Altered Mental Status (AMS) signals an acute change in a patient’s brain function. Documenting this finding allows medical teams to identify and treat the underlying cause quickly. Clarifying how AMS is classified within professional nursing standards is important for patient safety and consistent care planning.
Defining Altered Mental Status
Altered Mental Status describes any deviation from a person’s typical level of consciousness, attention, or cognition. It is not a specific disease but a clinical sign indicating a disruption in normal brain function. The manifestations of AMS can range widely, encompassing a spectrum of observable changes.
These changes might include acute confusion, disorientation, or sudden forgetfulness. Severe AMS presents as lethargy, stupor, or a total lack of awareness (coma). The presence of AMS demands immediate attention because it suggests an underlying physiological or psychological issue, such as infection, metabolic imbalance, or a neurological event.
Understanding the Nursing Diagnosis Framework
A nursing diagnosis is a standardized label used to identify a patient’s response to actual or potential health problems. This framework guides the selection of appropriate nursing interventions to achieve patient outcomes. It differs from a medical diagnosis because it focuses on the human experience of illness rather than the disease pathology itself.
The most widely used classification system is provided by NANDA International (NANDA-I). A common structure for writing a problem-focused nursing diagnosis is the P-E-S format: Problem (the NANDA-I label), Etiology (the related factor or cause), and Signs/Symptoms (the observable characteristics).
The Distinction Between Medical Signs and Nursing Focus
Altered Mental Status is a clinical observation or medical sign, not a stand-alone NANDA-I nursing diagnosis. Medical diagnoses, such as delirium or stroke, focus on identifying the specific pathological process causing the change in mental status. Treating AMS medically involves addressing the root cause, such as administering glucose for hypoglycemia or antibiotics for infection.
The nursing focus centers on the patient’s functional response to AMS and the associated risks. For instance, while the medical diagnosis addresses the cause, the nurse focuses on the patient’s inability to communicate needs or the high risk of falling due to impaired judgment. Nursing interventions manage the manifestations of AMS and ensure patient safety, capturing the functional impairment to direct the care plan.
Appropriate NANDA-I Diagnoses for Manifestations of AMS
Since AMS is a sign, nurses use specific NANDA-I diagnoses to articulate the human responses they observe. The most common diagnosis for cognitive changes is “Acute Confusion,” which relates to a sudden onset of disturbances in attention and awareness. This diagnosis directs the nurse to implement interventions like frequent reorientation and cognitive stimulation.
Other appropriate diagnoses address functional impairments. If AMS affects the ability to express thoughts or understand language, “Impaired Verbal Communication” is used. If the patient has difficulty recalling information, the nurse may use “Impaired Memory.” Because AMS often involves impaired judgment and uncoordinated movement, “Risk for Injury” is frequently selected. This risk diagnosis mandates interventions focused on fall prevention, maintaining a safe environment, and close monitoring.