Altered Mental Status Nursing Diagnosis: A Comprehensive Guide

Nurses are essential in the care of patients experiencing altered mental status, ensuring that individualized nursing care plans are implemented. These plans encompass mental status assessments, safety measures, behavioral management, and effective communication with interdisciplinary teams and families. This nursing diagnosis guide aims to facilitate the development of robust care plans for patients with altered mental status.

Understanding Altered Mental Status

Altered mental status, frequently used in nursing, describes a range of cognitive impairments indicating disruptions in cerebral metabolism. Acute altered mental status, often referred to as delirium or acute confusional state, can affect individuals of all ages and develop rapidly, from hours to days. Cognitive impairments in older adults can manifest in various ways. Notably, difficulties with instrumental Activities of Daily Living (ADLs) have been linked to dementia and may serve as early indicators of cognitive decline. A variety of factors can precipitate altered mental status or disorientation, including infections, fluid and electrolyte imbalances, and cerebrovascular accidents (Haddad et al., 2019).

Risk factors for delirium and confusional states are broadly categorized into those increasing baseline vulnerability and those precipitating the disturbance. Baseline vulnerabilities include pre-existing brain diseases like dementia, stroke, or Parkinson’s disease. Precipitating factors often involve infections, sedatives, and immobility. Typically, altered mental status arises from an underlying medical condition, substance intoxication, or medication side effects.

Diagnosing delirium or confusion promptly can be challenging due to the variability in clinical presentations and symptoms. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the primary symptom of delirium is impaired awareness and attention, frequently accompanied by cognitive disturbances (Zoremba & Coburn, 2019).

It is crucial to note that individuals with dementia can also experience acute confusion (delirium). Thorough assessment is vital to ascertain pre-hospital functional levels and collaborate with families to identify any deterioration.

Nurse assessing patient's mental status

Alt text: A nurse carefully assesses a patient’s cognitive function, focusing on alertness and orientation, to evaluate for altered mental status.

Etiology of Altered Mental Status

The exact pathophysiology of acute altered mental status or delirium remains incompletely understood, likely involving multiple interacting etiologies. Various theories attempt to explain the potential causes, suggesting that each case of delirium may involve a complex interplay of these factors (Echeverría, 2022). Common contributing factors include:

Age over 60 years
Pre-existing Dementia
Alcohol or drug abuse
History of Delirium
Hepatic encephalopathy
Hypercapnia
Neurotransmitter imbalances (acetylcholine, dopamine, serotonin, GABA)
Post-operative states following surgical procedures
Adverse effects of certain medications, particularly anticholinergics

Recognizing Signs and Symptoms

A comprehensive physical examination, including a detailed mental status assessment, is crucial. Vital signs monitoring, encompassing temperature, pulse, blood pressure, and respiration, is mandatory. Healthcare providers rely heavily on nursing notes and health records to detect fluctuating symptom patterns, making meticulous documentation of observed signs and symptoms paramount (Alagiakrishnan & Xiong, 2019).

Key signs and symptoms of altered mental status include:

Diminished motivation to initiate or complete goal-directed behaviors
Fluctuations in psychomotor activity (tremors, abnormal body movements)
Perceptual distortions
Cognitive variability
Increased agitation or restlessness
Fluctuating levels of consciousness
Disrupted sleep-wake cycles
Hallucinations (visual, auditory), and illusions
Impaired awareness and attention
Disorientation
Dysphasia and dysarthria

Goals and Expected Outcomes

Nursing goals for patients with acute altered mental status are centered on identifying and treating the underlying cause, ensuring patient safety and preventing injury, optimizing cognitive function and functional status, and educating both patients and their families about effective management strategies.

Desired outcomes include:

Reduction in delirium episodes.
Restoration of normal reality orientation and consciousness level.
Verbalized understanding of causative factors, when identified.
Adoption of lifestyle or behavioral modifications to minimize recurrence.
Demonstration of appropriate motor behavior.
Active participation in activities of daily living (ADLs).

Nursing Diagnosis for Altered Mental Status

Following a thorough nursing assessment, a nursing diagnosis of acute confusion is formulated, reflecting the nurse’s clinical judgment and the patient’s specific presentation. While nursing diagnoses provide a structured framework for care organization, their direct application can vary in clinical practice. The nurse’s expertise is paramount in tailoring the care plan to meet individual patient needs and priorities.

Example nursing diagnosis statements for altered mental status:

Acute Confusion related to [specify related factor, e.g., infection, metabolic imbalance, medication side effects] as evidenced by [specify defining characteristics, e.g., disorientation to time and place, fluctuating levels of consciousness, restlessness].
Risk for Injury related to altered mental status as evidenced by disorientation, impaired judgment, and potential for falls.

Nursing Assessment and Rationales

Nursing assessment for altered mental status involves a systematic approach to gather data regarding cognitive function, medical history, medication usage, and potential contributing factors. This comprehensive assessment is essential for identifying the root cause of confusion and formulating a targeted care plan.

1. Identify predisposing factors such as substance abuse, seizure history, recent electroconvulsive therapy (ECT), fever/pain episodes, acute infections (especially urinary tract infections in older adults), exposure to toxins, traumatic events, and environmental changes (unfamiliar noises, excessive visitors).
Rationale: Establishing baseline information is crucial for developing an individualized care plan. Delirium or acute confusion can be triggered by a wide range of medical conditions, intoxications, or medications, often with multiple contributing factors. Identifying each potential cause is essential for effective management. Postictal states and unfamiliar environments are also recognized triggers (Alagiakrishnan & Xiong, 2019).

2. Perform a comprehensive mental status examination using validated assessment tools.
Rationale: Tools like the Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are reliable for delirium screening in intensive care settings. CAM-ICU is particularly noted for its reliability in ICU delirium detection. For general medical units, the Nursing Delirium Screening Scale (Nu-DESC) and the 3D-CAM are validated instruments (Zoremba & Coburn, 2019).

3. Continuously and systematically assess the patient’s behavior and cognition throughout the day and night.
Rationale: Delirium is characterized by acute fluctuations in mental status. Therefore, knowing the patient’s baseline cognitive function is crucial for identifying delirium. Disturbances in the sleep-wake cycle, including insomnia, daytime drowsiness, and disturbing dreams or nightmares, are common. Patients may have difficulty recalling their reason for hospitalization or events during the delirious period (Alagiakrishnan & Xiong, 2019).

4. Evaluate and report potential physiological changes (e.g., sepsis, hypoglycemia, hypotension, infection, temperature changes, fluid and electrolyte imbalances, medications with cognitive or psychotropic side effects).
Rationale: These physiological changes can contribute to confusion and require prompt correction. Differentiating delirium or acute confusion from other neurocognitive disorders and ensuring it is not solely due to the pathophysiological effects of a physical disease is vital for accurate diagnosis (Zoremba & Coburn, 2019).

5. Closely monitor laboratory results, including hypoxemia, electrolyte imbalances, BUN, creatinine, ammonia levels, serum glucose, signs of infection, and drug levels (peak/trough as appropriate).
Rationale: Identifying and treating underlying causes is paramount once acute confusion is recognized. Complete blood counts can aid in diagnosing infection and anemia. Glucose levels are assessed to rule out hypoglycemia, diabetic ketoacidosis, and hyperosmolar nonketotic states. Serum markers like calcium-binding protein S-100 B may also be elevated in delirium (Alagiakrishnan & Xiong, 2019).

6. Review current medications and drug use history, paying particular attention to antianxiety agents, barbiturates, lithium, methyldopa, disulfiram, cocaine, alcohol, amphetamines, hallucinogens, and opiates, and their usage patterns.
Rationale: Medications are a significant modifiable risk factor for delirium, especially anticholinergics, antipsychotics, and hypnosedatives. Drug-induced delirium is frequently observed in medical settings, particularly in hospitals. Older adults are at higher risk of anticholinergic toxicity, and frail older adults and those with dementia are more susceptible to medication-induced delirium (Alagiakrishnan & Xiong, 2019).

7. Assess the extent of impairment in orientation, attention span, ability to follow directions, communication skills, and response appropriateness.
Rationale: This evaluation determines the severity of cognitive impairment. Patients may exhibit difficulty maintaining attention, disorientation, short-term memory deficits, poor insight, and impaired judgment. Attention deficits can be assessed using bedside tests requiring sustained attention to novel tasks, like reciting months backward or serial subtraction (Alagiakrishnan & Xiong, 2019).

8. Document the occurrence and timing of agitation, hallucinations, and violent behaviors, and assess for sundown syndrome.
Rationale: Sundown syndrome, characterized by increased restlessness, agitation, and confusion in the late afternoon, is associated with confusion. It may indicate sleep disorders, hunger, thirst, or unmet toileting needs. Dimming light and the perceived need to change activities or “go home” can trigger sundowning, as can evening darkness which may amplify feelings of insecurity (Goyer, 2022).

9. Differentiate between dementia, depression, and delirium.
Rationale: Confusion can be present in depression, dementia, and delirium. However, in older adults, confusion is often attributed to dementia like Alzheimer’s disease, leading to assumptions that interventions are futile. The Geriatric Depression Scale is a useful tool for screening depression in older adults to guide further assessment.

10. Evaluate the patient’s level of consciousness and administer a three-step task.
Rationale: A three-step task, part of the Mini-Mental State Examination, provides a baseline for assessing confusion. This complex task is a general indicator of brain function and can also detect delirium due to its attentional demands.

11. Assess pain using a 0-10 rating scale.
Rationale: Acute confusion can be a manifestation of pain. If a patient cannot use a scale, observe for behavioral cues like grimacing, clenched fists, or restlessness. Effective pain management is crucial in the overall treatment plan (Zoremba & Coburn, 2019).

Nursing Interventions and Rationales

Nursing interventions for managing altered mental status and delirium are aimed at treating the underlying cause, promoting patient safety, optimizing cognitive function, and educating patients and families about prevention and management strategies.

1. Facilitate treatment of underlying medical conditions (e.g., drug intoxication, infections, hypoxemia, metabolic imbalances, nutritional deficiencies, pain).
Rationale: Addressing the root cause is essential to maximize function and prevent further decline. While the cause of delirium may remain unidentified in some cases, supportive and pharmacological management are crucial (Alagiakrishnan & Xiong, 2019).

2. Orient the patient to their surroundings, staff, and planned activities regularly. Present reality clearly and concisely.
Rationale: Enhanced orientation promotes patient safety. Hospitalization can be disruptive, leading to disorientation. Reorientation techniques like calendars, clocks, and family photos can be beneficial (Zoremba & Coburn, 2019; Alagiakrishnan & Xiong, 2019).

3. Modulate sensory input by providing a calm environment and minimizing extraneous noise and stimuli.
Rationale: Confused patients can misinterpret excessive visual and auditory stimulation. A stable, quiet, and well-lit environment is optimal. Studies indicate that reducing nighttime noise, such as through earplugs in the ICU, can decrease delirium risk and improve sleep perception (Alagiakrishnan & Xiong, 2019).

4. Encourage family and caregiver involvement in reorientation and providing familiar input (e.g., current events, family news).
Rationale: Family presence can enhance patient comfort and understanding. Family and staff should explain procedures, reinforce orientation, and offer reassurance. Support from familiar individuals is crucial (Alagiakrishnan & Xiong, 2019).

5. Provide simple, step-by-step directions and allow ample time for the patient to respond, communicate, and make decisions.
Rationale: Clear communication reduces anxiety in unfamiliar environments. While correcting misunderstandings is appropriate, listening attentively helps nurses understand the depth of confusion and the patient’s context (Haddad et al., 2019).

6. Avoid challenging illogical thinking to prevent defensive reactions.
Rationale: Challenging confused thinking can be perceived as threatening. Respectful and kind treatment is essential. Corrections should be gentle and reassuring, providing a sense of security (Haddad et al., 2019).

7. Ensure safety measures such as supervision, side rails, seizure precautions, call bell within reach, clear pathways, and appropriate ambulation aids.
Rationale: These measures prevent injury and promote safety. Simple environmental adjustments, such as color-coded toilet doors and picture-based ward signs, can minimize confusion and prevent falls (Agency for Clinical Innovation Aged Health Network, 2015).

8. Avoid physical restraints, as they may exacerbate agitation and increase complications.
Rationale: Restraints can worsen agitation and increase the risk of injury. Constant observation or sitters may be more effective and cost-efficient than restraints for severely delirious patients (Alagiakrishnan & Xiong, 2019).

9. Maintain fluid and electrolyte balance, adequate nutrition, normal body temperature, oxygenation, blood glucose, and blood pressure.
Rationale: These measures address underlying physiological causes of delirium. Careful administration of fluids and nutrition is necessary due to potential patient unwillingness or inability to maintain intake. Patients with suspected alcohol toxicity or withdrawal should receive multivitamins, particularly thiamine (Alagiakrishnan & Xiong, 2019).

10. Communicate the patient’s status, cognitive function, and behavioral manifestations to all healthcare providers during handovers.
Rationale: Consistent communication ensures continuity of care and prevents misinterpretations of fluctuating cognition as patient preference. Effective information exchange is vital to prevent medication errors, readmissions, and delays in diagnosis and treatment (Agency for Clinical Innovation Aged Health Network, 2015).

11. Plan care to promote a regular sleep-wake cycle.
Rationale: Minimizing sleep disturbances is crucial, as nocturnal exacerbations can worsen delirium. Eye masks and earplugs can reduce noise and light exposure, improving sleep quality. Hospital routines often disrupt sleep, necessitating careful management (Zoremba & Coburn, 2019).

12. Encourage reduced caffeine intake.
Rationale: Decreasing caffeine can reduce agitation and restlessness, as caffeine can disrupt sleep patterns and quality, potentially increasing dementia risk (Jerath, 2020).

13. Encourage visits from family and friends and place familiar objects in the patient’s environment.
Rationale: Familiar environments and social support provide orienting cues, balance sensory stimulation, and enhance safety. Creating a warm, friendly atmosphere and involving family members can improve the patient experience (Agency for Clinical Innovation Aged Health Network, 2015).

14. Identify yourself by name at each interaction and address the patient by their preferred name.
Rationale: Respectful communication techniques are essential for confused patients. Person-centered care, focusing on listening and engaging with patients as equals, can improve health outcomes and patient satisfaction (Agency for Clinical Innovation Aged Health Network, 2015).

15. Offer reassurance and utilize therapeutic communication frequently.
Rationale: Reassurance and communication build trust, promote orientation, and reduce anxiety. Delirium can be distressing for patients and families, necessitating counseling and education post-resolution (Agency for Clinical Innovation Aged Health Network, 2015).

16. Promptly identify, assess, and treat pain.
Rationale: Inadequate pain management can cause delirium. Pain assessment, monitoring, and appropriate relief are essential. While opiates can induce confusion, they should be used judiciously with close monitoring (Agency for Clinical Innovation Aged Health Network, 2015).

17. Provide continuity of care with consistent caregivers and minimize room changes. Ensure accurate information transfer during care transitions.
Rationale: Continuity of care reduces disorientation. Clear communication is vital during care transfers, especially for follow-up care, potential patient deterioration, or complex needs (Agency for Clinical Innovation Aged Health Network, 2015).

18. Support families in developing coping strategies.
Rationale: Families need guidance to support patient functioning and quality of life. Success-based activities like music, hobbies, and games can reduce boredom and enhance well-being. Diversional therapies like rummage boxes can also be beneficial (Agency for Clinical Innovation Aged Health Network, 2015).

19. Educate families to recognize early signs of confusion and seek timely medical help.
Rationale: Early intervention can prevent long-term complications. Family history and caregiver input are crucial, especially as delirious patients may be unable to provide accurate information. Delirium should be suspected with any new or acute decline in behavior, cognition, or function, particularly in older, demented, or depressed individuals (Alagiakrishnan & Xiong, 2019).

20. Ensure patients use vision and hearing aids appropriately.
Rationale: Correcting sensory impairments is a fundamental step. Clean and functional glasses and hearing aids enable patients to better perceive their environment and communicate effectively (Zoremba & Coburn, 2019).

21. Facilitate physical and occupational therapy.
Rationale: Early physical and occupational therapy reduces delirium rates and improves the likelihood of returning to independent living. Daytime physiotherapy can also improve nighttime sleep through physical fatigue (Zoremba & Coburn, 2019).

22. Avoid polypharmacy and over-the-counter medications.
Rationale: Multiple medications, especially in older adults, increase delirium risk due to drug interactions affecting neurotransmitter systems. Regular medication review and discontinuation of unnecessary drugs are crucial for delirium prevention (Zoremba & Coburn, 2019).

23. Administer benzodiazepines for delirium related to drug or alcohol withdrawal, as prescribed.
Rationale: Benzodiazepines are preferred for delirium due to seizures or withdrawal from alcohol or sedative-hypnotics. They may also be used for delirium from hallucinogens, cocaine, or stimulant toxicity. Caution is needed due to respiratory depression risk, especially in older adults (Alagiakrishnan & Xiong, 2019).

24. Administer antipsychotics as indicated for psychotic symptoms of delirium.
Rationale: Antipsychotics are the medication of choice for psychotic symptoms in delirium. Low-dose haloperidol is often used to minimize overdose risk and potential worsening of delirium (Zoremba & Coburn, 2019).

25. Consider melatonin supplements as indicated.
Rationale: Melatonin and its receptor agonists may aid in delirium prevention and management by regulating sleep-wake cycles, which are often disrupted in delirium (Alagiakrishnan & Xiong, 2019).

26. Provide comprehensive education and support to patients and families regarding confusion, dementia, and delirium.
Rationale: Education empowers patients and families to manage confusion effectively. Providing information on support groups and respite services is also beneficial. Cultural sensitivity and language accessibility are important in delivering education (Agency for Clinical Innovation Aged Health Network, 2015).

27. Establish a regular toileting schedule, offering a urinal or bedpan every two hours during waking hours and every four hours at night.
Rationale: Scheduled toileting addresses potential incontinence related to confusion and memory deficits. Keeping toileting aids within easy reach is crucial as confused patients may not use call lights effectively.

28. If the patient displays hostile behavior, avoid arguing and leave the room if violence escalates.
Rationale: Avoiding arguments prevents escalation of anger in confused patients. Leaving the room and re-approaching later as if it is a new encounter can be effective due to short-term memory deficits in acute confusion.

29. Re-evaluate the ongoing need for certain therapies that may become irritating stimuli.
Rationale: Therapies like feeding tubes or indwelling catheters may become sources of irritation for confused patients. Regularly assess and discontinue these therapies when appropriate to minimize discomfort and agitation.

Recommended Resources

For further information and expanded resources on nursing diagnoses and care plans, consider these recommended books:

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (Amazon Link)
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition) (Amazon Link)

Alt text: Book cover image for Nursing Care Plans – Nursing Diagnosis & Intervention 10th Edition, a comprehensive guide for nursing students and professionals.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales (Amazon Link)
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (Amazon Link)

Alt text: Book cover image for Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care, a resource for detailed nursing diagnosis information and care planning.

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (Amazon Link)

References and Sources

Alagiakrishnan, K., & Xiong, G. L. (2019). Delirium in the older patient. Canadian Journal of Psychiatry, 64(2), 64–77.
Agency for Clinical Innovation Aged Health Network. (2015). Delirium prevention, detection and management in hospitalised older people.
Echeverría, G. C. (2022). Pathophysiology of delirium: an overview of current concepts. Journal of Clinical and Experimental Investigations, 10(2).
Goyer, P. (2022, November 28). What is sundowning? Verywell Mind.
Haddad, E., Arabi, Y., & Almalik, M. (2019). Approach to the acutely confused elderly patient in the emergency department. Saudi Journal of Emergency Medicine, 1(1), 2.
Jerath, R. (2020). Caffeine and sleep disorders. Annals of Neurosciences, 27(1), 47–59.
Zoremba, M., & Coburn, M. (2019). Delirium in the intensive care unit. Deutsches Ärzteblatt International, 116(10), 167.