Altered Mental Status (AMS) Nursing Diagnosis & Care Plan – devshopsimplenursing

Altered Mental Status (AMS) Nursing Diagnosis & Care Plan

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By Amanda Thomas
Updated On May 2025
Medically Reviewed by:
Angela Slater FNP, RN
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Identifying an altered mental status nursing diagnosis early is critical for guiding assessment and intervention. 

Whether the cause is neurological, metabolic, or infectious, changes in mental status often signal a shift in patient stability. Nurses play a key role in recognizing subtle symptoms, escalating care, and monitoring for complications that can rapidly become life-threatening.

What is Altered Mental Status?

When a patient’s behavior or awareness suddenly shifts, it’s a sign that something deeper may be going on. 

Understanding the possible causes behind these changes lays the groundwork for accurate assessment and effective nursing care.

Definition and Overview

AMS is a broad term describing a decline in cognitive function, consciousness, or behavior. 

It can present as confusion, disorientation, lethargy, or agitation and may indicate an acute or chronic condition affecting the brain. AMS is a medical emergency when it develops suddenly, as it may signal life-threatening conditions like stroke, sepsis, or hypoxia.

Common Causes of AMS

AMS can result from various medical conditions, including:

Differentiating AMS from Dementia, Delirium, and Psychiatric Conditions

Feature AMS  Dementia Delirium Psychiatric Condition
Onset Acute Chronic, progressive Acute, fluctuating Variable
Cause Medical condition Neurodegenerative Medical condition Mental health disorder
Reversibility Often reversible Irreversible Usually reversible Variable
Symptoms Confusion, agitation, lethargy Memory loss, gradual cognitive decline Disorientation, hallucinations, agitation Hallucinations, delusions, mood disturbances

Causes of Altered Mental Status (Related To)

  • Hypoxia, hypoglycemia, and electrolyte imbalances – Lack of oxygen, low blood sugar, or sodium imbalances can impair brain function.
  • Infections (e.g., sepsis, UTI in older adult patients) – Systemic infections cause inflammation and confusion, especially in older adults.
  • Neurological conditions (e.g., stroke, traumatic brain injury) – Damage to brain tissue disrupts cognitive and motor functions.
  • Medication-induced AMS (e.g., opioids, sedatives, polypharmacy) – Overmedication or drug interactions can cause drowsiness, confusion, or hallucinations.

Signs and Symptoms of Altered Mental Status (As Evidenced By)

  • Confusion, disorientation, difficulty concentrating – Patients may struggle to recognize their surroundings or follow conversations.
  • Agitation, restlessness, or lethargy – AMS can present as hyperactivity or extreme drowsiness.
  • Hallucinations or delusions – Patients may report seeing or hearing things that aren’t real.
  • Changes in speech, coordination, or behavior – Slurred speech, unsteady gait, or unusual personality changes may indicate AMS.

Risk Factors for Altered Mental Status

Pinpointing a nursing diagnosis related to altered mental status starts with knowing who’s at risk. 

From hospitalized patients to those managing multiple meds, certain populations are more likely to experience changes in mental status — and spotting those risk factors early is key to preventing complications.

  • Older adult patients and those with chronic conditions – Older adults are more prone to AMS due to frailty and underlying health issues.
  • Patients with recent hospitalizations or intensive care unit stays – Delirium is common in hospitalized and post-operative patients.
  • Polypharmacy and drug interactions – Taking multiple medications increases the risk of side effects that alter cognition.
  • Patients with pre-existing neurological disorders – Dementia, Parkinson’s disease, or epilepsy may exacerbate AMS.

Nursing Assessment for Altered Mental Status

Spotting AMS starts with knowing what to look and listen for. 

A strong nursing assessment combines what a patient reports with measurable findings. Together, they help paint a clear picture of what’s happening beneath the surface.

Objective vs. Subjective Data

  • Subjective data: Family or patient reports of confusion, memory loss, or behavior changes
  • Objective data: Altered Glasgow Coma Scale (GCS) score, Mini-Mental State Exam (MMSE) results, abnormal lab findings

Common Assessment Tools

  • GCS: Measures eye, verbal, and motor responses to assess consciousness.
  • MMSE: Evaluates cognitive function, including orientation and memory.
  • CAM: Screens for delirium.

Key Diagnostic Tests

  • Blood glucose: Identifies hypoglycemia or hyperglycemia
  • Arterial blood gases (ABGs): Detects hypoxia and acidosis
  • Electrolytes and renal function tests: Assesses sodium, potassium, and kidney function
  • CT scan/MRI: Identifies strokes, brain injuries, or tumors
  • Urinalysis and blood cultures: Checks for infections

Nursing Diagnosis for Altered Mental Status

Identifying the right nursing diagnosis for altered mental status depends on the cause and how the patient presents. 

Whether it’s confusion from infection or impaired communication after a stroke, the goal is to recognize risks early and provide focused, effective care.

  1. Ineffective cerebral tissue perfusion related to stroke or hypoxia
  2. Acute confusion related to metabolic imbalances or infection
  3. Risk for injury related to impaired judgment, falls, or agitation
  4. Impaired verbal communication related to neurological deficits

Expected Outcomes & Nursing Goals

With altered mental status, the goal isn’t just clarity — it’s stability, safety, and progress. 

These outcomes guide the care plan, helping track what’s working and when it’s time to level up interventions.

  • Improved cognitive function and orientation – Patient responds appropriately to stimuli and follows commands
  • Stabilized vital signs and metabolic balance – Blood pressure, glucose, and oxygen levels return to normal
  • Reduced risk of injury and complications – Miminized falls and self-harm risks

Nursing Interventions for Altered Mental Status

When a patient’s mental status starts shifting, quick and consistent action is key. 

Nursing interventions for altered mental status focus on early detection, stabilizing the basics — like oxygen and glucose — and staying one step ahead of potential complications.

Monitoring and Assessment Interventions

  • Frequent neurological checks to assess changes in mental status.
  • Monitor oxygenation and blood glucose levels to prevent hypoxia or hypoglycemia.

Treatment-Based Interventions

  • Administer medications to treat infections, metabolic imbalances, or neurological disorders.
  • Ensure adequate hydration and nutrition to prevent dehydration-related confusion.

Patient Safety and Environmental Modifications

  • Fall precautions and bed alarms to prevent injury.
  • Reducing sensory overload by maintaining a quiet, calm environment.

Patient and Caregiver Education

  • Signs of worsening mental status to report to healthcare providers
  • Medication management and adherence to prevent drug-induced AMS

Altered Mental Status Nursing Care Plan Examples

Nurses should tailor nursing care plans for altered mental status to the root cause — whether it’s infection, medication, or a chronic condition. 

Each plan focuses on restoring cognitive function while addressing the factors that triggered the change.

Quick tip: Always treat the underlying cause first — AMS is a symptom, not the main event.

Care Plan #1: AMS Related to Infection (Sepsis, UTI, Pneumonia)

Nursing Diagnosis

Acute confusion related to systemic infection, as evidenced by disorientation and agitation

Expected Outcomes

  • Patient will return to baseline cognitive function within 48 hours of treatment
  • Patient will demonstrate improved alertness and orientation

Assessment

  • Monitor for fever, tachycardia, and hypotension.
  • Evaluate confusion using the CAM tool.

Interventions

  • Administer IV antibiotics for infection.
  • Provide IV fluids to prevent dehydration.

Care Plan #2: AMS Due to Neurological Conditions (Stroke, TBI, Dementia)

Nursing Diagnosis

Ineffective cerebral tissue perfusion related to stroke, as evidenced by altered speech and hemiparesis

Expected Outcomes

  • Patient will demonstrate improved cognitive function and neurological status
  • Patient will follow simple commands and participate in rehabilitation

Assessment

  • Conduct neurological exams (National Institutes of Health stroke scale, GCS).
  • Monitor blood pressure and cerebral perfusion pressure.

Interventions

  • Administer thrombolytics (if applicable) for ischemic stroke.
  • Encourage passive and active range of motion exercises to prevent muscle atrophy.

Care Plan #3: AMS from Medication Toxicity or Polypharmacy

Nursing Diagnosis

Risk for injury related to medication-induced confusion and sedation

Expected Outcomes

  • Patient will show improved alertness after medication adjustments.
  • Patient will verbalize understanding of medication side effects.

Assessment

  • Review current medications and potential interactions.
  • Assess for bradycardia, respiratory depression, or excessive sedation.

Interventions

  • Discontinue or adjust medications contributing to AMS.
  • Educate caregivers on proper medication administration.

Prevention of Altered Mental Status and Complications

What is the best way to manage an altered mental status? 

Stop it before it starts. From keeping infections at bay to staying sharp with med safety, prevention plays a huge role in protecting patients and avoiding complications.

  • Identifying early signs of deterioration through continuous monitoring
  • Managing medications safely to prevent overdoses and interactions
  • Preventing infections through proper hygiene and vaccinations

Patient Education & Discharge Planning

Education and discharge planning are key to keeping patients safe at home. 

Whether it’s reviewing red flags with families or setting up fall precautions, nursing care includes making sure everyone’s ready for what comes next.

  • Teaching families about AMS causes and warning signs
  • Home safety considerations for AMS patients (fall prevention, medication management)
  • Importance of follow-up care and monitoring

Quick tip: Use the teach-back method with family members to confirm they understand when to call the provider — especially if confusion returns or worsens.

Recommended Resources for Altered Mental Status

Staying current on best practices for assessing and managing altered mental status is essential in academic and clinical settings. 

These recommended resources offer evidence-based guidance on delirium, dementia, and cognitive dysfunction — ideal for deepening clinical knowledge and supporting patient care.

  • Alzheimer’s Association: Offers comprehensive education, clinical tools, and caregiver support for managing dementia-related cognitive changes

Nursing Care Plan Resources

References and Sources

  1. American Association of Neurological Surgeons. (2023). Altered Mental Status: Causes, Diagnosis, and Management. 
  1. National Institute of Neurological Disorders and Stroke (NINDS). (2023). Neurological Disorders and Cognitive Impairment.
  2. U.S. Centers for Disease Control and Prevention. (2023). Delirium and Acute Confusion in Hospitalized Patients.
  3. Hickey, J. V. (2019). The Clinical Practice of Neurological and Neurosurgical Nursing (8th ed.). Lippincott Williams & Wilkins.
  4. Sadock, B. J., Sadock, V. A., & Ruiz, P. (2024). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry (11th ed.). Wolters Kluwer.
  5. American Delirium Society (ADS). (2023). Delirium Prevention, Recognition, and Treatment Guidelines.