Altered mental status (AMS) is a significant clinical presentation indicating a disruption in brain function. It’s not a disease itself, but rather a symptom reflecting a wide spectrum of conditions, ranging from mild disorientation to a complete loss of consciousness, such as a coma. In essence, AMS signifies a change from a patient’s baseline mental state, encompassing both their level of consciousness and cognitive abilities. Recognizing and effectively managing altered mental status is crucial in healthcare settings, particularly in automotive repair scenarios where unexpected medical events can occur. For nurses and healthcare professionals, understanding the nuances of AMS, establishing accurate nursing diagnoses, and implementing comprehensive care plans are paramount to ensuring patient safety and optimal outcomes.
Understanding Altered Mental Status
Mental status is broadly composed of two key elements: consciousness and cognition. Consciousness refers to the patient’s awareness of self and the environment, often described as their level of alertness and responsiveness. Cognition, on the other hand, encompasses a range of higher-level brain functions, including memory, attention, language, and executive functions like problem-solving and decision-making. A patient experiencing altered mental status may exhibit abnormalities in either or both of these components.
The causes of altered mental status are incredibly diverse, reflecting the complexity of the brain and its susceptibility to various internal and external factors. However, these causes can generally be categorized into the following groups, which are vital for developing an effective “Altered Mental Status Nursing Diagnosis Care Plan”:
- Primary Intracranial Disease: Conditions directly affecting the brain itself, such as:
- Stroke (ischemic or hemorrhagic)
- Traumatic brain injury (TBI)
- Brain tumors
- Central nervous system infections (meningitis, encephalitis)
- Seizures
- Systemic Illness Affecting the Central Nervous System: Conditions originating outside the brain that impact its function, including:
- Systemic infections (sepsis, pneumonia, urinary tract infections in the elderly)
- Metabolic disorders (hypoglycemia, hyperglycemia, electrolyte imbalances like hyponatremia or hypernatremia, liver failure, kidney failure, thyroid disorders)
- Hypoxia (due to respiratory or cardiac issues)
- Exogenous Toxins: Exposure to harmful substances, such as:
- Environmental toxins (carbon monoxide poisoning)
- Heavy metal poisoning
- Drug-Related Causes:
- Drug overdose (prescription medications, illicit drugs)
- Drug withdrawal (alcohol, benzodiazepines, opioids)
It’s also important to consider age-specific causes of AMS. In newborns and young children, trauma, metabolic abnormalities, and toxic ingestions are the most frequent culprits. Young adults often experience AMS due to toxic substance exposure or trauma. Elderly individuals are more susceptible to AMS secondary to stroke, infections, polypharmacy (drug-drug interactions), and changes in their living environments that might lead to falls or injuries.
Prompt identification of altered mental status is paramount. It serves as an early warning sign, signaling the need for immediate assessment and intervention to mitigate potential morbidity and mortality.
Nursing Process for Altered Mental Status
The nursing process is a systematic approach to patient care, and it’s particularly crucial in managing patients with altered mental status. The primary goals are to identify early indicators of AMS, determine the underlying cause, and implement appropriate and timely care. Nurses play a pivotal role in each step of this process, from initial assessment to ongoing monitoring and intervention.
Assessment: A thorough assessment is the cornerstone of managing AMS. This includes:
- History Taking: Gathering information about the patient’s baseline mental status, the onset and progression of symptoms, past medical history, current medications (including over-the-counter and herbal supplements), allergies, and potential exposure to toxins or drugs. Collateral history from family members or caregivers is often invaluable.
- Physical Examination: A complete physical examination is necessary to identify potential systemic causes of AMS. This includes:
- Vital Signs: Monitoring for abnormalities in blood pressure, heart rate, respiratory rate, and temperature, which can indicate shock, infection, or metabolic disturbances.
- Neurological Examination: A detailed neurological assessment is crucial. This involves evaluating:
- Level of Consciousness (LOC): Using standardized tools like the Glasgow Coma Scale (GCS) or the Alert, Verbal, Pain, Unresponsive (AVPU) scale to quantify LOC.
- Orientation: Assessing orientation to person, place, time, and situation.
- Pupillary Response: Checking pupil size, equality, and reactivity to light.
- Motor Function: Evaluating strength and movement in all extremities.
- Sensory Function: Testing sensation to touch, pain, and temperature.
- Reflexes: Assessing deep tendon reflexes and pathological reflexes.
- Systemic Examination: Assessing other body systems for signs of infection, trauma, or metabolic derangements.
Nursing Diagnosis: Based on the assessment findings, nurses formulate nursing diagnoses. For altered mental status, common nursing diagnoses include:
- Ineffective Cerebral Tissue Perfusion
- Acute Confusion
- Risk for Injury
These diagnoses guide the development of individualized care plans.
Planning and Implementation: Nursing care plans for altered mental status prioritize symptomatic management and addressing the underlying cause. Symptomatic management may include:
- Volume Resuscitation: For patients in shock due to hypoperfusion.
- Antibiotics: For infections like sepsis or meningitis.
- Glucose Administration: For hypoglycemia.
- Airway Management and Intubation: To prevent deterioration and ensure adequate oxygenation in patients with severely depressed LOC.
Evaluation: Continuous monitoring and evaluation are essential to assess the effectiveness of interventions and make necessary adjustments to the care plan. Neurological status, vital signs, and response to treatment are closely monitored.
Safety is a paramount concern in patients with AMS. Impaired consciousness and cognition increase the risk of falls, injuries, and aspiration. Nurses implement safety measures such as:
- Bed alarms
- Side rail use (with appropriate assessment and justification)
- Fall precautions
- Close monitoring
- Safe environment (removing hazards)
Nursing Care Plans for Altered Mental Status: Examples
Once nursing diagnoses are identified, nursing care plans are developed to prioritize assessments and interventions. These plans outline both short-term and long-term goals of care. Here are examples of nursing care plans for common nursing diagnoses associated with altered mental status:
Ineffective Cerebral Tissue Perfusion
Ineffective cerebral tissue perfusion in the context of altered mental status refers to a reduction in blood flow to the brain, which can compromise neurological function and contribute to AMS. This can arise from various underlying conditions.
Nursing Diagnosis: Ineffective Tissue Perfusion (Cerebral)
Related to:
- Decreased cerebral blood flow
- Metabolic conditions (hypoglycemia, hypoxia, electrolyte imbalances)
- Primary intracranial disease (stroke, increased intracranial pressure)
- Systemic disease affecting the central nervous system (CNS infections)
- Exogenous toxins
- Drug withdrawal
As evidenced by:
- Decreased Glasgow Coma Scale (GCS) score
- Decreased level of consciousness (LOC)
- Diminished reflexes
- Alterations in pulse rate (bradycardia or tachycardia)
- Alterations in blood pressure (hypotension or hypertension)
- Increased intracranial pressure (if monitored)
- Decreased cerebral perfusion pressure (if monitored)
- Behavioral changes (irritability, confusion, lethargy)
Expected Outcomes:
- Patient will demonstrate effective cerebral tissue perfusion as evidenced by improvement or stabilization in GCS and LOC within established limits for their baseline.
- Patient will not experience worsening of AMS, such as progression to coma, and will not require intubation solely due to cerebral hypoperfusion.
Assessment:
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Assess vital signs and identify potential underlying causes. Persistent fluctuations in vital signs can directly impact cerebral blood flow. Hypotension can reduce perfusion pressure, while hypertension can be a sign of increased intracranial pressure or systemic illness. The nurse should monitor vital signs frequently and correlate them with the patient’s clinical picture. A thorough history and physical exam are crucial to identify the root cause of potential perfusion issues, such as sepsis, dehydration, or cardiac arrhythmias.
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Conduct a comprehensive neurological assessment. A detailed neurological assessment, including serial GCS and LOC evaluations, is essential to monitor trends and detect subtle changes. Neurological checks should be performed at regular intervals, as ordered and as clinically indicated, to facilitate early recognition of neurological deterioration or improvement. Pay close attention to trends in GCS scores and individual components (eye-opening, verbal response, motor response).
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Review medication history and assess for intoxicant use. Certain medications, particularly antihypertensives, sedatives, and narcotics, can contribute to hypotension or CNS depression, impacting cerebral perfusion. Conversely, withdrawal from substances like alcohol or benzodiazepines can also cause neurological instability. A thorough medication review and inquiry about alcohol and substance use are vital to identify iatrogenic or substance-related causes of altered perfusion.
Interventions:
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Determine the appropriate level of care in collaboration with the interdisciplinary team. Patients with AMS related to compromised cerebral perfusion often require intensive monitoring and specialized interventions best delivered in a Neuro-ICU or similar setting. Collaboration with physicians, advanced practice providers, and other specialists ensures that the patient receives the necessary level of care and expertise.
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Administer intravenous fluids and electrolytes as prescribed. Fluid resuscitation is a cornerstone of improving cerebral tissue perfusion, particularly in cases of hypovolemia or shock. Isotonic crystalloids like normal saline or lactated Ringer’s are often used to expand intravascular volume and optimize hemodynamics. Electrolyte imbalances can also exacerbate neurological dysfunction; therefore, electrolyte replacement should be guided by laboratory values and clinical assessment.
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Prepare the client for potential surgical procedures as indicated. In some cases, surgical intervention may be necessary to restore cerebral perfusion. For example, patients with carotid artery stenosis may require carotid endarterectomy to improve blood flow to the brain. Evacuation of cerebral hematomas or lesions causing mass effect can also relieve pressure and improve perfusion. The nurse plays a crucial role in pre-operative preparation, patient education, and post-operative monitoring to optimize outcomes.
Acute Confusion
Acute confusion, often referred to as delirium, is a state of disturbed consciousness and altered cognition that develops acutely and tends to fluctuate. It’s a common manifestation of altered mental status and is typically reversible when the underlying cause is addressed.
Nursing Diagnosis: Acute Confusion
Related to:
- Alteration in brain function (neurotransmitter imbalances, neuronal dysfunction)
- Alteration in sleep-wake cycles
- Alcohol or drug abuse and withdrawal
- Hypoxia
- Metabolic imbalances (electrolyte abnormalities, hypoglycemia, hypercalcemia)
- Delirium (underlying medical conditions, medications)
- Disrupted sensory perception (sensory overload or deprivation)
Evidenced by:
- Hallucinations (visual, auditory, tactile)
- Restlessness and agitation
- Decreased level of consciousness (fluctuating)
- Impaired cognition (disorientation, memory deficits, attention deficits)
- Disrupted psychomotor functioning (ranging from hypoactive to hyperactive)
- Inability to perform purposeful behavior
- Inappropriate verbal responses or incoherent speech
Expected Outcomes:
- Patient will regain orientation to person, place, and time as confusion resolves.
- Patient and/or caregivers will identify lifestyle modifications and strategies to prevent recurrence of acute confusion, where applicable.
Assessment:
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Determine possible causative factors for acute confusion. Acute confusion is a symptom with a broad differential diagnosis. A systematic approach to identifying potential causes is essential. This includes considering:
- Hypoxia: Assess oxygen saturation, respiratory status, and consider conditions like pneumonia or COPD exacerbation.
- Metabolic Derangements: Review electrolytes (sodium, potassium, calcium, magnesium), glucose, renal function, and liver function tests.
- Endocrine Disorders: Consider thyroid abnormalities, adrenal insufficiency.
- Neurological Conditions: Evaluate for stroke, seizures, meningitis, encephalitis.
- Toxins: Consider medication side effects, drug interactions, alcohol or drug withdrawal, environmental exposures.
- Infections: Assess for fever, signs of localized infection (UTI, pneumonia), and consider systemic infections like sepsis.
- Nutritional Deficiencies: Evaluate nutritional status, particularly thiamine deficiency in alcohol abuse.
- Acute Psychiatric Illnesses: While less common as a primary cause of acute confusion in a medical setting, consider if psychiatric conditions are exacerbating the situation.
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Conduct a thorough mental status assessment. A comprehensive mental status examination (MSE) helps differentiate acute confusion from other conditions like dementia, depression, or primary psychiatric disorders. Assess:
- Appearance and Behavior: Observe posture, dress, hygiene, psychomotor activity.
- Speech: Note rate, volume, fluency, and content of speech.
- Mood and Affect: Assess the patient’s prevailing emotional state and the outward expression of emotion.
- Thought Process and Content: Evaluate for disorganized thinking, delusions, hallucinations, and suicidal ideation.
- Cognition: Assess orientation, attention span, memory (immediate, recent, remote), language, and executive functions.
- Perception: Inquire about hallucinations or illusions.
- Insight and Judgment: Assess the patient’s awareness of their condition and their ability to make sound decisions.
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Monitor relevant laboratory values. If underlying medical causes are suspected, review laboratory results, including:
- Complete Blood Count (CBC): To assess for infection (elevated white blood cell count) or anemia.
- Arterial Blood Gases (ABGs): To evaluate oxygenation and acid-base balance.
- Electrolyte Panel: To detect imbalances in sodium, potassium, calcium, magnesium.
- Liver Function Tests (LFTs): To assess liver function and rule out hepatic encephalopathy.
- Renal Function Tests (BUN, Creatinine): To evaluate kidney function and rule out uremic encephalopathy.
- Urinalysis: To screen for urinary tract infection.
- Toxicology Screen: If substance abuse or overdose is suspected.
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Assess current medication use and history of substance abuse. Polypharmacy and certain medication classes (anticholinergics, benzodiazepines, opioids, corticosteroids) are strongly associated with delirium. Alcohol and illicit drug use, as well as withdrawal syndromes, are also major risk factors. Obtain a detailed medication history, including dosages and timing, and inquire sensitively about alcohol and substance use patterns.
Interventions:
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Provide constant orientation to person, place, and time as needed. Frequent reorientation helps ground the patient in reality and reduces confusion. Use clear, simple language and repeat information as necessary. Address the patient by name, state the current date and time, and describe the surroundings. Avoid challenging illogical thinking directly, as this can increase agitation. Instead, gently and consistently present reality.
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Implement strategies to prevent sundowning. Sundowning, or worsening confusion in the evening, is common in acute confusion. Strategies to mitigate sundowning include:
- Maximize daytime light exposure: Open curtains, encourage outdoor time if feasible.
- Establish a consistent daily routine: Regular mealtimes, activity periods, and bedtime.
- Limit daytime napping: Encourage activity and engagement during the day to promote nighttime sleep.
- Provide familiar objects: Personal items from home can provide comfort and reduce disorientation.
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Educate caregivers on monitoring and when to seek help at home. If the patient is being discharged home while still experiencing some confusion, caregiver education is crucial. Caregivers should be instructed to monitor for:
- Worsening confusion or agitation.
- Changes in behavior or new symptoms.
- Difficulty with medication management.
- Safety concerns at home.
- Caregivers should be provided with clear instructions on when and how to contact the healthcare provider for concerns.
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Provide a stable and calm environment to minimize overstimulation. A quiet, calm environment reduces sensory overload and promotes rest, which can help reduce confusion and agitation. Minimize noise, excessive lighting, and frequent interruptions. Provide a safe and predictable environment to decrease anxiety and promote a sense of security.
Risk for Injury
Risk for injury is a significant nursing diagnosis for patients with altered mental status because impaired consciousness, cognition, and perception increase vulnerability to harm.
Nursing Diagnosis: Risk for Injury
Related to:
- Alteration in brain function (impaired judgment, slowed reaction time)
- Impaired sleep cycle (fatigue, reduced alertness)
- Hypoxia (leading to dizziness, weakness, impaired coordination)
- Intoxication (impaired balance, judgment, coordination)
Note: Risk diagnoses are not evidenced by signs and symptoms because the problem has not yet occurred. Interventions are focused on prevention.
Expected Outcomes:
- Patient will verbalize understanding of risk factors that increase the potential for injury.
- Patient will identify behaviors and measures to reduce risk factors and protect themselves from injury.
- Patient will remain free from injury during the episode of altered mental status.
Assessment:
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Assess potential safety issues in the environment and related to the patient’s condition. A thorough safety assessment is essential to proactively identify and mitigate hazards. This includes evaluating:
- Environmental Hazards: Clutter, spills, unsecured cords, improper lighting, slippery floors.
- Patient-Specific Risks: Impaired mobility, weakness, sensory deficits, cognitive limitations, medication side effects.
- Risk of Falls: History of falls, gait instability, balance problems.
- Risk of Aspiration: Impaired swallowing, decreased cough reflex, reduced gag reflex.
- Risk of Self-Harm or Injury to Others: Agitation, impulsivity, confusion, disorientation.
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Assess the client’s and caregiver’s knowledge of safety precautions. Evaluate the patient’s (if possible) and caregiver’s understanding of safety risks and preventive measures. Assess their:
- Awareness of safety needs related to AMS.
- Knowledge of injury prevention strategies.
- Motivation to implement safety measures.
- Identify any knowledge deficits that need to be addressed through education.
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Note individual risk factors that may increase vulnerability to injury. Individual patient characteristics significantly influence injury risk. Consider:
- Age: Elderly individuals are at higher risk for falls and injuries.
- Developmental Stage: Children and adolescents may engage in riskier behaviors.
- Cognitive Status: The degree of cognitive impairment directly impacts safety awareness and judgment.
- Functional Limitations: Mobility impairments, sensory deficits, and medical conditions increase risk.
- Decision-Making Capacity: Reduced capacity to make safe choices increases vulnerability.
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Ascertain caregiver expectations and abilities regarding patient safety. If the patient has caregivers, assess their:
- Understanding of safety risks and precautions.
- Ability to provide a safe environment.
- Capacity to monitor the patient and implement safety measures.
- Identify any unrealistic expectations or caregiver burden that may compromise patient safety.
Interventions:
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Provide safe nursing care and promote a culture of safety. Nurses are role models for safe practice. Implement evidence-based safety protocols and advocate for a safety-conscious environment. This includes:
- Adhering to facility safety policies and procedures.
- Using proper body mechanics and lifting techniques.
- Maintaining a clean and organized work environment.
- Reporting safety hazards and incidents promptly.
- Promoting open communication about safety concerns within the healthcare team.
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Inform the client (and caregivers) about all treatments and medications, emphasizing safety implications. Clear communication builds trust and empowers patients and caregivers to participate actively in safety measures. Explain:
- Purpose and potential side effects of medications.
- Rationale for treatments and procedures.
- Safety precautions related to medications and treatments.
- Encourage questions and address concerns openly and honestly.
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Implement measures to reduce the risk of injury specific to the patient’s needs. Tailor safety interventions to the individual patient’s risk factors and limitations. Examples include:
- Bed Alarm: Use bed alarms to alert staff if the patient attempts to get out of bed unassisted.
- Call Bell within Reach: Ensure the call bell is easily accessible so the patient can summon help when needed.
- Assistive Devices: Provide walkers, canes, wheelchairs, or other assistive devices as appropriate.
- Environmental Modifications: Remove clutter, secure rugs, improve lighting, install grab bars in bathrooms.
- Close Supervision: Increase frequency of rounding and observation, especially for confused or agitated patients.
- Fall Prevention Strategies: Implement fall precautions protocols, such as non-slip footwear, gait belts, and bed in a low position.
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Prepare the client and caregivers for a safe home environment prior to discharge. Discharge planning must include a thorough assessment of the home environment and education on home safety. Discuss:
- Equipment Needs: Recommend necessary assistive devices or home modifications.
- Fall Prevention in the Home: Provide specific strategies to reduce fall risks at home (e.g., removing throw rugs, improving lighting, installing grab bars).
- How to Call for Help: Ensure the patient and caregivers know how to contact emergency services and healthcare providers.
- Medication Safety: Review medication schedules, storage, and potential side effects.
- Emergency Plan: Develop a plan for managing worsening confusion or other medical emergencies at home.
References
- 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/
