Altered mental status (AMS) is a critical clinical presentation that signifies a disturbance in a patient’s cognitive function and level of consciousness. It’s not a disease itself, but rather a symptom indicating an underlying medical or psychiatric condition that requires prompt assessment and intervention. Ranging from mild confusion to coma, AMS can manifest in diverse ways, impacting a patient’s awareness, attention, thinking, mood, and behavior. For nurses, recognizing and responding effectively to altered mental status is paramount for ensuring patient safety and facilitating appropriate medical management.
This article provides an in-depth exploration of altered mental status, specifically focusing on its relevance to nursing practice and the Altered Mental Status Nanda Diagnosis. We will delve into the definition, encompassing conditions, underlying causes, comprehensive nursing assessment, targeted interventions, and relevant nursing diagnoses. This guide aims to equip nurses with the knowledge and tools necessary to provide exceptional care for patients experiencing AMS.
Understanding Altered Mental Status
Altered mental status is an umbrella term that encompasses a spectrum of conditions affecting the brain’s ability to function properly. It reflects a deviation from a patient’s normal baseline cognitive and conscious state. This alteration can involve changes in:
- Consciousness: The patient’s awareness of self and the environment. Changes in consciousness are described along a continuum:
- Hyperalert: Excessively awake and reactive to stimuli.
- Confused: Unable to think clearly or quickly; disoriented to time, place, or person.
- Delirious: A state of acute confusion characterized by disorientation, hallucinations, delusions, and agitation.
- Somnolent: Drowsy or sleepy, easily aroused.
- Lethargic: Sluggish, apathetic, difficult to arouse.
- Obtunded: Decreased alertness, slowed responses to stimuli, requires repeated stimulation to maintain attention.
- Stuperous: Unresponsive except to vigorous and repeated stimuli.
- Comatose: Unarousable, unresponsive to stimuli.
- Cognition: Mental processes involved in knowing, learning, and understanding. Cognitive changes can manifest as:
- Disorientation: Confusion about time, place, or person.
- Forgetfulness: Memory impairment.
- Hallucinations: Sensory perceptions that are not real (visual, auditory, tactile, olfactory, gustatory).
- Delusions: Fixed false beliefs not based in reality.
- Nonsensical Speech: Incoherent or irrelevant verbal communication.
- Slowed Responses: Delayed reaction time to questions or commands.
These changes in consciousness and cognition can also be accompanied by alterations in mood, behavior, and motor function, further complicating the clinical picture. It’s essential to recognize that AMS can be either reversible or irreversible, depending on the underlying cause. Acute conditions like alcohol withdrawal or metabolic imbalances often lead to reversible AMS, while chronic neurodegenerative diseases such as Alzheimer’s dementia result in progressive and irreversible cognitive decline.
Broad Categories of Causes
The etiology of altered mental status is vast and varied. Understanding the broad categories of potential causes helps guide the diagnostic process. These categories include:
- Neurological Diseases: Conditions directly affecting the brain structure or function, such as:
- Stroke (ischemic or hemorrhagic)
- Traumatic brain injury (TBI)
- Seizures and postictal states
- Brain tumors
- Meningitis and encephalitis
- Neurodegenerative diseases (Alzheimer’s, Parkinson’s, Huntington’s)
- Infections: Systemic infections that can impact brain function:
- Sepsis
- Urinary tract infections (UTIs), particularly in older adults
- Pneumonia
- Toxic Causes: Exposure to substances that disrupt brain activity:
- Drug intoxication (alcohol, opioids, benzodiazepines, stimulants)
- Drug withdrawal (alcohol, benzodiazepines, opioids)
- Medication side effects and interactions (polypharmacy)
- Environmental toxins (carbon monoxide poisoning, heavy metals)
- Metabolic Disturbances: Imbalances in essential bodily functions:
- Hypoglycemia or hyperglycemia
- Electrolyte imbalances (sodium, calcium, potassium)
- Hypoxia (low oxygen levels)
- Hypercapnia (high carbon dioxide levels)
- Hepatic encephalopathy (liver failure)
- Uremic encephalopathy (kidney failure)
- Thyroid disorders
- Vitamin deficiencies (thiamine, B12)
- Systemic Illnesses: Conditions affecting multiple organ systems that can indirectly impact brain function:
- Shock (hypovolemic, cardiogenic, septic)
- Dehydration
- Hypothermia or hyperthermia
The Nursing Process and Altered Mental Status
Nurses play a crucial role in the early identification, assessment, and management of altered mental status. A systematic nursing process is essential to provide comprehensive and effective care. This process involves:
Nursing Assessment: Gathering Crucial Data
A thorough nursing assessment is the foundation of care for patients with AMS. It involves collecting subjective and objective data to understand the patient’s condition and guide interventions.
Review of Health History: Subjective Data Collection
Obtaining a detailed history is crucial, although it may be challenging due to the patient’s altered mental state. Information from family members, caregivers, or bystanders is often invaluable. Key areas to explore include:
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Changes in Mentation: Specifically inquire about the onset, duration, and nature of any changes in:
- Self-awareness: Does the patient recognize themselves and their situation?
- Mood: Any recent changes in emotional state (e.g., increased anxiety, depression, irritability, euphoria)?
- Expression: How is the patient communicating? Is their speech clear, coherent, and logical?
- Language: Are there any difficulties understanding or using language?
- Emotions: Are the patient’s emotional responses appropriate to the situation?
- Cognition: Any decline in memory, attention, problem-solving, or judgment?
- Motor Control: Changes in movement, coordination, or muscle strength?
- Behavior: Any unusual or concerning behaviors (e.g., agitation, withdrawal, aggression)?
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Identifying Potential Underlying Causes: Consider the broad categories of causes and explore specific possibilities:
- Neurological: History of stroke, seizures, head trauma, neurological disorders?
- Infectious: Fever, recent illness, symptoms of infection (cough, dysuria, wounds)?
- Toxic: Exposure to drugs, alcohol, toxins, new medications, medication changes?
- Metabolic: History of diabetes, liver disease, kidney disease, thyroid problems, electrolyte imbalances?
- Systemic: History of heart failure, respiratory disease, recent surgery, dehydration?
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Risk Factors for Altered Mental Status: Identify predisposing factors that increase the likelihood of AMS:
- Age over 65: Older adults are more vulnerable to AMS due to age-related physiological changes and increased prevalence of comorbidities.
- Anesthesia: Postoperative AMS is common, especially in older adults.
- ICU Stay: Critical illness and the ICU environment itself can contribute to delirium.
- Social Isolation: Lack of social interaction can exacerbate cognitive decline.
- Sleep Deprivation: Disrupted sleep patterns can impair cognitive function.
- Visual or Hearing Impairment: Sensory deficits can contribute to confusion, especially in unfamiliar environments.
- Pre-existing Cognitive Impairment: Dementia or other cognitive disorders increase susceptibility to AMS.
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Mental Illness History: Differentiate between AMS due to medical conditions and psychiatric disorders. While some mental illnesses can mimic AMS symptoms (e.g., psychosis, mood disorders), it’s crucial to rule out medical causes first.
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Age-Specific Considerations: Recognize that the common causes of AMS vary across different age groups:
- Infants and Young Children: Infections (meningitis, encephalitis), febrile seizures, trauma, metabolic disorders, ingestion of toxins.
- Young Adults: Substance abuse, trauma, infections, psychiatric conditions.
- Older Adults: Stroke, infections (UTIs, pneumonia), drug interactions, metabolic disturbances, dementia, environmental changes.
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Family/Caregiver Interview: Essential for obtaining baseline information, especially if the patient cannot provide a reliable history. Family members can provide insights into:
- Patient’s usual mental status and cognitive function.
- Onset and progression of symptoms.
- Potential triggers or contributing factors.
- Medication history and allergies.
- Social and environmental context.
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Medication History: A meticulous medication review is critical to identify potential drug-related causes of AMS:
- Prescription medications, over-the-counter drugs, herbal supplements, and nutritional supplements.
- New medications or recent changes in medication regimens.
- Common culprit drug classes: antibiotics, antidepressants, antipsychotics, benzodiazepines, opioids, sedatives, anticholinergics.
- Assess for potential drug interactions and cumulative anticholinergic burden.
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Substance Use History: Explore the possibility of alcohol or illicit drug use, as both intoxication and withdrawal can cause AMS. Be direct and non-judgmental when asking about substance use. Toxicology screening may be necessary if substance use is suspected or cannot be ruled out.
Physical Assessment: Objective Data Collection
The physical assessment provides objective data to evaluate the patient’s current condition and identify potential underlying causes.
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ABCs: Airway, Breathing, Circulation: Prioritize assessment of vital functions to ensure hemodynamic stability. AMS can be a sign of compromised ABCs, and immediate intervention may be required.
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Neurological Status: A comprehensive neurological assessment is fundamental:
- Level of Consciousness (LOC): Use descriptive terms (alert, confused, lethargic, obtunded, stuporous, comatose) and standardized scales like the Glasgow Coma Scale (GCS) to quantify LOC, especially in cases of suspected head injury or stroke.
- Orientation: Assess orientation to person, place, time, and situation (“What is your name?”, “Where are you?”, “What day is today?”, “Why are you here?”).
- Pupillary Response: Assess pupil size, shape, equality, and reactivity to light. Abnormalities can indicate neurological compromise.
- Speech: Evaluate speech clarity, fluency, content, and appropriateness. Note any slurring, aphasia (language impairment), or dysarthria (difficulty articulating speech).
- Sensation and Motor Function: Assess strength, sensation, reflexes, and coordination as appropriate to identify focal neurological deficits.
- Glasgow Coma Scale (GCS): Use GCS to objectively assess eye-opening, verbal response, and motor response in patients with decreased LOC.
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Appearance, Behavior, and Movement: Observe and document:
- Hygiene and Attire: Neglect of personal hygiene or inappropriate dress can be indicative of AMS or psychiatric conditions.
- Behavior: Note overall behavior, including agitation, restlessness, withdrawal, combativeness, or cooperation.
- Eye Contact and Facial Expression: Assess for appropriate eye contact and facial expressions that match the situation.
- Posture and Body Language: Note posture, gait, and any abnormal movements (tremors, rigidity, abnormal posturing).
- Psychomotor Activity: Observe for slowed (psychomotor retardation) or increased (psychomotor agitation) movements.
- Catatonia: State of immobility and unresponsiveness, sometimes seen in psychiatric conditions.
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Cognition Assessment: Use formal and informal methods to evaluate cognitive domains:
- Attention and Concentration: Assess the ability to focus and maintain attention (e.g., digit span, serial 7s).
- Memory: Test immediate, recent, and remote memory (e.g., recall a short list of words, ask about recent events, ask about historical facts).
- Language: Assess naming, repetition, comprehension, and reading/writing skills.
- Thought Content and Processes: Evaluate the flow of thought, presence of delusions, hallucinations, or disorganized thinking.
- Executive Function: Assess higher-level cognitive skills like planning, problem-solving, and judgment (e.g., clock drawing test, verbal fluency).
- Formal Cognitive Screening Tools:
- Mini-Mental State Examination (MMSE): A widely used brief cognitive assessment tool.
- Confusion Assessment Method (CAM): Specifically designed to diagnose delirium.
- 4 A’s Test (Alertness, Attention, Abbreviated Mental Test-4, Agitation): Another tool for delirium screening.
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Physical Signs of Trauma: Systematically examine for any evidence of physical injury, especially in patients with AMS of unknown origin:
- Head, scalp, and face for lacerations, contusions, swelling, or deformities.
- Extremities and back for fractures, dislocations, or soft tissue injuries.
- Signs of infection: redness, warmth, swelling, drainage.
- Ecchymosis (bruising) in unusual locations.
- Track marks from intravenous drug use.
- Transdermal patches that might indicate medication use or overdose.
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Vital Signs and ECG Monitoring: Continuous monitoring of vital signs is essential. Abnormalities can provide clues to the underlying cause of AMS:
- Hypothermia or Hyperthermia: Temperature extremes can directly affect mental status.
- Hypotension or Hypertension: Abnormal blood pressure can impair cerebral perfusion.
- Tachycardia or Bradycardia: Heart rate abnormalities may indicate cardiac or metabolic issues.
- Tachypnea or Bradypnea: Respiratory rate changes can reflect respiratory or metabolic disturbances.
- Hypoxemia: Low oxygen saturation can cause or worsen AMS.
- Electrocardiogram (ECG): Obtain ECG to assess for cardiac arrhythmias or ischemia, especially if cardiac etiology is suspected.
Diagnostic Procedures: Confirming Suspicions
Diagnostic tests are crucial to identify the underlying cause of altered mental status and guide treatment.
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Rapid Glucose Level: Immediately check blood glucose, as hypo- or hyperglycemia are common and readily reversible causes of AMS.
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Laboratory Tests: Collect blood and urine specimens for various lab tests based on clinical suspicion:
- Serum Electrolytes: Sodium, potassium, calcium, magnesium, and phosphate imbalances.
- Complete Blood Count (CBC): Evaluate for infection, anemia.
- Serum Ammonia: Assess for hepatic encephalopathy.
- Blood Gas Analysis (ABG/VBG): Evaluate oxygenation, ventilation, and acid-base balance.
- Blood Cultures: If infection is suspected.
- Liver Function Tests (LFTs): Assess for liver dysfunction.
- Kidney Function Tests (BUN, Creatinine): Assess for renal impairment.
- Urinalysis: Evaluate for UTI, dehydration, ketones.
- Thyroid Function Tests (TSH, Free T4): Assess for thyroid disorders.
- Serum Vitamin B12 Levels: Rule out B12 deficiency.
- Syphilis Serology (RPR/VDRL): Consider in patients with new-onset dementia or unexplained neurological symptoms.
- Toxicology Screening (Urine and/or Blood): Detect presence of drugs or alcohol.
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Imaging and Specialized Tests: Consider advanced diagnostics based on clinical presentation:
- Head CT Scan: Indicated if stroke, head trauma, intracranial hemorrhage, or mass lesion is suspected.
- Chest X-ray: Rule out pneumonia or other respiratory infections.
- Lumbar Puncture (Spinal Tap): Perform if meningitis or encephalitis is suspected (after ruling out contraindications like increased intracranial pressure).
- Electroencephalogram (EEG): Rule out seizures (non-convulsive status epilepticus) or diagnose encephalopathy (metabolic, infectious).
Nursing Interventions: Restoring and Supporting Function
Nursing interventions for altered mental status are multifaceted and focus on treating the underlying cause, managing symptoms, ensuring patient safety, and providing supportive care.
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Treat the Underlying Cause: The primary intervention is to identify and treat the root cause of AMS. This may involve:
- IV Fluids for Shock/Dehydration: Restore intravascular volume and improve cerebral perfusion.
- Antibiotics for Sepsis/Infection: Combat infection and prevent further systemic compromise.
- Glucose for Hypoglycemia: Rapidly correct low blood sugar.
- Neurosurgical Intervention for Brain Trauma/Hemorrhage: Address structural brain injuries.
- Intubation and Oxygen Therapy for Hypoxia/Respiratory Failure: Support oxygenation and ventilation.
- Medications for Drug Overdose/Withdrawal: Administer antidotes (e.g., naloxone for opioid overdose) or manage withdrawal symptoms.
- Electrolyte Replacement: Correct electrolyte imbalances.
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Reduce Environmental Stimulation: Create a calm and therapeutic environment, especially for patients with delirium:
- Dim lights to reduce visual overstimulation.
- Minimize noise levels (alarms, conversations, television).
- Provide a quiet and private room if possible.
- Reassure the patient and orient them to their surroundings frequently.
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Sedation (Pharmacological Management of Agitation): Consider medications if non-pharmacological measures are insufficient to manage agitation and ensure safety:
- Antipsychotics (Haloperidol, Quetiapine): Often used for delirium-related agitation.
- Benzodiazepines (Lorazepam): Primarily reserved for alcohol withdrawal or seizures, as they can worsen delirium in other contexts. Use cautiously in older adults.
- Avoid Restraints if Possible: Restraints should be a last resort due to potential physical and psychological harm. If necessary, use the least restrictive method, monitor closely, and follow institutional policies.
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Ensure Patient Safety: AMS significantly increases the risk of falls and injury:
- Fall Precautions: Implement standard fall precautions (bed alarm, side rails, clear pathways, non-slip footwear).
- Close Supervision: Consider 1:1 supervision or frequent checks, especially for patients who are confused, agitated, or at high risk for falls.
- Safe Environment: Remove potential hazards from the patient’s environment.
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Administer Medications as Ordered: Once the underlying cause is identified, specific medications may be prescribed:
- Donepezil, Rivastigmine, Galantamine, Memantine for Dementia: Cognitive enhancers for neurodegenerative dementias.
- Naloxone for Narcotic Toxicity: Opioid antagonist to reverse overdose.
- Antiseizure Medications (Phenytoin, Levetiracetam): Manage seizures and prevent recurrence.
- Antipsychotics for Psychotic Disorders: Treat underlying psychiatric conditions.
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Delirium Prevention Strategies: Implement proactive measures to reduce the risk of delirium, especially in hospitalized patients at risk:
- Adequate Hydration and Nutrition: Maintain fluid and electrolyte balance and provide appropriate nutritional support.
- Minimize Invasive Devices: Limit use of indwelling catheters and IV lines when clinically appropriate.
- Manage Constipation and Urinary Retention: Address these common discomforts that can contribute to delirium.
- Promote Regular Sleep-Wake Cycles: Encourage daytime activity and minimize nighttime disruptions.
- Provide Stimulating Activities During the Day: Engage patients in meaningful activities appropriate to their cognitive level.
- Ensure Sensory Aids are Utilized: Make sure patients have and use their eyeglasses and hearing aids.
- Effective Pain Management: Address pain promptly and appropriately.
- Orientation to Time and Place: Regularly reorient the patient and provide visual cues (calendar, clock).
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Reduce Polypharmacy Risk: Especially important in older adults, who are more susceptible to adverse drug events:
- Medication Reconciliation: Thoroughly review all medications (prescription, OTC, supplements) to identify potential duplicates, interactions, or inappropriate dosages.
- Discuss Discontinuation of Unnecessary Medications with the Provider: Simplify medication regimens whenever possible.
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Referral to Appropriate Disciplines: Collaborate with other healthcare professionals to provide holistic care:
- Neurologists: For neurological conditions.
- Pharmacists: For medication management and reconciliation.
- Mental Health Professionals (Psychiatrists, Psychologists): For psychiatric disorders or co-existing mental health needs.
- Substance Abuse Counselors: For substance use disorders.
- Social Workers and Case Managers: For discharge planning, resource coordination, and psychosocial support.
Nursing Care Plans and NANDA Diagnoses for Altered Mental Status
Nursing care plans are structured frameworks that guide nursing care based on identified patient needs and nursing diagnoses. For patients with altered mental status, several NANDA-I nursing diagnoses are commonly applicable. These diagnoses help prioritize interventions and establish expected outcomes.
Here are some key NANDA diagnoses relevant to altered mental status, expanded from the original article:
1. Acute Confusion (NANDA-I: 00128)
Definition: Abrupt onset of a cluster of global transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, or sleep-wake cycle.
Related Factors (Risk Factors):
- Alteration in brain function (e.g., neurological disorder, head trauma, stroke)
- Alteration in sleep-wake cycle
- Alcohol or drug abuse/withdrawal
- Electrolyte imbalances
- Hypoxia
- Infection (systemic or CNS)
- Metabolic imbalances (hypoglycemia, hypernatremia, uremia)
- Delirium
- Sensory overload or deprivation
- Age > 65 years
- Dementia
Defining Characteristics (Signs and Symptoms):
- Objective:
- Decreased level of consciousness (fluctuating or reduced)
- Disorientation to time, place, person, or situation
- Impaired attention and concentration
- Impaired memory (recent and/or remote)
- Restlessness, agitation, or combativeness
- Sleep-wake cycle disturbance (insomnia, daytime drowsiness, reversed sleep patterns)
- Psychomotor activity changes (increased, decreased, or fluctuating)
- Subjective:
- Hallucinations (visual, auditory, tactile)
- Delusions (false beliefs)
- Anxiety, fear, or paranoia
- Illusions (misinterpretations of real stimuli)
- Incoherent or illogical speech
- Difficulty following directions
Expected Outcomes:
- Patient will regain orientation to person, place, time, and situation.
- Patient will demonstrate improved cognitive function and attention span.
- Patient will exhibit a more regular sleep-wake cycle.
- Patient will remain safe and free from injury related to confusion.
- Patient will identify and address modifiable risk factors to prevent recurrence of acute confusion.
Nursing Interventions:
- Comprehensive Assessment:
- Detailed mental status examination (MMSE, CAM, 4AT).
- Thorough history (patient, family, caregivers) to identify potential causes and risk factors.
- Review medication history and substance use.
- Assess for underlying medical conditions (infection, metabolic disorders, neurological issues).
- Monitor vital signs and neurological status frequently.
- Review laboratory results and diagnostic imaging.
- Orientation and Reassurance:
- Orient patient frequently to person, place, time, and situation.
- Use clear and simple language; speak slowly and calmly.
- Provide visual cues (clock, calendar, familiar objects).
- Reassure patient and family; explain procedures and treatments.
- Avoid challenging illogical thinking; focus on presenting reality gently.
- Environmental Management:
- Provide a safe and quiet environment with reduced stimulation.
- Ensure adequate lighting, especially at night.
- Minimize noise and clutter.
- Maintain a consistent routine and environment.
- Ensure assistive devices (glasses, hearing aids) are used.
- Promote Sleep and Rest:
- Establish a regular sleep schedule.
- Limit daytime napping.
- Promote relaxation techniques (music therapy, guided imagery).
- Ensure a comfortable and dark sleep environment.
- Address Underlying Causes:
- Collaborate with the medical team to treat identified underlying medical conditions.
- Administer medications as prescribed (antibiotics, glucose, electrolyte replacement, etc.).
- Manage pain effectively.
- Address substance withdrawal if present.
- Safety Measures:
- Implement fall precautions.
- Provide close supervision as needed.
- Remove potential hazards from the environment.
- Consider bed alarms or chair alarms.
- Education and Support:
- Educate patient and caregivers about the causes, symptoms, and management of acute confusion.
- Provide strategies for preventing recurrence.
- Connect caregivers with support resources.
2. Impaired Verbal Communication (NANDA-I: 00051)
Definition: Decreased, delayed, or absent ability to receive, process, transmit, and/or use symbols in spoken, written, and/or sign language.
Related Factors (Risk Factors):
- Cognitive dysfunction (delirium, dementia, cognitive impairment)
- Central nervous system impairment (stroke, head injury, neurological disorders)
- Psychotic disorder
- Physiological conditions (respiratory distress, tracheostomy, intubation)
- Language barrier
- Sensory deficits (hearing impairment, visual impairment)
- Cultural differences
Defining Characteristics (Signs and Symptoms):
- Verbal:
- Difficulty expressing thoughts verbally (expressive aphasia)
- Difficulty comprehending spoken or written language (receptive aphasia)
- Slurred speech (dysarthria)
- Hoarseness or abnormal voice quality (dysphonia)
- Absence of speech (mutism)
- Inappropriate verbalization
- Stuttering or stammering
- Difficulty naming objects (anomia)
- Nonverbal:
- Difficulty in comprehending nonverbal cues
- Incongruent facial expressions or body language
- Disorientation
- Aphasia (global, expressive, receptive)
- Anarthria (inability to articulate speech due to motor dysfunction)
- Dysarthria (difficulty speaking due to impaired motor control of speech muscles)
- Dysphonia (voice impairment)
Expected Outcomes:
- Patient will utilize alternative methods of communication effectively during episodes of AMS.
- Patient will demonstrate improved ability to express needs and understand communication from others.
- Patient will return to their baseline level of communication ability (if reversible AMS).
- Patient will experience reduced frustration and anxiety related to communication difficulties.
Nursing Interventions:
- Communication Assessment:
- Assess baseline communication abilities (interview patient, family, caregivers).
- Identify specific communication deficits (expressive, receptive, motor speech).
- Determine barriers to communication (cognitive, sensory, language, physical).
- Assess for conditions affecting speech (stroke, neuromuscular disorders).
- Facilitate Communication:
- Establish a therapeutic relationship and create a calm, patient-centered communication environment.
- Use nonverbal communication effectively (eye contact, touch, gestures).
- Speak slowly, clearly, and directly to the patient.
- Use simple language and short sentences.
- Repeat and rephrase information as needed.
- Allow ample time for the patient to respond.
- Minimize distractions and noise.
- Use visual aids (pictures, diagrams, written words).
- Utilize communication boards, picture cards, or electronic devices as needed.
- Involve family members or caregivers to assist with communication.
- Consider a translator if language barrier is present.
- Education and Support:
- Educate patient and caregivers about communication strategies and alternative methods.
- Provide resources and support groups for communication disorders.
- Encourage patience and understanding from caregivers.
- Refer to speech therapy or communication specialists as needed.
3. Ineffective Cerebral Tissue Perfusion (NANDA-I: 00200)
Definition: Decrease in blood circulation to the brain tissue that may compromise tissue oxygenation.
Related Factors (Risk Factors):
- Decreased cerebral blood flow (hypoperfusion)
- Hypotension or hypertension
- Hypovolemia (dehydration, hemorrhage)
- Cardiovascular disorders (heart failure, arrhythmias)
- Cerebrovascular disorders (stroke, TIA)
- Increased intracranial pressure (ICP)
- Metabolic conditions (hypoglycemia, hypoxia, electrolyte imbalances)
- Primary intracranial disease (brain tumor, hematoma)
- Systemic diseases affecting the CNS (sepsis)
- Exogenous toxins (drugs, alcohol)
- Drug withdrawal
Defining Characteristics (Signs and Symptoms):
- Neurological:
- Decreased Glasgow Coma Scale (GCS) score
- Decreased level of consciousness (LOC)
- Changes in pupillary response (sluggish, unequal, fixed, dilated)
- Weakness or paralysis (hemiparesis, hemiplegia)
- Sensory deficits
- Seizures
- Changes in reflexes (hyperreflexia, hyporeflexia, absent reflexes)
- Positive Babinski reflex
- Vital Signs:
- Alterations in pulse rate (tachycardia, bradycardia)
- Alterations in blood pressure (hypotension, hypertension)
- Irregular respirations (Cheyne-Stokes, ataxic)
- Other:
- Behavioral changes (irritability, restlessness, confusion)
- Restlessness
- Agitation
- Headache
- Dizziness, vertigo
Expected Outcomes:
- Patient will demonstrate effective cerebral tissue perfusion as evidenced by GCS and LOC within normal limits for patient’s baseline.
- Patient will maintain stable vital signs within acceptable parameters.
- Patient will not experience worsening neurological deficits or complications (coma, herniation).
- Patient will receive timely and appropriate medical interventions to improve cerebral perfusion.
Nursing Interventions:
- Neurological Monitoring:
- Frequent neurological assessments (LOC, GCS, pupillary response, motor function, sensation, reflexes).
- Monitor vital signs closely and frequently (blood pressure, heart rate, respiratory rate, oxygen saturation).
- Assess for signs and symptoms of increased ICP (headache, vomiting, altered LOC, pupillary changes).
- Continuously monitor ECG for arrhythmias.
- Optimize Cerebral Perfusion:
- Maintain adequate blood pressure to support cerebral blood flow (follow physician orders for target BP).
- Ensure adequate oxygenation (administer supplemental oxygen as needed).
- Position patient to promote venous drainage from the head (elevate head of bed 30 degrees unless contraindicated).
- Avoid activities that increase ICP (straining, coughing, Valsalva maneuver).
- Administer prescribed medications to improve cerebral perfusion (e.g., vasopressors, antihypertensives, antiplatelets, anticoagulants).
- Administer IV fluids and electrolytes as prescribed to maintain hydration and electrolyte balance.
- Manage Underlying Causes:
- Collaborate with the medical team to identify and treat the underlying cause of impaired cerebral perfusion (stroke, hemorrhage, shock, metabolic disorders).
- Prepare patient for diagnostic procedures (CT scan, MRI, angiography).
- Prepare patient for potential surgical interventions (carotid endarterectomy, craniotomy).
- Safety Measures:
- Implement seizure precautions if at risk.
- Implement fall precautions.
- Maintain a safe environment to prevent injury.
- Education and Support:
- Educate patient and family about the importance of cerebral perfusion and potential complications.
- Explain diagnostic and treatment procedures.
- Provide emotional support to patient and family.
4. Ineffective Coping (NANDA-I: 00069)
Definition: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.
Related Factors (Risk Factors):
- Cognitive dysfunction (AMS, delirium, dementia)
- Psychological barriers (anxiety, depression, fear)
- Inaccurate threat appraisal
- Loss of control
- Situational crises
- Lack of support systems
- Unmet needs
- Pain
- Substance misuse
- Developmental stage or age
Defining Characteristics (Signs and Symptoms):
- Behavioral:
- Altered concentration
- Destructive behavior towards self or others
- Substance misuse
- Risky behaviors
- Poor hygiene or self-care
- Avoidance behaviors
- Withdrawal from social situations
- Restlessness, agitation
- Irritability, aggression
- Difficulty organizing information
- Poor problem-solving skills
- Emotional:
- Anxiety, fear, panic
- Depression, sadness, hopelessness
- Feelings of being overwhelmed
- Difficulty expressing emotions
- Low self-esteem
- Emotional lability
- Verbal:
- Change in usual communication patterns
- Negative self-talk
- Verbalization of inability to cope or ask for help
- Expressing feelings of being overwhelmed
Expected Outcomes:
- Patient will demonstrate improved coping mechanisms as evidenced by reduced agitation and anxiety.
- Patient will verbalize feelings of increased psychological comfort and sense of control.
- Patient will participate in their plan of care to the extent possible.
- Patient will utilize available support systems effectively.
- Patient will remain free from self-harm or harm to others.
Nursing Interventions:
- Coping Assessment:
- Assess patient’s cognitive, emotional, and mental state.
- Identify factors contributing to ineffective coping (AMS, psychological barriers, lack of support, stressors).
- Observe behavioral manifestations of ineffective coping (agitation, withdrawal, substance misuse).
- Assess patient’s perception of the stressor and available coping resources.
- Monitor for physiological alterations that may contribute to ineffective coping (sepsis, metabolic imbalances).
- Promote Adaptive Coping:
- Establish a trusting and therapeutic nurse-patient relationship.
- Create a calm and supportive environment.
- Encourage verbalization of feelings and concerns.
- Active listening and empathy.
- Validate patient’s feelings and experiences.
- Assist patient in identifying strengths and coping resources.
- Teach relaxation techniques (deep breathing, guided imagery, music therapy).
- Encourage participation in activities that promote a sense of control and accomplishment.
- Help patient break down problems into smaller, manageable steps.
- Provide realistic reassurance and hope.
- Enhance Support Systems:
- Identify and involve support persons (family, friends, caregivers).
- Facilitate communication between patient and support system.
- Connect patient with social workers, counselors, or support groups as needed.
- Manage Underlying Factors:
- Address underlying medical conditions contributing to AMS and ineffective coping.
- Collaborate with mental health professionals to manage psychiatric symptoms.
- Refer to substance abuse counselors if substance misuse is a factor.
- Safety Measures:
- Monitor for self-harm or aggressive behaviors.
- Implement safety precautions as needed.
- Ensure a safe and secure environment.
5. Risk for Injury (NANDA-I: 00035)
Definition: Vulnerable to physical damage due to environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.
Risk Factors (Related Factors):
- Internal:
- Altered mental status (confusion, delirium, dementia)
- Impaired mobility (weakness, paralysis, gait instability)
- Sensory deficits (visual, hearing, tactile)
- Age extremes (very young, older adults)
- History of falls
- Seizures
- Medication side effects (sedation, dizziness)
- Substance intoxication or withdrawal
- Underlying medical conditions (osteoporosis, cardiovascular disease)
- External:
- Unsafe environment (clutter, poor lighting, slippery floors)
- Lack of safety devices (bed rails, grab bars)
- Improper use of assistive devices
- Restraints
- Healthcare procedures (invasive procedures, medication errors)
- Chemical hazards (toxic substances, medications)
- Physical hazards (sharp objects, electrical hazards)
Defining Characteristics:
- 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 verbalize understanding of risk factors that contribute to injury.
- Patient will identify and implement behaviors and measures to reduce risk factors and protect themselves from injury.
- Patient will remain free from injury during hospitalization or care period.
- Patient’s environment will be free from hazards.
- Caregivers will demonstrate understanding of safety precautions and injury prevention strategies.
Nursing Interventions:
- Risk Assessment:
- Comprehensive assessment of individual risk factors for injury (AMS, mobility, sensory deficits, medications, medical conditions).
- Environmental safety assessment (home, healthcare setting).
- Assess patient’s and caregiver’s knowledge of safety precautions.
- Identify specific potential hazards in the patient’s environment.
- Use fall risk assessment tools (e.g., Morse Fall Scale).
- Environmental Safety Management:
- Ensure a safe and clutter-free environment.
- Provide adequate lighting, especially at night.
- Remove or secure potential hazards (loose rugs, electrical cords).
- Install safety devices (bed rails, grab bars, handrails).
- Keep frequently used items within reach.
- Ensure proper functioning of assistive devices (walkers, wheelchairs).
- Use bed alarms or chair alarms as indicated.
- Implement medication safety practices.
- Patient and Caregiver Education:
- Educate patient and caregivers about risk factors for injury and preventive measures.
- Teach safe ambulation and transfer techniques.
- Instruct on proper use of assistive devices.
- Explain medication safety guidelines.
- Provide written materials and resources on injury prevention.
- Assess understanding of safety precautions and provide reinforcement as needed.
- Safe Nursing Care Practices:
- Adhere to principles of safe patient handling and movement.
- Communicate clearly with the patient about procedures and treatments.
- Maintain vigilant monitoring and supervision, especially for patients at high risk.
- Implement fall precautions consistently.
- Use restraints only as a last resort and according to policy, with frequent monitoring and release.
- Advocate for a culture of safety within the healthcare setting.
- Home Safety Planning:
- Assess home environment for safety hazards before discharge.
- Collaborate with social workers or case managers for home safety evaluations and modifications.
- Provide referrals to community resources for home safety assistance.
Conclusion
Altered mental status is a complex clinical challenge that demands astute nursing assessment, timely intervention, and comprehensive care planning. By understanding the diverse causes, recognizing the subtle and overt signs and symptoms, and applying the nursing process systematically, nurses can significantly impact patient outcomes. The altered mental status NANDA diagnosis framework provides a valuable structure for identifying patient needs, prioritizing interventions, and evaluating the effectiveness of care. By focusing on patient safety, treating underlying causes, and providing holistic support, nurses play an indispensable role in the management of altered mental status and improving the well-being of affected individuals.
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.
- Herdman, T.H., & Kamitsuru, S. (Eds.). (2018). NANDA International, Inc. nursing diagnoses: Definitions & classification 2018-2020. (11th ed.). Thieme Publishers.
