Altered mental status (AMS) is a broad term used to represent a variety of diseases or causes affecting mental functioning. AMS describes conditions ranging from mild to severe, including delirium, psychosis, and 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. Alterations in the patient’s consciousness or cognition may also affect their mood, movement, and behavior.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Impaired Verbal Communication
- Ineffective Cerebral Tissue Perfusion
- Ineffective Coping
- Risk for Injury
Overview
The following terms may be used to describe a change in consciousness from a state of heightened arousal to sustained unconsciousness:
- Hyperalert
- Confused
- Delirious
- Somnolent
- Lethargic
- Obtunded
- Stuperous
- Comatose
Changes in cognitive function and mood may cause symptoms like:
- Disorientation
- Forgetfulness
- Hallucinations
- Delusions
- Nonsensical speech
- Slowed responses
- Agitation
- Anxiety
- Depression
- Euphoria
Altered mental status may or may not be reversible. For example, Alzheimer’s dementia is a chronic condition affecting mental status, while alcohol withdrawal would be a reversible cause of AMS.
The range of causes is extensive; however, they can usually be classified into the following categories:
- Neurological disease
- Infectious
- Toxic
- Metabolic
- Systemic
Nursing Process
It is necessary to identify early indicators of altered mental status, determine the underlying cause, and administer prompt care to decrease patient morbidity and mortality.
A thorough physical examination and history taking are necessary to evaluate changes in mental status. The nurse then assists with symptom management and continuous monitoring. The nurse also prioritizes safety, as AMS can lead to falls and injury.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to altered mental status.
Review of Health History
1. Ask the patient about changes in mentation.
Along with altered consciousness, AMS can affect the following:
- Self-awareness
- Mood
- Expression
- Language
- Emotions
- Cognition
- Motor control
- Behavior
2. Determine the underlying cause.
The nurse considers the following categories when evaluating for the cause of AMS:
- Central nervous system causes: Concussion, stroke, brain tumor, epilepsy
- Toxins: Medications, alcohol or drug use/withdrawal, environmental factors
- Metabolic disturbances: Hyper/hypoglycemia, electrolyte abnormalities, hyper/hypothyroidism
- Systemic diseases: Arrhythmias, dehydration, hypoxia
- Infections: Sepsis, urinary tract infections, pneumonia, meningitis
3. Review risk factors for altered mental status.
The following risk factors may contribute to AMS:
- Age over 65
- Anesthesia
- ICU stay
- Social isolation
- Sleep deprivation
- Visual or hearing impairment
4. Assess for a mental illness.
Some psychological disorders may seem to cause alterations in mental status, such as euphoria or depression that characterizes bipolar disorders or hallucinations and delusions of schizophrenia.
5. Consider the patient’s age.
When the patient presents with a change in mental status, consider the most common causes for that population.
- Infants and young children are more likely to experience AMS from infections, traumatic accidents, metabolic changes, or ingesting toxins.
- Young adults present with AMS as a result of exposure to toxic substances or trauma.
- In older adults, strokes, infections, drug-drug interactions, or modifications to the living environment can result in AMS.
6. Interview the patient’s family or others surrounding them.
The nurse may need to interview family members, caregivers, bystanders, teachers, etc., who can offer information about the patient’s baseline mental status. Most patients experiencing AMS will be unable to offer any historical data to the nurse, so any details provided by people familiar to the patient are crucial.
7. Review the patient’s medication history.
Obtaining a thorough medication history is essential to rule out drug interactions as a possible reason for AMS. Inquire about any new medications or over-the-counter, herbal, or nutritional supplements. Assess for the most common offenders:
- Antibiotics
- Antidepressants
- Antipsychotics
- Benzodiazepines
- Opioids
- Sedatives
8. Consider the use of alcohol or illegal substances.
Drug intoxication, as well as withdrawal, can result in a change in mental status. The patient may or may not be able to tell the nurse which drugs they have taken, in which case a toxicology report can be useful.
Physical Assessment
1. Assess the ABCs.
Prioritize the patient’s airway, breathing, and circulation according to the severity and symptoms of altered mental status to ensure the patient is hemodynamically stable.
2. Evaluate the neurological status.
Assess the patient’s level of consciousness and Glasgow Coma Scale (GCS) if a brain injury is suspected. Evaluate the patient’s orientation status, pupils, speech, sensations, reflexes, and coordination as necessary.
3. Assess the patient’s appearance, behavior, and movement.
Note the patient’s hygiene, attire, and behavior, including eye contact, facial expressions, posture, ability to cooperate with the assessment, and whether their movements are exaggerated, slowed, or catatonic. Certain findings may correlate with some mental illnesses or drug use.
4. Assess the patient’s cognition.
The nurse can ask the patient questions or perform tests to assess the patient’s attention, memory, language, thought content/processes, and ability to follow directions or carry out tasks. Common tests include:
- The Mini-Mental Status Exam (MMSE)
- The Confusion Assessment Method (CAM)
- The 4 A’s Test
5. Inspect for physical signs of trauma.
Examine the head, extremities, and back for any indications of physical trauma, such as infection, ecchymosis, lacerations, or deformities that could be associated with AMS. Track marks from drug injections or transdermal patches may also provide insight.
6. Monitor vital signs and ECG.
Continuously monitor vital signs as abnormalities may align with conditions like hypothermia, hypoxemia, or a hypertensive crisis. Obtain an ECG as necessary.
Diagnostic Procedures
1. Quickly obtain a glucose level.
This is one of the first actions taken when a client presents with AMS as hypo or hyperglycemia are common causes of a change in mentation.
2. Collect specimens for lab tests.
Collect blood or urine for the following tests as indicated:
- Serum electrolytes
- Complete blood count
- Serum ammonia
- Blood gas analysis
- Blood cultures
- Liver function
- Kidney function
- Urinalysis
- Thyroid function
- Serum B12 levels
- Syphilis
- Toxicology screening
3. Consider imaging and other tests.
Consider a head CT scan if there is a suspicion of a stroke or head trauma or a chest x-ray to rule out pneumonia. Lumbar punctures should be performed if meningitis is suspected. An electroencephalogram can rule out seizures or diagnose metabolic encephalopathy or infectious encephalitis.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions related to altered mental status.
1. Treat the underlying cause.
The management of altered mental status involves treating the underlying cause, which may include:
- IV fluids for shock
- Antibiotics for sepsis
- Glucose for hypoglycemia
- Neurosurgical intervention for brain trauma
- Intubation or oxygen
2. Reduce stimulation.
Patients experiencing delirium require reassurance and a calm environment to reduce confusion and prevent worsening agitation. Keep lights dimmed and limit noise and alarms.
3. Sedate the patient if necessary.
Medications may be necessary if other measures are ineffective to manage unsafe behaviors. Antipsychotics like haloperidol or quetiapine are commonly administered to cause sedation. Benzodiazepines may worsen delirium and should only be used to treat alcohol withdrawal or seizures.
4. Use restraints as a last resort.
Physical restraints should only be applied if all other strategies have failed to keep the patient safe from harming themselves or others.
5. Ensure safety.
The patient with AMS is at an increased risk for falls and injury. Institute fall precautions and consider 1:1 supervision if necessary.
6. Administer medications as ordered.
Once the underlying cause is identified, specific medications may be necessary. These may include:
- Donepezil for dementia
- Naloxone for narcotic toxicity
- Antiseizure medications for seizures
- Antipsychotics for mental illnesses
7. Prevent delirium.
If the patient is at risk for delirium or sundowning, implement the following measures to reduce the risk of confusion:
- Ensure adequate hydration and proper nutrition
- Limit the use of IV lines and catheters
- Assess for constipation or urinary retention
- Provide stimulating activities during the day
- Ensure hearing aids or eyeglasses are utilized
- Manage pain effectively
- Orient the patient to time and place as needed
8. Reduce the risk of polypharmacy.
Older adults, in particular, are at risk for polypharmacy. Perform medication reconciliation to review for duplicates or inaccurate dosing. Discuss discontinuation with the provider as needed.
9. Refer to appropriate disciplines.
Depending on the cause of AMS, refer or consult with other healthcare professionals, such as:
- Neurologists
- Pharmacists
- Mental health professionals
- Substance abuse counselors
- Social workers
- Case managers
Nursing Care Plans
Once the nurse identifies nursing diagnoses for 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 a patient suffering from AMS.
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.
Impaired Verbal Communication
Altered mental status can affect verbal communication, resulting in slurred and incoherent speech, memory problems, slow responses to stimuli, confusion, and disorientation.
Nursing diagnosis: Impaired Verbal Communication
Related to:
- Cognitive dysfunction
- Central nervous system impairment
- Psychotic disorder
- Physiological condition
As evidenced by:
- Difficulty expressing thoughts verbally
- Difficulty comprehending information
- Incongruent facial expressions/body language
- Disorientation
- Aphasia
- Anarthria
- Dysarthria
- Dysphonia
- Slurred speech
Expected outcomes:
- Patient will utilize alternative methods of communication while experiencing AMS.
- Patient will experience a return to their baseline level of communication.
Assessment:
1. Assess the patient’s baseline communication abilities.
The nurse may need to confer with family members or caregivers to understand the patient’s usual level of communication and if their current status is within normal limits or unusual.
2. Assess for barriers to communication.
The nurse should assess potential barriers to effective communication, such as the patient’s cognition, language, or the use of devices such as hearing aids.
3. Note conditions that affect speech.
If the patient is experiencing new-onset speech changes along with AMS, this should alert the nurse to evaluate for a stroke.
Interventions:
1. Explain all procedures and tasks before initiating.
Patients experiencing AMS may become agitated or fearful of healthcare professionals, equipment, or procedures. The nurse must communicate their movements and actions even if the patient is unable to effectively verbalize their thoughts in order to support a therapeutic relationship.
2. Allow time to respond to communication.
Patients with AMS may need more time to comprehend speech and formulate thoughts. Allowing them ample time to respond assists with effective communication.
3. Limit distractions and stimulation.
Patients with AMS may find it easier to communicate in a calm environment. Keep the patient engaged by limiting distractions and unnecessary stimuli like television.
4. Utilize family members to convey information.
Patients with AMS may feel more comfortable if a familiar face is present to aid in communication between the healthcare team and the patient.
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.
Ineffective Coping
Patients with altered mental status exhibit ineffective coping due to the patient’s inability to assess the situation and understand and participate in their care.
Nursing Diagnosis: Ineffective Coping
Related to:
- Cognitive dysfunction
- Psychological barriers
- Inaccurate threat appraisal
- Loss of control
- Lack of support
As evidenced by:
- Altered concentration
- Change in communication
- Destructive behavior
- Substance misuse
- Difficulty organizing information
Expected outcomes:
- Patient will remain free from agitated behavior.
- Patient will verbalize improved psychological comfort as evidenced by reduced stress and anxiety and a sense of control.
Assessment:
1. Assess factors that contribute to ineffective coping.
Along with AMS, ineffective coping can be precipitated by various factors, including a lack of support, recent life changes, grief, and a lack of problem-solving skills.
2. Assess the patient’s cognitive, emotional, and mental state.
Patients with altered mental and cognitive states due to a psychological disorder may be unable to cope until their anxiety, delusions, or depressive symptoms are managed appropriately.
3. Monitor for physiological alterations.
Sepsis, hypoglycemia, electrolyte imbalances, hypoxia, and more may be an underlying cause of AMS, also contributing to ineffective coping.
Interventions:
1. Attempt relaxation techniques.
The nurse may attempt strategies like guided visualization and music therapy to help patients with AMS feel relaxed, reduce anxiety, and feel a sense of control over the situation.
2. Establish a trusting relationship with the patient.
Establishing a trusting relationship with the patient helps reduce anxiety, resulting in more enhanced coping and management of the situation.
3. Encourage participation in the plan of care as applicable.
Depending on the patient’s level of consciousness or cognition, the nurse should involve the patient in their care planning as much as possible to increase cooperation and effective coping.
4. Identify support persons.
It may be helpful to the healthcare team and patient to identify family members, friends, or others familiar to the patient to assist in supporting coping measures. Social workers or mental health counselors should also be considered to help with coping strategies.
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
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing 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
- Altered mental status (AMS): Causes, symptoms & treatment. (2022, June 2). Cleveland Clinic. Retrieved January 2024, from https://my.clevelandclinic.org/health/diseases/23159-altered-mental-status-ams
- 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/
- Veauthier, B., Hornecker, J. R., & Thrasher, T. (2021). Recent-Onset Altered Mental Status: Evaluation and Management. American family physician, 104(5), 461–470.
