohol on the drugs.5. Teach patient to identify impending signs and symptoms of fits.6. Teach patient to take precautionary measures if any evidence of

impending sign and symptoms.7. Advice on proper storage of drugs.8. Keep drugs out of children reach.9. Avoid hazardous activities.10.Documentation progress of teaching and learning.

EVALUATION:-Patient knowledge about the disease increase in time to time.-Patient stay in comfortable position.

3. NURSING DIAGNOSIS:Altered Body Temperature Related to Disease Process.GOAL:

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Maintain Body Temperature at The Normal Range:36.8 to 37.2 Degree Celsius.NURSING INTERVENTIONS:

1. Assess patient condition.2. Monitor vital signs four hourly.3. Perform tepid sponging if patient temperature becomes 38.5 Degree

Celsius.4. Give medication as doctor’s order. (Patient seen by doctor Euphrasia

today). Start intravenous infusion of quinine. Check Dextrose before and after (QID) 6am, 12md, 6pm, 12am. Tablet paracetamol when body temperature increase. Intravenous Normal Saline 5 pint for 24 hours.

5. Allow patient orally as tolerate.6. Strictly Intake and Output chart.7. Encourage oral fluids intake.8. Repeat BSMP & FBC as doctor order.9. Report immediately to doctors if there is any abnormalities in patients’

condition. EVALUATION:-Patient stay in comfortable condition but today patient body temperature is intermittent.-Vital Signs Today at 2pm: Blood Pressure: 116/62 Pulse Rate: 88/min Respiration Rate: 20 Temperature: 36.9 degree Celsius Pain Score: 1 DXT: 4.2 mmol/L (before) 6pm: B/P: 124/60 P/R: 96 R/R: 24 TEMP: 37.7 Degree Celsius PAIN SCORE: 3 DXT: 8 mmol/L (after)

4. NURSING DIAGNOSIS:Activity Intolerance Related to Fatigue.GOAL:Patient can doing activity as tolerated.

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NURSING INTERVENTION:1. Assess patient general condition.2. Encourage patient for oral fluids intake so that patient can tolerate orally.3. Allow patient to doing simple activity first then rest in bed.4. Restrict visitors when patient in a weak condition.5. Use patient bed side rails to avoid patient from fall down.6. Give medication as doctors ordered.7. Put on mosquito net during bedtime to avoid patient from mosquito bite.8. Inform immediately to doctor if there is any abnormalities in patient

condition.EVALUATION:-Patient tolerate in doing few activity then before.-Patient maintain in comfortable condition.-Vital Signs today: B/P: 120/50 mmHg P/R: 58/min R/R: 22 TEMP: 37.2 Degree Celsius PAIN SCORE: 0

5. NURSING DIAGNOSIS: Potential /Actual Injury Related to Disorientation During Admission.GOAL:

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Patient will free of injury through his stay in hospital.NURSING INTERVENTION:

1. Assess patient condition.2. Nurse patient on a lower bed.3. Put up side rails.4. Pad the side and head of bed with pillows.5. Stay with patient when agitated.6. Prepare padded tongue, airway at bedside.7. Assist with ambulating, personal care as needed /provide supervision.8. Restrain patient when necessary.9. Administer drugs as ordered.10. Inform doctor immediately if there is any incident in the ward.

EVALUATION:-Patient stay in comfortable condition.-No injury noted during patient hospitalization.

HEALTH EDUCATION15

IN WARD:

Encourage patient to taking all the medication serve in ward. In ward, patient must taken hospital dietary because hospital dietary have enough balanced diet. Patient also must use the mosquito net during night time in ward. Encourage for personal and environment hygiene to avoid any other infection during warded time. Allow patient to take orally fluids. Give emotional support to patient during warded.

AT HOME:

Keep maintain what he has done in ward. Teach patient about the disease and complication of the disease. Teach also the mother so that she can keep taking care for her son. Do not simply let her son going to farm without use complete dressed to avoid from mosquito bite. Tell patient and the family member they must use mosquito net during bedtime. Clean house and environment to avoid the Anopheles Mosquitoes. Avoid also the water sum ping around house and environment. Tell the patient prevention is better than cure.

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SUMMARY D was discharge when his condition is stable. Patient already given health education. Patient does not given any review because three days before and for three times the BSMP result is NO MALARIA PARASITE SEEN in his blood. The result was noted to Dr Euphrasia.D can going home when Dr Euphrasia declared that D can discharged today 17 MARCH 2010 @ 12.00 Mid day. D was off drip with IV Quinine and continues with tablet quinine 525mg TDS for one week. On the time that D was discharge; his WBC is 5.8 and platelet become normal from 36 to 122.D was told that Malaria Disease is dangerous and can be life threatening if not managed properly. It also can lead to complication and death. I hope D did not get Malaria Disease next time.

CONCLUSION

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Malaria is an infectious disease due to the presence of parasitic protozoa of the genus, within the red blood cells. The disease is transmitted by the Anopheles mosquito and is confined mainly to tropical and subtropical areas. Parasites in the blood of an person are taken into the stomach of mosquito as it feeds. Here they multiply and then invade the salivary glands. When the mosquito bites an individual, parasites are injected into the bloodstream and migrate to the liver and other organs where they multiply. After an incubation period varying from 12 days to 10 months parasites return to the bloodstream and invade the red blood cells. Rapid multiplication of the parasite results in destruction of the red cells and the release of more parasites results in destruction of the red cells. This causes a short bout of shivering, fever and sweating, and the loss of healthy red cells results in Anemia. Preventive and curative treatment must be given immediately to Malaria patient.

REFFERENCE18

PATIENT’S CASE NOTE. GUIDELINES FOR THE MANAGEMENT OF MALARIA BOOK (VECTOR

BORNE DISEASE CONTROL PROGRAMME, MINISTRY OF HEALTH MALAYSIA).

TEXT OF MEDICAL SURGICAL NURSING ELEVENTH EDITION (VOLUME 1). WWW.MALARIA.COM

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APPENDIXCALCULATION OF MALARIA PARASITES PER UL BASED ON A FIGURE OF 8000

WBC’S PER UL

If this is the number of WBC’S you counted then

This figure is to be multiplied

X The number of parasites you

counted

= The number of parasites

per UL of blood

25 320 X =

50 160 X =

75 107 X =

100 80 X =

150 53 X =

200 40 X =

250 32 X =

300 27 X =

350 23 X =

400 20 X =

450 18 X =

500 16 X =

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