Altered mental status (AMS) is a significant clinical presentation indicating a disturbance in brain function. It’s not a disease itself but rather a symptom of an underlying medical condition, ranging from mild confusion to severe conditions like coma. For nurses, recognizing and responding to AMS is critical in ensuring patient safety and effective treatment. This article provides an in-depth look at altered mental status, focusing on NANDA nursing diagnoses relevant to this condition, and offering a comprehensive guide for assessment, intervention, and care planning.
Understanding Altered Mental Status
Altered mental status encompasses a wide spectrum of conditions that affect a patient’s level of consciousness and cognition. These two components are fundamental in defining mental status. Consciousness refers to the patient’s awareness of self and environment, while cognition involves mental processes such as thinking, memory, and reasoning. AMS can manifest as changes in either or both of these areas, and may also impact mood, movement, and behavior.
The terminology used to describe changes in consciousness ranges from heightened alertness to complete unresponsiveness:
- Hyperalert: An excessively heightened state of awareness and responsiveness.
- Confused: Disoriented to time, place, or person; difficulty thinking clearly.
- Delirious: Acute state of confusion characterized by disturbances in attention, cognition, and consciousness.
- Somnolent: Drowsy or sleepy, easily aroused by stimuli.
- Lethargic: sluggish and apathetic, difficult to arouse and keep awake.
- Obtunded: Decreased alertness and psychomotor retardation, responds slowly to stimuli.
- Stuperous: Unresponsive except to vigorous and repeated stimuli.
- Comatose: Unarousable unresponsiveness.
Changes in cognitive function and mood can present with a variety of symptoms, including:
- Disorientation: Confusion about time, place, and person.
- Forgetfulness: Memory deficits.
- 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 reaction time to questions or commands.
- Agitation: Restlessness and increased psychomotor activity.
- Anxiety: Feelings of worry, nervousness, or unease.
- Depression: Persistent sadness, loss of interest, and feelings of hopelessness.
- Euphoria: Exaggerated feeling of well-being or happiness.
Image alt text: An elderly patient looking confused and disoriented in a hospital bed, illustrating altered mental status.
The causes of altered mental status are diverse, and can be broadly categorized as:
- Neurological disease: Conditions such as stroke, seizures, meningitis, encephalitis, and traumatic brain injury.
- Infectious: Systemic infections like sepsis, urinary tract infections (UTIs), and pneumonia, as well as central nervous system infections.
- Toxic: Drug overdose, alcohol intoxication or withdrawal, and exposure to environmental toxins.
- Metabolic: Conditions like hypoglycemia, hyperglycemia, electrolyte imbalances, liver failure, kidney failure, and thyroid disorders.
- Systemic: Conditions affecting the whole body, such as shock, hypoxia, and hyperthermia or hypothermia.
The Nursing Process for Altered Mental Status
Nurses play a vital role in the early detection, assessment, and management of altered mental status. A systematic nursing process is essential to identify the underlying cause, provide timely interventions, and minimize potential complications. This process includes assessment, diagnosis, planning, implementation, and evaluation.
Nursing Assessment
A thorough nursing assessment is the first critical step in addressing altered mental status. It involves gathering subjective and objective data to understand the patient’s condition comprehensively.
Review of Health History
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Elicit Changes in Mentation: Directly inquire about any changes in the patient’s mental state. Explore alterations in:
- Self-awareness: Understanding of one’s own identity and situation.
- Mood: Emotional state.
- Expression: Ability to communicate thoughts and feelings.
- Language: Ability to understand and use language.
- Emotions: Range and appropriateness of feelings.
- Cognition: Thinking processes, memory, and judgment.
- Motor control: Coordination and movement.
- Behavior: Actions and mannerisms.
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Determine Potential Underlying Causes: Consider the broad categories of causes for AMS: neurological, infectious, toxic, metabolic, and systemic. This helps narrow down potential etiologies.
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Identify Risk Factors: Assess for predisposing factors that increase the likelihood of AMS:
- Age over 65: Older adults are more susceptible to AMS due to age-related physiological changes and comorbidities.
- Anesthesia: Postoperative AMS is a known complication.
- 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 older adults.
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Assess for Mental Illness: Differentiate AMS from primary psychiatric disorders. Conditions like bipolar disorder or schizophrenia may present with symptoms that mimic AMS, but require different management strategies.
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Consider Patient’s Age: Age is a significant factor in determining the likely causes of AMS.
- Infants and young children: Infections, trauma, metabolic disorders, and toxin ingestion are common causes.
- Young adults: Substance abuse and trauma are frequent culprits.
- Older adults: Stroke, infections, medication interactions, and environmental changes are more prevalent.
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Interview Family or Caregivers: Obtain information from individuals familiar with the patient’s baseline mental status. This is crucial because patients with AMS may be unable to provide reliable history. Details from family, caregivers, teachers, or bystanders are invaluable.
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Review Medication History: A comprehensive medication review is essential to identify potential drug-induced AMS. Inquire about:
- New medications.
- Over-the-counter drugs.
- Herbal supplements.
- Nutritional supplements.
- Pay special attention to medications known to contribute to AMS: antibiotics, antidepressants, antipsychotics, benzodiazepines, opioids, and sedatives.
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Inquire About Alcohol and Substance Use: Substance intoxication and withdrawal are significant causes of AMS. A toxicology screen may be necessary if the patient’s history is unreliable or unavailable.
Physical Assessment
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Assess ABCs (Airway, Breathing, Circulation): Prioritize the patient’s hemodynamic stability. Ensure a patent airway, adequate breathing, and stable circulation as AMS can be a symptom of life-threatening conditions.
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Evaluate Neurological Status:
- Level of Consciousness: Use standardized scales like the Glasgow Coma Scale (GCS) if head injury is suspected. Describe the patient’s responsiveness using terms like alert, lethargic, obtunded, stuporous, or comatose.
- Orientation: Assess orientation to person, place, time, and situation.
- Pupils: Evaluate pupil size, reactivity to light, and equality.
- Speech: Assess speech for clarity, coherence, and appropriateness.
- Sensations: Check for sensory deficits.
- Reflexes: Test reflexes as indicated.
- Coordination: Evaluate motor coordination.
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Observe Appearance, Behavior, and Movement: Note:
- Hygiene and attire: Changes may indicate self-neglect or altered self-perception.
- Behavior: Observe eye contact, facial expressions, posture, and cooperation with assessment.
- Movement: Note any exaggerated, slowed, or catatonic movements. These findings can be indicative of certain mental illnesses or substance use.
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Assess Cognition: Employ standardized cognitive assessment tools:
- Mini-Mental State Examination (MMSE): A widely used tool to screen for cognitive impairment.
- Confusion Assessment Method (CAM): Specifically designed to diagnose delirium.
- 4 ‘A’s Test (Alertness, Attention, Abbreviated Mental Test-4, Agitation): Another tool for delirium assessment.
- Assess attention, memory, language, thought content and processes, and ability to follow commands.
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Inspect for Physical Trauma: Examine for signs of injury, especially head trauma. Look for:
- Lacerations.
- Ecchymosis (bruising).
- Deformities.
- Infection.
- Track marks: May suggest intravenous drug use.
- Transdermal patches: Assess for potential overdose or misuse.
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Monitor Vital Signs and ECG: Continuous vital sign monitoring is crucial. Abnormalities may indicate conditions like:
- Hypothermia.
- Hypoxemia.
- Hypertensive crisis.
- Obtain an electrocardiogram (ECG) to rule out cardiac arrhythmias or ischemia, especially if cardiac etiology is suspected.
Diagnostic Procedures
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Rapid Glucose Level Check: Immediately check blood glucose. Hypoglycemia and hyperglycemia are common and rapidly reversible causes of AMS.
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Collect Specimens for Lab Tests: Obtain blood and urine samples for:
- Serum electrolytes: Sodium, potassium, calcium, magnesium imbalances can cause AMS.
- Complete blood count (CBC): To assess for infection or anemia.
- Serum ammonia: Elevated levels may indicate hepatic encephalopathy.
- Blood gas analysis: To evaluate oxygenation and acid-base balance.
- Blood cultures: If infection is suspected.
- Liver function tests (LFTs): To assess liver function.
- Kidney function tests (BUN, creatinine): To assess kidney function.
- Urinalysis: To rule out urinary tract infection and assess kidney function.
- Thyroid function tests (TSH, T4): To evaluate thyroid disorders.
- Serum B12 levels: B12 deficiency can cause neurological symptoms.
- Syphilis serology (RPR or VDRL): Neurosyphilis can present with AMS.
- Toxicology screening: To detect drugs or toxins.
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Consider Imaging and Other Tests:
- Head CT scan: If stroke, head trauma, or intracranial hemorrhage is suspected.
- Chest X-ray: To rule out pneumonia, especially in older adults.
- Lumbar puncture: If meningitis or encephalitis is suspected.
- Electroencephalogram (EEG): To rule out seizures or diagnose encephalopathy or encephalitis.
Image alt text: A medical team collaboratively examining a patient in a hospital room, emphasizing comprehensive patient care for altered mental status.
NANDA Nursing Diagnoses for Altered Mental Status
Based on the assessment data, several NANDA nursing diagnoses may be appropriate for patients with altered mental status. These diagnoses help guide the development of individualized care plans. Common NANDA diagnoses include:
1. Acute Confusion
Nursing Diagnosis: Acute Confusion
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:
- Alteration in brain function
- Alteration in sleep-wake cycle
- Alcohol or drug abuse
- Electrolyte imbalance
- Hypoxia
- Metabolic imbalances
- Delirium
- Disrupted perception
Evidenced by:
- Hallucinations
- Restlessness
- Decreased level of consciousness
- Impaired cognition
- 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 lifestyle changes to prevent recurrence of acute confusion (if applicable).
Nursing Interventions:
- Determine Causative Factors: Identify and address underlying causes of acute confusion (e.g., infection, metabolic imbalance).
- Assess Mental Status: Regularly assess cognitive function using appropriate tools like CAM or MMSE.
- Monitor Lab Values: Review relevant lab results (electrolytes, CBC, etc.) to identify and correct imbalances.
- Assess Medication and Substance Use: Obtain a thorough medication history and inquire about substance use.
- Provide Orientation: Frequently reorient the patient to person, place, time, and situation. Use clear, simple language.
- Prevent Sundowning: Establish a routine, maximize daytime light exposure, limit daytime naps, and provide familiar objects.
- Educate Caregivers: Instruct family or caregivers on monitoring for changes in cognition and behavior at home and when to seek medical attention.
- Provide a Calm Environment: Minimize noise and overstimulation. Ensure a safe, quiet, and comfortable environment.
2. Impaired Verbal Communication
Nursing Diagnosis: Impaired Verbal Communication
Definition: Decreased, delayed, or absent ability to receive, process, transmit, and/or use symbols in spoken and/or written systems.
Related Factors:
- Cognitive dysfunction
- Central nervous system impairment
- Psychotic disorder
- Physiological condition
Evidenced by:
- Difficulty expressing thoughts verbally
- Difficulty comprehending information
- Incongruent facial expressions/body language
- Disorientation
- Aphasia
- Anarthria
- Dysarthria
- Dysphonia
- Slurred speech
Expected Outcomes:
- Patient will utilize alternative methods of communication effectively while experiencing AMS.
- Patient will return to their baseline level of communication as AMS resolves.
Nursing Interventions:
- Assess Baseline Communication Abilities: Determine the patient’s usual communication abilities by consulting with family or caregivers.
- Assess Communication Barriers: Identify factors hindering communication (e.g., cognitive impairment, language barriers, hearing deficits).
- Note Speech-Affecting Conditions: Be alert to new-onset speech changes, which may indicate a stroke or other neurological event.
- Explain Procedures and Tasks: Communicate clearly and simply before initiating any procedure or task.
- Allow Response Time: Give the patient ample time to process information and respond.
- Limit Distractions: Create a quiet environment to facilitate communication.
- Utilize Family Members: Involve family members or familiar individuals to assist with communication.
3. Ineffective Cerebral Tissue Perfusion
Nursing Diagnosis: Ineffective Tissue Perfusion (Cerebral)
Definition: Decrease in oxygen resulting in the failure to nourish tissues at the capillary level.
Related Factors:
- Decreased cerebral blood flow
- Metabolic conditions (hypoglycemia, hypoxia)
- Primary intracranial disease (stroke, head trauma)
- Systemic disease affecting the central nervous system (CNS)
- Exogenous toxins
- Drug withdrawal
Evidenced by:
- Decreased Glasgow Coma Scale (GCS) score
- Decreased level of consciousness (LOC)
- Diminished reflexes
- Alterations in pulse rate
- Alterations in blood pressure
- Increased intracranial pressure (ICP)
- Decreased cerebral perfusion pressure (CPP)
- Behavioral changes
Expected Outcomes:
- Patient will demonstrate effective cerebral tissue perfusion as evidenced by GCS and LOC within normal limits for their baseline.
- Patient will not experience worsening AMS, such as coma, and will avoid the need for intubation (if applicable).
Nursing Interventions:
- Assess Vital Signs and Underlying Cause: Monitor vital signs closely and investigate potential underlying causes of decreased cerebral perfusion.
- Assess Neurological Status: Perform frequent neurological assessments, including GCS and LOC.
- Review Medications and Intoxicants: Assess medication regimen and substance use history.
- Determine Level of Care: Collaborate with the healthcare team to determine the appropriate level of care, which may include ICU monitoring.
- Administer Fluids and Electrolytes: Provide intravenous fluids and electrolytes as prescribed to optimize cerebral perfusion and hemodynamics.
- Prepare for Surgical Procedures: If indicated, prepare the patient for surgical interventions such as carotid endarterectomy or evacuation of hematoma.
4. Ineffective Coping
Nursing Diagnosis: Ineffective Coping
Definition: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.
Related Factors:
- Cognitive dysfunction
- Psychological barriers
- Inaccurate threat appraisal
- Loss of control
- Lack of support
Evidenced by:
- Altered concentration
- Change in communication patterns
- Destructive behavior
- Substance misuse
- Difficulty organizing information
Expected Outcomes:
- Patient will remain free from agitated behavior.
- Patient will verbalize improved psychological comfort, as evidenced by reduced stress and anxiety and a sense of control.
Nursing Interventions:
- Assess Contributing Factors: Identify factors contributing to ineffective coping (e.g., lack of support, recent life changes, psychological distress).
- Assess Cognitive, Emotional, and Mental State: Evaluate the patient’s overall mental and emotional state.
- Monitor Physiological Alterations: Address underlying physiological factors contributing to AMS and ineffective coping.
- Implement Relaxation Techniques: Utilize techniques like guided imagery or music therapy to promote relaxation and reduce anxiety.
- Establish Trusting Relationship: Build rapport with the patient to foster trust and reduce anxiety.
- Encourage Participation in Care: Involve the patient in care planning to the extent possible to enhance cooperation and coping.
- Identify Support Persons: Identify and involve family members, friends, or support networks to assist with coping strategies.
5. Risk for Injury
Nursing Diagnosis: Risk for Injury
Definition: Vulnerable to physical damage due to environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.
Related Factors:
- Alteration in brain function
- Impaired sleep cycle
- Hypoxia
- Intoxication
Evidenced by: 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 may cause injury.
- Patient will identify behaviors and measures to reduce risk factors and protect themselves from injury.
- Patient will remain free from injury.
Nursing Interventions:
- Assess Safety Issues: Conduct a thorough assessment of potential safety hazards in the patient’s environment.
- Assess Knowledge of Safety Precautions: Evaluate the patient’s and caregiver’s understanding of safety measures.
- Note Individual Risk Factors: Consider age, cognitive status, and other factors that increase risk of injury.
- Ascertain Caregiver Expectations: Understand caregiver capabilities and expectations regarding patient safety.
- Provide Safe Nursing Care: Implement safety protocols and maintain a safe environment.
- Inform Patient About Treatments and Medications: Clearly explain all treatments and medications to enhance understanding and cooperation.
- Reduce Risk of Injury: Implement specific interventions such as bed alarms, call bells within reach, assistive devices, and fall precautions.
- Prepare Safe Home Environment: Educate patients and caregivers on home safety measures, including fall prevention and medication safety.
Nursing Interventions for Altered Mental Status
Beyond addressing specific nursing diagnoses, general nursing interventions are crucial for managing patients with AMS. These interventions focus on treating the underlying cause, providing supportive care, and ensuring patient safety.
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Treat the Underlying Cause: The primary goal is to identify and treat the root cause of AMS. This may involve:
- Intravenous fluids for shock.
- Antibiotics for sepsis.
- Glucose for hypoglycemia.
- Neurosurgical intervention for brain trauma.
- Oxygen therapy or intubation for respiratory compromise.
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Reduce Stimulation: Create a calm and quiet environment, especially for patients with delirium. Dim lights, reduce noise levels, and minimize alarms to decrease agitation and confusion.
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Sedation (If Necessary): If non-pharmacological measures are insufficient to manage agitation or unsafe behaviors, medications may be required. Antipsychotics like haloperidol or quetiapine are often used. Benzodiazepines should be used cautiously, primarily for alcohol withdrawal or seizures, as they can worsen delirium in other situations.
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Restraints (As a Last Resort): Physical restraints should only be used when all other strategies have failed to ensure patient safety and prevent harm to self or others.
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Ensure Safety: Implement fall precautions for all patients with AMS. Consider 1:1 supervision if the patient is at high risk for falls or injury.
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Administer Medications as Ordered: Administer medications as prescribed based on the underlying cause of AMS. Examples include:
- Donepezil for dementia.
- Naloxone for opioid overdose.
- Antiseizure medications for seizures.
- Antipsychotics for mental health conditions.
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Prevent Delirium: For patients at risk of delirium, implement preventive measures:
- Maintain adequate hydration and nutrition.
- Limit invasive lines and catheters.
- Assess and manage constipation and urinary retention.
- Provide stimulating activities during the day.
- Ensure use of hearing aids and eyeglasses.
- Effectively manage pain.
- Orient the patient to time and place regularly.
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Reduce Polypharmacy: Especially in older adults, review medication lists for potential polypharmacy. Perform medication reconciliation and discuss potential medication adjustments with the physician.
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Refer to Appropriate Disciplines: Collaborate with other healthcare professionals as needed, including neurologists, pharmacists, mental health professionals, substance abuse counselors, social workers, and case managers.
Conclusion
Altered mental status is a complex clinical challenge requiring a comprehensive nursing approach. By understanding the various causes, conducting thorough assessments, utilizing appropriate NANDA nursing diagnoses, and implementing targeted interventions, nurses can significantly impact patient outcomes. Prioritizing patient safety, treating underlying conditions, and providing supportive care are paramount in managing altered mental status and promoting patient recovery.
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.
