OBJECTIVES: 1. To provide nursing management for patient 2. To understand more on nursing care plan related to disease 3.

Prepare for handle for patient with malaria disease

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 dont 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.

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

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.

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.

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 cant 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:

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 IV Artesunate Tab. Paracetamol Tab. Riamet

DOSE 144mg 1g 4tabs

FREQUENCY Once a Day Four times a day Two times a day

INDICATIONS Antimalaria Antipyretic antimalaria

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

INVESTIGATIONS: 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 HGB PLT RBC HCT BUSE TEST NA+ CHLORIDE UREA CREATININ RESULT 133 96 11.9 145 REFERENCE RANGE 135-145 98-107 2.5-6.4 71-115 UNIT mmol/L mmol/L mmol/L umol/L REMARK LOW LOW HIGH HIGH RESULT 11.3 19 4.33 30.9 REFERENCE RANGE MALE (12.2-18.1) 142-424 4.40-6.13 37.7-53.7 UNIT g/dl 103/uL 106/uL % REMARK LOW LOW LOW LOW

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: 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, patients temperature is 39c and tepid sponging done by us. We also encourage patient to bath during fever. After sponging, rechecked and temperature was reduced to 37.3c.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 Todays, patient appetite was improved, no vomited and vital signs was taken, his got a fever (39.1c) 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 todays, 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: Assessment: Assess patients condition if any changes or any abnormalities present. Assess patients skin condition. Assess patients vital signs. Assess patients 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.

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NURSING CARE PLAN:

Nursing diagnosis Altered comfort related to fever

goal Patients temperature will reduce within normal body temperature.

Nursing interventions o perform tepid sponging o Observe temperature 4 hourly or more frequent o Encourage fluid intake of 2-3 liters daily if not contraindicated o Remove/ reduce thick clothing or thick blanket o Advice patient to take a fresh air o Recheck patient temperature after sponging o Give antibiotic, antipyretic as ordered.

evaluation Patients temperature reduced after 15 minutes

Potential nutrition less than body requirement related to loss of appetite

Patient will maintain his nutrition status during hospitalization

Potential fluid volume deficit related to excessive fluid loss through vomiting

Patients hydration will be maintained throughout 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 o Assess for sign and symptom of dehydration o Observe vital signs and signs of bleeding o Monitor fluids intake and output o Administer intravenous infusion as ordered o Encourage oral fluids intake of 2- 3 liters/ day o Give O.R.S as ordered

Patient maintain his nutrition status during hospitalizati on Patients hydration maintained throughout hospitalizati on

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PLAN FOR DISCHARGED: Time: 08/02/2011 Date: 4pm HEALTH EDUCATION: 1. 2. 3. 4. Advice to the patient to maintain his hygiene. Advice to patient and his relatives to clean and tidy up their home. Advice patient to avoid smoke and drink alcohol. Avoid visit to crowded dirty area.

NUTRITIONAL: Ask patients 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 patients review with the doctor.

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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. Patients condition was monitored everyday during hospitalization. After patient conditions 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.

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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 malaria o 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 Falciparum o The most dangerous types of malaria (severe symptom) Plasmodium Vivax o Is midler than Falciparum Malaria Plasmodium Ovale o (relatively uncommon) a species found primarily in East and Central Africa Plasmodium Malariae o The species which causes quartan malaria Plasmodium Knowlesi o (rare type) a primate malaria parasites commonly found in Southeast Asia

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INCUBATION PERIOD:

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 days. Shorter periods P. falciparum P. malariae

Longer periods

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

CLINICAL MANIFESTATIONS:

Fever Chills Sweating Headache Jaundice

Nausea & Vomiting Muscle ache

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.

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DIAGNOSIS: o o o o o o o History taking Physical examination Blood Film Malaria Parasite (BFMP) Serology- detect antibodies against malaria parasite Polymerase Chain Reaction (PCR) test Full Blood Count (FBC) 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)

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MANAGEMENT: Monitor patients general condition thoroughly Check and monitor vital signs Keep a careful record of fluid intake and output Note any appearance of black urine (haemoglobinuria) Perform tepid sponging if patient having fever Administer paracetamol as an antipyretic if necessary Monitor the therapeutic response Carry out regular checks on packed cell volume (haematocrit) or hemoglobin concentration, glucose, urea or creatinine, and electrolytes o 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 o o o o o o o o MALARIA CONTROL o Use of insecticidal- treated bed nets by people infected with malaria and people at risk o Indoor residual spraying with insecticide to control the vector mosquitoes PRECAUTION MEASURES TO PREVENT MALARIA o o o o Avoid exposure to mosquitoes during the early morning and early evening Wear long sleeved shirts and long pants especially when doing outdoor activity Have screens over cover windows and doors 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

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REFERENCES: Brunner and Suddarths, (2001) text book of Medical Surgical- Nursing (11th ed)

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