Nursing care plan for a patient who was admitted for Altered Mental status

Sample Solution

Nursing Care Plan: Altered Mental Status

Patient Information:

• Name: [Patient Name]
• Age: [Patient Age]
• Admitting Diagnosis: Altered Mental Status (AMS)

Assessment:

• History of Present Illness: Gather details about the onset, duration, and progression of the altered mental status. Note any recent illnesses, medications, injuries, or changes in behavior.
• Mental Status Examination: Assess orientation to person, place, and time. Evaluate level of consciousness using tools like the Glasgow Coma Scale (GCS). Assess speech, memory, and cognitive function.

Full Answer Section

• Physical Examination:Perform a comprehensive physical examination to identify potential underlying causes of AMS, including vital signs, neurological assessment, and a thorough review of systems.
• Review of Medications:Review all current medications, including prescription and over-the-counter drugs, to identify potential interactions or medications that could contribute to AMS.
• Laboratory Tests:Anticipate laboratory tests like electrolytes, blood sugar, complete blood count, thyroid function tests, and blood alcohol levels to rule out potential causes of AMS.

• Risk for Injuryrelated to decreased awareness and impaired coordination.
• Ineffective Ineffective Copingrelated to altered thought processes and inability to meet basic needs.
• Deficient Knowledgerelated to lack of awareness of condition and self-care needs (may not apply to all patients).

• Risk for Injury:Patient will remain free from injury throughout their hospital stay.
• Ineffective Coping:Patient will demonstrate improved coping mechanisms to manage their altered mental status.
• Deficient Knowledge (if applicable):Patient will demonstrate understanding of their condition and self-care needs upon discharge (if applicable).

• Implement fall precautions:Bed alarm, low bed position, one-on-one supervision as needed.
• Maintain a safe environment:Remove clutter, ensure proper lighting, and keep assistive devices readily available.
• Orient the patient to reality:Frequently provide reminders of time, place, and person.

• Provide a calm and quiet environment.
• Speak slowly and clearly using simple language.
• Offer reassurance and emotional support.
• Maintain a consistent routine as tolerated.
• Encourage familiar objects or photos from home.
• Involve family members in patient care whenever possible.

• Explain the patient's condition and treatment plan in simple terms when appropriate.
• Provide written educational materials about AMS and self-care strategies.
• Encourage the patient to ask questions and address any concerns.

• Continuously monitor the patient's level of consciousness and mental status.
• Assess the patient's ability to participate in self-care activities.
• Evaluate the effectiveness of implemented interventions and modify them as needed.
• Document all assessments, interventions, and patient responses in the medical record.

• Identify the underlying cause of AMS and collaborate with the healthcare team to address it.
• Provide emotional support to the patient's family members and caregivers.
• Continue to assess the patient's needs as their condition changes and adjust the care plan accordingly.