Altered mental status (AMS) is a broad term used to represent a variety of diseases affecting mental functioning ranging from mild disorientation to coma. Fundamentally, a patient’s level of consciousness and cognition are combined to form their mental status. Patients may have abnormalities of either one or both of these components. Show
The range of differential diagnoses is extensive, however, they can often be classified in the following categories:
Trauma, metabolic abnormalities, and toxic ingestion are the most frequent causes of altered mental status in newborns and young children. Young adults most frequently exhibit altered mental status as a result of exposure to toxic substances or trauma. The most frequent causes of altered mental status in the elderly include stroke, illness, drug-drug interactions, or modifications to the living environment. The Nursing ProcessTo lower patient morbidity and mortality, it is necessary to identify the early indicators of altered mental status, determine the underlying cause, and administer the proper care. The nurse can assist in symptomatic management techniques including volume resuscitation for shock, antibiotics for sepsis, glucose for hypoglycemia, or the prevention of deterioration by intubating. A thorough physical examination and history taking are necessary to manage and evaluate changes in mental status. Mental status changes can appear suddenly and are a symptom of an underlying cause. Safety is also a priority as AMS can lead to falls and injury. Nursing Care Plans Related to Altered Mental StatusIneffective Cerebral Tissue PerfusionIneffective cerebral tissue perfusion associated with altered mental status can be caused by decreased cerebral blood flow due to underlying conditions such as metabolic conditions (e.g. hypoglycemia or hypoxia), low levels of acetylcholine synthesis, and substrate deficiency for neural function. Nursing Diagnosis: Ineffective Tissue Perfusion Related to:
As evidenced by:
Expected outcomes:
Ineffective Cerebral Tissue Perfusion Assessment1. Assess vital signs and underlying cause. 2. Assess neurological status. 3. Review medications and use of intoxicants. Ineffective Cerebral Tissue Perfusion Interventions1. Determine the appropriate level of care. 2. Administer fluids and electrolytes as prescribed. 3. Prepare the client for surgical procedure as indicated. Acute ConfusionAcute confusion associated with altered mental status can be caused by a disruption to consciousness, attention, cognition, and perception that occurs suddenly and is reversible. Nursing Diagnosis: Acute Confusion Related to:
Evidenced by:
Expected outcomes:
Acute Confusion Assessment1. Determine possible causative factors. 2. Assess mental status. 3. Monitor lab values. 4. Assess for current medication use and presence of substance
abuse. Acute Confusion Interventions1. Provide constant orientation to person, place, and time as needed. 2. Prevent sundowning. 3. Educate caregivers to monitor the client at home. 4. Provide a stable and calm environment. Risk for InjuryRisk for Injury associated with altered mental status can result in physical harm due to a disruption of consciousness, attention, and cognition as well as impaired perception. This increases the risk of an unsafe environment and the risk of injury. Nursing Diagnosis: Risk for Injury Related to:
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are aimed at prevention. Expected outcomes:
Risk for Injury Assessment1. Assess safety issues. 2. Assess the client’s knowledge of safety precautions. 3. Note individual risk factors. 4. Ascertain caregiver’s expectations. Risk for Injury Interventions1. Provide safe nursing care. 2. Inform the client about all treatments and medications. 3. Reduce the risk of injury. 4. Prepare the client for a safe home environment. References and Sources
Which are the priority nursing actions when providing care to a trauma client?The priority nursing actions when providing care for a trauma client include starting a large-bore IV, immobilizing any obvious deformities, and removing clothing to allow for an adequate examination.
Which nursing actions are the priority actions after the completion of the secondary survey when providing care for a trauma client with a penetrating wound?The priority nursing actions after completion of the secondary survey during the emergency assessment include documenting all patient care and administering tetanus prophylaxis.
Which emergency severity index level should be considered a high priority for the nurse caring for a client in the emergency department?The Emergency Severity Index (ESI) stratifies patients into five acuity groups: Level 1 (resuscitation) requires immediate, life-saving intervention. Level 1 includes patients with cardiopulmonary arrest, major trauma, severe respiratory distress, and seizures.
Which member of the healthcare team when using the team nursing approach is responsible for prioritizing client care?The nurse is responsible for prioritizing and individualizing a client's plan of care. Prioritization is defined as “deciding which needs or problems require immediate action and which ones could be delayed until a later time because they are not urgent” (Silvestri, 2004, p. 65).
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