Altered Mental Status Nursing Diagnosis and Care Plans

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Altered Mental Status Nursing Care Plans Diagnosis and Interventions

Altered Mental Status NCLEX Review and Nursing Care Plans

Altered mental status (AMS) may refer to one or a combination of the following: ambiguity, amnesia (impaired memory), loss of attentiveness, mental confusion (not fully aware of self, time, or place), deficiencies in personal judgment or thought, unusual or peculiar behavior, inadequate coping styles, and instabilities in perception, psychomotor skills, and behavioral patterns.

While Altered mental status is generally associated with psychological and emotional disorders, physical ailments and traumas that induce brain damage, such as alcohol or drug intoxication and withdrawal syndromes, can also trigger mental stability disturbances. Dementia, apathy, insanity, confusion, encephalopathy, and organic brain syndrome are some of the medical conditions characterized by changes in mental health status.

Causes of Altered Mental Status

Altered mental status usually manifests an existing ailment or condition rather than being a terrible disease itself. Therefore, altered mental status does not generally appear on its own. For instance, the causes of the altered mental status may be alcohol intoxication and traumatic injury. It is therefore beneficial to identify the underlying cause when altered mental status arises to deliver appropriate therapy and treatment. Among the potential causes of altered mental status are:

  • Alzheimer’s disease or dementia
  • Insufficient oxygen supply
  • Stroke
  • Pulmonary disease
  • Traumatic injury
  • Excessive alcohol consumption
  • Withdrawal from drugs or alcohol abuse
  • Malignant tumor
  • Medications with adverse effects that affect the mental status
  • toxicity
  • improper intake of opioids
  • hypoglycemia or hyperglycemia
  • cerebral inflammation at high altitude
  • infections of the central nervous system (CNS)
  • Korsakoff’s syndrome
  • convulsions
  • lipid storage diseases
  • liver failure
  • Wernicke’s disease
  • severe cerebral hemorrhage
  • vascular dementia
  • Wilson’s disease

Risk Factors of Altered Mental Status

The following are the common risk factors for impaired or altered mental status:

  • A blood relative, such as a parent or siblings, has a history of mental illness.
  • A history of mental illness
  • Persistent (chronic) medical condition.
  • Stressful life events such as Financial struggles, the death in the family or loved ones, or divorce
  • Brain damage caused by a catastrophic accident, such as a forceful hit to the head (traumatic brain injury)
  • Few friends or a small number of healthy relationships
  • Traumatic life events
  • Excessive intake of alcoholic beverages or recreational substances
  • A history of abuse or mistreatment during childhood years.

Diagnosis of Altered Mental Status

The physician or nurse will inquire about the normal mental state of the patient and his family. The doctor will evaluate if the changes happened all at once or progressively and focus on recent events, such as accidents or other traumatic injuries or ailments.

Furthermore, the physician may interview witnesses such as family members or other significant others about the actions of the patient. The healthcare professional will also assess the patient’s medications and drug abuse issues.

To ascertain the cause of altered mental status, the doctor may additionally require the following tests:

  • Neurological exam – a neurological exam informs healthcare experts if the patient has problems with the brain or nerves. The reflexes will be assessed during the exam.
  • Physical exam – checking vital signs provide healthcare providers with important information about the present state of health of the patient. The nurse will monitor the heart rate, pulse rate, breathing patterns, and temperature. 
  • Blood tests – performed to assess the health of the liver, kidneys, and lungs. They will also reveal whether the patient has an infection or other poisons in their body. The blood glucose level will be measured as well.
  • Imaging tests  – these may include:
    • Chest X-ray –  A chest x-ray shows an illustration of the lungs and heart to examine symptoms of infection, such as pneumonia, that could be causing the altered mental status.
    • CT Scan – used to capture photographs of the head. The images could show cancer cells, edema, or hemorrhage.
    • Lumbar Puncture – A spinal tap is another terminology for a lumbar puncture. The patient must remain still throughout a lumbar puncture procedure. The doctor may give the patient an anesthetic drug to numb a tiny portion of the back. A needle will be inserted into the spine and extract the surrounding fluid from the spinal cord. The tests look for signs of infection, hemorrhage around the brain and spinal cord, and other abnormalities.

Treatment for Altered Mental Status

  1. Medical treatment. When possible, treat the underlying cause. The treatment should aim to repair or address the underlying pathology of altered mental status.
  1. Non-pharmacologic interventions. Reorient the patient frequently, provide eyeglasses and hearing aids, avoid restraints and Foley catheters and maintain regular sleep-wake cycles.
  1. Pharmacologic interventions. Medications such as antipsychotics and anxiolytics are prescribed if delirium or altered mental status interferes with necessary medical care or endangers the safety of the patient. Antipsychotics at low doses are preferable. Benzodiazepines should only be used in cases of alcohol withdrawal because their usage in other conditions can prolong or exacerbate delirium.

Prevention of Altered Mental Status

  1. Keep an eye out for warning signals. Patients should be advised to consult a doctor or therapist to determine what may be causing the problems. It is important to devise a strategy to know what to do if the symptoms reappear. If there are any symptoms, consult a therapist or doctor. Consider enlisting the help of family members or friends to check out for warning indicators constantly.
  1. Get regular medical attention. Advise the patient to have regular checkups or appointments with a primary care provider, mainly if some mental disturbances are observed.
  1. Do not falter to seek medical help if needed. Waiting until symptoms worsen can make it more difficult to manage mental health disorders. Long-term maintenance therapy may also assist in preventing relapses of symptoms.
  1. Adapt a healthy lifestyle. It is critical to get enough sleep, eat healthily, and engage in regular physical activity. However, if symptoms like sleeping difficulties or having issues with food or physical activity, consult the health care practitioner right away.

Altered Mental Status Nursing Diagnosis

Nursing Care Plan for Altered Mental Status 1

Disturbed Thought Process

Nursing Diagnosis: Disturbed Thought Process related to head injuries, alcohol or substance abuse, and anxiety secondary to altered mental status as evidenced by confusion, erroneous perception of stimuli, whether internally or externally, and impairments in cognition.

Desired Outcome: The patient will learn to retain a reality orientation, communicate coherently with others and identify changes in thought or conduct.

Desired Outcome: The patient will learn to retain a reality orientation, communicate coherently with others and identify changes in thought or conduct.

Nursing Interventions for Altered Mental StatusRationale
Help the patient in the management of underlying factors such anorexia, head trauma or increased intracranial pressure, sleep disturbances, and metabolic abnormalities.  Treatment or correction of medical or psychiatric disorders frequently enhances cognitive processing and thinking.  
When communication reveals a shift in thought, use the strategies of consensual validation and clarification.  These strategies expose the patient to how others perceive him or her, while the nurse takes responsibility for not understanding.    
Encourage the patient to join in one-on-one activities first, then in small groups, and eventually in bigger groups.  Initially, a skeptical patient should only deal with one person. When the patient appears to cope in communicating with one person such as member of the staff, gradually introduce others.    
Assist the patient during regular neurological or behavioral exams and compare current results to baseline data.  Early detection of mental status alterations encourages proactive changes to the care regimen.  
Present reality succinctly and effectively, and avoid challenging delusional thinking. Avoid statements that are ambiguous or misleading.  Delusional individuals are usually very sensitive to other people’s remarks and can detect disingenuousness. Mistrust or misconceptions are reinforced by evasive words or hesitancy.  
Acknowledge and praise the patient’s achievements, such as finished projects, responsibilities accomplished, or interactions established.  Acknowledging the patient’s achievements can help reduce worry hence the need for hallucinations as a source of self-confidence.    
Encourage the patient to express his or her actual feelings. When angry feelings are directed towards him or her, avoid acting aggressive.    The expression of feelings in a non-threatening setting may assist the patient in learning to cope with long-unresolved concerns.
Teach the patient to interrupt when irrational or negative thoughts take over by employing thought-stopping tactics.    A technique such as a hand clap can be used to break up the unpleasant idea. This noise or instruction diverts the individual’s attention away from the negative thinking that frequently accompanies unfavorable feelings or behaviors.
When problems are persistent or long-term, engage the patient and family in devising a care regimen.  Early preparation for home healthcare, transportation, aid with care activities, assistance, and respite for caregivers enhance health management in the home setting.    
Determine the presence of causes such as acute or chronic brain syndrome, recent stroke, Alzheimer’s disease, brain damage or increased intracranial pressure, anoxia, bacterial infections, malnutrition, sleep or sensory disturbances, and persistent mental disorder like schizophrenia.    It is essential to identify the existing factors to determine the causative or contributing elements.
Determine whether the patient has used alcohol or other drugs.  Drugs can have real implications on the brain and adverse effects, dose-related effects, and cumulative impact on thinking processes and sensory perception.  
As needed, offer safety measures such as handrails and padding and constant observation and seizure precautions.    It is always vital to take into consideration the patient’s safety.

Nursing Care Plan for Altered Mental Status 2

Impaired Verbal Communication

Nursing Diagnosis: Impaired Verbal Communication related to dysphasia, secondary to altered mental status as evidenced by difficulty in communicating effectively.

Desired Outcome: The patient will improve his communication skills and learn to express himself more freely.

Nursing Interventions for Altered Mental StatusRationale
Learn about the patient’s needs and pay close attention to nonverbal signals.  The nurse should schedule sufficient time to devote to all areas of healthcare. When there is a communication issue, care measures may take longer.  
Provide other methods of communication to the patient.  Complementary communication methods such as flashcards, symbol boards, electronic messaging can assist the patient in expressing thoughts and communicating needs.    
Allow enough time for the patient to reply.  Patients may struggle to answer beneath pressure. They may require additional time to formulate thoughts. Therefore, identify the relevant term, or make appropriate language translations.    
Allow the patient to relax while communicating.      Patients with altered mental status may find it easier to communicate when they are comfortable and relaxed and speak to only one person simultaneously.
Examine for the existence of expressive dysphasia (loss of the ability to communicate information verbally) and receptive dysphasia (word meaning may be confused during the patient’s brain’s information processing).  The patient with expressive dysphasia has language impairment speech but has common verbal understanding. This sort of dysphasia may impede one’s ability to read and understand. The patient with receptive dysphasia speaks fluently, but the substance of his or her conversation is frequently nonsensical.  
When speaking with the patient, minimize interruptions such as television and radio to a minimum.  To keep the patient engaged, reduce the amount of information sent to the brain for processing, and employ active listening techniques.  
Unless the patient has a hearing impairment, avoid speaking loudly.  If the barriers include primary language, aphasia, or sensory impairment, speaking loudly does not increase the patient’s comprehension.    
When communicating, keep eye contact with the patient. Come closer to the patient, within his or her line of sight, generally midline.  Patients may have a deficiency in their range of view, or they may need to see the nurses’ faces or lips to grasp better what is stated.  
Generate a checklist of words that the patient can utter and add new ones as needed. Distribute this checklist to family, friends, significant others, and other caregivers.    Providing information with others expands the patient’s network of persons with whom he or she can interact.  
Allow the family and friends to raise inquiries pertaining to the patient’s communication issue.  The family must recognize that there are numerous ways to transmit information to someone and that time may be required to grasp the patient’s particular needs.  
Recommend to relevant resources such as a speech pathologist, group therapy, supportive psychotherapy, and psychiatric counseling.  Individualized services may be required to accommodate the needs of the patient.    
Monitor the patient’s mental health status, and assess the existence of psychotic illnesses such as manic-depressive disorder and schizoid/affective behavior.  Examine the psychological reaction to communication impairment and the desire to pursue alternative modes of communication. It is critical to assess the patient’s psychological condition to identify relevant elements.  

Nursing Care Plan for Altered Mental Status 3

Risk for Injury

Nursing Diagnosis: Risk for Injury related to modifications in cognitive performance and hypoxia secondary to altered mental status as evidenced by complex decision making.

Desired Outcome: The patient will identify the elements that enhance their risk of injury and display injury-avoidance behaviors.

Nursing Interventions for Altered Mental StatusRationale
Determine the patient’s age, growth level, overall health, lifestyle, impaired communication, intellectual disabilities, movement, conceptual understanding, and decision-making abilities.  These elements influence the patient’s capacity to safeguard oneself from harm. When developing a treatment plan or educating patients about safety precautions, nurses must properly analyze each of these aspects.  
Assist the patient in becoming acquainted with their environment.  Place the call light in easy reach and educate the patient on using it to summon help. To avoid injuries, the patient should be familiar with the area’s layout. Items that are too far away from the patient may pose a risk.  
Acknowledge the patient’s sentiments and worries about potential environmental hazards.  Validation informs the patient that the nurse has heard and comprehended the facts and concerns expressed. It also aids in the promotion of nurse-patient interaction.  
Examine the home environment for any hazards.  Patients with reduced mobility, visual acuity, and altered mental status, including dementia and other cognitive functioning disorders, are vulnerable to common dangers. Slips, trips, and falls in the home caused by household risks are associated with older people with a history of falls or functional impairment.  
Perform a safety evaluation in the patient’s home or care setting.  Nurses conduct an environmental assessment to determine the existence of devices or items such as cords or hooks that could be utilized in suicidal hanging. As a result, it must be eliminated to safeguard the patient’s protection.    

Nursing Care Plan for Altered Mental Status 4

Risk for Falls

Nursing Diagnosis: Risk for Falls related to impaired alertness, changes in intellectual function, and behavior secondary to altered mental status as evidenced by modifications in cognitive behavior and disorientation.

Desired Outcome: The patient will exhibit chosen prevention measures and establish techniques to promote home security and avoid falls.

Nursing Interventions for Altered Mental StatusRationale
Create a personalized care measure to avoid falls. Provide a treatment plan that is tailored to the patient’s specific requirements.  A diverse strategy is required to plan a personalized fall prevention program for nursing care in every healthcare setting. Avoid depending too heavily on general fall prevention because everyone’s demands are different.  
Advise the patient about the benefits of using glasses and hearing aids.  Encourage patients to have their eyesight and hearing examined regularly. The risk of injury can be lowered if the patient employs appropriate aids to promote visual and auditory orientation to the surroundings. Falls can be exacerbated by visual impairment.    
Examine any changes in mental condition.  Individuals with impaired awareness and confusion may be unsure of where they are or what they can do to help themselves. They may wander from one location to another, putting their safety at risk. Furthermore, uncertainty and impaired judgment raise the patient’s risk of falling.    
Examine the patient’s medication list.  Medication use, such as antihypertensive medications, ACE inhibitors, diuretics, tricyclic antidepressants, alcohol consumption, anti-anxiety medications, opiates, and hypnotics or tranquilizers, is also a risk factor for falls.  
Increase patient’s home support.    Several community outreach organizations aid patients and create safe settings in their homes.

Nursing Care Plan for Altered Mental Status 5

Ineffective Coping

Nursing Diagnosis: Ineffective Coping related to negative feelings while dealing with demands and stressors of life secondary to altered mental status as evidenced by anxiety and inability to resolve problems.

Desired Outcome: The patient will learn to cope with life’s problems and deal with them without being anxious.

Nursing Interventions for Altered Mental StatusRationale
Look for grounds of unsuccessful coping, such as low self-esteem, bereavement, a lack of problem-solving capabilities, insufficient support, or a dramatic shift in one’s life situation.  Situational elements must be discovered to acquire knowledge of the patient’s present position and assist the patient in properly coping.  
For examination and counseling, contact medical community assistance.  As part of the medical plan of care, this will support adequate coping.    
Promote cognitive-behavioral relaxation techniques such as music therapy and guided visualization.  Meditation, desensitization, and relaxation therapy help patients manage, seize control, and reduce anxiety.  
Communicate with empathy.  Recognizing and having empathy with others fosters a supportive environment that improves coping.    
Establish a proper relationship with the patient by providing a continuum of care.    A continuing friendship fosters trust, lowers the sense of loneliness, and may enhance mental status alteration.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

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Nursing Stat Facts

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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