KIBOGORA POLYTECHNIC On27/9/2024
DEPARTEMENT: MIDWIFERY
CLINICAL PLACEMENT: I
CLINICAL SETTING: KIBOGORA HOSPITAL
CLINICAL LEARNING ACTIVITY 1
[Link]…………………
TOPIC: Severe malaria
Definition: malaria is infectious disease caused by protozoan parasites from the Plasmodium family that can be
transmitted by the bite of the Anopheles mosquito or by a contaminated needle or transfusion ( Ministry of
Health, 2012).
Pathophysiology: Malaria infection develops via two phases: exoerythrocytic phase that involves the liver and
erythrocytic phase that involves red blood cells or erythrocytes. When an infected mosquito pierces a person's
skin to take a blood meal, sporozoites in the mosquito's saliva enter the bloodstream and migrate to the liver
where they infect hepatocytes, multiplying asexually and asymptomatically for a period of 8–30 days. these
organisms differentiate to yield thousands of merozoites, which, following rupture of their host cells, escape
into the blood and infect red blood cells to begin the erythrocytic stage of the life cycle periodically breaking
out of their host cells to invade fresh red blood cells. The blockage of the microvasculature causes symptoms
such as in placental malariaSequestered red blood cells can breach the blood–brain barrier and cause cerebral
malaria (Dellinger et al., 2008).
Signs and symptoms: feverchillsheadachesdiaphoresisdizziness, malaise, myalgia, abdominal pain, nausea,
vomiting, mild diarrhea, and dry coughtachycardia, jaundice, pallor, orthostatic hypotension, hepatomegaly, and
splenomegaly (Ministry of Health, 2012).
Causes and risk factors: is caused by obligate intraerythrocytic protozoa of the genus Plasmodium. People in
hot tropic regions and pregnant woman are in risk of malaria (World Health Organisation, (2013).
Diagnosis of malaria: thick and thin stained blood smear, Rapid dipstick immunoassays Rapid dipstick
immunoassays (World Health Organisation, (2013).
Treatment of severe malaria: Quinine dihydrochloride 7 mg salt/kg iv, Doxycycline 1.5 mg/kg, Quinidine
gluconate 10 mg salt/kg, Artesunate 2.4 mg/kg iv. Mefloquine 15 mg/kg, Artemether 3.2 mg/kg i.m
First choice: Artesunate IV 2.4 mg/kg IV (time = 0), then at 12h and 24h, then once a day for three
days. Then continue with Artemisinin combination therapy (ACT): Artemether 20 mg and
Lumefantrine 120 mg, twice a day for 3 days; Supportive treatment are diazepam to relieve
convulsions, and paracetamol to relieve fever and pain (Ministry of Health, 2012).
Nursing Diagnoses for Malaria: Impaired Circulation related to anemia and destruction of RBC, Hyperthermia
related to increased metabolism, dehydration, Fluid Volume deficit, Imbalanced Nutrition, less than body
requirements (Ministry of Health, 2012).
Nursing care: Assess level of consciousness, Monitor vital signs and urine output, Assess for signs of anemia,
Monitor for hypoglycemia (Ministry of Health, 2012).
Case presentation
Patient identification: a 22 years old female who is single, she came from Rwanda in ouest province
Nyamasheke kanjongo munini. She is a student; she prays in adventiste Church, she MUSA as
insurance, she has no allergies, no chronic disease.
Past medical history: she had had simple malaria last year, no history of surgery
Family history: she is the second child, there is another child in family with malaria, and the father
has known history of asthma.
Life style: she studies inS6, the lie always in mosquito net
History of present illness: started with abdominal pain, vomiting, fever on 24thApril,they came on
motor cycle , convulsions started when they were coming to the hospital, she had been taking coartem.
Patient profile: she was admitted on 26/9/2024 at admission the reason of transfer were unconscious,
complaints were vomiting abdominal pain and nausea, ABCD assessment findings were good, she was
weak, vital signs were: T0=38.4 0C; P=138b/min;SpO2=94%.
Investigation done and their results: FBC: WBCs=10.49 ; RBC=2.85 ; Hgb=7.4 ; Hct= 20.2, CRP:
positive; blood glucose=136mg/dl; blood smear= positive; blood group: A+
Rationale for investigations: FBC ( WBCs was to inducate change in white blood cells which is an
inducator of infection; RBCs to indicate if there is loss of red blood cells, CRP: to inducate presence
of infection, blood glucose was to indicate if there is no diabetic shock as she was in coma blood,
smear to indicate the presence of malaria parasites in blood, blood group was to know compatibility
during blood transfusion as needed in case anemia.
Treatment: RL 1l/3hours; artesunate 51mg IV; diazepam i.v 5mg prn; cefotaxime 1g QID; ampicillin
850 mg QID i.v
Rationale for this treatment: for lacted ringer was to make fluid rescisitation because the client had
had vomiting, artesunate was treating plasmodium parasites, diazepam was for relieving convulsions,
cefotaxime and ampicillin are antibiotics for treating infection. (Dellinger et al., 2008).
My nursing management:
Chef complaint was unconsciousness,
Physical examination: vital signs T0=37.20C; P=120 b/min; R.R= 22c/min SpO2=95%
Glasgow coma scale 11/15; by inspection there was foul smell in the bed, she had regular tachycardia,
inability to eat and drink, she was on fluid Lacted Ranger (RL). By palpation; spleen and liver were
not anlarged, there was abdominal tenderness.
Nursing care done and their rationale: vital signs monitoring (to indicate an change, assessment of
signs of anemia, monitor glucose level in blood to indicate if there is acidosis, fluid replacement for
hydration , maintenance of airway by positioning in recovery position to facilitate breathing and avoid
expiration, urinary catheterization to avoid urination in bed and help urine output as an indication of
renal function, provide bed hygiene with help of the second kin, Drug administration of anti malaria
artesunate as prescribed to treat parasites infection (World Health Organisation, (2013).
Notice: the client is on artesunate 51mg IV; diazepam i.v 5mg prn; cefotaxime 1g QID; ampicillin 850
mg QID i.v; now she is improving but low collaboration, inability to feed and weakness, she had
admitted in pediatric ward, patient exposure are: lack of hygiene because of self care defecit,
malnutrition, dehydration, anxiety due to disease status.
Responding: the client was treated in right way due to literature, Recommendation: nurses must
make close monitoring of vital signs, blood glucose, assessment for complications, urine output,
administer drugs as ordered, providing patient education, maintain patient hygiene. Physician must
respect the medical round, assess the complications, and modify medication as were as possible.
Switch oral medication when patient is able to swallow.
For the recovery of this client I would like to make the following interventions: monitor vital signs,
repositioning, bed making, and bed bath, encourage feeding when possible, and making patient
education. Malaria of both types is most condition that occurred in this zone of kibogora hospital, so it
have to be taken into consideration and provide community health education to population around the
zone (World Health Organisation, (2013).
Reflecting: according to my evaluation done, I have seen that my interventions were effective but not
full complete. Based on new information I would like to increase my professional skills in
management of malaria and critical thinking in my nursing care, to provide adequate education which
fit all needed informations to facilitate patient, as a nurse I have to keep updated on new modified
medical tools for anti malaria medications like artesunate administration.
References
[Link], B., Corbett, Y., Castelli, F., & Taramelli, D. (2012). Pathogenesis of Malaria in Tissues and
Blood. Mediterranean Journal of Hematology and Infectious Diseases, 4(1), e2012061.
[Link]
2. Dellinger RP et al.: (2008) Surviving Sepsis Campaign: International guidelines for management of
severe sepsis and septic shock:; Vol. 36, (1): 296-327
3. World Health Organisation, (2013). Management of severe malaria. 2nd ed. Geneva
4. Ministry of Health, (2012). Internal medicine: Clinical Treatment Guidelines. `C. 5, P.143-146
