Altered mental status (AMS) is a common clinical presentation that signifies a disturbance in brain function. As a crucial indicator of underlying medical or neurological issues, recognizing and responding to AMS is a fundamental aspect of nursing care. While “altered mental status” encompasses a broad spectrum of conditions, focusing specifically on an Altered Level Of Consciousness Nursing Diagnosis allows for targeted assessments and interventions to improve patient outcomes. This article will delve into the nuances of altered level of consciousness as a nursing diagnosis, expanding upon the foundational knowledge of AMS to provide an in-depth guide for nurses.
Understanding Altered Level of Consciousness
The terms used to describe changes in consciousness form a continuum, reflecting the severity of neurological impairment. These range from subtle shifts to profound unresponsiveness:
- Hyperalert: An exaggerated state of alertness, often associated with anxiety or stimulant use.
- Confused: Disorientation to time, place, or person; difficulty thinking clearly.
- Delirious: Acute state of confusion characterized by fluctuating levels of consciousness, inattention, and disorganized thinking.
- Somnolent: Excessive drowsiness or sleepiness; easily aroused but quickly returns to sleep.
- Lethargic: Severe drowsiness; difficult to arouse and maintain alertness.
- Obtunded: Decreased alertness; requires repeated stimuli to arouse and may respond slowly or inappropriately.
- Stuperous: Minimal responsiveness; responds only to vigorous and repeated stimuli (e.g., pain).
- Comatose: Unarousable unresponsiveness; no response to external stimuli, including pain.
Changes in cognition and mood often accompany altered consciousness, manifesting in symptoms such as:
- Disorientation and confusion
- Memory deficits and forgetfulness
- Hallucinations (sensory perceptions without external stimuli)
- Delusions (false, fixed beliefs)
- Incoherent or nonsensical speech
- Slowed reaction times
- Agitation and restlessness
- Anxiety and fear
- Depression or flattened affect
- Euphoria or inappropriate cheerfulness
It’s crucial to differentiate between reversible and irreversible causes of altered level of consciousness. Conditions like infections, metabolic imbalances, and medication side effects often lead to reversible AMS, while neurodegenerative diseases like Alzheimer’s disease cause progressive and irreversible cognitive decline. Identifying the underlying cause is paramount for effective management and nursing interventions. The etiology of altered level of consciousness can be broadly categorized:
- Neurological Diseases: Stroke, traumatic brain injury, seizures, meningitis, encephalitis, brain tumors.
- Infections: Sepsis, urinary tract infections (UTIs), pneumonia, central nervous system infections.
- Toxicities: Drug overdose, alcohol intoxication or withdrawal, environmental toxins.
- Metabolic Imbalances: Hypoglycemia, hyperglycemia, electrolyte abnormalities (sodium, calcium), liver failure, kidney failure, thyroid disorders.
- Systemic Conditions: Hypoxia, hypercapnia, hypothermia, hyperthermia, shock, cardiac arrest.
Nursing Process for Altered Level of Consciousness
Prompt recognition and intervention are critical in managing patients with an altered level of consciousness. The nursing process provides a structured approach to assessment, diagnosis, planning, implementation, and evaluation of care for these patients. Nurses play a vital role in the early detection of subtle changes in consciousness, determining the potential underlying causes, and implementing timely interventions to minimize morbidity and mortality. A comprehensive assessment, continuous monitoring, and symptom management are essential components of nursing care. Patient safety is a primary concern, as altered consciousness significantly increases the risk of falls and injuries.
Nursing Assessment: Identifying Altered Level of Consciousness
The nursing assessment is the cornerstone of care for patients with suspected altered level of consciousness. It involves gathering subjective and objective data to establish a baseline, identify contributing factors, and guide subsequent interventions.
Review of Health History
1. Elicit a detailed history of changes in mentation: Beyond simply noting altered consciousness, explore specific changes in:
- Self-awareness: Does the patient recognize themselves and their situation?
- Mood and affect: Are there changes in emotional state, such as increased irritability, anxiety, or flattened affect?
- Expression and communication: Is there difficulty finding words, slurred speech, or inability to understand language?
- Language: Is the patient using appropriate language, or is their speech nonsensical or disorganized?
- Emotions: Are the patient’s emotional responses appropriate to the situation?
- Cognition: Assess for deficits in attention, memory, orientation, and executive function.
- Motor control: Are there any new motor deficits, weakness, or abnormal movements?
- Behavior: Has there been a change in typical behavior patterns, such as increased agitation, withdrawal, or confusion?
2. Investigate potential underlying causes: Consider the broad categories of causes for AMS, and specifically altered level of consciousness:
- Neurological: History of seizures, stroke, head trauma, neurological disorders.
- Infectious: Recent fever, signs of infection, exposure to infectious agents.
- Toxic/Metabolic: History of substance abuse, medication changes, known metabolic disorders (diabetes, liver, kidney disease).
- Systemic: Cardiovascular disease, respiratory disease, endocrine disorders.
3. Identify risk factors for altered level of consciousness: Certain factors increase susceptibility to AMS:
- Age over 65 years: Older adults are more vulnerable due to age-related physiological changes and polypharmacy.
- Anesthesia and surgery: Postoperative cognitive dysfunction is a recognized complication.
- Intensive Care Unit (ICU) admission: ICU environment and critical illness contribute to delirium.
- Social isolation and lack of social support: Social isolation can exacerbate cognitive decline and delirium.
- Sleep deprivation: Disrupted sleep-wake cycles can contribute to confusion and cognitive impairment.
- Sensory impairments (visual or hearing): Sensory deprivation can worsen confusion and disorientation.
- Pre-existing cognitive impairment or dementia: These conditions increase vulnerability to acute changes in consciousness.
4. Differentiate from primary mental illness: While some psychiatric disorders can mimic altered level of consciousness, it’s important to distinguish between them. Consider features of:
- Bipolar disorders: Euphoria, mania, or severe depression might present with altered behavior but typically not a decreased level of consciousness in the same way as medical AMS.
- Schizophrenia: Hallucinations and delusions are present, but level of consciousness is usually intact unless co-existing medical conditions are present.
5. Consider patient age: Age is a significant factor in determining likely causes:
- Infants and young children: Infections (meningitis, encephalitis), febrile seizures, trauma, metabolic disorders, and ingestions are more common.
- Young adults: Trauma, substance abuse, and psychiatric conditions are frequent causes.
- Older adults: Stroke, infections (UTI, pneumonia), medication side effects/interactions, and changes in living environment are more likely.
6. Obtain collateral history from family or caregivers: Information from those familiar with the patient’s baseline mental status is invaluable. They can provide insights into:
- Baseline cognitive function: Is the current presentation a change from their usual state?
- Onset and progression of symptoms: When did the changes begin, and how have they evolved?
- Potential triggers: Recent illnesses, medication changes, stressors, or environmental changes.
7. Conduct a thorough medication review: Polypharmacy and drug interactions are significant contributors to altered level of consciousness, especially in older adults. Inquire about:
- Prescription medications: Obtain a complete list, including dosages and frequency.
- Over-the-counter (OTC) medications: Many OTC drugs, particularly anticholinergics, can cause confusion.
- Herbal and nutritional supplements: These can interact with prescription medications or have independent effects on cognition.
- Recent medication changes: New medications or dosage adjustments may be the culprit.
- Common culprit medications: Be particularly vigilant for:
- Antibiotics (especially quinolones and macrolides)
- Antidepressants (tricyclic antidepressants, SSRIs)
- Antipsychotics
- Benzodiazepines
- Opioids
- Sedatives and hypnotics
- Anticholinergics (antihistamines, bladder medications)
8. Explore alcohol and substance use: Intoxication and withdrawal are frequent causes of AMS.
- Current alcohol or drug use: Quantity, frequency, and type of substances used.
- History of substance use disorder: Increased risk of withdrawal syndromes.
- Time of last use: Helps determine if intoxication or withdrawal is more likely.
- Toxicology screening: May be necessary if history is unreliable or unclear.
Physical Assessment: Objective Data Collection
1. Assess the ABCs (Airway, Breathing, Circulation): Prioritize basic life support. Ensure:
- Patent airway: Assess for obstruction and intervene as needed (positioning, suctioning, artificial airway).
- Adequate breathing: Respiratory rate, depth, and effort; oxygen saturation. Provide supplemental oxygen if needed.
- Stable circulation: Heart rate, blood pressure, peripheral pulses. Address hypotension or shock.
2. Neurological Status Evaluation: A detailed neurological exam is crucial:
- Level of Consciousness (LOC): Use descriptive terms (alert, confused, lethargic, etc.) and standardized scales like the Glasgow Coma Scale (GCS) for objective assessment.
- Glasgow Coma Scale (GCS): Assess eye-opening, verbal response, and motor response to quantify LOC, especially in trauma or severe AMS.
- Orientation: Person, place, time, and situation.
- Pupillary response: Size, shape, reactivity to light (PERRLA – Pupils Equal, Round, Reactive to Light and Accommodation).
- Speech: Clear, slurred, nonsensical, aphasic.
- Sensations: Response to touch, pain, temperature (if appropriate and safe).
- Reflexes: Deep tendon reflexes, plantar reflex (Babinski).
- Coordination and gait: Assess if patient is able to safely ambulate (if appropriate LOC allows).
3. Observe Appearance, Behavior, and Movement: These observations can provide clues to underlying conditions:
- Hygiene and attire: Neglect of hygiene, inappropriate dress may suggest cognitive or psychiatric issues.
- Behavior: Agitation, restlessness, withdrawal, combativeness, cooperation with assessment.
- Eye contact and facial expressions: Appropriate, flat affect, anxious, fearful.
- Posture: Normal, slumped, rigid.
- Movements: Tremors, tics, slowed movements (bradykinesia), exaggerated movements (hyperkinesia), catatonia (immobility and unresponsiveness).
4. Cognitive Assessment: Formal and informal cognitive testing:
- Attention and concentration: Digit span, serial sevens.
- Memory: Immediate, recent, and remote memory recall.
- Language: Naming objects, following commands, repetition.
- Thought content and processes: Assess for delusions, hallucinations, disorganized thinking.
- Executive function: Ability to follow multi-step directions, problem-solving (clock drawing test).
- Standardized Cognitive Tests:
- Mini-Mental State Examination (MMSE): Brief screening tool for cognitive impairment.
- Confusion Assessment Method (CAM): Specifically designed to diagnose delirium.
- 4 A’s Test (Alertness, Attention, Agitation/Aggression, and Acute change from baseline): Another delirium screening tool.
5. Physical Signs of Trauma: Thorough examination for injuries:
- Head: Scalp lacerations, hematomas, signs of skull fracture.
- Extremities: Fractures, dislocations, soft tissue injuries.
- Back and spine: Palpate for tenderness, deformity.
- Skin: Ecchymosis, lacerations, puncture wounds, track marks (IV drug use), transdermal patches (medication overdose).
- Signs of infection: Wound drainage, redness, swelling.
6. Vital Signs and ECG Monitoring: Continuous monitoring is essential:
- Vital signs: Blood pressure, heart rate, respiratory rate, temperature, oxygen saturation. Note patterns and trends. Abnormalities may indicate hypothermia, hyperthermia, hypoxemia, hypertensive crisis, sepsis, or shock.
- Electrocardiogram (ECG): Assess for cardiac arrhythmias, ischemia, or electrolyte imbalances affecting cardiac function.
Diagnostic Procedures: Identifying the Underlying Cause
1. Rapid Glucose Level Check: Hypoglycemia is a readily reversible and dangerous cause of altered level of consciousness. Perform a bedside glucose test immediately.
2. Laboratory Specimen Collection: Blood and urine tests to evaluate for underlying causes:
- Serum electrolytes: Sodium, potassium, calcium, magnesium imbalances.
- Complete blood count (CBC): Infection (elevated white blood cell count), anemia.
- Serum ammonia: Hepatic encephalopathy.
- Blood gas analysis (ABGs or VBGs): Hypoxia, hypercapnia, acid-base imbalances.
- Blood cultures: Sepsis, bacteremia.
- Liver function tests (LFTs): Hepatic encephalopathy, liver failure.
- Kidney function tests (BUN, creatinine): Uremic encephalopathy, kidney failure.
- Urinalysis: Urinary tract infection, ketones (diabetic ketoacidosis), drug screen.
- Thyroid function tests (TSH, T4): Hypothyroidism, hyperthyroidism.
- Serum B12 levels: B12 deficiency encephalopathy.
- Syphilis serology (RPR/VDRL): Neurosyphilis.
- Toxicology screening (urine and/or blood): Drug overdose, substance abuse.
3. Imaging and Specialized Tests: Consider based on clinical suspicion:
- Head CT scan: Rule out stroke, intracranial hemorrhage, head trauma, hydrocephalus, brain tumor.
- Chest X-ray: Rule out pneumonia as a source of infection or hypoxia.
- Lumbar puncture (spinal tap): If meningitis or encephalitis is suspected (after ruling out contraindications like increased intracranial pressure).
- Electroencephalogram (EEG): Rule out seizures (non-convulsive status epilepticus), diagnose encephalopathy, or infectious encephalitis.
Nursing Interventions for Altered Level of Consciousness
Nursing interventions are directed at treating the underlying cause, providing supportive care, ensuring patient safety, and preventing complications.
1. Treat the Underlying Cause: This is the primary goal. Specific treatments depend on the identified etiology:
- IV fluids: For dehydration, hypovolemia, shock.
- Antibiotics: For infections (sepsis, meningitis, pneumonia, UTI).
- Glucose (Dextrose IV): For hypoglycemia.
- Electrolyte replacement: For electrolyte imbalances (sodium, potassium, calcium).
- Neurosurgical intervention: For brain trauma (hematoma evacuation), hydrocephalus.
- Intubation and mechanical ventilation: For respiratory failure, airway protection.
- Naloxone: For opioid overdose.
- Thiamine and benzodiazepines: For alcohol withdrawal.
2. Reduce Environmental Stimulation: Create a calm and quiet environment, especially for patients with delirium:
- Dim lights: Reduce overstimulation and promote sleep-wake cycle regulation.
- Minimize noise: Limit alarms, overhead paging, and loud conversations.
- Simple and familiar surroundings: Orienting cues like clocks, calendars, and familiar objects.
- Reassurance and calm communication: Speak in a clear, calm, and reassuring tone.
3. Sedation (Pharmacological Management of Agitation): Use cautiously and judiciously for severe agitation that poses a safety risk:
- Antipsychotics (Haloperidol, Quetiapine): Often used for delirium-related agitation.
- Benzodiazepines: Generally avoided in delirium (can worsen confusion) except for alcohol withdrawal or seizures.
4. Physical Restraints (Last Resort): Only when all other de-escalation strategies fail and patient safety is at immediate risk.
- Follow hospital policy and protocols: Requires physician order, frequent monitoring, and reassessment.
- Use least restrictive method: Choose the least restrictive restraint necessary.
- Monitor skin integrity and circulation: Prevent injury from restraints.
- Address underlying cause of agitation: Restraints are not a treatment for delirium or agitation, but a temporary safety measure.
5. Ensure Patient Safety: Fall prevention and injury minimization are paramount:
- Fall precautions: Bed alarm, side rails (if appropriate and not contraindicated), non-slip footwear, clear pathways.
- Close monitoring and supervision: Consider 1:1 observation if high risk for falls or self-harm.
- Safe environment: Remove clutter, secure lines and tubes, pad side rails if needed.
6. Administer Medications as Ordered: Specific medications based on the underlying cause:
- Donepezil, Rivastigmine, Galantamine, Memantine: For dementia-related cognitive impairment (not for acute AMS, but for underlying condition management).
- Naloxone: For narcotic overdose.
- Antiseizure medications: For seizures or status epilepticus.
- Antipsychotics or mood stabilizers: For underlying mental illnesses.
7. Prevent Delirium (Proactive Strategies): Implement preventive measures for patients at risk:
- Adequate hydration and nutrition: Maintain fluid and electrolyte balance.
- Minimize invasive devices: Limit IV lines, urinary catheters, when clinically appropriate.
- Address constipation and urinary retention: These can contribute to delirium.
- Promote daytime activity and nighttime rest: Maintain regular sleep-wake cycle.
- Ensure use of sensory aids: Hearing aids, eyeglasses, dentures.
- Effective pain management: Uncontrolled pain can contribute to delirium.
- Orientation and reorientation: Regularly orient patient to time, place, and situation.
8. Reduce Risk of Polypharmacy: Especially important in older adults:
- Medication reconciliation: Review all medications (prescription, OTC, supplements).
- Identify potential drug interactions: Pharmacist consultation may be helpful.
- Simplify medication regimens: Reduce unnecessary medications, consider combination pills when appropriate.
- Discuss medication discontinuation: With physician, consider deprescribing medications that are no longer necessary or contributing to AMS.
9. Refer to Appropriate Disciplines: Collaborative care is essential:
- Neurologist: For neurological causes (stroke, seizures, etc.).
- Pharmacist: Medication review, drug interaction assessment.
- Mental health professionals (Psychiatrist, Psychologist): If underlying psychiatric disorder is suspected or contributing to AMS.
- Substance abuse counselors: For substance use disorders.
- Social workers and case managers: Discharge planning, community resources, support for patient and family.
Nursing Care Plans for Altered Level of Consciousness
Nursing care plans provide a framework for organizing and delivering individualized care for patients with altered level of consciousness. Common nursing diagnoses associated with AMS include:
Acute Confusion
Nursing Diagnosis: Acute Confusion
Related to:
- Alteration in brain function
- Metabolic imbalances
- Infection
- Hypoxia
- Sleep deprivation
- Alcohol or drug withdrawal
- Delirium
- Disrupted perception
As Evidenced By:
- Decreased level of consciousness
- Disorientation to time, place, person
- Impaired cognition and memory
- Hallucinations and delusions
- Restlessness and agitation
- Inappropriate verbal responses
- Disrupted psychomotor functioning
- Inability to perform purposeful behavior
Expected Outcomes:
- Patient will regain orientation to person, place, and time.
- Patient will demonstrate improved cognitive function.
- Patient will identify and manage factors contributing to acute confusion.
Assessments:
- Determine causative factors: Thorough history and physical exam, review of labs and diagnostics.
- Mental status assessment: Baseline and ongoing monitoring using standardized tools (MMSE, CAM, GCS).
- Monitor lab values: Electrolytes, glucose, CBC, ABGs, liver and kidney function.
- Assess medication and substance use history: Identify potential contributing agents.
Interventions:
- Provide frequent orientation: Reorient to person, place, time, situation; use visual cues (clocks, calendars).
- Prevent sundowning: Maximize daytime light exposure, structured daily routine, limit daytime naps, familiar objects.
- Educate caregivers: Recognize signs of worsening confusion, when to seek medical help.
- Provide calm and stable environment: Reduce noise and overstimulation, promote rest.
Impaired Verbal Communication
Nursing Diagnosis: Impaired Verbal Communication
Related to:
- Cognitive dysfunction
- Central nervous system impairment
- Psychotic disorder
- Physiological condition (e.g., stroke, encephalopathy)
As Evidenced By:
- Difficulty expressing thoughts verbally
- Difficulty comprehending information
- Incongruent facial expressions/body language
- Disorientation
- Aphasia, dysarthria, dysphonia, anarthria
- Slurred speech
Expected Outcomes:
- Patient will utilize alternative communication methods (gestures, writing) as needed.
- Patient will demonstrate improved comprehension.
- Patient will return to baseline communication abilities as condition improves.
Assessments:
- Assess baseline communication abilities: Family/caregiver input, pre-existing communication deficits.
- Identify barriers to communication: Cognitive impairment, language barriers, sensory deficits (hearing, vision).
- Note conditions affecting speech: Stroke symptoms, neurological deficits.
Interventions:
- Explain procedures and tasks: Clear, simple language, even if patient appears unresponsive.
- Allow ample time for response: Patience, avoid interrupting.
- Limit distractions: Quiet environment for communication.
- Utilize family members: Facilitate communication, interpret patient cues.
Ineffective Cerebral Tissue Perfusion
Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion
Related to:
- Decreased cerebral blood flow (hypotension, shock)
- Metabolic conditions (hypoglycemia, hypoxia)
- Primary intracranial disease (stroke, increased intracranial pressure)
- Systemic disease affecting CNS
- Exogenous toxins
- Drug withdrawal
As Evidenced By:
- Decreased Glasgow Coma Scale (GCS)
- Decreased level of consciousness (LOC)
- Diminished reflexes
- Alterations in vital signs (pulse rate, blood pressure)
- Increased intracranial pressure (ICP)
- Decreased cerebral perfusion pressure (CPP)
- Behavioral changes
Expected Outcomes:
- Patient will demonstrate effective cerebral tissue perfusion (GCS and LOC within normal limits for patient).
- Patient will not experience worsening neurological status (coma, intubation).
Assessments:
- Assess vital signs and underlying cause: Monitor for trends, identify contributing factors.
- Neurological status assessment: Frequent GCS, LOC, pupillary response, motor function checks.
- Review medications and substance use: Identify potential contributing agents.
Interventions:
- Determine appropriate level of care: ICU monitoring, neuro-ICU if indicated.
- Administer fluids and electrolytes: Maintain hemodynamic stability, optimize cerebral perfusion.
- Prepare for surgical procedures: Carotid endarterectomy, hematoma evacuation if indicated.
Ineffective Coping
Nursing Diagnosis: Ineffective Coping
Related to:
- Cognitive dysfunction
- Psychological barriers (anxiety, fear)
- Inaccurate threat appraisal
- Loss of control
- Lack of support
As Evidenced By:
- Altered concentration
- Change in communication patterns
- Destructive behavior (agitation, aggression)
- Substance misuse
- Difficulty organizing information
Expected Outcomes:
- Patient will remain free from agitated or destructive behavior.
- Patient will verbalize reduced stress and anxiety, and increased sense of control (as able).
Assessments:
- Assess contributing factors: Lack of support, recent life changes, grief, inadequate coping skills, underlying psychiatric conditions.
- Assess cognitive, emotional, and mental state: Anxiety, delusions, depressive symptoms.
- Monitor for physiological alterations: Sepsis, metabolic imbalances, hypoxia contributing to ineffective coping.
Interventions:
- Implement relaxation techniques: Guided imagery, music therapy (if appropriate for LOC).
- Establish trusting relationship: Calm, reassuring approach, therapeutic communication.
- Encourage participation in care (as able): Involve patient in decision-making to enhance sense of control.
- Identify support persons: Family, friends, social workers, mental health counselors.
Risk for Injury
Nursing Diagnosis: Risk for Injury
Related to:
- Altered brain function
- Impaired sleep cycle
- Hypoxia
- Intoxication
- Decreased level of consciousness
- Impaired cognition and perception
As Evidenced By:
- Risk diagnosis – not evidenced by signs and symptoms. Interventions focused on prevention.
Expected Outcomes:
- Patient will verbalize understanding of risk factors for injury (as able).
- Patient will identify behaviors and measures to reduce injury risk (as able).
- Patient will remain free from injury.
Assessments:
- Assess safety issues: Environmental hazards, patient-specific risk factors.
- Assess knowledge of safety precautions: Patient and caregiver understanding of safety needs.
- Note individual risk factors: Age, cognitive status, mobility, medications.
- Ascertain caregiver expectations: Support and resources available at home.
Interventions:
- Provide safe nursing care: Culture of safety, adherence to protocols.
- Inform patient about treatments and medications: Clear communication, build trust and cooperation.
- Reduce risk of injury: Fall precautions, bed alarm, call bell, assistive devices, safe environment.
- Prepare for safe home environment: Home safety assessment, equipment needs, fall prevention education.
Conclusion
Altered level of consciousness is a critical clinical finding demanding prompt and thorough nursing assessment and intervention. By focusing on the altered level of consciousness nursing diagnosis, nurses can provide targeted care, address the underlying causes, and prioritize patient safety. Utilizing the nursing process and implementing evidence-based interventions are essential for optimizing outcomes and improving the well-being of patients experiencing this complex condition.
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.
