OBJECTIVES:

1. To provide nursing management for patient 2. To understand more on nursing care plan related to disease3. Prepare for handle for patient with malaria disease

1

INTRODUCTION:

I was posted at Ling Zhi Isolation Hospital for this clinical posting (semester 7). I finished my practical at Infectious Disease Ward for 4 weeks. Our Clinical Instructor (CI) during this practical period was Miss Suzon and sometimes will change with other CI.

The objectives for this semester are pediatric and maternity but I don’t have any chance to go to this ward. I had chosen Knowlesi Malaria with thrombocytopenia as my case study because this case is the most cases at Infectious Disease Ward.

Malaria can define as a disease that causes recurrent fever, caused by a parasite transmitted by mosquitoes. This patient, Mr. MQ admitted to the Infectious Disease Ward on 5/02/2011 at 6.35 pm, ambulating well and the case was transfer from Accident and Emergency Department Kudat Hospital.

2

BIOGRAPHICAL DATA:

Patient name: Mr. MQ

Date of Birth: 11/12/1978

Date of Admission: 05/02/2011 @ 6.35pm

Age: 32 Years

Gender: Male

Weight: 60Kg

Height: 154cm

Marital Status: Married

Race: Rungus

Religion: Christian

Occupation: Farmer

Home Address: Kg Barombongan Kudat

3

Patient condition on admission:

On 05th February 2011, on Saturday at 6.35pm, this patient admitted to the Infectious Disease Ward with ambulating well. This case referred direct from Accident and Emergency Department Kudat Hospital, escorted by ambulance and his family members. Observation was taken during admission and the results are:

Blood pressure: 105/60 mmHg

Temperature: 37.6° c

Pulse: 88 Bpm

Respiration: 28 Bpm

The patient has fever and the staff nurse done tepid sponging. The respiration also fast but it is the sign of the disease. Patient complaint had loss of appetite since 2 days ago.

4

HISTORY OF PAST ADMISSION:

Patient ever admitted at Kudat Hospital 2 years ago cause of dengue.

PAST HEALTH HISTORY:

Medical History: No

Surgical History: No

Allergies: No

Injuries/ accident: No

Blood Transfusion: No

FAMILY HEALTH HISTORY:

All family members are health.

SOCIAL HISTORY:

The patient married and lives in Kudat. He worked as a farmer. His is a smoker and drinking alcohol but irregular like 2 times a week.

5

REVIEW OF SYSTEM (PHYSICAL EXAMINATION)

Since the patient came to the ward, he was done his orientation by the staff nurse. His condition is good, physiological status is good, conscious and alert but his having fever. Patient hair is tidy and clean, the skin also clean, dry and a bit pale. No discharge in the nose, ear and mouth noted. Respiration bit fast and no cardiovascular changes. He just bowel open and the patient complaint his stool is hard. Patient no complaint with the ward and can moved or walk very well. He also no allergies all types of food or medications. The patient can speak Dusun and Malay. He understood English but can’t speak well. The patient gives response to the staff nurse and doctor if they ask questions and taking specimen. Patient mobility is good, and no need for assist or wheelchair.

MEDICAL MANAGEMENT:

6

IV Artesunate 144mg on daily (OD)

Tab. Paracetamol 1g four times per day (QID)

Tab. Riamet 4 tab two times per day (BD) x 5/7

DRUG DOSE FREQUENCY INDICATIONS

IV Artesunate 144mg Once a Day Antimalaria

Tab. Paracetamol 1g Four times a day Antipyretic

Tab. Riamet 4tabs Two times a day antimalaria

Patient no complaint of allergies with the medication and he can take orally. Patient knows what it’s for and effect of this medications. All medications prescribed by Dr. Bridget from Australia and she is the specialist for malaria cases.

INVESTIGATIONS:

7

For this patient, doctor order to do the BSMP, chest X-ray and another test specimen that is Full Blood Count (FBC), Blood Urea Serum Electrolytes (BUSE) and Liver Function Tests to see the abnormalities. That is the result:

FBC

TEST RESULT REFERENCE RANGE UNIT REMARKHGB 11.3 MALE (12.2-18.1) g/dl LOWPLT 19 142-424 10ˆ3/uL LOWRBC 4.33 4.40-6.13 10ˆ6/uL LOWHCT 30.9 37.7-53.7 % LOW

BUSE

TEST RESULT REFERENCE RANGE UNIT REMARKNA+ 133 135-145 mmol/L LOWCHLORIDE 96 98-107 mmol/L LOWUREA 11.9 2.5-6.4 mmol/L HIGHCREATININ 145 71-115 umol/L HIGH

Doctor ordered to monitor patient oxygen saturation to avoid any changes. Doctor also ordered IVD 5 pint for this patient, 3 pint Normal Saline alternated 2 pint Dextrose 5%.

PLAN FOR PATIENT:

8

6/02/2011

This morning, patient complains that he has vomited for three times (clear fluid). Staff nurse give tablet Maxolon 10mg to the patient. Patient also has coughed whitish clear sputum. Just now, patient complains that he still loss of appetite. Today, patient was in strictly input and output chart. Vital signs were taken and all are normal except his pulse a bit fast that is 112 beat per minutes. So I just informed to the staff nurse and advice patient to take a rest. At the evening, patient’s temperature is 39°c and tepid sponging done by us. We also encourage patient to bath during fever. After sponging, rechecked and temperature was reduced to 37.3°c.Today the patients will going for chest X-ray in Queen Elizabeth Hospital (QEH), doctor order for IVD 5 pint, 3 pints NS alternated 2 pints D5% for 24 hours. He also monitored for bleeding tendencies, and daily BSMP with density count.

7/02/2011

Today’s, patient appetite was improved, no vomited and vital signs was taken, his got a fever (39.1°c) and the staff nurse give PCM 1g to the patient. Patient also feel headache this morning and myalgia. Patient still on strict I/O chart but doctor ask to off the drip today. Medications served as prescribed. For the investigations, that is sputum AFBx3, sputum c+s, BSMP with density count and on daily DXT. Patient goes to eye clinic at 2pm.

8/02/2011

Based on his results today’s, the investigations for this patient showed improved which his platelet become increased. His temperature also became maintain and no fever today. DXT and PCM were off today. Vital signs taken and no abnormality showed. Patient has pass urine for almost 1000 ml but he also drunk a lot of water. Patient discharge today but I was not there on that time. But before that, I already gave health education so that he can take care of himself during at home.

NURSING MANAGEMENT:

9

Assessment:

Assess patient’s condition if any changes or any abnormalities present. Assess patient’s skin condition. Assess patient’s vital signs. Assess patient’s input and output chart. Assess for increased warm and redness.

Interventions:

Always ask patient if he not comfortable and take time to speak with the patient or ask him to walk in the therapeutic garden.

Make sure patient clean and dry to prevent from get any infection to the skin and for his comfortable.

To check any abnormalities on patient condition such as fever so that the nurse can give the medication as prescribed by doctor.

Monitor amount of intake fluid and amount of urine to monitor how much input and output of this patient. This is to make sure that balance between his fluid intake and urine output to prevent dehydration.

Ask patient to avoid wear tick blanket because it will cause warm and sweat.

NURSING CARE PLAN:

10

Nursing diagnosis

goal Nursing interventions evaluation

Altered comfort related to fever

Patient’s temperature will reduce within normal body temperature.

o perform tepid spongingo Observe temperature 4 hourly or more

frequento Encourage fluid intake of 2-3 liters

daily if not contraindicatedo Remove/ reduce thick clothing or thick

blanketo Advice patient to take a fresh airo Recheck patient temperature after

spongingo Give antibiotic, antipyretic as ordered.

Patient’s temperature reduced after 15 minutes

Potential nutrition less than body requirement related to loss of appetite

Patient will maintain his nutrition status during hospitalization

o Serve patient with well balanced diet with required calorie and protein

o Give small amount but frequently meals

o Allows patient relatives to bring nourishing food from home/ outside

o Serve food at correct temperature and proper arrangement

o Give emotional support

Patient maintain his nutrition status during hospitalization

Potential fluid volume deficit related to excessive fluid loss through vomiting

Patient’s hydration will be maintained throughout hospitalization

o Assess for sign and symptom of dehydration

o Observe vital signs and signs of bleeding

o Monitor fluids intake and outputo Administer intravenous infusion as

orderedo Encourage oral fluids intake of 2- 3

liters/ dayo Give O.R.S as ordered

Patient’s hydration maintained throughouthospitalization

11

PLAN FOR DISCHARGED:

Time: 08/02/2011

Date: 4pm

HEALTH EDUCATION:

1. Advice to the patient to maintain his hygiene.2. Advice to patient and his relatives to clean and tidy up their home.3. Advice patient to avoid smoke and drink alcohol.4. Avoid visit to crowded dirty area.

NUTRITIONAL:

- Ask patient’s relative to give proper nutritional and encourage fluid intake 2-3 liters/ day according to his activity.

MEDICATIONS:

- Advice and teach patient to take his medications on the right time, dose, route as ordered by doctor.

FOLLOW UP:

- Inform and remind to the patient about the date and time for patient’s review with the doctor.

12

CONCLUSION:

My case study for this semester 7 is Malaria. This patient admitted to Infectious Disease Ward Ling Zhi on 05/02/2011. Patient was fully alert and conscious during admitted. Patient on medication and the medication prescribed are IV Artesunate 144mg, tab. PCM 1g, and tab. Riamet 4 tablets for five days. Patient’s condition was monitored everyday during hospitalization. After patient condition’s become well, he was discharged to his home after being in the ward for 3 days. Health education was given to the patient with his relatives so that they can help patient to improving his health status. It is including nutritional, medication, and follows up. Patient discharged on 08/02/2011.

13

REVIEW OF THE DISORDER:

KNOWLESI MALARIA WITH THROMBOCYTOPENIA

INTRODUCTION:

o Malaria is an infectious disease transmitted by mosquitoes. It cause by parasitic

protozoa of the genus plasmodium.

ETIOLOGY:

o It is cause by four species of protozoan parasites of the genus plasmodium:

P. Falciparum, P. Vivax, P. Malariae, and P. Ovale and is transmitted by female anopheles species mosquitoes.

o Host= Human

o Vector= Anopheles mosquito

ANOPHELES MOSQUITO

o There are approximately 460 recognized species: while over 100 can transmit

human malariao Female anopheles mosquito act as malaria vector

o Most anopheles mosquitoes are active at dusk or down or at night

FIVE TYPES OF PLASMODIUM CAUSE HUMAN MALARIA

Plasmodium Falciparumo The most dangerous types of malaria (severe symptom)

Plasmodium Vivaxo Is midler than Falciparum Malaria

Plasmodium Ovaleo (relatively uncommon) a species found primarily in East and Central Africa

Plasmodium Malariaeo The species which causes quartan malaria

Plasmodium Knowlesio (rare type) a primate malaria parasites commonly found in Southeast Asia

14

INCUBATION PERIOD:

CLINICAL MANIFESTATIONS:

Cycles of chills, fever, and sweating that repeat every one, two, or three days are typical

The clinical manifestations usually appear between 10 and 15 days after the mosquito bite.

15

When a person becomes infected with one of the Plasmodium parasites that cause malaria, the infected person may feel normal from days to months after infection, inside the body the malaria parasites are multiplying

In the most cases varies from 7 to 8

Shorter

Longer

P. falciparum

P. malariae

Antimalaria drugs which are taken as prophylaxis by travelers can delay the appearance of malaria symptoms by weeks or months.

Fever

Sweating

Nausea & Vomiting

Headache

Muscle acheJaundice

Chills

DIAGNOSIS:

o History taking

o Physical examination

o Blood Film Malaria Parasite (BFMP)

o Serology- detect antibodies against malaria parasite

o Polymerase Chain Reaction (PCR) test

o Full Blood Count (FBC)

o Liver Function Test (LFT)

TREATMENT:

MEDICATIONS

Control/ reduce fever – paracetamol Antimalaria drugs – chloroquine, quinine, mefloquine, doxcycline, proguanil

*primaquine (should not be taken by pregnant women or people with G6PD deficiency)

16

MANAGEMENT:

o Monitor patient’s general condition thoroughly

o Check and monitor vital signs

o Keep a careful record of fluid intake and output

o Note any appearance of black urine (haemoglobinuria)

o Perform tepid sponging if patient having fever

o Administer paracetamol as an antipyretic if necessary

o Monitor the therapeutic response

o Carry out regular checks on packed cell volume (haematocrit) or hemoglobin

concentration, glucose, urea or creatinine, and electrolyteso Avoid drugs that increase the risk of gastrointestinal bleeding (aspirin,

corticosteroids)o Report changes in the level of consciousness, occurrence of convulsions or

changes in behavior of the patient immediately

MALARIA CONTROL

o Use of insecticidal- treated bed nets by people infected with malaria and people

at risko Indoor residual spraying with insecticide to control the vector mosquitoes

PRECAUTION MEASURES TO PREVENT MALARIA

o Avoid exposure to mosquitoes during the early morning and early evening

o Wear long sleeved shirts and long pants especially when doing outdoor activity

o Have screens over cover windows and doors

o Spray insecticide in the bedroom before going to bed

PROGNOSIS:

o If malaria patient is not treated, malaria can quickly become life- threatening by

disrupting the blood supply to vital organs

17

REFERENCES:

Brunner and Suddarth’s, (2001) text book of Medical Surgical- Nursing (11th ed)

18