Altered mental status (AMS), or a change in mental status, is a critical clinical presentation that signifies a disruption in brain function. It’s not a disease itself, but rather a symptom of an underlying medical condition, ranging from mild confusion to severe coma. Nurses play a pivotal role in the early recognition, assessment, and management of patients experiencing changes in their mental status. Understanding the nuances of “Change In Mental Status Nursing Diagnosis” is crucial for effective patient care and improved outcomes. This guide provides a comprehensive overview of AMS, focusing on the nursing process, relevant nursing diagnoses, and evidence-based interventions.
Understanding Altered Mental Status
Mental status encompasses both consciousness and cognition. Consciousness refers to the patient’s awareness of self and environment, while cognition involves mental processes such as memory, thinking, and reasoning. A change in mental status indicates an alteration in one or both of these components. These changes can manifest in various ways, affecting mood, behavior, and motor function.
The spectrum of altered mental status is broad, encompassing:
- Hyperalertness: An exaggerated state of alertness and responsiveness.
- Confusion: Disorientation to time, place, or person; difficulty thinking clearly.
- Delirium: An acute, fluctuating confusional state characterized by inattention, disorganized thinking, and altered level of consciousness.
- Somnolence: Excessive drowsiness or sleepiness.
- Lethargy: Severe drowsiness with slowed responses to stimuli.
- Obtundation: Decreased alertness and responsiveness; requires repeated stimuli to maintain consciousness.
- Stupor: Unresponsiveness except to vigorous and repeated stimuli.
- Coma: Complete unresponsiveness to stimuli, including pain.
Cognitive and mood changes associated with AMS can include:
- Disorientation: Lack of awareness of time, place, and person.
- Forgetfulness: Memory impairment.
- Hallucinations: Sensory perceptions without real external stimuli.
- Delusions: False beliefs that are firmly held despite contradictory evidence.
- Nonsensical Speech: Speech that is incoherent or illogical.
- Slowed Responses: Delayed reactions to questions or commands.
- Agitation: Restlessness and irritability.
- Anxiety: Excessive worry and nervousness.
- Depression: Persistent sadness and loss of interest.
- Euphoria: Exaggerated feeling of well-being.
It’s important to note that AMS can be reversible or irreversible, depending on the underlying cause. Conditions like Alzheimer’s disease represent chronic, irreversible causes, while alcohol withdrawal is an example of a reversible cause.
The causes of altered mental status are diverse but generally fall into these categories:
- Neurological Diseases: Stroke, seizures, meningitis, encephalitis, brain tumors, head trauma.
- Infections: Sepsis, urinary tract infections, pneumonia.
- Toxicities: Drug overdose, alcohol intoxication, environmental toxins.
- Metabolic Imbalances: Hypoglycemia, hyperglycemia, electrolyte disturbances, liver failure, kidney failure, thyroid disorders.
- Systemic Illnesses: Hypoxia, hyperthermia, hypothermia, shock.
The Nursing Process for Altered Mental Status
Prompt recognition and intervention for altered mental status are crucial to minimize patient morbidity and mortality. The nursing process provides a systematic approach to care, encompassing assessment, diagnosis, planning, implementation, and evaluation.
Nursing Assessment
A thorough nursing assessment is the cornerstone of managing altered mental status. It involves gathering subjective and objective data to identify the nature and potential causes of the change.
Review of Health History
1. Elicit History of Changes in Mentation: Begin by directly asking the patient (if possible) and family or caregivers about the onset, duration, and nature of any changes in mental functioning. Explore changes in:
- Self-awareness
- Mood
- Expression
- Language
- Emotions
- Cognition
- Motor control
- Behavior
2. Determine Potential Underlying Causes: Consider the broad categories of causes (neurological, infectious, toxic, metabolic, systemic) to guide history taking.
3. Identify Risk Factors: Assess for predisposing factors that increase the likelihood of AMS:
- Age over 65 years
- Anesthesia
- Intensive Care Unit (ICU) stay
- Social isolation
- Sleep deprivation
- Visual or hearing impairment
4. Evaluate for Mental Illness: Differentiate AMS from primary psychiatric disorders. While conditions like bipolar disorder or schizophrenia can present with altered behavior and cognition, they are distinct from AMS caused by medical conditions. Consider if the patient has a history of:
- Bipolar disorders (euphoria, depression)
- Schizophrenia (hallucinations, delusions)
5. Consider Patient Age: Age is a significant factor in determining likely causes of AMS:
- Infants and Young Children: Infections, trauma, metabolic disorders, toxin ingestion.
- Young Adults: Toxic substances, trauma.
- Older Adults: Stroke, infections, medication interactions, changes in living environment.
6. Interview Family and Caregivers: Obtain crucial information from those familiar with the patient’s baseline mental status. Family, caregivers, bystanders, or teachers can provide valuable insights, especially when the patient is unable to communicate effectively.
7. Medication History Review: A detailed medication history is critical to rule out drug-induced AMS. Inquire about:
- Prescription medications
- Over-the-counter medications
- Herbal supplements
- Nutritional supplements
- New medications
- Changes in dosages
Pay particular attention to medications commonly associated with AMS, such as:
- Antibiotics
- Antidepressants
- Antipsychotics
- Benzodiazepines
- Opioids
- Sedatives
8. Assess Alcohol and Substance Use: Explore the possibility of substance intoxication or withdrawal as a cause of AMS. Obtain a history of alcohol and illicit drug use. Toxicology reports may be necessary if the patient cannot provide reliable information.
Physical Assessment
1. Assess the ABCs (Airway, Breathing, Circulation): Prioritize assessment of vital functions to ensure hemodynamic stability. Address any immediate threats to airway, breathing, or circulation.
2. Neurological Status Evaluation: Perform a comprehensive neurological assessment:
- Level of Consciousness: Use standardized scales like the Glasgow Coma Scale (GCS) if head injury is suspected. Describe the patient’s level of alertness and responsiveness using descriptive terms (alert, confused, lethargic, etc.).
- Orientation: Assess orientation to person, place, time, and situation.
- Pupillary Response: Evaluate pupil size, equality, and reaction to light.
- Speech: Assess speech clarity, fluency, and content.
- Sensation: Test sensory function as appropriate.
- Reflexes: Assess reflexes as indicated.
- Coordination: Evaluate motor coordination.
3. Appearance, Behavior, and Movement Assessment: Observe and document:
- Hygiene and grooming
- Dress and attire
- Eye contact
- Facial expressions
- Posture
- Cooperation with assessment
- Motor activity (agitation, slowed movements, catatonia)
These observations can provide clues to underlying mental health conditions or substance use.
4. Cognitive Assessment: Evaluate cognitive function using formal or informal methods:
- Attention: Assess the ability to focus and concentrate.
- Memory: Test immediate, recent, and remote memory.
- Language: Evaluate language comprehension and expression.
- Thought Content and Processes: Assess for logical thinking, delusions, hallucinations, or disorganized thoughts.
- Ability to Follow Directions: Test the ability to understand and execute simple commands.
Standardized cognitive assessment tools include:
- Mini-Mental State Examination (MMSE)
- Confusion Assessment Method (CAM)
- 4 ‘A’s Test (Alertness, Attention, Abbreviated Mental Test-4, Agitation)
5. Trauma Assessment: Inspect for physical signs of trauma:
- Head, extremities, and back examination
- Ecchymosis (bruising)
- Lacerations
- Deformities
- Signs of infection
- Track marks (drug injection sites)
- Transdermal patches
6. Vital Signs and ECG Monitoring: Continuously monitor vital signs. Abnormalities may indicate underlying conditions such as:
- Hypothermia
- Hypoxemia
- Hypertensive crisis
Obtain an electrocardiogram (ECG) as needed to assess cardiac function.
Diagnostic Procedures
1. Rapid Glucose Level Check: Immediately check blood glucose levels. Hypoglycemia and hyperglycemia are common and readily reversible causes of AMS.
2. Specimen Collection for Laboratory Tests: Collect blood and urine samples for indicated tests:
- Serum electrolytes (sodium, potassium, calcium, magnesium)
- Complete blood count (CBC)
- Serum ammonia levels
- Arterial blood gas (ABG) analysis
- Blood cultures (if infection suspected)
- Liver function tests (LFTs)
- Kidney function tests (BUN, creatinine)
- Urinalysis
- Thyroid function tests (TSH, T4)
- Serum B12 levels
- Syphilis serology (RPR or VDRL)
- Toxicology screen (urine and/or blood)
3. Imaging and Other Tests: Consider further investigations based on clinical suspicion:
- Head CT Scan: Suspected stroke, head trauma, intracranial hemorrhage.
- Chest X-ray: Rule out pneumonia.
- Lumbar Puncture (Spinal Tap): Suspected meningitis.
- Electroencephalogram (EEG): Rule out seizures, diagnose encephalopathy or encephalitis.
Nursing Interventions
Nursing interventions for altered mental status are directed at treating the underlying cause, managing symptoms, and ensuring patient safety.
1. Treat the Underlying Cause: Address the root cause of AMS. This may involve:
- Intravenous (IV) fluids for dehydration or shock
- Antibiotics for infections (sepsis, meningitis, pneumonia)
- Glucose administration for hypoglycemia
- Neurosurgical intervention for brain trauma or hemorrhage
- Oxygen therapy or intubation for respiratory compromise
2. Reduce Environmental Stimulation: Create a calm and quiet environment, especially for patients with delirium.
- Dim lights
- Minimize noise and alarms
- Provide reassurance and reorientation
3. Sedation (Pharmacological Management): Consider sedation if non-pharmacological measures are insufficient to manage agitation or unsafe behaviors.
- Antipsychotics (haloperidol, quetiapine) are often used for delirium-related agitation.
- Benzodiazepines should be used cautiously, primarily for alcohol withdrawal or seizures, as they can worsen delirium in other contexts.
4. Restraints (Last Resort): Physical restraints should only be used when all other strategies have failed and the patient poses an imminent danger to themselves or others. Follow institutional policies and guidelines for restraint use.
5. Ensure Patient Safety: Patients with AMS are at increased risk for falls and injuries.
- Implement fall precautions (bed alarms, side rails, non-slip footwear).
- Consider 1:1 supervision, especially for confused or agitated patients.
- Maintain a safe environment, free of hazards.
6. Medication Administration: Administer medications as prescribed to address the underlying cause or manage specific symptoms. Examples include:
- Donepezil or other cholinesterase inhibitors for dementia
- Naloxone for opioid overdose
- Antiseizure medications for seizures
- Antipsychotics for mental health disorders
7. Delirium Prevention: Implement preventive measures for patients at risk for delirium:
- Maintain adequate hydration and nutrition.
- Minimize invasive lines and catheters.
- Assess and manage constipation and urinary retention.
- Provide daytime stimulation and activity.
- Ensure use of hearing aids and eyeglasses.
- Effectively manage pain.
- Regularly orient the patient to time and place.
8. Reduce Polypharmacy Risk: Especially important in older adults.
- Perform medication reconciliation to identify potential drug interactions or duplicates.
- Collaborate with the provider to simplify medication regimens and discontinue unnecessary medications.
9. Referral to Interdisciplinary Team: Consult and collaborate with other healthcare professionals as needed:
- Neurologists
- Pharmacists
- Mental health professionals
- Substance abuse counselors
- Social workers
- Case managers
Nursing Care Plans and Diagnoses for Altered Mental Status
Nursing diagnoses provide a framework for organizing and prioritizing nursing care. Several nursing diagnoses are relevant to patients with altered mental status. Here are some key examples:
Acute Confusion
Nursing Diagnosis: Acute Confusion
Related Factors:
- Alteration in brain function
- Physiological alterations (hypoxia, metabolic imbalances, electrolyte imbalances)
- Infections (CNS infections, systemic infections)
- Delirium
- Substance intoxication or withdrawal
- Sleep deprivation
- Disrupted perception
Defining Characteristics (Evidenced by):
- Hallucinations
- Restlessness, agitation
- Decreased level of consciousness
- Impaired cognition (disorientation, memory deficits)
- Disrupted psychomotor functioning
- Inability to perform purposeful behavior
- Inappropriate verbal responses
Expected Outcomes:
- Patient will regain orientation to person, place, and time.
- Patient will identify factors that contribute to acute confusion and implement preventive strategies.
Nursing Interventions:
- Determine and treat underlying cause: Address the root cause of confusion.
- Frequent mental status assessment: Monitor for changes in level of consciousness and cognition.
- Monitor laboratory values: Assess for metabolic or electrolyte imbalances.
- Assess medication and substance use history: Identify potential contributing factors.
- Provide frequent orientation: Reorient to person, place, time, and situation.
- Prevent sundowning: Promote regular sleep-wake cycles, light exposure, and familiar environment.
- Educate caregivers: Instruct family on monitoring for changes and seeking help.
- Maintain a calm and safe environment: Reduce overstimulation and ensure safety.
Alt Text: An elderly patient exhibiting signs of confusion and disorientation while sitting in a hospital bed, highlighting the need for careful nursing assessment and intervention for altered mental status.
Impaired Verbal Communication
Nursing Diagnosis: Impaired Verbal Communication
Related Factors:
- Cognitive dysfunction
- Central nervous system impairment (stroke, head injury)
- Psychotic disorder
- Physiological conditions affecting speech (e.g., dysarthria, aphasia)
Defining Characteristics (As evidenced by):
- Difficulty expressing thoughts verbally
- Difficulty comprehending information
- Incongruent facial expressions/body language
- Disorientation
- Aphasia (language impairment)
- Anarthria (motor speech disorder)
- Dysarthria (slurred speech)
- Dysphonia (voice impairment)
- Slurred speech
Expected Outcomes:
- Patient will utilize alternative methods of communication effectively.
- Patient will return to baseline communication abilities as AMS resolves.
Nursing Interventions:
- Assess baseline communication abilities: Determine the patient’s usual communication patterns.
- Identify communication barriers: Assess for cognitive, language, or sensory deficits.
- Note conditions affecting speech: Evaluate for signs of stroke or neurological conditions.
- Explain procedures and tasks: Provide clear and simple explanations before interventions.
- Allow ample time for response: Provide sufficient time for the patient to process information and respond.
- Limit distractions: Create a quiet environment to facilitate communication.
- Utilize family members: Involve family to aid in communication and understanding.
Ineffective Cerebral Tissue Perfusion
Nursing Diagnosis: Ineffective Tissue Perfusion (Cerebral)
Related Factors:
- Decreased cerebral blood flow
- Metabolic conditions (hypoglycemia, hypoxia)
- Primary intracranial disease (stroke, increased intracranial pressure)
- Systemic diseases affecting CNS
- Exogenous toxins
- Drug withdrawal
Defining Characteristics (As evidenced by):
- Decreased Glasgow Coma Scale (GCS) score
- Decreased level of consciousness (LOC)
- Diminished reflexes
- Alterations in pulse rate and blood pressure
- Increased intracranial pressure (if applicable)
- Decreased cerebral perfusion pressure (CPP)
- Behavioral changes
Expected Outcomes:
- Patient will demonstrate effective cerebral tissue perfusion (GCS and LOC within normal limits).
- Patient will not experience worsening AMS (coma, need for intubation).
Nursing Interventions:
- Assess vital signs and underlying cause: Monitor for fluctuations and identify contributing factors.
- Frequent neurological assessment: Monitor LOC, GCS, and neurological signs.
- Review medications and substance use: Identify potential toxicities or medication effects.
- Determine appropriate level of care: ICU admission may be necessary for close monitoring.
- Administer fluids and electrolytes: Maintain hemodynamic stability and optimize cerebral perfusion.
- Prepare for surgical procedures: If indicated (e.g., carotid endarterectomy, hematoma evacuation).
Alt Text: A nurse performing a neurological assessment on a patient, emphasizing the importance of regular neurological checks in monitoring and managing changes in mental status related to cerebral perfusion.
Ineffective Coping
Nursing Diagnosis: Ineffective Coping
Related Factors:
- Cognitive dysfunction
- Psychological barriers (anxiety, depression)
- Inaccurate threat appraisal
- Loss of control
- Lack of support
Defining Characteristics (As evidenced by):
- Altered concentration
- Changes in communication patterns
- Destructive behavior
- Substance misuse
- Difficulty organizing information
Expected Outcomes:
- Patient will remain free from agitated or destructive behavior.
- Patient will verbalize improved psychological comfort (reduced stress, anxiety, sense of control).
Nursing Interventions:
- Assess contributing factors: Identify stressors and coping mechanisms.
- Assess cognitive, emotional, and mental state: Address underlying psychological issues.
- Monitor for physiological alterations: Rule out medical causes of ineffective coping.
- Implement relaxation techniques: Guided imagery, music therapy, deep breathing.
- Establish a trusting relationship: Build rapport to reduce anxiety and promote cooperation.
- Encourage participation in care: Involve the patient in care planning as appropriate.
- Identify support persons: Engage family, friends, and mental health professionals.
Risk for Injury
Nursing Diagnosis: Risk for Injury
Related Factors:
- Altered brain function
- Impaired judgment and cognition
- Decreased level of consciousness
- Impaired sleep cycle
- Hypoxia
- Intoxication
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 for injury.
- Patient will identify behaviors and measures to reduce injury risk.
- Patient will remain free from injury.
Nursing Interventions:
- Assess safety issues: Identify potential hazards in the environment.
- Assess knowledge of safety precautions: Evaluate the patient’s understanding of safety measures.
- Note individual risk factors: Consider age, cognitive status, and physical limitations.
- Ascertain caregiver expectations: Understand caregiver capabilities and needs.
- Provide safe nursing care: Adhere to safety protocols and best practices.
- Inform patient about treatments and medications: Enhance understanding and cooperation.
- Implement injury prevention measures: Bed alarms, side rails, fall precautions, safe environment.
- Prepare for safe home environment: Educate on home safety modifications and resources.
Alt Text: A hospital setting demonstrating fall prevention measures, such as clear signage and handrails, highlighting the critical role of nurses in ensuring patient safety for individuals with altered mental status who are at increased risk of injury.
Conclusion
Changes in mental status are a significant clinical concern requiring prompt and comprehensive nursing care. By understanding the various causes, assessment techniques, and relevant nursing diagnoses related to “change in mental status nursing diagnosis,” nurses can effectively contribute to early detection, appropriate interventions, and improved patient outcomes. Prioritizing patient safety, addressing the underlying cause, and implementing tailored nursing care plans are essential components of managing patients experiencing altered mental status.
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.
