CHAPTER ONE

1.0 Assessment of patient and family

Assessment is the first stage of the nursing process. A nursing assessment is a process where a
nurse gathers, sorts and analyses a patient’s health information using evidenced informed tools to
learn more about a patient’s overall health and concerns. This includes considering the patient
biological, social, psychological, cultural and spiritual values and beliefs (Toney-Butler &
Unison-Pace, 2021).

1.1 The patient’s particulars

Mr. C.K.B is a 35-year-old man who was born on 2 nd March, 1990. He comes from Jamasi, in
Asante region of Ghana. Mr. C.K.B is dark in skinned complexion and weighs 27.5kg. He is a
Christian and an Asante by tribe. Mr. C.K.B is a police officer who works at the walewale
divisional command. His next of kin is his son by name Benjamin Boadu.

1.2 Family medical history

According to the mother, there is no known chronic, hereditary diseases in their family. On the
contrary, they often treat minor sickness such as headache, diarrhea, vomiting, common cold and
abnormal pain with over-the-counter (OTC) medications.

1.3 Socioeconomic history

Mr. C.K.B resides with his family and two siblings at the Walewale Police Residence. He is a
police officer whose basic needs, including shelter, food, and security, are supported through his
employment and family structure. His parents are farmers who cultivate a variety of crops and
also contribute financially to the general upkeep of the household.

According to him, all members of the family, including Mr. C.K.B, are enrolled in the National
Health Insurance Scheme (NHIS), which caters for their healthcare needs. The family maintains
active participation in social activities such as funerals and naming ceremonies, and they
occasionally attend these events together.

1.4 Patient’s developmental history

Mr. C.K.B was born on 2nd March, 1990. He was delivered at hospital through spontaneous
vaginal delivery. Mr. C.K.B was born normal with no congenital defects or birth abnormalities.
He was vaccinated against the Vaccine Preventable Diseases namely tetanus, measles, pertussis,

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diphtheria, poliomyelitis and tuberculosis. He was exclusively breastfed for 6months. Teething
started at about 8months old. According to Mr. C.K.B, he started to sit when he was 6months
old, crawled at the age of 8months and began to walk when he was at the age of 12 months. Mr.
C.K.B started toilet training when he was about 1-2years of age. Mr. C.K.B started schooling at
age of seven (7).

1.5 Patient’s lifestyle and hobbies

On an average day, Mr. C.K.B wakes up at 6:00am in the morning. He empties his bowel and
brushes his teeth with toothpaste and a toothbrush. Mr. C.K.B takes his breakfast and by 7:00am
he prepares for work depending on his shift. He closes from work at 2:30pm. In the evening, Mr.
C.K.B goes out with his friends to play football.

According to Mr. C.K.B’s, his favorite meal is “TZ” and “Ayoyo” soup. His breakfast is usually
tea and bread or porridge. At lunch, he is served with “waakye” or “gari” and beans. His supper
is mostly “TZ” or “Banku”. At his leisure time, he loves to play football with his peers and
sometimes watch television when he is lonely. Before retiring for the day, Mr. C.K.B empties his
bowel, brushes his teeth and takes his bath. Mr. C.K.B goes to bed at 9:30 pm when he is not for
night duty.

1.6 Past medical/surgical history

Mr. C.K.B has neither suffered from any serious medical nor surgical condition. According to his
mother, Mr. C.K.B was once admitted at the hospital seven (7) years ago and treated for malaria.

The condition was managed with anti-malaria drugs and pain medications. Other common
sicknesses he has been suffering from are headache, abdominal pains, and common cold which
are often managed with over-the-counter (OTC) medications.

1.7 Present medical history

On the 14th July 2025, around 9am, Mr. C.K.B was well prior to the onset of his condition. He
started vomiting, followed with general body pains, chills, loss of appetite and fever. According
to Mr. C.K.B’s sister, Mr. C.K.B refused to eat after she had offered him a meal and
complaining of the above symptoms so he bought drugs from the pharmacy and toke as ordered.
The symptoms did not really subside so he decided to visit the District hospital accompanied by

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his friend and college at work. After consultation, Mr. C.K.B was diagnosed with severe malaria
by Doctor Adu.

1.8 Admission of patient

On the 14th of July 2025, around 1:45 pm, Mr. C.K.B was brought to the Males’ Medical Ward
with his friend through the Out-Patient Department (OPD) at the walewale municipal hospital.
Both were warmly welcomed at the nurse’s station. After going through his documents to
confirm the admission, he was given a bed. Mr. C.K.B’s particulars were entered into the
admission and discharge book, daily ward state and the nurse’s notes. All other necessary
documentations were also made.

His vital signs on admission were checked and recorded as:

 Temperature 38. 2 ⁰C
 Pulse 92 bpm
 Respiration 22 cpm
 Blood pressure 115/75mmhg
 Weight 77.5kg
 SPO2: 97 %

The following medications on admission were prescribed:

1. IV Artesunate 120mg at 0,12 and 24 hours

2. IV Metoclopramide 10mg st (PRN)
3. IV Paracetamol 1g tid x 24hours
4. Dextrose Normal Saline 500mls x 24 hourly
5. Ringer’s Lactate 500mls x 24hourly

The following laboratory investigations were requested on admission:

1. Hemoglobin Level Estimation

2. Blood Film for malaria parasite
3. Sickling test
4. Widal test

Blood sample was taken to the laboratory for the necessary investigations.

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During the admission process, Mr. C.K.B and his mother were reassured. They were introduced
to other patients in the ward. Patient and mother were oriented to the ward and its annexes.
Hospital and ward protocols were also explained to them. They were informed of the hospital’s
visiting hours, from 6am to 7am in the morning and 5pm to 6pm in the evening.

1.9 Patient concept of illness

Patient and family did not attribute the diseases to any supernatural forces or other factors. Mr.
C.K.B and his mother believed that the sickness was due to frequent mosquito bites. They
strongly believed that malaria is a normal sickness that anyone can be infected. Owing to this,
the mother believed that God would restore Mr. C.K.B health in no-time.

1.10 Literature review of malaria

Definition

Malaria

Malaria is an acute parasitic disease of the blood caused by protozoa of the genus Plasmodium. It
may present as either uncomplicated or severe malaria, depending on factors such as the
individual’s immune status, parasite load, and the presence of comorbid conditions like
malnutrition or anemia. Clinically, malaria is characterized by symptoms such as fever, chills,
sweating, and enlargement of the spleen (World Health Organization, 2023). It is also described
as an acute protozoan infection marked by intermittent episodes of high fever, profuse sweating,
and fatigue (White et al., 2022).

Incidence

Malaria affects people of all age groups and remains highly prevalent in tropical and subtropical
regions, particularly in sub-Saharan Africa. According to the World Health Organization (2023),
there were an estimated 249 million cases of malaria globally in 2022, with approximately
608,000 deaths reported. The African region continues to bear the greatest burden, accounting
for about 94% of all malaria cases and deaths, with children under five years being the most
affected group.

Globally, over 3.2 billion people remain at risk of malaria infection (WHO, 2023). Malaria also
has significant economic implications, reducing economic growth in endemic countries and
placing a heavy burden on healthcare systems.

In Ghana, malaria remains a leading cause of morbidity and mortality, particularly among
children under five years and pregnant women. It continues to be one of the most common
causes of outpatient visits and hospital admissions, contributing substantially to the national
disease burden (Ghana Health Service, 2023).

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Aetiology

Malaria is caused by five species of Plasmodium that infect humans, namely:

1. Plasmodium falciparum
2. Plasmodium vivax
3. Plasmodium ovale
4. Plasmodium malariae
5. Plasmodium knowlesi

Among these, Plasmodium falciparum is the most virulent and is responsible for the majority of
severe cases and deaths worldwide (WHO, 2023). Plasmodium knowlesi, originally found in
animals, has increasingly been reported in human infections, particularly in forested regions of
Southeast Asia (White et al., 2022).

Mode of Transmission

Malaria is primarily transmitted through the bite of an infected female Anopheles mosquito.
Transmission intensity depends on factors related to the parasite, the mosquito vector, the human
host, and environmental conditions. Mosquitoes breed in stagnant water such as puddles, rice
fields, and other collections of freshwater, with different species having specific breeding
preferences.

In many parts of Africa, including Ghana, the main vectors responsible for transmission are
Anopheles gambiae and Anopheles funestus, both of which predominantly bite at night (WHO,
2023).

Malaria can also be transmitted through non-vector routes, although these are less common.
These include blood transfusion with infected blood, sharing of contaminated needles, and from
mother to fetus during pregnancy (congenital malaria) (Centers for Disease Control and
Prevention, 2024).

Incubation period

The incubation period depends on the particular type of plasmodium causing the disease. Below
is a table indicating the types of parasites, their incubation periods and distribution.

Table 1.1 Types of malaria parasite, incubation period and distribution

NUMBER TYPE PARASITE INCUBATION DISTRIBUTION

PERIOD

1 Malignant Plasmodium 8-15days Equatorial region

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 Tertian falciparum

2 Benign Tertian Plasmodium 10-15days Equatorial and

vivax Mediterranean

3 Quartian Plasmodium 30-40days Equatorial

malariae

4 Ovale Plasmodium 10-15days North East Africa

ovale

5 Knowlesi Plasmodium 10-12 days South East Asia

knowlesi

Also, according to Van Den Berg et al (2002), the incubation period of the plasmodium parasite
in human is as follows;

1. Plasmodium falciparum: 8-25 days (average is 12 days)

2. Plasmodium vivax: 8-27 days (average is 14 days)
3. Plasmodium ovale and: 9-17 days (average is 15 days)
4. Plasmodium malariae: 15-30 days (average is 15 days)

Mosby’s dictionary (2006) had it that the incubation period is 1-4 weeks for Plasmodium vivax.

Smeltzer and Bare (2004) also said the period of incubation is 12-30 days for Plasmodium
malariae.

Pathophysiology

According to Atindabilla (2002) the life cycle of the parasite is divided into two phases:

1. Inside the human (schizogony).

2. Inside the mosquito (sporogony).

Phases of Parasite

 Inside human (schizogony) phase

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The first phase of the life cycle in man is termed as the exo-erythrocytic cycle (EEC) which takes
7-11 days depending on the species. At this phase, the parasites (sporozoites) are injected into
the blood stream of man through the bite of an infected female anopheles mosquito.

Within 24 hours, they enter the parenchyma cells of the liver and multiply into liver schizonts.
After 7-11 days depending on the species of the plasmodium, the liver schizonts undergo asexual
reproduction in which its nucleus splits to form new cells called merozoites which are released
into the blood.

The second phase of the cycle in man is called the erythrocytic cycle (EC). It starts when the
merozoites enter the red blood cells. During this stage the merozoites develop to form immature
or ring stage trophozoites which then progress to mature trophozoites. The mature trophozoites
develop into schizonts. These schizonts lead to the formation of 4 to 36 new parasites in each
infected cell within a 44 to 72-hour period. When the schizonts are matured, they rupture out
merozoites into the blood together with the accumulated material pigments (hemoglobin digested
by parasites) and toxins. It is the entry of these toxins into the blood that causes the fever and
chills.

 Inside the mosquito (sporogony\sexual) phase

Next begins the sexual cycle in mosquitoes. When a female Anopheles mosquito takes a blood
meal from an infected person, both male (microgametocytes) and female (macro- gametocytes)
may be ingested. The microgametocytes and macro gametocytes mature to become
microgametes and macrogametes, respectively. In the midgut of the mosquito, the microgametes
fertilize the macrogametes, forming a zygote. The zygote becomes elongated and motile, and is
then called an ookinete. The ookinetes invade the midgut wall of the mosquito where they
develop into oocytes. The oocytes grow and develop and finally rupture to release sporozoites.
The sporozoites make their way to the salivary glands of the mosquito so that they can be
inoculated in to the new human host during the mosquito’s next blood meal, thus perpetuating
the Plasmodium life cycle.

Image 1.0 Life cycle of plasmodium in man and mosquito

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Life Cycle of the Mosquito

The Anopheles mosquito, which is responsible for transmitting malaria, undergoes a complete
life cycle consisting of four stages: egg, larva, pupa, and adult. Breeding typically occurs in
water, with different species showing specific habitat preferences. For example, Anopheles
gambiae commonly breeds in small, temporary pools of water formed by rainfall and exposed to
sunlight, whereas Anopheles funestus prefers more permanent bodies of fresh, slow-moving
water such as streams and ponds (World Health Organization, 2023).

After the female mosquito lays eggs on the surface of water, they usually hatch within 2–3 days
under favorable warm conditions. The larvae that emerge remain in the water, where they feed
on microorganisms and organic matter. Within approximately 7–10 days, the larvae develop into
pupae (cocoons), which do not feed but undergo transformation into adult mosquitoes. After 2–4
days, adult mosquitoes emerge and are capable of flying distances of up to about 1–2 kilometers
from their breeding sites.

Adult Anopheles mosquitoes typically rest in dark, warm, and humid environments. A
distinguishing feature of the Anopheles mosquito is its resting posture, where the body is held at
an angle with the abdomen raised, unlike the Culex mosquito, which rests parallel to the surface.

The lifespan of the adult mosquito varies depending on environmental conditions, but female
Anopheles mosquitoes generally live for about 1–2 weeks, during which they feed on plant
sugars for energy and require blood meals for egg production (Centers for Disease Control and
Prevention, 2024).

Types of malaria

With regards to the type of malaria parasites involved, malaria can be classified into 2 main
types. These are;

1. Malignant Malaria: This type of malaria is caused by plasmodium falciparum and is the
most severe of all the malaria parasites. It prevails in the tropics and is characterized by
bunts of fever occurring every 36 hours which may be irregular. It usually runs on acute
onset and the temperature here has a step ladder rise like that of typhoid fever.

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 2. Benign Malaria: The benign form of malaria is relatively mild and less fatal. There exist
2 types namely; Tertian Malaria and Quartian Malaria
 Tertian Malaria is a type of malaria characterized by attacks of fever every 48 hours. It is
caused by Plasmodium Vivax and Plasmodium Ovale and has a lesser relapse rate which is
generally mild.
 Quartian Malaria is a type of malaria which has a long persistent attack of fever every 72
hours. It is caused by plasmodium Malariae and is usually not severe.

Clinical manifestations

1. Atindabilla (2002) indicated that, there is an onset of paroxysms of fever (39-40) ˚C that is
accompanied by convulsion in young children. The child also has chills, lasting 2-4 hours
which is then followed by sweating. In young children paroxysms are irregular where as in
older children they vary with the type of infection; 48 hours in cases of Plasmodium vivax,
Plasmodium falciparum, Plasmodium ovale and plasmodium Knowlesi and 72 hours in
Plasmodium malariae. In addition to this, they will have frequent diarrhoea, vomiting and
splenomegaly.
2. Sandra (2001) said that malaria is manifested by malarial paroxysm which is characterized
by chills, headache, rigor, cough and respiratory distress.
3. Mosby’s dictionary (2006) added that malaria is characterized by anaemia, myalgia,
arthralgia and weakness.
4. Boakye -Yiadom (2007) also contributes that malaria is characterized by bodily aches;
bitter taste in the mouth, abdominal pain and poor appetite are the clinical features in
adults and older children. In young children; poor appetite, may progress to fits and coma,
warm to touch, may be anaemic and feeling cold; with sweating and rigors.

Complications

 MOH (2004) states the complications of malaria as

1. Postural hypotension 5. Parasitaemia

2. Hyperpyrexia 6. Hypoglycaemia
3. Severe cerebral involvement 7. Acute pulmonary oedema
4. Renal failure 8. Electrolyte/fluid imbalance.

 According to Van Den Berg et al (2002), complications of malaria are;

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 1. Cerebral malaria 2. Acute/chronic splenomegaly.

 Sandra (2001) viewed the complications of malaria to include;

1. Shock
2. Acute encephalopathy
3. Cerebral and pulmonary oedema
4. Disseminated vascular coagulation
5. Coma.

GHS (2005) also added that when parasites get into the placenta, they interfere with the transfer
of oxygen and nutrients from the mother to the unborn baby. When this happens to the mother, it
increases his risk of having

1. Maternal anemia 3. Preterm birth

2. Spontaneous abortion 4. Placental infection

When it affects the placenta, it leads to foetal anemia, prematurity, low birth weight, still birth
and rarely congenital malaria (GHS, 2005).

Diagnostic investigations

According to MOH (2004), the diagnosis of malaria includes

1. Clinical features and history

2. Full blood count (FBC)

3. Blood film (BF) for malaria parasites (MPs)
4. Sickling test
5. Widal test.

Specific Treatment of Malaria

According to Mosby (2006), malaria prophylaxis involves the administration of

1. Chloroquine 3. Doxycycline
2. Tetracycline 4. Mefloquine.

Mosby (2006) also stated that treatment for active malaria include the administration of

1. Chloroquine

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 2. Doxycycline
3. Mefloquine
4. Pyremaquine
5. Sulphonamides
6. Pyrimethamine.

Treatment of Malaria

The Ministry of Health Ghana (2004) recommended Artesunate-Amodiaquine as the first-line

treatment for uncomplicated malaria in Ghana due to increasing resistance of Plasmodium
falciparum to chloroquine. This shift marked a transition to artemisinin-based combination
therapies (ACTs), which are more effective.

More recent guidelines from the World Health Organization (2023) and the Ghana Health
Service indicate that ACTs, including Artesunate-Amodiaquine, remain the standard treatment
for uncomplicated malaria.

For severe malaria, intravenous or intramuscular artesunate is currently the preferred treatment.
However, quinine may still be used as an alternative where artesunate is not available.
Intramuscular artemether can also serve as a second-line option in the management of severe
cases.

In summary, Artesunate-Amodiaquine is widely used for uncomplicated malaria, while

injectable artesunate is the drug of choice for severe malaria, with quinine and artemether
serving as alternatives depending on availability and clinical [Link] recommended
dosage regimen for the artesunate-amodiaquine combination is tabulated below;

Table 1.2 Artesunate tablets (50mg) uptake

WEIGHT (KG) AGE (YEARS) DAY 1 DAY 2 DAY 3

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 5-10 Infants 25mg 25mg 25mg

11-24 1-6 50mg 50mg 50mg

25-50 7-13 100mg 100mg 100mg

50+ 14+ 200mg 200mg 200mg

Source: ([Link])

Table 1.3 Amodiquine tablets (150mg) uptake

WEIGHT (KG) AGE (YEARS) DAY 1 DAY 2 DAY 3

5-10 Infants 75mg 75mg 75mg

11-24 1-6 150mg 150mg 150mg

25-50 7-13 300mg 300mg 300mg

50+ 14+ 600mg 600mg 600mg

Source: ([Link])

However, there is a caution that artesunate-amodiaquine should not be used in the treatment of
pregnant women in their first trimester. They are rather given full course of quinine orally 600mg
8 hourly for 7 days.

The current choice of drug is iv artesunate and tabled arthemeter lumefamtrin(AL).

Prevention and control

According to Van Den Berg et al (2022), the preventive measures are based on vector control,
health education, chemoprophylaxis and other measures.

Preventing the breeding of mosquito larvae

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The termination of mosquito larvae and pupas is a way of controlling the vector that spreads
malaria. This can be done by: regularly spraying the breeding sites with chemicals, always
keeping the environment clean, draining all standing waters, providing proper refuse disposal
methods

Avoiding mosquito bites

Mosquito’s bites can be prevented by:

1. Sleeping under a mosquito – proof net at night.

2. Wearing protective clothing like long sleeves, skirts and long pair of trousers at night.
3. Using mosquito repellents at night.
4. Closing doors and windows to prevent mosquitoes from entering the room.

Mosquitoes are destroyed by spraying long-acting insecticides on the walls and ceilings inside
the houses. The public has to be made aware that malaria can be prevented and so people should
take precautions against mosquito bites by maintaining personal and environmental hygiene and
using protective clothing and measures as outlined above.

Chemotherapy

Prophylaxis could be short or long term. It is short term for people who are visiting an endemic
region for a limited period of time or days and long term for those living in malaria regions or
areas. The course of short term prophylaxis must be started a week before the visit, maintained
during the stay and kept up for four weeks after the visit has ended.

Long term prophylaxis is acquired by means of parenteral depot of compound such as camolar.
An injection of this drug renders a person reasonably insusceptible for a period of four months.

MOH (2018) had it that, prevention of malaria on the unborn child is an intermittent preventive
therapy (IPT). The full dose of sulphadoxine- pyrimethamine (SP) is given to pregnant women
by the directly observed (DOT) method.

Other measures

1. The public has to be made aware that there will be an increase in malaria cases after
heavy rains.
2. Vector control has to be intensified.

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 3. There should be planning and implementation of new preventive programs with a regular
evaluation.
4. Resistances to drugs have to be monitored.
5. The endemic regions should preferably be visited during the dry season or when rainfall
is relatively low.

GHS (2005) states a strategy for controlling malaria in pregnancy as iron and folate
supplementation, de-worming, case management of illness and insecticide treated nets (ITNs).

WHO/Africa Regional Office (AFRO) strategic framework approach for malaria control during
pregnancy recommends the multi-prolonged approach which is insecticide treated net (ITN),
Intermittent Preventive Therapy (IPT) and case management of malaria illness.

Nursing Management of Malaria

 Psychological
1. Reassure patient to alleviate anxiety.
2. Explain the disease process to the patient.
3. Explain procedures to patient.
 Rest and sleep
1. Nurse patient in a serene, well ventilated environment.
2. Restrict visitors during sleeping periods.
3. Lay bed free from creases and crumps.
4. Drugs to aid sleep like Valium.
 Observation
1. Patient vital signs i.e. temperature, pulse, respiration and BP. Record and report any
abnormality found. If temperature is high, tepid sponge and serve prescribed anti-
pyretic and chilled drink.

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 2. Monitor intake and output by maintaining an Intake and Output Chart. Check for
signs of dehydration or fluid overload.
3. Observe vomitus for amount, odour, colour and blood.
4. Observe for signs of convulsion in children.
 Nutrition
1. Provide a well-balanced diet rich in protein, carbohydrate, irons and vitamins in bits
but at frequent intervals.
2. Serve rich fluid diet and enough fruits to replace lost fluids.
3. Serve food attractively to boost patient’s appetite.

 Personal hygiene
1. Ensure that patient takes the bath twice daily. Taking special attention to the
perineum.
2. Maintain oral hygiene and care of lips.
3. Groom Patient
4. Trim and clean nails.
5. Keep patient's bed clean and dry always.
 Elimination
1. Monitor bowel movement for constipation or diarrhoea.
2. Monitor stool and urine for amount, odour, colour and blood.
3. Observe for bowel and bladder patterns.
 Medications
1. Administer prescribed medications.
2. Observe and report any therapeutic and side effects of drugs.
3. Observe the 7 rights of drug administration.
 Patient education
1. Educate patient about the condition, treatment and prevention.
2. Educate patient about the medication and the need to adhere to it.
3. Teach the patient how to keep the environment clean always.
4. Advice patient to spray breeding places of mosquitoes with insecticides.
5. Teach patient on the need to live in mosquito proof houses and wear protective cloths.
6. Educate patient on the use of mosquito nets.

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 7. Educate patient on the need to eat well-balanced diet rich in protein, carbohydrate,
irons and vitamins.

1.11 Validation of data

According to, Oxford Advance Learners Dictionary, 6th edition, validation is to state officially
that something is useful and of acceptable standard. It is the act of confirming or verifying data.
The purpose is to make sure that the data is free from errors, bias and misinterpretation.

All information in this script was collected through interviews, history taking, rapport with
patient/family and observation during the period of hospitalization and subsequent home visits to
patient/family residence. This was compared to standard as shown below:

Confirmation was done using the patient’s folder which contains all information on the patient
and his disease condition. Based on the above, I declare that the information contained in this
script is reliable, accurate and factual

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