Altered mental status (AMS) is any change from a client’s usual level of alertness, attention, thinking, or behavior, from mild confusion to coma. It is a sign, not a disease: something is affecting the brain, and the nurse’s job is to protect the client while the cause is found and treated. AMS is not a nursing diagnosis; the nursing diagnoses used most often are Acute Confusion, Risk for Ineffective Cerebral Tissue Perfusion, Risk for Adult Falls, and Disturbed Sleep Pattern. Nursing care centers on checking airway, breathing, circulation, and blood glucose first, comparing the client with their own baseline, and preventing injury.
At a glance
- What it is
- A new or worsening change in level of consciousness, orientation, attention, memory, or behavior compared with how the client normally is.
- Common causes
- Low blood glucose, low oxygen, infection or sepsis, stroke, head injury, seizures, medications and alcohol or drug use or withdrawal, electrolyte problems such as low sodium, and kidney or liver failure. In older adults, a urinary tract infection or pneumonia often shows up as confusion first.
- Key signs
- Drowsiness or hard to wake, disorientation, trouble paying attention, rambling or slurred speech, agitation or unusual quietness, and confusion that comes and goes during the day.
- Nursing focus
- Airway, breathing, and circulation; a bedside blood glucose; neuro checks compared with baseline; delirium screening; medication review; fall prevention; and keeping the family involved.
- Act now
- A sudden drop in level of consciousness, new one-sided weakness, facial droop or speech trouble, unequal pupils, slow or noisy breathing, a seizure, or a low blood glucose needs immediate action — call the provider or rapid response team.
Why altered mental status happens
Being awake and aware needs two things working together. The reticular activating system in the brainstem keeps a person awake, and the cerebral hemispheres make sense of what is happening. Mental status changes when something damages one of these areas directly, such as a stroke, bleeding, or a tumor, or when something affects the whole brain at once, such as low glucose, low oxygen, infection, toxins, or drugs.
The brain stores almost no glucose or oxygen, so it needs a steady supply from the blood. That is why hypoglycemia and hypoxia can change mental status within minutes and why they are checked first. Both are quick to find and quick to treat.
Delirium is the most common form of AMS in hospitals, especially in older adults. It starts suddenly, over hours to days, and the confusion comes and goes. Inattention is its key feature. Delirium may be hyperactive (restless, pulling at lines), hypoactive (quiet, sleepy, withdrawn), or mixed. The hypoactive type is the one most often missed, because a quiet client does not look like a problem.
Delirium is different from dementia, which develops slowly over months to years. A client with dementia can also develop delirium, so any change from their usual baseline still needs to be reported.
Common causes and the first nursing check
| Cause | Clues | Nursing check |
|---|---|---|
| Hypoglycemia | Sweating, shakiness, fast heart rate; client on insulin or a sulfonylurea | Bedside blood glucose right away; treat per hypoglycemia protocol |
| Hypoxia or high carbon dioxide | Low oxygen saturation, fast or slow breathing, COPD, oversedation | Airway, respiratory rate, oxygen saturation; arterial blood gas if ordered |
| Infection or sepsis | Fever or low temperature, fast heart rate, new urinary or respiratory symptoms | Full vital signs, urine and blood cultures as ordered, sepsis screening |
| Stroke or bleeding in the brain | Sudden one-sided weakness, facial droop, speech or vision change, severe headache | Time last known well, stroke scale per protocol, activate the stroke alert |
| Medications, alcohol, or drugs | New opioid, sedative, or anticholinergic drug; alcohol use; recent dose change | Medication list including over-the-counter drugs; signs of withdrawal |
| Electrolyte or organ problems | Vomiting, diarrhea, poor intake, kidney or liver disease | Sodium, calcium, BUN and creatinine, liver tests, ammonia as ordered |
| Head injury or seizure | Recent fall, bruising on the head, incontinence, tongue biting | Neuro checks and pupils; report a fall or a seizure at once |
Nursing assessment
Subjective data
- The client’s usual mental status, from family or caregivers: Do they normally know the date? Do they manage their own medicines and money?
- When the change started, whether it came on suddenly or slowly, and whether it comes and goes
- All medications, including new ones, dose changes, and over-the-counter sleep aids and cold remedies
- Alcohol and drug use, and when the last drink or dose was
- Recent falls or head injury, fever, pain, cough, urinary symptoms, vomiting, or poor eating and drinking
- History of diabetes, stroke, seizures, dementia, kidney or liver disease, and use of glasses or hearing aids
Objective data
- Airway, breathing, respiratory rate and pattern, oxygen saturation
- Heart rate, blood pressure, and temperature, trended over time
- Bedside blood glucose
- Level of consciousness and Glasgow Coma Scale (scored 3 to 15)
- Orientation and attention, and a delirium screen such as the Confusion Assessment Method (CAM)
- Pupil size and reaction, strength in all four limbs, facial symmetry, and speech
- Signs of infection, dehydration, urinary retention, or constipation
- Lab results as ordered: CBC, electrolytes, kidney and liver function, urinalysis, drug levels, and imaging such as a head CT
Nursing diagnoses used with altered mental status
- Acute Confusion — sudden, fluctuating changes in attention, thinking, and awareness (delirium)
- Risk for Ineffective Cerebral Tissue Perfusion — conditions that could reduce blood flow to the brain
- Risk for Adult Falls — confusion, unfamiliar surroundings, and trying to get up alone
- Disturbed Sleep Pattern — noise, light, and nighttime care in the hospital
- Risk for Aspiration — drowsiness or a weak cough and swallow
- Impaired Verbal Communication — trouble finding or understanding words
- Chronic Confusion — long-term changes from dementia, used when the confusion is the client’s usual baseline
Worked care plans
Four plans in the same ADPIE shape. The scenario is an 81-year-old man brought to the emergency department by his daughter. He lives alone, manages his own medicines and bills, and was “sharp as a tack” last week. For two days he has been mixing up day and night, talking to people who are not there, and getting lost in his own house. He has high blood pressure, wears glasses and a hearing aid, and has been taking an over-the-counter diphenhydramine sleep aid every night for a week. Temperature is 38.3°C (100.9°F), heart rate 102, blood pressure 128/74 (usually about 140/80), respiratory rate 20, and oxygen saturation 95% on room air. His bedside glucose is 118 mg/dL. He is oriented to person only, cannot keep his attention on a question, and his Glasgow Coma Scale score is 14 (confused speech). Pupils are equal and reactive, and he moves all four limbs equally. His urinalysis suggests a urinary tract infection, and a head CT shows no acute changes. He is admitted with delirium, started on IV fluids and antibiotics, and his sleep aid is stopped.
1. Acute Confusion
Problem-focusedSubjective: Daughter: “This isn’t him. Last week he was doing his own taxes.” Client: “I need to get to work, the bus is coming.”
Objective: Oriented to person only. Cannot name the months of the year backward. Drifts off mid-sentence and is alert one hour, sleepy the next. Picks at his IV line. CAM positive.
Acute Confusion related to urinary tract infection, dehydration, anticholinergic medication use, and an unfamiliar environment, as evidenced by sudden onset over two days, fluctuating level of consciousness, inattention, disorientation, and hallucinations.
- Client returns to his usual mental status, as described by his daughter, before discharge
- Client screens negative for delirium (CAM) before discharge
- Client stays free from injury and keeps his IV line in place without physical restraints
- Screen for delirium with the CAM every shift and whenever behavior changes, and compare with his baseline
- Give antibiotics and IV fluids as ordered, and track intake and output
- Review his medication list with the provider and pharmacist; avoid new sedating or anticholinergic drugs
- Put on his glasses and hearing aid, and speak face to face in short, simple sentences
- Use a clock, calendar, and whiteboard, and gently reorient him without arguing
- Encourage his daughter to visit and bring familiar photos, and keep the same nurses when possible
- Hide or secure the IV line with a sleeve, and check for pain, a full bladder, and constipation
- Avoid physical restraints; if he becomes a danger to himself, call the provider and follow restraint policy
By day 3 he was oriented to person, place, and time, could name the months backward, and his CAM was negative. His daughter said, “He’s back to himself.” No restraints were used. Goal met; continue screening until discharge.
2. Risk for Ineffective Cerebral Tissue Perfusion
Risk diagnosis- Infection with fever that could progress to sepsis and low blood pressure
- Dehydration from poor intake
- Long-standing hypertension
- Older age
No “as evidenced by” — he has no signs of poor blood flow to the brain. His pupils are equal and reactive, he has no one-sided weakness or facial droop, and his head CT shows no acute changes.
Risk for Ineffective Cerebral Tissue Perfusion related to infection, dehydration, and hypertension.
- Any drop in level of consciousness or new neurological sign is found and reported at once
- Blood pressure, oxygen saturation, and blood glucose stay within the limits the provider sets
- Glasgow Coma Scale score returns to 15 as the infection is treated
- Do neuro checks at the frequency ordered: level of consciousness, Glasgow Coma Scale, pupils, limb strength, facial symmetry, and speech
- Report any drop in Glasgow Coma Scale score, new weakness, facial droop, speech change, or unequal pupils immediately; note the time last known well
- Monitor blood pressure and heart rate, and report readings outside the ordered parameters
- Give IV fluids as ordered and watch for signs of fluid overload
- Keep oxygen saturation within the ordered range and give oxygen as ordered
- Recheck blood glucose if his mental status changes
- Screen for sepsis each shift: temperature, heart rate, respiratory rate, blood pressure, and new confusion
Blood pressure stayed close to his baseline, oxygen saturation stayed in the ordered range, and his fever resolved by day 2. Neuro checks never showed a focal deficit, and his Glasgow Coma Scale score was 15 by day 3. Goal met; discontinue at discharge.
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3. Risk for Adult Falls
Risk diagnosis- Acute confusion with poor judgment about his own safety
- Urinary urgency from the urinary tract infection
- Unfamiliar room, IV pole, and tubing
- Recent use of a sedating, anticholinergic sleep aid
- Impaired vision and hearing; older age
- Tries to get out of bed alone at night
No “as evidenced by” — he has not fallen.
Risk for Adult Falls related to acute confusion, urinary urgency, sensory impairment, and an unfamiliar environment.
- Client has no falls during the hospital stay
- Client uses the call light or accepts help to get up, with reminders
- Daughter states three ways to prevent falls at home
- Complete a fall risk assessment with your facility’s tool on admission, every shift, and after any change
- Keep the bed low and locked, the call light and urinal within reach, and the path to the bathroom clear
- Offer toileting on a regular schedule and before sleep
- Use non-slip socks, a night light, and his glasses whenever he is awake
- Use a bed or chair alarm and a room near the nurses’ station if your policy allows
- Check on him often and anticipate needs such as thirst, pain, and toileting
- Ask for a physical therapy assessment and help him walk several times a day
He had no falls. By day 2 he used the call light when reminded, and by day 3 he walked to the bathroom with a walker and one person standing by. His daughter named a night light, removing loose rugs, and keeping his glasses by the bed. Goal met; continue fall precautions until discharge.
4. Disturbed Sleep Pattern
Problem-focusedSubjective: “I didn’t sleep a wink. Too much noise.” Daughter says he started the sleep aid because he could not sleep at home.
Objective: Awake and calling out most of the first night, then asleep through breakfast and lunch. Vital signs and IV checks every few hours overnight. Room faces a busy hallway.
Disturbed Sleep Pattern related to an unfamiliar, noisy environment and frequent nighttime care, as evidenced by reports of not sleeping, being awake most of the night, and sleeping through the day.
- Client sleeps for longer stretches at night within 2 to 3 nights
- Client stays awake for meals and activity during the day
- Client and daughter state why over-the-counter sleep aids with diphenhydramine should be avoided
- Cluster care at night, and ask the provider whether overnight vital signs and lab draws can be spaced out
- Open the curtains and turn on the lights in the day; dim the lights and lower noise at night
- Keep him up for meals and walks, and limit long daytime naps
- Offer a bedtime routine: toileting, a warm drink without caffeine, and earplugs or an eye mask if he likes
- Use non-drug sleep measures first; ask the provider before any sleep medicine
- Teach that diphenhydramine and similar sleep aids can cause confusion in older adults
By night 3 he slept most of the night with one wake-up to use the urinal, and he was awake for meals and walks in the day. His daughter said she would throw out the sleep aid. Goal met; continue plan.
Interventions and rationales
Client and family teaching
- Delirium is a sign of illness, not a sign of “getting old,” and it usually improves when the cause is treated, though it can take days to weeks
- Tell the nurses what the client is normally like; you are the best judge of a change
- Bring glasses, hearing aids, dentures, and familiar photos, and visit as often as you can
- Talk calmly, use short sentences, and gently remind the client of the day and place without arguing
- Avoid over-the-counter “PM” or nighttime sleep products and allergy medicines that contain diphenhydramine or doxylamine unless the provider approves
- Keep an up-to-date list of all medicines, including vitamins and over-the-counter products, and bring it to every visit
- Encourage fluids and regular meals unless the provider has limited them
- At home, use night lights, remove loose rugs, and keep the path to the bathroom clear
- Plan for someone to stay with the client for the first days after discharge if confusion is still improving
- Call the provider for new or worsening confusion, sleepiness, fever, or a fall; call emergency services for sudden weakness, facial droop, trouble speaking, a seizure, or if the client is hard to wake
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A 76-year-old client admitted with pneumonia was alert this morning. Now the client is difficult to wake and mumbles in response to questions. Which action should the nurse take first?
Why B. A sudden drop in level of consciousness in a client with pneumonia may mean hypoxia or high carbon dioxide, and a drowsy client may not protect the airway. Airway and breathing come first. Reorienting does not address the cause, the baseline can be gathered after the client is safe, and waiting an hour delays care. Prep also explains why each wrong option looks reasonable.
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Frequently asked questions
What is the nursing diagnosis for altered mental status?
Altered mental status is a medical finding, so it goes in the “related to” or risk factor part. Common nursing diagnoses are Acute Confusion, Risk for Ineffective Cerebral Tissue Perfusion, Risk for Adult Falls, Disturbed Sleep Pattern, Risk for Aspiration, and Impaired Verbal Communication.
What should the nurse check first when a client has altered mental status?
Airway, breathing, and circulation, including oxygen saturation, followed right away by a bedside blood glucose. Then do a neuro check, look for stroke signs, and compare with the client’s baseline.
Is altered mental status the same as delirium?
No. Altered mental status is a broad term for any change in alertness or thinking, including coma. Delirium is one type: a sudden, fluctuating disturbance of attention and awareness caused by an underlying illness, medicine, or substance.
What is the difference between Acute Confusion and Chronic Confusion?
Acute Confusion starts suddenly, comes and goes, and is often reversible, as in delirium. Chronic Confusion develops slowly and lasts, as in dementia. A client with dementia can also develop Acute Confusion on top of it.
What does AEIOU TIPS stand for?
It is a memory aid for causes of altered mental status. Versions vary, but a common one is: Alcohol; Epilepsy, Electrolytes, Encephalopathy; Insulin (glucose problems); Opioids and overdose; Uremia; Trauma and Temperature; Infection; Poisoning and Psychiatric causes; Shock, Stroke, and Seizure.
Should a confused client be restrained?
Only as a last resort. Restraints can increase agitation and cause injury. Try the least restrictive measures first, such as family presence, hiding lines, frequent checks, and a bed alarm, and follow your facility’s restraint policy and the provider’s order if they are needed.
References
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). NANDA International Nursing Diagnoses: Definitions and Classification, 2024–2026. Thieme.
- Inouye, S. K., Westendorp, R. G. J., & Saczynski, J. S. Delirium in elderly people. The Lancet, 2014;383(9920):911–922.
- Inouye, S. K., van Dyck, C. H., Alessi, C. A., et al. Clarifying confusion: the confusion assessment method. Annals of Internal Medicine, 1990;113(12):941–948.
- 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 2023;71(7):2052–2081.
- National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care (CG103). NICE, 2010, updated 2023.
- Teasdale, G., & Jennett, B. Assessment of coma and impaired consciousness: a practical scale. The Lancet, 1974;2(7872):81–84.
- Hinkle, J. L., Cheever, K. H., & Overbaugh, K. J. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (15th ed.). Wolters Kluwer, 2022.
Neuro check frequency, escalation triggers, blood glucose thresholds and hypoglycemia treatment, oxygen saturation targets, blood pressure parameters, IV fluid orders, thiamine use, antipsychotic use, restraint rules, and fall prevention tools vary by client, by provider, and by facility. Follow the provider’s written orders and your own institution’s policies. This page supports study and does not replace course instruction or clinical judgment.
