This guide is about altered mental status, altered mental status nursing assessment, and altered mental status care plan. It can be employed in the creation of altered mental status care plans for educational purposes.
Altered Mental Status
The diagnosis Altered Mental Status describes an individual with altered perception and cognition that interferes with daily living. Causes are biochemical or psychological disturbances like depression and personality disorders.
The focus of nursing is to reduce altered thinking and promote reality orientation. Often, confusion in older adults is erroneously attributed to aging. Confusion in older adults can be caused by a single factor or multiple factors such as depression, dementia, medication side effects, or metabolic disorders. Depression causes impaired thinking in older adults more frequently than dementia.
Here are some factors that may be related to Altered Mental Status:
- Head injuries
- Substance abuse
- Emotional changes
- Mental disorders
- Late-life depression
Situational (Personal, Environmental)
- Abuse (physical, sexual, mental)
- Childhood trauma
Signs and Symptoms
Altered Mental Status is characterized by the following signs and symptoms:
Major (Must Be Present)
- Inaccurate interpretation of stimuli, internal or external
Minor (May Be Present)
- Cognitive deficits (abstraction, problem-solving, memory deficits)
- Inappropriate social behavior
- Lack of consensual validation
- Ritualistic behavior
Goals and Outcomes
The following are the common goals and expected outcomes for Altered Mental Status:
- Patient maintains reality orientation and communicate clearly with others
- Patient recognizes changes in thinking/behavior.
- Patient recognizes and clarifies possible misinterpretations of the behaviors and verbalization of others.
- Patient identifies situations that occur before hallucination/delusions.
- Patient uses coping strategies to deal with effectively with hallucinations/delusions.
- Patient participates in unit activities.
- Patient expresses delusional material less frequently.
- Patient appropriately interacts and cooperates with staff and peers in therapeutic community setting.
Altered Mental Status Nursing Assessment
The following are the comprehensive assessments for Altered Mental Status:
|Identify factors present [acute/chronic brain syndrome (recent stroke, Alzheimer’s disease), brain injury or increased intracranial pressure, anoxic event, acute infections, malnutrition, sleep or sensory deprivation, chronic mental illness (schizophrenia)].||Identifying factors present is important to know the causative/contributing factors.|
|Determine alcohol/other drug use.||Drugs can have direct effects on the brain, or have side effects, dose-related effects, and/or cumulative effects that alter thought patterns and sensory perception.|
|Review laboratory values for abnormalities such as metabolic alkalosis, hypokalemia, anemia, elevated ammonia levels, and signs of infection.||Monitoring laboratory values aids in identifying contributing factors.|
|Assess dietary intake/nutritional status.||This helps in identifying contributing factors.|
|Assess attention span/distractibility and ability to make decisions or problem solve.||This determines the ability of the p[atient to participate in planning/executing care.|
|Assist with testing/review results evaluating mental status according to age and developmental capacity.||This is to assess the degree of impairment.|
|Interview SO or caregiver to determine patient’s usual thinking ability, changes in behavior, length of time problem has existed, and other pertinent information.||This is to provide baseline for comparison.|
|Perform periodic neurological/behavioral assessments, as indicated, and compare with baseline.||Early recognition of changes promotes proactive modifications to plan of care.|
Altered Mental Status Care Plan
The following are the therapeutic nursing interventions for Altered Mental Status:
|Assist with treatment for underlying problems, such as anorexia, brain injury/increased intracranial pressure, sleep disorders, biochemical imbalances.||Cognition/thinking often improves with treatment/correction of medical/psychiatric problems.|
|Reorient to time/place/persin, as needed.||Inability to maintain orientation is a sign of deterioration.|
|Have patient write name periodically; keep this record for comparison and report differences.||These are important measures to prevent further deterioration and maximize level of function.|
|Provide safety measures (e.g., side rails, padding, as necessary; close supervision, seizure precautions), as indicated.||It is always necessary to consider the safety of the patient.|
|Schedule structured activity and rest periods.||This provides stimulation while reducing fatigue.|
|Maintain a pleasant and quiet environment and approach patient in a slow and calm manner.||Patient may respond with anxious or aggressive behaviors if startled or overstimulated.|
|Present reality concisely and briefly and do not challenge illogical thinking. Avoid vague or evasive remarks.||Delusional patients are extremely sensitive about others and can recognize insincerity. Evasive comments or hesitation reinforces mistrust or delusions.|
|Be consistent in setting expectations, enforcing rules, and so forth.||Clear, consistent limits provide a secure structure for the patient.|
|Reduce provocative stimuli, negative criticism, arguments, and confrontations.||This is to avoid triggering fight/flight responses.|
|Refrain from forcing activities and communications.||Patient may feel threatened and may withdraw or rebel.|
|Do not flood patient with data regarding his or her past life.||Individuals who are exposed to painful information from which the amnesia is providing protection may decompensate even further into a psychotic state.|
|Identify specific conflicts that remain unresolved, and assist patient to identify possible solutions.||Unless these underlying conflicts are resolved, any improvement in coping behaviors must be viewed as only temporary.|
|Provide nutritionally well-balanced diet, incorporating patient’s preferences as able. Encourage patient to eat. Provide pleasant environment and allow sufficient time to eat.||These enhance intake and general well-being.|
|Recognize and support the patient’s accomplishments (projects completed, responsibilities fulfilled, or interactions initiated).||Recognizing the patient’s accomplishments can lessen anxiety and the need for delusions as a source of self-esteem.|
|Use touch cautiously, particularly if thoughts reveal ideas of persecution.||Patients who are suspicious may perceive touch as threatening and may respond with aggression.|
|Use the techniques of consensual validation and seeking clarification when communication reflects alteration in thinking. (Examples: “Is it that you mean . . . ?” or “I don’t understand what you mean by that. Would you please explain?”)||These techniques reveal to the patient how he or she is being perceived by others, while the responsibility for not understanding is accepted by the nurse.|
|Engage the patient in one-to-one activities at first, then activities in small groups, and gradually activities in larger groups.||A distrustful patient can best deal with one person initially. Gradual introduction of others when the patient can tolerate is less threatening.|
|Encourage patient to verbalize true feelings. Avoid becoming defensive when angry feelings are directed at him or her.||Verbalization of feelings in a non-threatening environment may help patient come to terms with long-unresolved issues.|
|Teach patient to intervene, using thought-stopping techniques, when irrational or negative thoughts prevail.||Thought stopping involves using the command “stop!” or a loud noise (such as hand clapping) to interrupt unwanted thoughts. This noise or command distracts the individual from the undesirable thinking that often precedes undesirable emotions or behaviors.|
|Encourage patient to participate in resocialization activities/groups when available.||This is to maximize level of function.|
|Assist in identifying ongoing treatment needs/rehabilitation program for the individual.||This measure is important to maintain gains and continue progress if able.|
|Identify problems related to aging that are remediable and assist patient to seek appropriate assistance/access resources.||These encourage problem-solving to improve condition rather that accept the status quo.|
|Assist patient and SO develop plan of care when problems are progressive/long term.||Advance planning addressing home care, transportation, assistance with care activities, support and respite for caregivers, enhance management of patient in home setting.|
|Refer to community resources (e.g., day-care programs, support groups, drug/alcohol rehabilitation, mental health treatment programs).||These measures are necessary to promote wellness.|
Altered Mental Status Care Plan Examples
Nursing Care Plan for Altered Mental Status 1
Nursing Diagnosis: Impaired Thought Process related to altered perception of the surroundings secondary to schizophrenia as evidenced by delusions and hallucinations.
Desired outcome: The patient will learn to recognize delusional thoughts if they continue and appropriately perceive the environment.
|Nursing Interventions for Altered Mental Status||Rationale|
|Collaborate with patients based on what is going on around them. Try to divert the client’s attention away from their hallucinations by engaging them in activities such as arts and crafts or card and board games.||When the client’s thoughts are concentrated on reality-based activities, he or she is free of deluded thinking. It also aids in externally focusing attention.|
|If a patient believes they need to defend themselves from a specific person, use safety measures to safeguard them or others. Precautions must be taken.||During the acute period, the client’s delusional thinking may lead them to believe that they must harm others or themselves to be safe. External controls may be required.|
|Put effort into comprehending the significance of these beliefs to the patient during their presentation.||The patient’s seemingly nonsensical hallucinations contain significant insight into their underlying concerns and issues.|
|Recognize feelings associated with delusions. For example: The patient may feel afraid if he or she thinks that someone will harm him or her. It will help to reorient the patient.If the patient believes that someone or something is directing their thoughts, they may feel helpless.||Anxiety may decrease when people believe they are understood. As a result, this technique is a beneficial intervention for schizophrenia.|
|with patients based on what is going on around them. Try to avert the patient’s attention away from their hallucinations by participating in reality-based activities (e.g., card games, simple arts and crafts projects).||When the patient’s thoughts are concentrated on actual life activities, he or she is free of fallacious beliefs. It aids in objectively focusing attention.|
Nursing Care Plan for Altered Mental Status 2
Eating Disorders (Anorexia and Bulimia)
Nursing Diagnosis: Altered mental status related to deranged body image and severe low self-esteem secondary to eating disorder as evidenced by even if they have average body weight or are severely emaciated, they perceive themselves to be overweight.
Desired outcome: The patient will develop a more authentic body image and accept himself as unique.
|Nursing Interventions for Altered mental status||Rationale|
|Encourage active participation in a personal improvement program, specifically in a group environment. Deliver information on correct cosmetics and grooming applications.||Understanding how to improve one’s look may benefit one’s long-term feeling of self-esteem and reputation. Other people’s opinions might boost one’s self-esteem.|
|Help the patient in confronting puberty-related changes and sexual anxieties. As needed, conduct sex education.||Adolescents experience significant physical and psychological changes, contributing to eating disorders. Feelings of impotence and inability to control feelings (especially sexual sensations) result in a subconscious urge to desexualize oneself. The patient frequently assumes that these worries may be resolved by controlling body and physical growth and function.|
|Declares the regulations for weighing, remaining in sight during medicine and feeding times, and the consequences for not adhering to the rules. Be thorough in enforcing regulations without making unnecessary comments.||Building rapport requires consistency. As a component of the behavioral therapy program, the patient is aware of the potential risks of not adhering to specified norms (decrease in privileges). Failure to meet regulations is considered a patient’s decision and is matter-of-factly acknowledged by personnel so that bad behavior is not reinforced.|
|Be mindful of personal reactions to a patient’s conduct. Arguing should be avoided.||When dealing with these individuals, feelings of revulsion, hatred, and frustration are common. Even with weight increases, the prognosis is frequently poor because other disorders may persist. Many patients continue to perceive themselves as overweight, and there is a significant prevalence of affective disorders, specific anxiety, obsessive-compulsive symptoms, substance misuse, and psychosexual dysfunction. The nurse must deal with her reactions and feelings to not compromise with the treatment.|
|Encourage the patient to take responsibility for her or his own life more healthily by making her or his judgments and embracing herself or himself as she or he is at this time (including inadequacies and strengths).||The patient frequently does not know what she or he wants for himselF. Parents (usually the mother) frequently make decisions on behalf of the patient. The patient may also think that he must be the greatest at anything and keep himself accountable for being perfect.|
Nursing Care Plan for Altered Mental Status 3
Nursing Diagnosis: Altered mental status related to stressful life situations secondary to major depression as evidenced by the inadequate capacity to understand concepts or organize thoughts.
Desired Outcome: The patient will learn to accurately recall recent and distant knowledge and have a well-organized mental process.
|Nursing Interventions for altered mental status||Rationale|
|Use plain, concrete language.||Cognition is hampered by delayed thinking and trouble concentrating.|
|Allow adequate time for the patient to ponder and frame responses.||Slower thinking needs more time to consider a response.|
|Allow the patient more time than average to complete their usual activities of daily living (ADL) (e.g., eating, dressing).||Typical tasks may take quite a long time; requests that the patient hurry heightens the tension and impede the patient’s ability to think effectively.|
|Assist the patient in deferring critical major life decisions.||Making sound life decisions necessitates excellent psychophysiological functioning.|
|Reduce the patient’s duty while he is significantly depressed.||This approach reduces feelings of guilt, anxiety, and stress.|