Malaria Nursing Care Management & Study Guide

Malaria is one of the most common infectious diseases worldwide and a leading cause of morbidity and mortality. It is concentrated in tropical and subtropical regions, sub-Saharan Africa, Asia, and Latin America, where the Anopheles mosquito that carries the parasite lives. The patient in front of you got sick the same way everyone does: a mosquito bite in or from an endemic area. Ask about travel early, because P falciparum can kill.

What is Malaria?

Malaria is a potentially life-threatening disease caused by infection with Plasmodium protozoa, transmitted by an infective female Anopheles mosquito.

• The parasite infects a mosquito that feeds on humans, and the disease can be fatal.
• Patients are typically very sick with high fevers, shaking chills, and flu-like illness.
• The 5 Plasmodium species that cause human malaria are P falciparum, P vivax, P ovale, P malariae, and P knowlesi.
• Identifying the infecting species fast matters: P falciparum can be fatal and is often resistant to standard chloroquine treatment.
• P falciparum is distinguished from the other plasmodia by its high level of parasitemia and the banana shape of its gametocytes.

Types

The Anopheles species present in an area drive the intensity of transmission.

• Plasmodium falciparum. The most malignant form. It infects RBCs of all ages, producing high parasitemia. Sequestration is a property specific to P falciparum: as it develops through its 48-hour life cycle, it adheres to and sequesters in small postcapillary vessels.
• Plasmodium vivax. Untreated, it usually lasts 2-3 months with diminishing paroxysms. Of patients infected with P vivax, 50% relapse within a few weeks to 5 years after the initial illness. P vivax infects only immature RBCs, so parasitemia is limited.
• Plasmodium ovale. Similar to P vivax but usually less severe, and it often resolves without treatment. Like P vivax, it infects only immature RBCs, and parasitemia is usually lower than with P falciparum.
• Plasmodium malariae. Patients stay asymptomatic far longer than with P vivax or P ovale. Recrudescence is common.
• Plasmodium knowlesi. Autochthonous cases are documented in Malaysian Borneo, Thailand, Myanmar, Singapore, the Philippines, and neighboring countries, and simian malaria probably also occurs in Central and South America. Treat these patients as aggressively as those with falciparum malaria, since P knowlesi can be fatal.

Pathophysiology

Malaria cycles between humans and female Anopheles mosquitoes.

• In humans, the parasites first grow and multiply in the liver cells, then in the red cells of the blood.
• In the blood, successive broods grow inside red cells and destroy them, releasing daughter parasites (merozoites) that invade other red cells.
• The blood-stage parasites cause the symptoms. When gametocytes (male and female forms) are ingested by a feeding female Anopheles, they mate in the mosquito's gut and begin growth and multiplication.
• After 10-18 days, a sporozoite form migrates to the mosquito's salivary glands.
• When the mosquito takes another blood meal, anticoagulant saliva and sporozoites are injected, the sporozoites migrate to the liver, and a new cycle begins.
• The infected mosquito carries the disease from one human to another as a vector, while infected humans transmit the parasite back to mosquitoes. The mosquito itself is unharmed.

Statistics and Incidences

Malaria is one of the most severe public health problems worldwide.

• Almost all US cases are imported from patients traveling from endemic areas.
• Locally transmitted US outbreaks have been small and isolated, but re-emergence is possible given competent vectors, especially in the southern states.
• In 2016, an estimated 445,000 people died of malaria, most of them young children in sub-Saharan Africa.
• In the last decade, increasing partners and resources rapidly expanded malaria control.
• This scale-up has saved millions of lives and cut malaria mortality by 25% from 2010 to 2016, raising hopes for elimination and eventual eradication.
• In high-transmission areas, the most vulnerable are young children, who have not yet developed immunity, and pregnant women, whose immunity is decreased by pregnancy.
• Nearly half the world's population lives in areas at risk in 91 countries and territories.
• In 2016, malaria caused an estimated 216 million clinical episodes and 445,000 deaths, and an estimated 90% of those deaths were in the WHO African Region.

Causes

• Endemic areas. Most patients acquire the infection in an endemic area after a mosquito bite.
• Transfusion. Infection from transfusion of infected blood is extremely rare.
• Poor immunity. Outcome depends on host immunity. Those with immunity can clear the parasites spontaneously. Those without immunity see the infection expand.
• Climate. Climate determines geographic distribution and seasonality. Without sufficient rainfall, mosquitoes cannot survive, and without sufficient warmth, parasites cannot survive in the mosquito.

Clinical Manifestations

The classic malaria attack lasts 6-10 hours and has three stages:

• Cold stage. Cold sensation and shivering.
• Hot stage. Fever, headache, vomiting, and seizures in young children.
• Sweating stage. Sweating, return to normal temperature, and tiredness.

Assessment and Diagnostic Findings

Rapid, accurate diagnosis drives appropriate treatment and limits spread.

• Blood smears. Confirm by identifying parasites on a thin or thick smear. Thick smears are 20 times more sensitive than thin smears but make speciation harder. Thin smears are less sensitive but allow identification of the species.
• Rapid diagnostic tests. Immunochromatographic tests for histidine-rich protein-2 (PfHRP2), parasite LDH (pLDH), or Plasmodium aldolase are sensitive and specific. Some RDTs detect P falciparum at parasitemias below the threshold of reliable microscopy. Only one RDT (BinaxNOW) is approved to date for diagnosing malaria in the United States.
• Other tests. New molecular techniques, PCR assay and nucleic acid sequence-based amplification (NASBA), are more sensitive than thick smears but expensive and unavailable in most developing countries.

Medical Management

Treatment depends on disease severity, the infecting species, and where the infection was acquired.

• Inpatient. Admit patients with elevated parasitemia (>5% of RBCs infected), CNS infection, otherwise severe symptoms, or P falciparum infection to ensure medicines are tolerated. Obtain daily blood smears to track the response.
• Prevention. Limit exposure at peak biting times (dawn, dusk), wear long-sleeved clothing, use insect repellent, and avoid perfumes and colognes.
• Consultations. Consider infectious disease consultation for diagnosis, treatment, and management.

Pharmacologic Management

The 4 major drug classes used to treat malaria are quinoline-related compounds, antifolates, artemisinin derivatives, and antimicrobials. No single drug eradicates all stages of the parasite's life cycle.

• Antimalarials. These agents concentrate in the parasite's acid vesicles, raising its internal pH, and inhibit hemoglobin utilization and parasite metabolism.

Nursing Management

Nursing Assessment

• History. A history of recent or remote travel to an endemic area is critical. Ask explicitly whether the patient has ever traveled to a tropical area, to enhance recall. Keep a high index of suspicion in any patient with malarial symptoms and a travel history.
• Demographic data. Determine immune status, age, and pregnancy status, allergies and other medical conditions, and current medications.

Nursing Diagnosis

• Risk for infection related to a weakened immune system.
• Hyperthermia related to increased metabolic rate and dehydration.
• Impaired tissue perfusion related to a decrease in the cellular components that deliver oxygen and nutrients.
• Fluid volume deficit related to excessive sweating and dehydration.
• Knowledge deficit related to lack of information about the disease, treatment, and prognosis.

Nursing Care Planning and Goals

• Prevent infection.
• Reduce and regain normal body temperature.
• Improve tissue perfusion.
• Improve fluid volume.
• Gain information on the disease process, treatment, and prognosis.

Nursing Interventions

• Improve body temperature. Apply a warm water compress to the forehead and both axillae (no more than 15 minutes each time). Keep the environment warm with blankets and adequate clothing. The patient may sweat heavily, so keep clothes and linens dry. Give antipyretics as ordered.
• Improve tissue perfusion. Give supplemental oxygen if the condition is severe. Keep the room well ventilated, raise the head of the bed to 30 degrees, and reduce activities requiring moderate to high exertion.
• Improve fluid volume. Expect fluid loss through sweat. Teach fluid balance and replacement, encourage oral intake, and give parenteral fluids as ordered.
• Educate patient and family. Review the disease process and therapy, focusing on the patient's concerns. Stress adherence. Go over medication purpose, frequency, dosage, and side effects. Have a family member or trusted person learn the treatment plan when the patient prefers.

Evaluation

Goals are met when the patient shows:

• Prevention of infection.
• Reduced body temperature.
• Improved tissue perfusion.
• Improved fluid volume.
• Retained information on the disease process, treatment, and prognosis.

Documentation Guidelines

• Individual findings, including factors affecting the patient, interactions, nature of social exchanges, and specifics of behavior.
• Cultural and religious beliefs and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward the desired outcome.