Nursing care plan for altered mental status

Introduction

Altered mental status is a medical emergency that can occur in both the elderly and the young. Altered mental state is characterized by decreased awareness and responsiveness, confusion, disorientation, agitation, and delirium. When a patient's mental or cognitive functioning deviates from their normal level of functioning it is a serious health issue.

Assessment

Neurologic/Psychiatric Functioning: The patient’s neurologic or psychiatric functioning should be assessed, including level of consciousness, attention span, response to stimuli, orientation, memory deficits, and language functioning. Vital signs and nutrition, hydration, and rest needs also need to be evaluated.

Psychosocial History: It is important to obtain an understanding of the patient’s psychosocial history. This involves collecting information about their social support system, history of trauma, substance use and abuse, psychosis, depression, and other psychological factors.

Nursing Diagnosis

Ineffective Coping: The patient has difficulty expressing thoughts and emotions and is unable to cope with the current situation.

Risk for Injury: The patient’s lack of awareness and decreased physical coordination places them at risk for injury.

Alteration of Comfort: The patient experiences a decreased level of comfort and physical discomfort due to the altered mental state.

Outcomes

The patient will be able to verbalize coping strategies to manage the current situation.

The patient will be safely contained, protected from harm, and free from injury.

The patient will experience a improved level of comfort and physical well-being.

Interventions

• Support and reassure the patient.
• Provide a safe environment that reduces external stimuli.
• Provide frequent orientation to prevent self-injury.
• Use calming techniques and interventions for agitation.
• Encourage the patient to participate in problem-solving activities.
• Provide adequate food, fluids, and rest.

Rationales

• Supporting the patient and reassuring them helps to reduce anxiety and fear.
• A safe and comfortable environment promotes a feeling of security and helps to reduce agitation.
• Frequent orientation helps the patient to remain oriented and alleviates confusion.
• Calming techniques help the patient manage agitation.
• Problem solving activities provide a means for the patient to express their feelings and gain control of a situation.
• Adequate food, fluids, and rest can help to improve functioning.

Evaluation

The patient verbalized coping strategies to manage their current situation. The patient remained safely contained and free from injury. The patient experienced a decrease in their level of anxiety and an increase in their comfort level.

Conclusion

Altered mental status is a medical emergency that requires proper assessment, diagnosis, and treatment. A nursing care plan for an altered mental state should include interventions to promote safety, reduce agitation and promote improved physical comfort. Evaluation should be done to assess outcome goals and assess the effectiveness of interventions.

FAQs

• What is altered mental status? Altered mental status is a medical emergency that can occur in both the elderly and the young. Altered mental state is characterized by decreased awareness and responsiveness, confusion, disorientation, agitation, and delirium.
• What are some nursing diagnosis for altered mental status? Ineffective Coping, Risk for injury and Alteration of Comfort.
• What are some interventions for altered mental status? Support and reassure the patient, Provide a safe environment, Use calming techniques and interventions, Encourage the patient to participate in problem-solving activities, Provide adequate food, fluids, and rest.
• What is included in the evaluation of altered mental status? The patient’s verbalization of coping strategies, the patient’s containment and freedom from injury and the patient’s comfort level.
• Is altered mental status a serious health issue? Yes, when a patient’s mental or cognitive functioning deviates from their normal level of functioning it is a serious health issue.