Altered mental status (AMS), also referred to as altered level of consciousness (LOC), is a significant clinical presentation indicating changes in brain function. It’s not a disease itself, but a symptom of various underlying medical conditions affecting cognitive abilities and awareness. AMS encompasses a spectrum of conditions, from mild confusion to severe coma, and includes states like delirium and psychosis. Essentially, AMS reflects a deviation from a patient’s normal baseline of consciousness and cognition, impacting their interactions with the world and their ability to function. Recognizing and addressing altered LOC is a critical skill in nursing, demanding prompt assessment and intervention to improve patient outcomes.
Understanding Altered Level of Consciousness (LOC)
Changes in consciousness are described using a range of terms that reflect the degree of arousal, moving from heightened alertness to complete unresponsiveness. These terms include:
- Hyperalert: Excessively watchful and reactive to stimuli.
- Confused: Disoriented to time, place, or person; difficulty thinking clearly.
- Delirious: Agitated confusion, often with hallucinations and disorientation.
- Somnolent: Drowsy or sleepy, easily aroused.
- Lethargic: Difficult to arouse, but able to respond to stimuli.
- Obtunded: Very difficult to arouse, requires continuous stimulation to maintain attention.
- Stuperous: Responds only to vigorous and repeated stimulation.
- Comatose: Unresponsive to any stimuli, including pain.
Cognitive and mood changes associated with altered LOC can manifest in various symptoms, such as:
- Disorientation to person, place, or time
- Forgetfulness and memory deficits
- Hallucinations (sensory experiences without external stimuli)
- Delusions (false beliefs not based in reality)
- Nonsensical or incoherent speech
- Slowed reaction times and responses
- Agitation and restlessness
- Anxiety and nervousness
- Depression or feelings of sadness
- Euphoria or an elevated mood
It’s important to note that altered LOC can be either reversible or irreversible, depending on the underlying cause. For instance, AMS caused by infections or medication side effects may be reversible with appropriate treatment. However, chronic conditions like Alzheimer’s disease lead to progressive and irreversible cognitive decline and altered LOC. Acute conditions like stroke or traumatic brain injury may result in altered LOC with varying degrees of reversibility depending on the extent of neurological damage and the effectiveness of interventions.
The causes of altered LOC are diverse, but generally fall into these categories:
- Neurological disorders (e.g., stroke, seizures, meningitis, encephalitis, brain tumors)
- Infections (systemic infections, sepsis, urinary tract infections in elderly)
- Toxic exposures (drugs, alcohol, environmental toxins, medication overdose)
- Metabolic imbalances (hypoglycemia, hyperglycemia, electrolyte abnormalities, liver or kidney failure)
- Systemic illnesses (hypoxia, shock, cardiac arrest, hypothermia, hyperthermia)
The Nursing Process for Altered LOC
Nurses play a crucial role in the early detection, assessment, and management of altered LOC. Prompt nursing actions are essential to identify the underlying cause, provide timely interventions, and minimize potential complications. A systematic nursing process is vital in caring for patients with altered LOC, encompassing assessment, diagnosis, planning, implementation, and evaluation.
Nursing Assessment of Altered LOC
The nursing assessment is the foundation of care for patients with altered LOC. It involves gathering comprehensive data – subjective, objective, and historical – to understand the patient’s condition and guide subsequent interventions.
Health History Review
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Elicit Changes in Mentation: Directly inquire about any changes in the patient’s mental state. Beyond consciousness, assess for alterations in:
- Self-awareness and orientation
- Mood and affect
- Verbal expression and communication
- Language comprehension
- Emotional responses
- Cognitive functions (memory, attention, executive function)
- Motor control and coordination
- Behavior and personality
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Identify Potential Underlying Causes: Systematically consider the broad categories of causes for AMS to guide history taking and further investigation:
- Neurological: Head trauma, seizures, headaches, weakness, numbness, history of stroke or neurological conditions.
- Infectious: Fever, chills, cough, urinary symptoms, recent infections.
- Toxic: Exposure to toxins, drug use, alcohol consumption, new medications, changes in medication regimen.
- Metabolic: History of diabetes, liver disease, kidney disease, thyroid disorders, recent changes in diet or fluid intake.
- Systemic: Chest pain, shortness of breath, palpitations, changes in bowel or bladder habits.
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Determine Risk Factors for Altered LOC: Identify predisposing factors that increase the likelihood of AMS:
- Age over 65 years (increased vulnerability to delirium and medical comorbidities)
- Anesthesia and surgery (postoperative cognitive dysfunction)
- Intensive Care Unit (ICU) admission (ICU delirium)
- Social isolation and lack of social support
- Sleep deprivation and disrupted sleep-wake cycles
- Visual or hearing impairments (sensory deprivation contributing to confusion)
- Pre-existing cognitive impairment or dementia
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Assess for Mental Illness: Differentiate AMS from primary psychiatric disorders. Some mental health conditions may mimic or coexist with altered LOC:
- Bipolar disorder (mania or depression can affect mental status)
- Schizophrenia (psychosis can present with altered perception and cognition)
- Anxiety disorders (severe anxiety can cause confusion and agitation)
- Major depressive disorder (severe depression can mimic cognitive impairment)
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Consider Patient Age: Age is a significant factor in the differential diagnosis of AMS. The most likely causes vary across age groups:
- Infants and young children: Infections (meningitis, encephalitis), febrile seizures, trauma, metabolic disorders, ingestions.
- Young adults: Substance abuse, trauma, infections, psychiatric disorders.
- Older adults: Infections (UTI, pneumonia), stroke, medication side effects and interactions, metabolic imbalances, dementia, delirium, environmental changes.
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Interview Family and Caregivers: Obtain collateral history from family members, caregivers, or witnesses. They can provide crucial information about:
- Patient’s baseline mental status and cognitive function
- Onset and progression of symptoms
- Recent changes in behavior, mood, or function
- Medical history, medications, allergies
- Social history and living situation
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Medication History Review: Thoroughly review all medications, including prescription, over-the-counter, herbal supplements, and illicit drugs. Pay attention to:
- New medications or recent dosage changes
- Polypharmacy (multiple medications increasing risk of interactions)
- Medications known to cause cognitive side effects (anticholinergics, benzodiazepines, opioids, antipsychotics, antidepressants, sedatives, antibiotics)
- Potential drug-drug interactions
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Substance Use Inquiry: Assess for alcohol and illicit drug use, both current and past. Consider:
- Intoxication as a cause of AMS
- Withdrawal syndromes as a cause of AMS (alcohol withdrawal delirium, benzodiazepine withdrawal)
- Type of substance, amount, frequency, and last use
- Need for toxicology screening
Physical Assessment
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ABCs Assessment: Immediately assess and stabilize Airway, Breathing, and Circulation. Prioritize life-sustaining functions in patients with AMS:
- Ensure patent airway
- Evaluate respiratory rate, depth, and effort
- Assess heart rate, blood pressure, and peripheral perfusion
- Provide supplemental oxygen if needed
- Monitor for signs of respiratory distress or circulatory compromise
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Neurological Status Evaluation: Perform a comprehensive neurological examination:
- Level of Consciousness (LOC): Use standardized scales like the Glasgow Coma Scale (GCS) to quantify LOC, especially in trauma or suspected brain injury. Describe LOC using terms like alert, confused, lethargic, obtunded, stuporous, comatose.
- Orientation: Assess orientation to person, place, time, and situation.
- Pupillary Response: Evaluate pupil size, equality, reactivity to light (PERRLA – Pupils Equal, Round, Reactive to Light and Accommodation).
- Speech: Assess speech clarity, fluency, coherence, and content.
- Motor Function: Evaluate strength, tone, and coordination in all extremities.
- Sensory Function: Assess sensation to light touch and pain.
- Reflexes: Check deep tendon reflexes and plantar reflexes.
- Cranial Nerves: Assess relevant cranial nerve function.
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Appearance, Behavior, and Movement: Observe and document the patient’s:
- Hygiene and grooming
- Dress and attire
- Eye contact and facial expressions
- Posture and body movements
- Ability to cooperate with assessment
- Presence of abnormal movements (tremors, rigidity, restlessness, catatonia)
- General behavior (agitation, withdrawal, apathy)
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Cognitive Assessment: Administer brief cognitive screening tools to assess specific cognitive domains:
- Mini-Mental State Examination (MMSE): Assesses orientation, memory, attention, language, and visuospatial skills.
- Confusion Assessment Method (CAM): Specifically designed to diagnose delirium.
- 4 A’s Test (Alertness, Attention, Agitation, and Acute change in cognition): Rapid assessment for delirium.
- Assess attention span, memory (immediate, recent, and remote), language skills (naming, repetition, comprehension), thought content and processes (logical, organized, delusional, suicidal ideation), and executive functions (problem-solving, judgment).
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Trauma Signs Inspection: Carefully examine for physical signs of trauma:
- Head and scalp for lacerations, contusions, hematomas
- Extremities for fractures, dislocations, soft tissue injuries
- Back and spine for injury
- Assess for signs of infection, ecchymosis, swelling, deformities
- Note presence of track marks from intravenous drug use or transdermal patches.
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Vital Signs and ECG Monitoring: Continuously monitor vital signs:
- Heart rate, blood pressure, respiratory rate, temperature, oxygen saturation.
- Abnormal vital signs can indicate underlying medical conditions (hypothermia, hyperthermia, hypoxemia, hypotension, hypertension, tachycardia, bradycardia).
- Obtain a 12-lead ECG to assess for cardiac arrhythmias or ischemia, especially if cardiac etiology is suspected.
Diagnostic Procedures for Altered LOC
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Rapid Glucose Level Check: Immediately check blood glucose using a fingerstick glucose meter. Hypoglycemia and hyperglycemia are common and rapidly reversible causes of AMS.
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Specimen Collection for Lab Tests: Collect blood and urine samples as indicated by the suspected underlying cause:
- Serum electrolytes: Sodium, potassium, calcium, magnesium (imbalances can cause AMS).
- Complete blood count (CBC): White blood cell count (infection), hemoglobin and hematocrit (anemia).
- Serum ammonia: Elevated in hepatic encephalopathy.
- Arterial blood gas (ABG) analysis: Oxygenation, carbon dioxide levels, pH (hypoxia, hypercapnia, metabolic acidosis/alkalosis).
- Blood cultures: If infection/sepsis is suspected.
- Liver function tests (LFTs): Elevated in liver failure/hepatic encephalopathy.
- Kidney function tests (BUN, creatinine): Elevated in kidney failure/uremic encephalopathy.
- Urinalysis: Urinary tract infection, ketones (diabetic ketoacidosis).
- Thyroid function tests (TSH, T4): Hypothyroidism or hyperthyroidism.
- Serum B12 levels: B12 deficiency.
- Syphilis serology (RPR/VDRL): Neurosyphilis.
- Toxicology screening: Urine and/or blood drug screen if substance use is suspected.
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Imaging and Specialized Tests: Consider advanced diagnostics based on clinical suspicion:
- Head CT scan: Rule out intracranial hemorrhage, stroke, mass lesions, hydrocephalus, especially in trauma, new-onset seizures, focal neurological deficits.
- Chest X-ray: Rule out pneumonia or other pulmonary infections.
- Lumbar puncture: If meningitis or encephalitis is suspected (after ruling out increased intracranial pressure with CT scan if indicated).
- Electroencephalogram (EEG): Rule out seizures (non-convulsive status epilepticus), diagnose encephalopathy, assess for specific patterns in certain conditions (e.g., triphasic waves in hepatic encephalopathy).
Nursing Interventions for Altered LOC
Nursing interventions for altered LOC are multifaceted and aimed at treating the underlying cause, managing symptoms, preventing complications, and ensuring patient safety.
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Treat the Underlying Cause: Address the root cause of AMS as the primary intervention. This may involve:
- IV fluids: For dehydration, hypovolemic shock, sepsis.
- Antibiotics: For infections (pneumonia, UTI, meningitis, sepsis).
- Glucose administration: For hypoglycemia (oral glucose if conscious, IV dextrose if unconscious).
- Electrolyte replacement: For electrolyte imbalances (sodium, potassium, calcium, magnesium).
- Neurosurgical intervention: For brain trauma, intracranial hemorrhage, mass lesions.
- Intubation and mechanical ventilation: For respiratory failure, airway protection.
- Naloxone: For opioid overdose.
- Thiamine and glucose: For suspected Wernicke’s encephalopathy in alcohol use disorder.
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Reduce Environmental Stimulation: Create a calm and quiet environment to minimize agitation and confusion, especially in delirium:
- Dim lights, reduce noise levels, minimize alarms.
- Provide a quiet room, reduce traffic and interruptions.
- Offer reassurance and orient patient frequently.
- Avoid overstimulation.
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Sedation for Agitation (Judicious Use): Pharmacological sedation may be necessary for severe agitation or when patient safety is compromised. Use cautiously, especially in delirium:
- Antipsychotics (haloperidol, quetiapine): Often preferred for delirium-related agitation.
- Benzodiazepines (lorazepam): Use cautiously in delirium, primarily for alcohol withdrawal or seizures. May worsen delirium in other situations.
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Restraints as a Last Resort: Physical restraints should only be used when all other de-escalation and safety measures have failed and the patient poses an imminent danger to themselves or others.
- Follow institutional policies and procedures for restraint use.
- Obtain physician order for restraints.
- Continuously monitor patient in restraints.
- Reassess need for restraints frequently.
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Ensure Patient Safety: Patients with altered LOC are at high risk for falls and injuries. Implement comprehensive safety precautions:
- Fall risk assessment and appropriate fall precautions (bed alarm, side rails, low bed position, non-slip footwear, clear pathways).
- Close monitoring and supervision, consider 1:1 observation if necessary.
- Protect from aspiration (positioning, suction equipment at bedside).
- Prevent skin breakdown (frequent turning and repositioning).
- Pad side rails if seizure risk.
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Medication Administration (Targeted Therapy): Administer medications as prescribed to address the underlying cause or manage specific symptoms:
- Donepezil, rivastigmine, memantine: For dementia (symptom management).
- Antiseizure medications: For seizure disorders or status epilepticus.
- Antipsychotics: For mental illnesses, psychosis, agitation.
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Delirium Prevention Strategies: Implement proactive measures to prevent delirium in at-risk patients (elderly, post-operative, ICU patients):
- Ensure adequate hydration and nutrition.
- Early mobilization and physical activity.
- Limit use of indwelling catheters and IV lines.
- Assess and manage constipation and urinary retention.
- Provide cognitive stimulation during the day (orientation, conversation, familiar objects).
- Ensure use of hearing aids and eyeglasses if needed.
- Effective pain management.
- Promote sleep hygiene and regular sleep-wake cycles.
- Reorient patient frequently to time, place, and person.
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Reduce Polypharmacy Risk: Especially in older adults, medication reconciliation is crucial to minimize drug interactions and adverse effects contributing to AMS:
- Review all medications (prescription, OTC, supplements).
- Identify potential duplicates, interactions, inappropriate dosages.
- Collaborate with physician and pharmacist to simplify medication regimen and discontinue unnecessary medications.
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Interdisciplinary Referrals: Collaborate with other healthcare professionals for comprehensive patient care:
- Neurologist consultation for neurological causes of AMS.
- Pharmacist consultation for medication review and management.
- Mental health professionals (psychiatrist, psychologist) for psychiatric evaluation and management.
- Substance abuse counselors for substance use disorders.
- Social workers and case managers for discharge planning and support services.
Nursing Care Plans for Altered LOC
Nursing diagnoses provide a framework for developing individualized care plans for patients with altered LOC. Here are examples of common nursing diagnoses and associated care planning considerations:
Acute Confusion
Nursing Diagnosis: Acute Confusion
Related Factors: Alteration in brain function, physiological disturbances (hypoxia, metabolic imbalances, electrolyte imbalances, hypoglycemia, infection, sleep deprivation, sensory overload or deprivation, medication side effects, substance intoxication or withdrawal), delirium, dementia.
Evidenced by: Disorientation to time, place, person, or situation; fluctuating levels of consciousness; impaired memory; decreased attention span; hallucinations; delusions; restlessness; agitation; incoherent speech; impaired judgment.
Expected Outcomes:
- Patient will regain orientation to person, place, and time.
- Patient will demonstrate improved cognitive function to baseline.
- Patient will experience resolution of acute confusion.
- Patient/caregiver will identify strategies to prevent recurrence of acute confusion.
Nursing Assessments:
- Determine causative factors: Thoroughly investigate potential medical, neurological, and environmental factors contributing to acute confusion.
- Mental status assessment: Regularly assess LOC, orientation, attention, memory, language, and executive function using standardized tools (MMSE, CAM, 4AT). Differentiate from dementia or mental illness.
- Monitor lab values: Review electrolytes, glucose, renal and liver function, CBC, ABGs to identify metabolic or systemic causes.
- Medication and substance use history: Assess for medications or substances that could induce confusion or delirium.
Nursing Interventions:
- Provide frequent orientation: Reorient patient to person, place, time, and situation regularly. Use visual cues (calendar, clock). Address patient by name.
- Prevent sundowning: Optimize lighting, maintain daytime activity routine, limit daytime napping, provide familiar objects, ensure safety measures are in place, especially at night.
- Educate caregivers: Instruct family/caregivers on recognizing signs of confusion, safety measures at home, and when to seek medical attention.
- Create a calm environment: Reduce noise and stimulation, provide a quiet and safe space, promote rest and sleep.
Impaired Verbal Communication
Nursing Diagnosis: Impaired Verbal Communication
Related Factors: Cognitive dysfunction, central nervous system impairment (stroke, head injury, neurological disorders), psychosis, physiological conditions affecting speech mechanisms (dysarthria, aphasia, dysphonia), language barrier.
As Evidenced by: Difficulty expressing thoughts verbally, difficulty comprehending spoken or written language, slurred speech, incoherent speech, aphasia, dysarthria, dysphonia, disorientation, inappropriate verbal responses, inability to follow commands, frustration with communication attempts.
Expected Outcomes:
- Patient will utilize alternative methods of communication effectively.
- Patient will demonstrate improved ability to communicate needs and understand information.
- Patient will experience a reduction in communication barriers.
- Patient will return to baseline communication abilities as condition improves.
Nursing Assessments:
- Assess baseline communication abilities: Determine patient’s usual communication methods and level of function prior to current illness. Consult family if needed.
- Identify communication barriers: Assess for cognitive impairments, language deficits, hearing or visual impairments, physical limitations affecting speech.
- Note conditions affecting speech: Evaluate for dysarthria, aphasia, dysphonia, and potential underlying causes (stroke, neurological conditions).
Nursing Interventions:
- Explain procedures clearly: Provide simple and clear explanations of all procedures and care activities before initiating them. Use nonverbal cues and gestures to enhance understanding.
- Allow ample response time: Give patient sufficient time to process information and formulate responses. Be patient and avoid interrupting.
- Limit distractions: Minimize environmental distractions and noise during communication attempts.
- Utilize family assistance: Involve family members to facilitate communication and understanding, especially if they are familiar with the patient’s communication style. Explore use of communication aids (picture boards, writing, assistive technology) as appropriate.
Ineffective Cerebral Tissue Perfusion
Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion
Related Factors: Decreased cerebral blood flow (hypotension, hypovolemia, cardiac dysfunction, increased intracranial pressure, vasoconstriction, thrombus, embolus), metabolic conditions (hypoglycemia, hypoxia, electrolyte imbalances), primary intracranial disease, systemic disease affecting CNS, exogenous toxins, drug withdrawal.
As Evidenced by: Changes in level of consciousness (decreased GCS, lethargy, confusion, coma), neurological deficits (weakness, paralysis, sensory loss, speech impairment, visual disturbances), vital sign changes (hypotension, hypertension, bradycardia, tachycardia, irregular respirations), restlessness, agitation, seizures.
Expected Outcomes:
- Patient will demonstrate effective cerebral tissue perfusion as evidenced by stable vital signs, improved LOC, and absence of new neurological deficits.
- Patient will not experience worsening of neurological status or complications related to impaired cerebral perfusion.
- Patient will maintain GCS and LOC within acceptable limits.
Nursing Assessments:
- Assess vital signs and underlying cause: Monitor BP, HR, RR, O2 saturation closely for fluctuations indicative of hypoperfusion. Investigate potential causes through history and physical exam.
- Neurological status assessment: Frequent neurological checks including GCS, LOC, pupillary response, motor and sensory function, reflexes to detect changes early.
- Review medications and intoxicants: Assess for medications or substances that may contribute to hypotension or altered cerebral perfusion.
Nursing Interventions:
- Determine appropriate level of care: Collaborate with team to determine need for ICU or specialized neuro care.
- Administer fluids and electrolytes: Provide IV fluids as prescribed to optimize blood volume and hemodynamics. Correct electrolyte imbalances.
- Prepare for procedures: Prepare patient for potential procedures to improve cerebral perfusion (carotid endarterectomy, thrombectomy, hematoma evacuation) as indicated. Position patient to optimize cerebral blood flow (avoid Trendelenburg unless specifically ordered, maintain neutral head position). Monitor for signs of increased intracranial pressure (ICP).
Ineffective Coping
Nursing Diagnosis: Ineffective Coping
Related Factors: Cognitive dysfunction, psychological barriers (anxiety, fear, depression), inaccurate threat appraisal, loss of control, lack of support, situational crises, overwhelming stressors.
As Evidenced by: Agitation, anxiety, irritability, restlessness, emotional lability, anger, aggression, withdrawal, social isolation, difficulty organizing information, poor problem-solving skills, substance misuse, destructive behavior, altered concentration.
Expected Outcomes:
- Patient will remain free from agitated or destructive behavior.
- Patient will demonstrate improved psychological comfort and reduced anxiety and stress.
- Patient will verbalize increased sense of control and ability to cope with situation.
- Patient will utilize adaptive coping mechanisms.
Nursing Assessments:
- Assess contributing factors: Identify stressors, psychological factors, lack of support, cognitive impairments contributing to ineffective coping.
- Cognitive, emotional, mental state assessment: Evaluate patient’s anxiety level, mood, thought processes, and presence of delusions or hallucinations impacting coping abilities.
- Monitor physiological alterations: Address underlying medical conditions (sepsis, hypoglycemia, hypoxia) that may exacerbate AMS and ineffective coping.
Nursing Interventions:
- Relaxation techniques: Implement guided imagery, music therapy, deep breathing exercises to reduce anxiety and promote relaxation.
- Establish trust: Build a therapeutic nurse-patient relationship based on trust and empathy to reduce anxiety and enhance cooperation.
- Encourage participation in care: Involve patient in care planning as much as possible to increase sense of control and promote coping.
- Identify support persons: Connect patient with family, friends, social workers, or mental health counselors for emotional support and coping resources.
Risk for Injury
Nursing Diagnosis: Risk for Injury
Related Factors: Altered brain function, decreased LOC, impaired judgment, cognitive deficits, sensory or perceptual disturbances, weakness, impaired mobility, agitation, seizures, medication side effects, hypoxia, intoxication, unsafe environment.
As Evidenced by: (Risk diagnosis – no defining characteristics present, interventions focused on prevention).
Expected Outcomes:
- Patient will verbalize understanding of risk factors for injury.
- Patient will identify and implement safety measures to prevent injury.
- Patient will remain free from injury during hospitalization.
- Patient’s environment will be safe and free of hazards.
Nursing Assessments:
- Assess safety issues: Evaluate potential safety hazards in the environment and patient-specific risk factors for injury.
- Assess knowledge of safety precautions: Determine patient’s and caregiver’s understanding of safety measures and injury prevention strategies.
- Note individual risk factors: Consider age, cognitive status, mobility, sensory impairments, and medical conditions that increase injury risk.
- Ascertain caregiver expectations: Assess caregiver’s ability to provide a safe environment and support patient’s safety needs.
Nursing Interventions:
- Provide safe nursing care: Adhere to safety protocols, use proper body mechanics, maintain a safe environment.
- Inform patient about treatments and medications: Explain all procedures and medications to enhance cooperation and reduce anxiety.
- Reduce risk of injury: Implement fall precautions, bed alarms, side rails, clear pathways, assistive devices, appropriate supervision, seizure precautions if indicated.
- Prepare for safe home environment: Educate patient and caregivers on home safety measures, fall prevention, medication safety, emergency contact information, and equipment needs for safe discharge.
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.
