Altered Mental Status (AMS) is a critical clinical presentation encountered across various healthcare settings. As a broad term, AMS signifies a deviation from a patient’s baseline cognitive and consciousness levels, reflecting an underlying disturbance in brain function. This condition can manifest along a spectrum, ranging from mild confusion and disorientation to severe states like delirium, psychosis, and coma. Fundamentally, AMS is an indicator of compromised neurological integrity, affecting both the level of consciousness and cognitive abilities, with potential repercussions on mood, movement, and behavior.
Understanding Altered Mental Status
Changes in consciousness are described using a range of terms that reflect the depth of altered awareness, progressing from heightened arousal to complete unresponsiveness. These terms include:
- Hyperalertness: An exaggerated state of vigilance and responsiveness.
- Confusion: Disorientation to time, place, or person, with impaired decision-making.
- Delirium: An acute, fluctuating confusional state characterized by disturbances in attention, cognition, and consciousness.
- Somnolence: Abnormal drowsiness or sleepiness.
- Lethargy: A state of decreased alertness and responsiveness, with sluggishness and apathy.
- Obtundation: Reduced alertness with slowed responses to stimuli and decreased interest in the environment.
- Stupor: A state of deep sleep or unresponsiveness from which the patient can be aroused only by vigorous and repeated stimulation.
- Coma: A state of complete unresponsiveness, with no spontaneous movement or response to external stimuli, even pain.
Cognitive and mood alterations in AMS can lead to a variety of symptoms, including:
- Disorientation: Lack of awareness of person, place, or time.
- Forgetfulness: Memory impairment, difficulty recalling recent or past events.
- Hallucinations: Sensory perceptions in the absence of external stimuli, such as seeing or hearing things that are not there.
- Delusions: Fixed, false beliefs that are not based in reality and are resistant to reason.
- Nonsensical Speech: Incoherent or illogical speech patterns.
- Slowed Responses: Delayed reactions to questions or commands.
- Agitation: Restlessness, irritability, and increased motor activity.
- Anxiety: Excessive worry, nervousness, and unease.
- Depression: Persistent sadness, loss of interest, and feelings of hopelessness.
- Euphoria: An exaggerated feeling of well-being or happiness, often inappropriate to the situation.
A nurse conducts a neurological assessment to evaluate a patient’s mental status, crucial for diagnosing AMS and guiding appropriate interventions.
The reversibility of AMS is highly dependent on the underlying cause. Conditions like Alzheimer’s dementia represent chronic, irreversible causes of AMS, while acute conditions such as alcohol withdrawal are typically reversible with appropriate medical management. The etiology of AMS is diverse but generally falls into several broad categories:
- Neurological Diseases: Conditions directly affecting the brain, such as stroke, seizures, tumors, and neurodegenerative disorders.
- Infections: Systemic or central nervous system infections like meningitis, encephalitis, and sepsis.
- Toxicities: Exposure to drugs, alcohol, environmental toxins, or medication side effects.
- Metabolic Disturbances: Electrolyte imbalances, hypo- or hyperglycemia, liver or kidney failure, and thyroid disorders.
- Systemic Illnesses: Conditions affecting the whole body, such as sepsis, shock, and respiratory failure.
The Nursing Process for Altered Mental Status
Early recognition of AMS and prompt intervention are crucial in minimizing patient morbidity and mortality. The nursing process provides a structured approach to care, beginning with a comprehensive assessment to identify the underlying cause and guide subsequent interventions. Nurses play a pivotal role in continuous monitoring, symptom management, and ensuring patient safety, as AMS significantly elevates the risk of falls and injuries.
Nursing Assessment: Gathering Subjective and Objective Data
The initial step in nursing care involves a thorough assessment encompassing physical, psychosocial, emotional, and diagnostic data. This section outlines the subjective and objective data collection pertinent to Ams Nursing Diagnosis.
Review of Health History
1. Elicit Patient Reports of Changes in Mentation: Inquire about any changes in the patient’s cognitive function, including but not limited to self-awareness, mood, expression, language, emotions, cognition, motor control, and behavior. Detailed questioning can help establish the nature and onset of AMS.
2. Identify Potential Underlying Causes: Consider the broad categories of neurological, infectious, toxic, metabolic, and systemic causes. Gather information related to recent illnesses, injuries, exposures, and pre-existing conditions.
3. Review Risk Factors for Altered Mental Status: Assess for established risk factors such as:
- Age over 65: Older adults are more susceptible to AMS due to age-related physiological changes and increased prevalence of comorbidities.
- Anesthesia: Postoperative AMS is a known complication, particularly in elderly patients.
- ICU Stay: Critical illness and the ICU environment itself can contribute to delirium and AMS.
- Social Isolation: Lack of social interaction is linked to cognitive decline and increased vulnerability to AMS.
- Sleep Deprivation: Insufficient or disrupted sleep can impair cognitive function and exacerbate AMS.
- Visual or Hearing Impairment: Sensory deficits can contribute to confusion and disorientation, especially in older adults.
4. Assess for Mental Illness: Differentiate AMS from primary psychiatric disorders. While conditions like bipolar disorder and schizophrenia can present with symptoms that mimic AMS, it is crucial to distinguish between acute changes in mental status due to medical conditions and exacerbations of pre-existing mental illnesses.
5. Consider Patient Age: Age is a significant factor in determining the likely causes of AMS.
- Infants and Young Children: Infections (meningitis, encephalitis), traumatic injuries, metabolic disorders, and toxin ingestion are more common causes.
- Young Adults: Toxic substance exposure (drugs, alcohol) and trauma are frequently implicated.
- Older Adults: Stroke, infections (UTI, pneumonia), medication interactions, and environmental changes are more prevalent causes.
6. Interview Family or Caregivers: Obtain collateral history from family members, caregivers, or bystanders. These individuals can provide crucial insights into the patient’s baseline mental status and the timeline of changes, especially as patients with AMS may be unreliable historians.
7. Review Medication History: A thorough medication reconciliation is essential. Inquire about all prescription medications, over-the-counter drugs, herbal supplements, and nutritional supplements. Pay particular attention to medications known to cause cognitive side effects, such as:
- Antibiotics (e.g., fluoroquinolones)
- Antidepressants (e.g., tricyclic antidepressants)
- Antipsychotics
- Benzodiazepines
- Opioids
- Sedatives
8. Inquire About Alcohol and Substance Use: Assess for both acute intoxication and withdrawal syndromes related to alcohol and illicit substances, as both can significantly alter mental status. Toxicology screening may be necessary if substance use is suspected but not readily admitted by the patient.
A nurse meticulously reviews a patient’s medication chart, checking for potential drug interactions that might be contributing to altered mental status.
Physical Assessment
1. Assess the ABCs (Airway, Breathing, Circulation): Prioritize assessment of airway patency, breathing effectiveness, and circulatory status. AMS can compromise these vital functions, and immediate stabilization is paramount.
2. Evaluate Neurological Status: Perform a comprehensive neurological examination. Assess:
- Level of Consciousness: Use standardized scales like the Glasgow Coma Scale (GCS) if head injury is suspected, or descriptive terms (alert, lethargic, stuporous, comatose).
- Orientation: Assess orientation to person, place, time, and situation.
- Pupils: Evaluate pupil size, reactivity to light, and equality.
- Speech: Assess speech clarity, fluency, and content.
- Sensation and Reflexes: Check sensory and motor function, and reflexes as indicated.
- Coordination: Observe gait and coordination if possible.
3. Assess Appearance, Behavior, and Movement: Observe the patient’s:
- Hygiene and Attire: Note grooming and clothing choices.
- Behavior: Assess eye contact, facial expressions, posture, and cooperation.
- Movement: Note any abnormal movements (tremors, rigidity, restlessness, catatonia, slowed movements). These findings can provide clues to underlying psychiatric or neurological conditions or substance use.
4. Assess Cognition: Utilize standardized cognitive assessment tools and bedside testing:
- Mini-Mental State Examination (MMSE): A widely used tool to screen for cognitive impairment.
- Confusion Assessment Method (CAM): Specifically designed for diagnosing delirium.
- 4 ‘A’s Test (Alertness, Abbreviated Mental Test-4, Attention, Acute Change): A rapid delirium screening tool.
- Assess attention, memory, language, thought content and processes, and ability to follow directions.
5. Inspect for Physical Signs of Trauma: Perform a thorough physical examination, looking for:
- Head Trauma: Scalp lacerations, hematomas, signs of skull fracture.
- Extremities and Back: Bruising, lacerations, deformities suggestive of injury.
- Signs of Infection: Wound infections, cellulitis, meningeal signs (neck stiffness).
- Track Marks or Transdermal Patches: Suggestive of intravenous drug use or medication delivery.
6. Monitor Vital Signs and ECG: Continuously monitor vital signs (heart rate, blood pressure, respiratory rate, temperature, oxygen saturation). Abnormalities can indicate underlying conditions such as hypothermia, hypoxemia, or hypertensive crisis. Obtain an electrocardiogram (ECG) to assess for cardiac arrhythmias or ischemia, especially if cardiac etiology is suspected.
Diagnostic Procedures
1. Rapid Glucose Level Check: Immediately obtain a capillary blood glucose level. Hypoglycemia and hyperglycemia are readily reversible metabolic causes of AMS that require prompt correction.
2. Collect Specimens for Laboratory Tests: Obtain blood and urine samples for indicated tests based on the suspected etiology:
- Serum Electrolytes (Sodium, Potassium, Calcium, Magnesium): Electrolyte imbalances are common causes of AMS.
- Complete Blood Count (CBC): To assess for infection (elevated white blood cell count) or anemia.
- Serum Ammonia: Elevated levels can indicate hepatic encephalopathy.
- Arterial Blood Gas (ABG) Analysis: To evaluate oxygenation and acid-base balance.
- Blood Cultures: If infection is suspected, to identify causative organisms.
- Liver Function Tests (LFTs): To assess for liver dysfunction, a cause of hepatic encephalopathy.
- Kidney Function Tests (BUN, Creatinine): To evaluate renal function and rule out uremic encephalopathy.
- Urinalysis: To assess for urinary tract infection (UTI) and other urinary abnormalities.
- Thyroid Function Tests (TSH, T4): To rule out thyroid disorders.
- Serum Vitamin B12 Levels: Vitamin B12 deficiency can contribute to neurological dysfunction.
- Syphilis Serology (RPR/VDRL): Neurosyphilis can present with AMS.
- Toxicology Screening (Urine and/or Blood): To detect drugs of abuse or medication overdose.
3. Consider Imaging and Other Specialized Tests: Depending on the clinical picture, consider:
- Head CT Scan: To rule out intracranial hemorrhage, stroke, tumors, or hydrocephalus, particularly after head trauma or suspicion of stroke.
- Chest X-ray: To evaluate for pneumonia or other pulmonary infections, especially in patients with respiratory symptoms or fever.
- Lumbar Puncture: If meningitis or encephalitis is suspected, to obtain cerebrospinal fluid (CSF) for analysis.
- Electroencephalogram (EEG): To rule out seizures (non-convulsive status epilepticus) or to assess for encephalopathy patterns.
Nursing Interventions for Altered Mental Status
Nursing interventions are crucial for managing AMS, focusing on treating the underlying cause, providing supportive care, and preventing complications.
1. Treat the Underlying Cause: The primary intervention is to identify and treat the root cause of AMS. This may involve:
- IV Fluids for Shock: To restore hemodynamic stability in cases of hypovolemic or septic shock.
- Antibiotics for Sepsis or Infections: To treat bacterial infections.
- Glucose for Hypoglycemia: To rapidly correct low blood sugar.
- Neurosurgical Intervention for Brain Trauma or Intracranial Hemorrhage: To relieve pressure or address structural brain injuries.
- Intubation and Oxygen Therapy for Respiratory Failure or Hypoxemia: To support oxygenation and ventilation.
2. Reduce Environmental Stimulation: For patients experiencing delirium, create a calm and structured environment.
- Dim Lights: Reduce visual overstimulation.
- Limit Noise and Alarms: Minimize auditory stimuli.
- Provide Reassurance and Orientation: Regularly orient the patient to time, place, and person. Use simple, clear language.
3. Sedation for Agitation (Judiciously): Pharmacological sedation may be necessary if non-pharmacological measures fail to manage severe agitation that poses a safety risk.
- Antipsychotics (e.g., Haloperidol, Quetiapine): Often used for delirium-related agitation.
- Benzodiazepines (Limited Use): Generally avoided in delirium as they can worsen confusion, except in cases of alcohol withdrawal or seizures.
4. Physical Restraints (Last Resort): Use physical restraints only as a last resort when all other de-escalation strategies have failed and the patient poses an imminent danger to themselves or others. Restraint use must be justified, carefully monitored, and discontinued as soon as safely possible.
5. Ensure Patient Safety: Implement comprehensive safety measures to prevent falls and injuries.
- Fall Precautions: Bed alarms, side rails (when appropriate and according to policy), non-slip footwear, clear pathways.
- 1:1 Supervision: Consider continuous observation for highly confused or agitated patients.
6. Administer Medications as Ordered: Once the underlying cause is identified, administer specific medications as prescribed:
- Donepezil or other Cholinesterase Inhibitors for Dementia: To manage cognitive symptoms in Alzheimer’s disease and related dementias.
- Naloxone for Narcotic Overdose: To reverse opioid-induced respiratory depression and AMS.
- Antiseizure Medications for Seizures: To control and prevent seizures.
- Antipsychotics for Psychotic Disorders: To manage psychotic symptoms.
7. Delirium Prevention Strategies: For patients at risk for delirium (e.g., post-surgical, critically ill, elderly), implement preventive measures:
- Ensure Adequate Hydration and Nutrition: Maintain fluid and electrolyte balance and provide appropriate nutrition.
- Limit Invasive Lines and Catheters: Minimize indwelling catheters and IV lines to reduce infection risk and patient discomfort.
- Assess and Manage Constipation and Urinary Retention: Address these common issues, as they can contribute to delirium.
- Provide Stimulating Activities During the Day: Promote daytime activity and cognitive engagement.
- Ensure Use of Hearing Aids and Eyeglasses: Optimize sensory input.
- Effective Pain Management: Adequately manage pain to reduce delirium risk.
- Orient Patient Frequently: Regularly remind the patient of time, place, and person.
8. Reduce Polypharmacy Risks: Especially in older adults, review medication regimens to identify potential polypharmacy issues. Collaborate with the physician and pharmacist to simplify medication lists, discontinue unnecessary medications, and optimize dosing.
9. Refer to Appropriate Disciplines: Consult or refer to other healthcare professionals as needed based on the underlying cause and patient needs. This may include:
- Neurologists
- Pharmacists
- Mental Health Professionals (Psychiatrists, Psychologists)
- Substance Abuse Counselors
- Social Workers
- Case Managers
Nursing Care Plans for AMS Nursing Diagnosis
Once nursing diagnoses are identified for AMS, nursing care plans guide the prioritization of assessments and interventions, setting both short-term and long-term goals. Here are examples of nursing care plans for common AMS-related nursing diagnoses.
Acute Confusion Nursing Care Plan
Acute confusion, a hallmark of AMS, is characterized by a sudden and reversible disturbance in consciousness, attention, cognition, and perception.
Nursing Diagnosis: Acute Confusion
Related Factors:
- Alteration in Brain Function
- Alteration in Sleep-Wake Cycle
- Alcohol or Drug Abuse/Withdrawal
- 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 regain orientation to person, place, and time.
- Patient will identify lifestyle changes to prevent recurrence of acute confusion.
Nursing Assessments:
- Determine Possible Causative Factors: Acute confusion is a symptom with diverse etiologies, including hypoxia, metabolic disorders, endocrine problems, neurological conditions, toxins, electrolyte imbalances, CNS infections, nutritional deficiencies, and acute psychiatric illnesses.
- Assess Mental Status: Perform a thorough mental status examination to differentiate between medical causes, mental illness, cognitive disability, and mood disorders. Utilize tools like MMSE, CAM, or 4AT.
- Monitor Lab Values: If medical causes are suspected, monitor CBC, ABGs, liver function tests, urinalysis, electrolytes, and other relevant labs to identify underlying metabolic or infectious causes.
- Assess Medication Use and Substance Abuse: Identify medications (prescription, OTC, herbal) and substance use history, as certain substances and withdrawal states are strongly associated with delirium and confusion.
Nursing Interventions:
- Provide Frequent Orientation: Reorient the patient to person, place, time, and situation regularly. Present reality calmly and clearly, avoiding challenging illogical thinking, which can increase agitation.
- Prevent Sundowning: Implement strategies to minimize sundowning (worsening confusion in the evening), such as maximizing daytime light exposure, maintaining a consistent daily routine, limiting daytime naps, and providing familiar objects in the environment.
- Educate Caregivers: Instruct caregivers on recognizing signs of worsening confusion or new changes in cognition and behavior, and when to seek medical attention.
- Provide a Stable and Calm Environment: Minimize environmental overstimulation. Create a quiet, safe, and predictable environment to promote rest and reduce agitation.
Impaired Verbal Communication Nursing Care Plan
AMS frequently affects verbal communication, leading to difficulties in speech, comprehension, and expression.
Nursing Diagnosis: Impaired Verbal Communication
Related Factors:
- Cognitive Dysfunction
- Central Nervous System Impairment
- Psychotic Disorder
- Physiological Condition
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 communication methods while experiencing AMS.
- Patient will return to their baseline communication level as AMS resolves.
Nursing Assessments:
- Assess Baseline Communication Abilities: Confer with family or caregivers to determine the patient’s usual communication abilities and identify deviations from baseline.
- Assess Communication Barriers: Evaluate potential barriers to effective communication, including cognitive deficits, language barriers, sensory impairments (hearing, vision), or physical limitations.
- Note Conditions Affecting Speech: If new-onset speech changes are present with AMS, consider acute neurological events like stroke and initiate appropriate assessment and response.
Nursing Interventions:
- Explain Procedures and Tasks: Clearly explain all procedures and care activities before initiating them, even if the patient’s comprehension is impaired. This promotes trust and reduces anxiety.
- Allow Time for Response: Provide ample time for the patient to process information and formulate responses. Avoid rushing or interrupting.
- Limit Distractions and Stimulation: Minimize environmental distractions (noise, television) to facilitate communication. Engage in one-on-one communication in a quiet setting.
- Utilize Family Members for Communication Assistance: With the patient’s consent, involve family members or familiar individuals to aid in communication and understanding.
Ineffective Cerebral Tissue Perfusion Nursing Care Plan
AMS can result from or be exacerbated by ineffective cerebral tissue perfusion, compromising oxygen and nutrient delivery to the brain.
Nursing Diagnosis: Ineffective Tissue Perfusion (Cerebral)
Related Factors:
- Decreased Cerebral Blood Flow
- Metabolic Conditions (Hypoglycemia, Hypoxia)
- Primary Intracranial Disease (Stroke, Increased ICP)
- Systemic Disease Affecting CNS (Sepsis, Shock)
- Exogenous Toxins
- Drug Withdrawal
Evidenced By:
- Decreased Glasgow Coma Scale (GCS)
- Decreased Level of Consciousness (LOC)
- Diminished Reflexes
- Alterations in Pulse Rate and Blood Pressure
- Increased Intracranial Pressure (ICP)
- Decreased Cerebral Perfusion Pressure (CPP)
- Behavioral Changes
Expected Outcomes:
- Patient will demonstrate effective cerebral tissue perfusion, as evidenced by GCS and LOC within normal limits for patient.
- Patient will not experience worsening AMS or neurological deterioration.
Nursing Assessments:
- Assess Vital Signs and Underlying Cause: Monitor vital signs closely for fluctuations that may indicate cerebral hypoperfusion. Investigate potential underlying causes through physical examination and history.
- Assess Neurological Status: Perform frequent and detailed neurological assessments, including GCS and LOC, to identify changes in neurological function promptly.
- Review Medications and Intoxicants: Assess medication regimen for potential overdoses (narcotics, antihypertensives) and inquire about alcohol or illicit substance use.
Nursing Interventions:
- Determine Appropriate Level of Care: Collaborate with the healthcare team to determine the appropriate level of care, which may include neuro-ICU monitoring for patients with compromised cerebral perfusion.
- Administer Fluids and Electrolytes: Administer IV fluids and electrolytes as prescribed to optimize hemodynamic status and improve cerebral perfusion.
- Prepare for Surgical Procedures (If Indicated): Prepare the patient for potential surgical interventions such as carotid endarterectomy, evacuation of hematoma, or lesion resection to improve cerebral blood flow, as indicated by the underlying cause.
Ineffective Coping Nursing Care Plan
AMS can impair a patient’s ability to cope effectively with their situation and participate in care.
Nursing Diagnosis: Ineffective Coping
Related Factors:
- Cognitive Dysfunction
- Psychological Barriers
- Inaccurate Threat Appraisal
- Loss of Control
- Lack of Support
Evidenced By:
- Altered Concentration
- Change in Communication Patterns
- Destructive Behavior
- Substance Misuse
- Difficulty Organizing Information
Expected Outcomes:
- Patient will remain free from agitated or destructive behavior.
- Patient will verbalize improved psychological comfort, as evidenced by reduced stress and anxiety, and an increased sense of control.
Nursing Assessments:
- Assess Contributing Factors to Ineffective Coping: Identify factors contributing to ineffective coping beyond AMS, such as lack of social support, recent life changes, grief, or inadequate problem-solving skills.
- Assess Cognitive, Emotional, and Mental State: Evaluate the patient’s cognitive function, emotional state (anxiety, depression), and mental state to understand the impact of psychological factors on coping.
- Monitor for Physiological Alterations: Assess for underlying physiological causes of AMS (sepsis, hypoglycemia, electrolyte imbalances) that may also contribute to ineffective coping.
Nursing Interventions:
- Implement Relaxation Techniques: Utilize relaxation techniques such as guided imagery, music therapy, or deep breathing exercises to reduce anxiety and promote a sense of calm.
- Establish a Trusting Relationship: Develop a therapeutic nurse-patient relationship based on trust and empathy to reduce anxiety and enhance coping.
- Encourage Participation in Care: Involve the patient in care planning and decision-making to the extent possible, based on their cognitive abilities, to increase cooperation and promote a sense of control.
- Identify Support Persons: Identify and involve family members, friends, or other support persons to assist in coping. Consider referrals to social workers or mental health counselors for ongoing support and coping strategies.
Risk for Injury Nursing Care Plan
Patients with AMS are at significantly increased risk for injury due to impaired judgment, coordination, and awareness of their surroundings.
Nursing Diagnosis: Risk for Injury
Related Factors:
- Alteration in Brain Function
- Impaired Sleep-Wake Cycle
- Hypoxia
- Intoxication
Evidenced By:
A risk diagnosis is not evidenced by actual signs and symptoms, as the problem has not yet occurred. Nursing interventions are focused on prevention.
Expected Outcomes:
- Patient will verbalize understanding of risk factors for injury.
- Patient will identify behaviors and measures to reduce injury risk.
- Patient will remain free from injury.
Nursing Assessments:
- Assess Safety Issues: Conduct a thorough assessment of potential safety hazards in the patient’s environment (hospital room, home).
- Assess Knowledge of Safety Precautions: Evaluate the patient’s and caregiver’s understanding of safety precautions and injury prevention strategies.
- Note Individual Risk Factors: Consider individual patient risk factors such as age, cognitive abilities, mobility limitations, and sensory deficits when assessing injury risk.
- Ascertain Caregiver Expectations: For patients with caregivers, assess caregiver understanding of safety needs and their ability to provide a safe environment.
Nursing Interventions:
- Provide Safe Nursing Care: Implement a culture of safety in nursing care delivery. Adhere to safety protocols and model safe practices.
- Inform Patient About Treatments and Medications: Provide clear and understandable information about treatments and medications to enhance patient cooperation and safety.
- Reduce Risk of Injury: Implement specific injury prevention measures: bed alarms, call bell within reach, assistive devices, fall precautions, environmental safety modifications (lighting, clutter removal).
- Prepare for Safe Home Environment: Prior to discharge, discuss home safety measures with the patient and caregivers, including equipment needs, fall prevention strategies, medication safety, and emergency contact information.
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.
