Understanding Altered Mental Status (AMS)
Altered mental status refers to a change in a person’s awareness, responsiveness, cognition, or perception. It can be caused by a myriad of factors, such as neurological disorders, metabolic imbalances, infections, intoxication, or trauma.
Common Causes of AMS
- Neurological conditions (e.g., stroke, seizures, head injury)
- Metabolic disturbances (e.g., hypoglycemia, hyponatremia, hepatic or renal failure)
- Infections (e.g., meningitis, encephalitis, sepsis)
- Toxicity or intoxication (e.g., alcohol, drugs, poisons)
- Psychological factors (e.g., psychiatric disorders, delirium)
- Medication effects or withdrawal
Significance of Accurate Nursing Diagnosis
Proper identification of nursing diagnoses related to AMS guides targeted interventions, facilitates communication among healthcare providers, and improves patient safety. It also helps in prioritizing care, monitoring progress, and evaluating treatment effectiveness.
Common Nursing Diagnoses for Altered Mental Status
The nursing diagnoses associated with altered mental status often fall into categories such as disturbed consciousness, risk for injury, impaired cognition, and ineffective airway clearance, among others.
1. Disturbed Sensory Perception
This diagnosis is used when a patient experiences a disruption in the normal sensory reception and perception, which can manifest as confusion, hallucinations, or delusions.
Related Factors:
- Neurological injury
- Infection
- Substance intoxication or withdrawal
- Medications affecting CNS
Defining Characteristics:
- Disorientation to time, place, person
- Hallucinations or delusions
- Difficulty interpreting stimuli
Nursing Interventions:
- Ensure a safe environment
- Reorient the patient frequently
- Use communication techniques suited to the patient’s level
- Monitor for worsening mental status
2. Impaired Cognitive Function
This diagnosis applies when the patient demonstrates difficulty with memory, attention, reasoning, or problem-solving.
Related Factors:
- Brain injury
- Metabolic imbalances
- Neurodegenerative diseases
Defining Characteristics:
- Forgetfulness
- Inability to follow commands
- Decreased attention span
Nursing Interventions:
- Use simple, clear communication
- Provide orientation aids (clocks, calendars)
- Involve family in care
- Monitor cognitive status regularly
3. Risk for Injury
Patients with AMS are at increased risk for falls, accidental self-harm, or injury due to impaired judgment or consciousness.
Related Factors:
- Altered sensorium
- Unsteady gait or weakness
- Medications causing sedation
Defining Characteristics:
- Unsteady gait
- Disorientation
- Sudden movements or agitation
Nursing Interventions:
- Keep bed rails up
- Employ fall precautions
- Keep the environment free of hazards
- Constant supervision
4. Ineffective Airway Clearance
Altered mental status can compromise airway protection, leading to aspiration or hypoxia.
Related Factors:
- Decreased consciousness
- Loss of gag reflex
- Secretions accumulation
Defining Characteristics:
- Coughing or choking
- Decreased oxygen saturation
- Gurgling or noisy breathing
Nursing Interventions:
- Position patient to maintain airway patency
- Suction secretions as needed
- Monitor respiratory status closely
- Prepare for advanced airway management if necessary
5. Risk for Impaired Skin Integrity
Prolonged immobility due to AMS increases the risk of pressure ulcers.
Related Factors:
- Unresponsive or immobile state
- Decreased sensation
- Friction and shear forces
Defining Characteristics:
- Reddened or broken skin
- Presence of pressure ulcers
Nursing Interventions:
- Reposition regularly
- Use pressure-relieving devices
- Maintain skin hygiene
- Inspect skin frequently
Assessment Strategies for AMS
Effective nursing diagnosis begins with thorough assessment. Key components include:
1. Patient History
- Onset and duration of mental status changes
- Recent illnesses or injuries
- Medication history
- Substance use
- Past neurological or psychiatric conditions
2. Physical Examination
- Level of consciousness (using Glasgow Coma Scale or AVPU scale)
- Neurological assessment (pupil size and reactivity, motor and sensory function)
- Vital signs and oxygen saturation
- Signs of infection or metabolic disturbances
3. Diagnostic Tests
- Blood tests (glucose, electrolytes, renal and liver function)
- Imaging studies (CT scan, MRI)
- Lumbar puncture if infection suspected
- Toxicology screening
Formulating Nursing Diagnoses
When developing nursing diagnoses for AMS, consider the following steps:
- Identify the patient's primary health problem based on assessment findings.
- Determine the related factors contributing to AMS.
- Establish defining characteristics to support diagnosis.
- Prioritize diagnoses based on severity and potential for harm.
Example:
- Nursing Diagnosis: Risk for Injury related to altered mental status as evidenced by disorientation and unsteady gait.
- Expected Outcomes: The patient will remain safe with no injuries during hospitalization.
Interventions and Management of AMS
Management of patients with AMS involves multidisciplinary efforts, with nursing interventions focusing on safety, monitoring, and supportive care.
1. Ensuring Safety
- Implement fall precautions
- Keep environment uncluttered
- Use bed alarms if necessary
2. Monitoring and Reassessment
- Regularly assess mental status
- Monitor vital signs and oxygenation
- Observe for signs of deterioration
3. Supporting Physiological Needs
- Maintain airway patency
- Manage hydration and nutrition
- Prevent skin breakdown
4. Communication and Reorientation
- Use simple language
- Reorient frequently
- Involve family members for familiar cues
5. Treat Underlying Causes
- Collaborate with medical team to address infections, metabolic imbalances, or neurological issues
- Administer medications as prescribed
- Monitor response to treatment
Conclusion
Nursing diagnosis for altered mental status is vital in guiding effective patient care. Recognizing the various potential diagnoses, understanding their related factors and defining characteristics, and implementing appropriate interventions can significantly improve patient safety and outcomes. Nurses must conduct comprehensive assessments, formulate precise diagnoses, and collaborate with the healthcare team to address the underlying causes of AMS. Through vigilant monitoring, safety measures, and supportive care, nurses play an essential role in managing patients with altered mental status and facilitating recovery or stabilization.
References
- Carpenito, L. J. (2010). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. Lippincott Williams & Wilkins.
- Ackley, B. J., & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. Elsevier.
- Lewis, S. L., et al. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.
- American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Frequently Asked Questions
What are the common nursing diagnoses for a patient with altered mental status?
Common nursing diagnoses include Risk for Injury, Impaired Memory, Impaired Verbal Communication, and Risk for Falls, related to the patient's altered level of consciousness and cognitive function.
How does a nurse assess for potential causes of altered mental status?
The nurse conducts a comprehensive assessment including neurological examination, vital signs, blood glucose levels, medication review, and evaluates for signs of infection, metabolic imbalances, or neurological deficits.
What interventions are prioritised in nursing care for patients with altered mental status?
Priorities include ensuring patient safety, maintaining airway patency, preventing falls, monitoring neurological status, providing orientation, and supporting physiological needs such as hydration and nutrition.
How can nurses evaluate the effectiveness of interventions for altered mental status?
Effectiveness is assessed by monitoring improvements in mental status, stabilization of vital signs, absence of injury or complications, and patient’s ability to respond appropriately to stimuli.
What are the key considerations for documentation when managing patients with altered mental status?
Documentation should include detailed descriptions of mental status changes, neurological findings, interventions performed, patient responses, safety measures implemented, and any communication with multidisciplinary teams.
