Malaria its Diagnostic and Treatment

Malaria is a contagious disease that infects red blood cells by a parasite known as plasmodium. It is characterized by cycles of chills, fever, pain and sweating.
Parasite enters into the human body when a infected mosquito bite a healthy person. Female anopheles mosquito is the vector for transmission.

Incubation period
It is based on the types:
P. Falciparum-12 days
P.Vivax-14 days
P. Malariae- 30 days

Mode of transmission 

• Mechanical transmission: Bite of an infected female anopheles mosquito is the vector medium to transmit disease.
• Parenteral transmission: It is through blood transfusion.
• Transplacental transmission: It is congenital and ia very rare.

Pathogenesis:
When mosquito sting on  the infected human and suck the blood parasite enters into the mosquito stomach.
The parasite undergoes sexual conjugation. A number of young parasites get release after 10-14 days which finds their way to salivary gland of the mosquito. The parasites are now present in the saliva which get transmitted if the infected mosquito bites the healthy person.
The female anopheles mosquito alone plays the role of a vector and definitive host in conveying the disease from man to man.
In human the parasite attack the RBC where they grow and undergo sexual schizogony.
Erythrocytic merozoites are produced leading to the rupture of the RBC upon the release of the tiny organisms.
Young merozoites attack a new batch of RBC to start another schizonic cycle.

Signs and symptoms:

•   Rapidly increasing fever with severe headache
• Paroxysms with shaking chills
• Profuse sweating
• Spleenomegaly (enlargement of spleen)
• Hepatomegaly (enlargement of liver)
• Hypotension in upright position
• Muscle pain
• Paroxysms may last for 12 hours then may be repeated daily or after a day or two

In children:  

• Continuous fever
• Convulsions
• Gastrointestinal symptoms are prominent
• Spleenomegaly
• In case of cerebral malaria
• Change in sensorium
• Severe headache
• Vomiting
• Jacksonian or grand mal seizure may be present

Diagnostic procedure: 

1. Malarial smear : A flim of blood is placed on a slide, stained and examined microscopically.
2. Rapid diagnostic test : It can be done outside the laboratory and in the field. It gives result within 10-15 minites. Malarial parasite antigen in the blood can be detected by this test.
   

Treatment:
Treatment choice depends upon two categories uncomplicated malaria and complicated malaria.
Uncomplicated malaria: Patient has no signs of complications. The treatment consists of:
A. Early and appropriate  antimalarial drugs:  The choice of drugs should be based on the drug sensitivities of malarial parasites in that area.
WHO (2006) has recommended Artemisinin based combination treatment as a first like drugs for P. Falciparum.
Quinine combined with doxycycline, for non pregnant adults and children > 8 years old, or clindamycin for pregnant women and children <8 years old given for 7 days  as a second line drugs.
If first line treatment dose is vomited within one hour it should be given again.
B. Symptomatic treatment
Treatment symptoms includes fever, body pain, nausea, vomiting or headaches with appropriate medicines.
Nursing care 

• Provide supportive care and symptomatic treatment such as tepid sponging for fever.
• Give health education regaeding personal protection, prevention of malaria and compliance for treatment.
• The patient should be told to return if there is fever, especially in the 2 months after treatment or with P. Vivax or P. Ovale infection.
• Advise patient to take full course of medication to prevent relapse of malaria.
• If vomiting occurs during the antimalarial drug take an antiemetics half hour or one hour prior the drugs.
• If there is fever take an antipyretic 1 hour prior taking the anti malarial medicine.
• The patient should rest for 1-2 hours after taking the drugs due to risk of dizziness, vomiting and hypotension.
• Give psychological support to the patient.
• All the cases of malaria should be recorded and reported to the appropriate health authorities to help to control malarial disease.
• Follow up is compulsory required to know the therapeutic response to the drugs and to evaluate the evidence of drug resistance.

Nursing Diagnosis:
Imbalanced nutrition less than body requirements related to inadequate food intake, anorexia, nausea/ vomiting
Risk for infection related to decreased immune system; invasive procedures
Hyperthermia related to increased metabolism, dehydration, a direct effect on the hypothalamic circulation of germs.

Complicated malaria
Criteria are listed below:  

• Impaired consciousness
• Multiple convulsions
• Respiratory distress
• Circulatory collapse
• Pulmonary edema
• Abnormal bleeding
• Haemoglobinuria
• Jaundice
• Prostration

Laboratory Tests: 

• Acidosis
• Hypoglycemia
• Severe anemia
• Renal impairment
• Hyperlactatemia
• Hyperparasitemia

Nursing care 

• Monitor the patient closely.
• Keep patient in lateral or semi prone position to avoid aspiration of fluid.
• Insert nasogastric tube and withdraw the stomach content to minimize risk of aspiration pneumonia.
• Give life support assessing the patient condition.
• Monitor intake and output every hourly, by placing a foleys catheter to measure output.
• Provide psychological support to the family, patient and the relatives.
• Assure that the airway is clear.
• Suction to clear the airway if necessary.
• Note any appearance of black urine ( hemoglobinuria)
• Monitor vital signs and level of consciousness.
• Check for the fluid infusion whether its going to fast or slow.
• Treat fever with tepid sponging and antipyretic drugs.
• Give 10% dextrose is blood sugar level is low.
• In case of seizures give diazepam.
• Encourage patient to complete full course of drugs.
• Educate patient and family members about preventive measures such as use of mosquito nets, repellent, mosquito coil etc.