Malaria is a parasitic infection of the red blood cells caused by Plasmodium species and spread by the bite of infected female Anopheles mosquitoes. Any fever in a person who has been in a malaria area is malaria until proven otherwise, because P. falciparum can become severe within hours. The nursing diagnoses used most often are Hyperthermia, Acute Confusion, Risk for Unstable Blood Glucose Level, and Ineffective Health Self-Management. Nursing care centers on a travel history, fast testing, prompt antimalarial treatment, close watch for signs of severe malaria, careful fluid and glucose monitoring, and prevention teaching.
At a glance
- What it is
- Infection with Plasmodium parasites (P. falciparum, P. vivax, P. ovale, P. malariae, P. knowlesi) that multiply in the liver and then destroy red blood cells.
- Who is at risk
- Anyone who lives in or travels to an area with malaria, especially travelers who skip or stop preventive medicine, people visiting friends and family in their country of origin, young children, and pregnant people.
- Key signs
- Fever with chills and sweats, headache, muscle aches, fatigue, nausea or vomiting, and in more serious illness jaundice, dark urine, confusion, or breathing difficulty. A regular fever cycle is often absent, especially with P. falciparum.
- Nursing focus
- Ask about travel, send blood smears right away, give antimalarials on time, monitor neuro status, glucose, fluids, urine output, and breathing, manage fever, and teach prevention and medicine adherence.
- Act now
- New confusion, a seizure, low blood glucose, breathing difficulty, low blood pressure, very low urine output, dark urine, or bleeding can mean severe malaria. Call the provider or rapid response team at once and follow your facility’s protocol; severe malaria needs IV artesunate and critical care.
Pathophysiology of malaria
An infected mosquito injects sporozoites, which travel to the liver and multiply there without symptoms. In P. vivax and P. ovale, some parasites stay dormant in the liver as hypnozoites and can cause a relapse months later. Parasites then enter the blood and invade red blood cells, multiply, and burst the cells. Each burst releases parasites and toxins that trigger fever, chills, and sweating, and the destroyed cells cause anemia and jaundice.
P. falciparum causes most severe disease. Infected red cells stick to the walls of small blood vessels in the brain, kidneys, lungs, and placenta, blocking blood flow. This leads to cerebral malaria (impaired consciousness or seizures), acute kidney injury, acute respiratory distress, metabolic acidosis, and shock. Low blood glucose is common because the parasites use glucose, the patient eats little, and some antimalarials increase insulin release. Pregnant people and young children are at highest risk of severe disease.
Symptoms usually start about one to four weeks after the bite, but they can start later, especially with P. vivax and P. ovale. Malaria does not spread from person to person by casual contact. Rarely, it spreads through blood transfusion, organ transplant, shared needles, or from a pregnant person to the baby.
Uncomplicated vs severe malaria
| Type | What it looks like |
|---|---|
| Uncomplicated | Fever, chills, sweats, headache, body aches, nausea, mild anemia. The patient is alert and can take oral medicine. Treated with an oral antimalarial chosen by species and where the infection was acquired. |
| Severe | Any of: impaired consciousness, coma, or seizures; severe anemia; breathing difficulty or ARDS; acute kidney injury; low blood glucose; acidosis; jaundice; shock; abnormal bleeding; or high parasitemia (CDC uses 5% or more). Treated with IV artesunate and critical care. |
Nursing assessment
Subjective data
- Travel history: countries and regions visited, dates of travel and return, and activities such as rural stays or outdoor evenings
- Whether preventive medicine was taken, which drug, and whether it was finished after return
- Use of insect repellent, long sleeves, and bed nets
- Fever, chills, sweats, headache, muscle and joint aches, fatigue, nausea, vomiting, diarrhea, abdominal pain
- Past malaria episodes and how they were treated
- Pregnancy status, recent blood transfusion, and known G6PD deficiency
- Current medicines, including heart medicines, because some antimalarials affect the QT interval
Objective data
- Temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation, and how they change over time
- Level of consciousness with the Glasgow Coma Scale, orientation, and any seizure activity
- Pallor, jaundice, enlarged liver or spleen, petechiae or bleeding
- Intake and output, urine color (dark or cola-colored urine), and signs of dehydration or fluid overload such as crackles
- Thick and thin blood smears: confirm malaria, name the species, and measure parasitemia; if negative and malaria is still suspected, smears are repeated, per CDC every 12 to 24 hours for a total of three sets
- Rapid diagnostic test if used, confirmed by microscopy
- Point-of-care and serum glucose, CBC with platelets, kidney and liver function, lactate, blood gases, and coagulation studies as ordered
- G6PD level before primaquine or tafenoquine, and pregnancy test as ordered
Nursing diagnoses used with malaria
- Hyperthermia — fever from the release of parasites and inflammatory chemicals when red cells burst
- Acute Confusion — changes in attention and thinking from cerebral malaria, low glucose, or poor oxygen delivery
- Risk for Unstable Blood Glucose Level — risk of low glucose from severe infection, poor intake, and some treatments
- Ineffective Health Self-Management — preventive medicine skipped or stopped, or a treatment course not completed
- Risk for Deficient Fluid Volume — fever, sweating, vomiting, and poor intake
- Risk for Bleeding — low platelets and clotting changes
- Impaired Gas Exchange — fluid in the lungs or ARDS in severe malaria
- Fatigue — anemia and the energy cost of infection
Worked care plans
Four plans in the same ADPIE shape. The scenario is a 34-year-old man who returned 12 days ago from three weeks visiting family in Nigeria. He did not take preventive medicine because he “grew up there and never got sick as a kid.” He has had fever, chills, drenching sweats, headache, and vomiting for 3 days. In the emergency department his temperature is 39.6 °C (103.3 °F), heart rate 118, blood pressure 104/62, respiratory rate 24, and oxygen saturation 95% on room air. He is drowsy and confused about the date (GCS 14) and mildly jaundiced. The thin smear shows P. falciparum with 6% parasitemia. Platelets are 48,000/mm³, hemoglobin 10.1 g/dL, and glucose 82 mg/dL. He has severe malaria, is admitted to the intensive care unit, and IV artesunate is started.
1. Hyperthermia
Problem-focusedSubjective: “I keep going from freezing to soaking wet.” “My head is pounding.”
Objective: Temperature 39.6 °C (103.3 °F), heart rate 118, respiratory rate 24. Skin hot and flushed, then diaphoretic. Rigors witnessed in the emergency department. P. falciparum on smear.
Hyperthermia related to the inflammatory response to Plasmodium falciparum infection, as evidenced by temperature 39.6 °C, tachycardia, tachypnea, flushed hot skin, rigors, and diaphoresis.
- Temperature trends down within 24 to 48 hours of starting antimalarial treatment
- Heart rate and respiratory rate return toward his baseline as fever falls
- Patient reports improved comfort and has no shivering from cooling measures
- Give IV artesunate exactly on schedule as ordered; treating the parasite is what ends the fever
- Monitor temperature at the frequency ordered and with every change in condition, and record the pattern
- Give acetaminophen as ordered; avoid NSAIDs and aspirin unless the provider orders them, because his platelets are low
- Use light covers, a cool room, and fresh linens after sweating; stop cooling measures that cause shivering
- Keep chills and sweats from hiding other changes: recheck heart rate, blood pressure, and mental status with each fever spike
- Report a temperature that does not fall as expected, or a new fever after improvement, to the provider
By 48 hours his temperature was 37.8 °C (100 °F) and falling, heart rate 92, respiratory rate 18. Rigors stopped and he rested between assessments. Repeat smears showed parasitemia falling. Goal met; continue to monitor until fever and parasitemia clear.
2. Acute Confusion
Problem-focusedSubjective: Wife reports, “He’s not himself. He asked me twice what day we flew home.” Patient says, “I can’t think straight.”
Objective: GCS 14 (confused). Disoriented to date, slow to answer, drifts off during questions. Pupils equal and reactive. No seizure activity. Glucose 82 mg/dL. Oxygen saturation 95% on room air. 6% parasitemia.
Acute Confusion related to impaired brain blood flow from severe P. falciparum malaria and high fever, as evidenced by disorientation to time, fluctuating attention, slowed responses, and GCS 14.
- Patient returns to his baseline mental status, oriented and able to follow conversation, as the infection is treated
- Any decline in level of consciousness or seizure is recognized and reported immediately
- Patient remains free from injury
- Assess GCS, orientation, pupils, and attention at the frequency ordered for an ICU patient, and compare with the last check
- Check blood glucose right away with any change in mental status, since low glucose can look like cerebral malaria and is quickly reversible
- Report a drop in GCS, a seizure, or new focal weakness at once; follow seizure precautions per facility policy and keep suction and oxygen ready
- Protect the airway: raise the head of the bed if not contraindicated, and turn to the side if vomiting while drowsy
- Reorient him often in short, simple sentences, keep his wife at the bedside when possible, and keep glasses, clock, and calendar in view
- Use fall precautions and a low bed, and keep the call light in reach
His GCS returned to 15 by day 2 and he was oriented and following instructions. He had no seizures and no falls. His wife said, “He’s back to himself.” Goal met.
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NCLEX Readiness Diagnostic
Fifty questions with a written rationale on every option, scored by section so you can see which content area is weakest. Sent as a PDF.
3. Risk for Unstable Blood Glucose Level
RiskSubjective: “I haven’t been able to eat anything for two days. Everything comes back up.”
Objective: Glucose 82 mg/dL on admission. Vomiting, almost no oral intake for 2 days. Severe P. falciparum malaria with 6% parasitemia. Drowsy, which can hide the early warning signs of low glucose.
Risk for Unstable Blood Glucose Level with risk factors of inadequate dietary intake and vomiting; associated condition: severe P. falciparum malaria.
Risk diagnosis: risk factors only, because low glucose has not occurred yet.
- Blood glucose stays within the range set by the provider or facility protocol throughout the acute illness
- Any low reading is recognized and treated within minutes
- Check point-of-care glucose at the frequency ordered, and any time he is sweaty, shaky, newly confused, or harder to wake
- Know your facility’s hypoglycemia protocol and keep IV dextrose available as ordered
- Give IV fluids with dextrose as ordered while he cannot eat, using an infusion pump
- Give antiemetics as ordered and offer small, frequent carbohydrate-containing meals once he can eat
- Remember that fever, sweating, and drowsiness from malaria can mask the usual signs of low glucose, so rely on the meter, not symptoms
- Report low readings and the treatment given to the provider
His glucose stayed within the ordered range on scheduled and as-needed checks. Vomiting stopped on day 2 and he ate small meals by day 3. Goal met; checks reduced as ordered.
4. Ineffective Health Self-Management
Problem-focusedSubjective: “I thought I was immune because I grew up there.” “We’re going back for my cousin’s wedding next year.” “Do I really need to finish the pills if I feel fine?”
Objective: Took no preventive medicine and used no repellent or bed net during travel. Will start an oral follow-on antimalarial course to finish at home. Plans future travel to a malaria area.
Ineffective Health Self-Management related to inadequate knowledge of the treatment regimen and belief that childhood exposure gives lasting protection, as evidenced by failure to take preventive actions during travel and expressed doubt about completing the prescribed course.
- Patient states why the full antimalarial course must be finished even after he feels better
- Patient explains that immunity from childhood fades after living away from a malaria area
- Patient describes a prevention plan for his next trip, including a pre-travel visit
- Patient states the symptoms that mean he must seek care right away
- Explore his beliefs respectfully, then explain that partial protection from childhood fades within a few years of living away, which is why people visiting family are a high-risk group
- Teach the name, schedule, and length of his follow-on course, and that some drugs must be taken with fatty food or milk to absorb well, as his pharmacist or label directs
- Explain that he needs a hemoglobin check after IV artesunate, because a delayed drop in red cells can occur in the weeks after treatment, and give him the follow-up appointment
- Use teach-back for the medicine plan and warning signs
- Teach bite prevention: EPA-registered repellent, long sleeves at dusk and night, and sleeping under an insecticide-treated net
- Advise a travel clinic or provider visit several weeks before his next trip to choose preventive medicine, and explain that each drug has its own start and stop schedule, and some continue for up to 4 weeks after return
- Teach that any fever within a year of travel needs prompt care, and to tell the clinician where he has been
Using teach-back, he named his follow-on medicine, explained why to take it with food and finish every dose, and stated the date of his hemoglobin check. He said, “Next time I’ll see the travel clinic a month before we go.” Goal met; reinforce at follow-up.
Interventions and rationales
Client and family teaching
- Finish every dose of your antimalarial medicine, even if you feel better
- Take your medicine exactly as your pharmacist or the label directs; some must be taken with fatty food or milk
- Keep follow-up blood tests and appointments after treatment
- Return right away for fever, confusion, severe headache, vomiting that stops you keeping medicine down, dark urine, yellow eyes, or trouble breathing
- Before future travel, see a travel clinic or your provider several weeks ahead to get the right preventive medicine for your destination
- Start and stop preventive medicine exactly as prescribed; some continue for up to 4 weeks after you get home
- No preventive medicine is 100% effective, so also prevent bites: repellent, long sleeves and pants at dusk and night, screened or air-conditioned rooms, and an insecticide-treated bed net
- Childhood malaria does not give lasting protection once you have lived away from a malaria area
- If you have a fever within a year of travel, tell the clinician where you have been
- Pregnant people should talk with a provider before travel to a malaria area, because malaria is more dangerous in pregnancy
NurseStudyPrep.com
You’ve read the care plan. Now answer one.
A priority item in the NCLEX format. On Prep, every option gets a written rationale — including the three that are wrong.
A client with P. falciparum malaria is receiving IV artesunate. The client was alert an hour ago but is now sweaty, shaky, and confused. Which action should the nurse take first?
Why B. Hypoglycemia is common in severe malaria, causes sweating, tremor, and confusion, and is quickly reversible. A bedside glucose check takes a minute and guides immediate treatment, and the nurse then notifies the provider of the change. Options A and C treat fever, which does not explain a sudden change in mental status. Option D is supportive but does not find or treat the cause. Prep also explains why each wrong option looks reasonable.
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Frequently asked questions
What is the nursing diagnosis for malaria?
Malaria is a medical diagnosis, so nurses choose NANDA-I diagnoses for the patient’s response. Common ones are Hyperthermia, Acute Confusion in cerebral malaria, Risk for Unstable Blood Glucose Level, Risk for Deficient Fluid Volume, Risk for Bleeding, Fatigue, and Ineffective Health Self-Management.
What is the priority nursing intervention for malaria?
Recognize it early and get antimalarial treatment started without delay, while watching airway, breathing, circulation, level of consciousness, and blood glucose. Signs of severe malaria, such as confusion, seizures, breathing difficulty, low urine output, or low blood pressure, need immediate escalation.
How is malaria diagnosed?
With thick and thin blood smears read under a microscope, which confirm the infection, identify the species, and measure the percentage of infected red cells. A rapid antigen test may be used first but is confirmed by smear. One negative smear does not rule malaria out; smears are repeated.
Does a patient with malaria need isolation?
No. Standard precautions are enough. Malaria spreads through infected mosquitoes, and only rarely through blood transfusion, organ transplant, shared needles, or from mother to baby.
Why is G6PD tested before primaquine?
Primaquine and tafenoquine kill the dormant liver forms of P. vivax and P. ovale that cause relapse, but they can destroy red blood cells in people with G6PD deficiency. The test must be done before the first dose.
Is there a malaria vaccine?
The WHO recommends two malaria vaccines, RTS,S/AS01 and R21/Matrix-M, for children living in areas with ongoing malaria transmission. They are not used for travelers, so travelers still rely on preventive medicine and bite prevention.
References
- Centers for Disease Control and Prevention. Clinical Guidance: Malaria Diagnosis & Treatment in the U.S. cdc.gov/malaria/hcp.
- Centers for Disease Control and Prevention. CDC Yellow Book: Health Information for International Travel, Malaria chapter. cdc.gov/yellow-book.
- World Health Organization. WHO Guidelines for Malaria. Geneva: WHO (updated regularly).
- World Health Organization. World Malaria Report. Geneva: WHO (annual).
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). NANDA International Nursing Diagnoses: Definitions and Classification, 2024–2026. Thieme.
- Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M. R., & Zanotti, M. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (13th ed.). Elsevier, 2023.
- Harding, M. M., Kwong, J., & Hagler, D. Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier, 2022.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier, 2023.
- Silvestri, L. A. Saunders Comprehensive Review for the NCLEX-RN Examination. Elsevier, 2023.
- Trampuz, A., Jereb, M., Muzlovic, I., & Prabhu, R. M. Clinical review: Severe malaria. Critical Care, 2003;7(4):315–323.
- Sarkar, P. K., Ahluwalia, G., Vijayan, V. K., & Talwar, A. Critical care aspects of malaria. Journal of Intensive Care Medicine, 2010;25(2):93–103.
Antimalarial drug choice and dosing, criteria for severe malaria, smear and glucose monitoring schedules, fluid plans, hypoglycemia protocols, vital sign parameters, and travel prevention advice vary by species, by region of travel, by patient, and by facility, and change as resistance patterns change. Follow the provider’s written orders, current CDC or WHO guidance, and your own institution’s policies. This page supports study and does not replace course instruction or clinical judgment.
