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Because early symptoms of malaria are often vague and nonspecific, an astute nursing assessment may be a crucial first step toward diagnosis and treatment.
By Sarah A. Bradwisch, MSN, RN Assistant Professor Kingsborough Community College Brooklyn, N.Y.
Youre working in the ED, caring for a 16-year-old girl who presents with a fever and chills. At first, your assessment is routine but after talking with the teenager and her parents, you discover that they recently returned from a vacation visiting family in Africa. You ask yourself: Could it be malaria? Yes, it could. Testing soon confirms your suspicions, and the teenager is successfully treated. A patients history tells its tale once again. Malaria is a serious illness, affecting about 400 million people worldwide and killing 655,000 people annually. In the United States, millions of residents travel to countries where malaria is endemic. Every year, approximately 1,500 patients are diagnosed with malaria in the United States, mostly returning travelers. Thats why you need to be aware of malaria and ask the right questions to uncover the clues.
to a human host by a single mosquito bite. This female anopheles mosquito is found mostly in tropical areas of Asia, Africa, and Central and South America, where high humidity and warm temperatures provide a hospitable environment for mosquito larvae to thrive. Malaria is caused by five species of the Plasmodium parasite. The most common and deadliest type is Plasmodium falciparum. Even with treatment, patients with this type of malaria have a poor prognosis. Other malariacausing parasites are P. vivax, P. ovale, P. malariae, and P. knowlesi (zoonotic malaria). Although the prognosis is good for these types of malaria, treatment should never be delayed. Symptoms generally begin 1 to 3 weeks after being bitten by the infected mosquito, but may take up to 8 to 10 months to appear. In some people, dormant parasites become reactivated years after the initial infection.
Whos at risk?
Malaria has made a significant impact on childhood mortality around the world. African children have the highest mortality from malaria due to many environmental factors, such as the extreme heat that lends itself to the inability to control the mosquito population and the lack of potable
water in many areas. Age also plays a significant factor in the predisposition for contracting malaria: Children under age 6 months arent as vulnerable to malaria because they receive acquired immunity from their mother; however, young children between ages 6 months and 5 years are especially vulnerable because their bodies havent developed a formidable immune system. Adults and teenagers are also vulnerable when traveling to countries with malaria. Noncompliance with preventive medication has been a serious barrier to eradicating this disease. All teens traveling to malariaridden countries must see their pediatrician for the most appropriate antimalarial treatment. Because teens may be noncompliant with the prescribed preventive course, emphasize the importance of antimalarial medications to this population. Pregnant women should be particularly cautious when traveling to countries where malaria is endemic because pregnancy reduces a womans resistance to malaria and puts her at risk for severe anemia and even death. For the unborn child, malaria increases the risk of spontaneous abortion, stillbirth, premature delivery, and low birth weighta leading cause of child mortality. Nursing made Incredibly Easy! 1
Copyright 2013 Wolters Kluwer Health | Lippincott, Williams & Wilkins. Unauthorized reproduction is prohibited.
History lessons
Initial signs and symptoms of malaria are similar to those caused by influenza. You can assess for signs and symptoms of malaria by using the acronym FANS: Fever Aches and pains Nausea Severe headache. For later signs and symptoms, use the acronym CASH: Cerebral ischemia Anemia Splenomegaly Hepatomegaly and Hypoglycemia. Because malarias incubation period can be lengthy, your patients history may provide the earliest clues to infection. Taking an accurate history involves carefully listening to your patient. Rather than diving in with a series of questions, give your patient enough time to tell you his or her story. Getting a valid account of whats troubling your patient and how it evolved over time is no easy task. It takes time, practice, patience, understanding, and concentration. An accurate history can sometimes mean the difference between life and death, so be vigilant and patient.
repellents, or with mosquito-control measures such as spraying insecticides and draining standing water. Prophylactic medications are indicated for people traveling to countries where malaria is endemic. The CDC recommends appropriate prophylaxis for specific countries; however, be aware that certain prophylactic medications can have adverse reactions, especially for children, pregnant women, and those who are immunocompromised. Antimalarial medications include: chloroquinea good choice for travelers taking long trips, but it cant be used in areas with chloroquine or mefloquine resistance. Exacerbation of psoriasis may occur when taking this drug. quininean antimalarial drug that also has antipyretic and analgesic properties. Its less expensive than chloroquine but it has more unpleasant adverse reactions, such as constipation, diarrhea, erectile dysfunction, and, in rare cases, pulmonary edema. Also note that this medication has a bitter taste when taken orally and may not be advisable for children. atovaquone/proguanilthe drug of choice for last-minute travelers, but it cant be used by pregnant or breastfeeding women. Its more expensive than some of the other drugs and shouldnt be used by people with severe renal impairment. mefloquinea good choice for long trips because it can be taken weekly and for pregnant or breastfeeding women. This drug shouldnt be taken by people with seizure disorders or psychiatric conditions. Its also advised that individuals with cardiac conduction abnormalities shouldnt take this drug. doxycyclinethis is a daily medication good for last-minute travelers. Those who are pregnant and children under age 8 cant take this
Copyright 2013 Wolters Kluwer Health | Lippincott, Williams & Wilkins. Unauthorized reproduction is prohibited.
medication. Yeast infections are a common adverse reaction, along with sun sensitivity. Because several antimalarial drugs are available for prophylaxis, the healthcare provider needs to consider what works best for the traveler. Many drugs must be taken for several weeks before theyre effective, but choices such as atovaquone/ proguanil and doxycycline are available for last-minute travelers. For travelers who will be extending their visit for a long period, chloroquine and mefloquine are better choices. Teach patients that no antimalarial drug is 100% protective; they must also take personal protective measures to prevent infection. Advise travelers to pack insect repellent, long-sleeve shirts, and long pants, and to make sure theyll be able to sleep in an insecticide-treated bed net.
and recognized the telltale signs of malaria: fever, aches and pains, nausea, and headache. She was immediately transferred to the ICU and the medical team worked to determine the best course of treatment. Because her condition was rapidly deteriorating, 24 hours after being admitted, she received exchange blood transfusions and regained consciousness 3 hours later. This story represents one of many from around the country and reminds us to be vigilant, take a thorough history of the patients travels, and look out for signs and symptoms of malaria.
memory jogger
Spell out the signs and symptoms of malaria. Use the FANS acronym to identify early signs and symptoms. Fever Aches and pains Nausea Severe headache Use the CASH acronym to identify later signs and symptoms. Cerebral ischemia Anemia Splenomegaly Hepatomegaly and Hypoglycemia
eradicate this disease continues, but significant progress and success give us hope for a future with no malaria.
No guarantees
Even careful and appropriate prophylaxis isnt always effective. In 2010, an undergraduate college student took her antimalarial drugs as prescribed for a trip to Ghana. Five days after her return to the United States, she was tired, feverish, and experiencing headaches; her healthcare provider thought she was exhibiting signs of jet lag, such as nausea and lethargy from the long flight and travel. But to everyones surprise, she was infected with P. falciparum. She experienced a high fever and hallucinations, and was admitted to the hospital where the triage nurse reviewed her recent travel history
Copyright 2013 Wolters Kluwer Health | Lippincott, Williams & Wilkins. Unauthorized reproduction is prohibited.