Altered mental status (AMS) is a broad term used to represent a variety of diseases affecting mental functioning ranging from mild disorientation to coma. Fundamentally, a patient’s level of consciousness and cognition are combined to form their mental status. Patients may have abnormalities of either one or both of these components.
The range of differential diagnoses is extensive, however, they can often be classified in the following categories:
- Primary intracranial disease
- Systemic illness that affects the central nervous system (infection)
- Exogenous toxins
- Drug withdrawal
Trauma, metabolic abnormalities, and toxic ingestion are the most frequent causes of altered mental status in newborns and young children. Young adults most frequently exhibit altered mental status as a result of exposure to toxic substances or trauma. The most frequent causes of altered mental status in the elderly include stroke, illness, drug-drug interactions, or modifications to the living environment.
Nursing Process
To lower patient morbidity and mortality, it is necessary to identify the early indicators of altered mental status, determine the underlying cause, and administer the proper care. The nurse can assist in symptomatic management techniques including volume resuscitation for shock, antibiotics for sepsis, glucose for hypoglycemia, or the prevention of deterioration by intubating.
A thorough physical examination and history taking are necessary to manage and evaluate changes in mental status. Mental status changes can appear suddenly and are a symptom of an underlying cause. Safety is also a priority as AMS can lead to falls and injury.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for an altered mental status, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for altered an mental status.
Ineffective Cerebral Tissue Perfusion
Ineffective cerebral tissue perfusion associated with altered mental status can be caused by decreased cerebral blood flow due to underlying conditions such as metabolic conditions (e.g. hypoglycemia or hypoxia), low levels of acetylcholine synthesis, and substrate deficiency for neural function.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Decrease cerebral blood flow
- Metabolic conditions
- Primary intracranial disease
- A systemic disease affecting the central nervous system (CNS)
- Exogenous toxins
- Drug withdrawal
As evidenced by:
- Decreased Glasgow coma scale (GCS)
- Decreased level of consciousness (LOC)
- Diminished reflexes
- Alterations in pulse rate
- Alterations in blood pressure
- Increased intracranial pressure
- Decrease cerebral perfusion pressure
- Behavioral changes
Expected outcomes:
- Patient will be able to demonstrate effective tissue perfusion as evidenced by the GCS and LOC within normal limits
- Patient will not experience worsening in AMS such as coma or require intubation
Assessment:
1. Assess vital signs and underlying cause.
Persistent fluctuations in vital signs may trigger cerebral hypoperfusion and inadequate blood supply in the brain. The nurse can monitor the vital signs and assess for an underlying cause through a thorough physical examination and history assessment.
2. Assess neurological status.
A detailed neurological and cognitive assessment including the Glasgow coma scale (GCS) and level of consciousness (LOC) is done to determine whether there is a nervous system problem. Neurological checks should be performed frequently and routinely to quickly recognize changes.
3. Review medications and use of intoxicants.
Assess the client’s medication regimen for overdoses of narcotics or improper use of antihypertensives. Assess for alcohol or illegal substance use affecting AMS.
Interventions:
1. Determine the appropriate level of care.
Collaborate with the interdisciplinary team to determine the appropriate level of care. Patients with AMS related to cerebral perfusion likely require monitoring in the neuro-ICU by specially trained nurses.
2. Administer fluids and electrolytes as prescribed.
Fluid resuscitation aims to improve cerebral tissue perfusion and hemodynamics. To compensate for losses and keep circulation and cellular function intact, provide fluids and electrolytes as needed.
3. Prepare the client for surgical procedure as indicated.
The client may be a candidate for a surgical procedure such as carotid endarterectomy or evacuation of cerebral hematoma or lesion. The nurse must prepare for a possible surgical procedure to improve tissue perfusion in the brain.
Acute Confusion
Acute confusion associated with altered mental status can be caused by a disruption to consciousness, attention, cognition, and perception that occurs suddenly and is reversible.
Nursing Diagnosis: Acute Confusion
Related to:
- Alteration in brain function
- Alteration in sleep
- Alcohol or drug abuse
- Hypoxia
- Metabolic imbalances
- Delirium
- Disrupted perception
Evidenced by:
- Hallucinations
- Restlessness
- Decreased level of consciousness
- Impaired cognition
- Disrupted psychomotor functioning
- Inability to perform purposeful behavior
- Inappropriate verbal responses
Expected outcomes:
- Patient will be able to regain orientation to person, place, and time
- Patient will identify lifestyle changes to prevent acute confusion reoccurrence
Assessment:
1. Determine possible causative factors.
Acute confusion is a symptom that can be brought on by a variety of causes, including hypoxia, metabolic, endocrine, and neurological problems, toxins, electrolyte imbalances, infections of the CNS, nutritional deficiencies, and acute psychiatric illnesses.
2. Assess mental status.
The nurse can perform a thorough mental status assessment that can assist in differentiating between mental illness, cognitive disability, and mood disorders.
3. Monitor lab values.
If mental or psychosocial issues are ruled out, obtain a CBC panel, ABGs, liver function levels, urinalysis, and more to decipher internal causes of AMS.
4. Assess for current medication use and presence of substance abuse.
Certain medications such as barbiturates, amphetamines, and opiates as well as substances like alcohol or illegal drugs are associated with a high risk of adverse reactions, delirium, and confusion, especially during the withdrawal stage.
Interventions:
1. Provide constant orientation to person, place, and time as needed.
Reorient as needed to person, place, time, and situation. Challenging illogical thinking may cause defensive reactions. Hence, presenting reality will help the client by eliminating confusion.
2. Prevent sundowning.
The nurse can encourage the client to get plenty of exposure to light, maintain a routine of activities, limit napping during the daytime, and provide familiar objects.
3. Educate caregivers to monitor the client at home.
Caregivers must know when to contact the healthcare provider for a sudden change or worsening in cognition and behavior.
4. Provide a stable and calm environment.
Prevent worsening confusion and potential agitation by providing an environment that is quiet without overstimulation that allows for rest.
Risk for Injury
Risk for Injury associated with altered mental status can result in physical harm due to a disruption of consciousness, attention, and cognition as well as impaired perception. This increases the risk of an unsafe environment and the risk of injury.
Nursing Diagnosis: Risk for Injury
Related to:
- Alteration in brain function
- Impaired sleep cycle
- Hypoxia
- Intoxication
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are aimed at prevention.
Expected outcomes:
- Patient will be able to verbalize an understanding of risk factors that may cause injury
- Patient will identify behaviors and measures to reduce risk factors and protect themselves from injury
- Patient will remain free from injury
Assessment:
1. Assess safety issues.
The nurse can make detailed evaluations of potential safety issues related to AMS. Inaccurate assessment, intervention, or referral may increase the risk of harm.
2. Assess the client’s knowledge of safety precautions.
Assess for awareness of the needs for safety, injury prevention, and motivation to do so in settings such as the home, community, and workplace. This may help the nurse identify areas of inaccuracy, knowledge deficits, and the need for education, especially for clients with AMS.
3. Note individual risk factors.
The client’s age, gender, developmental stage, capacity for making decisions, and degree of cognitive limit and competence should all be noted. These have an impact on the client’s capacity to protect oneself and/or others.
4. Ascertain caregiver’s expectations.
Clients who have AMS typically have caregivers. Review the expectations of caregivers who care for those who are elderly, mentally disabled, or emotionally fragile.
Interventions:
1. Provide safe nursing care.
The nurse must consider a culture of safety when implementing nursing care to promote client safety and serve as an example of safe conduct.
2. Inform the client about all treatments and medications.
Communication with the client is essential because it builds and preserves trust. Clear communication can help the client feel less angry, worried, and depressed as well as increase cooperation with the implementation of care and improve the safety of the client.
3. Reduce the risk of injury.
The nurse can identify safety measures and interventions that promote both individual and environmental safety. Examples include keeping the bed alarm on, keeping the call bell within reach, using assistive devices, and more.
4. Prepare the client for a safe home environment.
Discuss safety measures to improve the home environment such as equipment needs, fall prevention, how to call for help, medication safety, and more.
References
- Blanchard, G. (2022, May 13). Evaluation of altered mental status. Clinical decision support for health professionals. https://bestpractice.bmj.com/topics/en-us/843
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Hinkle, J. L., & Cheever, K. H. (2018). Management of Patients With Neurologic Dysfunction. In Brunner and Suddarth’s textbook of medical-surgical nursing (11th ed., pp. 5169-5213). Wolters Kluwer India Pvt.
- Patti, L., & Gupta, M. (2022, May 1). Change in mental status – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK441973/
