Altered Mental Status Nursing Care Plan: 2 Sample Plans and Interventions

Altered mental status is any change in how alert, aware, or oriented a client is compared to their normal. It can come from low blood sugar, low oxygen, infection, stroke, drugs, or brain injury. Your priorities are protecting the airway, finding the cause quickly, and preventing injury.

A · AssessmentD · DiagnosisP · PlanningI · InterventionE · Evaluation

Each care plan below follows the nursing process (ADPIE).

CARE PLAN 1 · NURSING DIAGNOSIS

Risk for Ineffective Cerebral Tissue Perfusion

Risk factors

Stroke or bleeding in the brain
Low blood pressure or low oxygen
Head injury or rising intracranial pressure

PLANNING · EXPECTED OUTCOMES

Short-term goals

Client's level of consciousness stays the same or improves within 24 hours
Vital signs stay within ordered limits

Long-term goals

Client returns to baseline neurologic function

ASSESSMENT

Level of consciousness and GCS
Pupil size and reaction
Neuro checks as ordered
Blood glucose right away
Vital signs and SpO2

INTERVENTIONS AND RATIONALES

INTERVENTION	RATIONALE
Check blood glucose as soon as the change is noticed	Low blood sugar is a common, fast-to-fix cause of altered mental status.
Report any drop in GCS or new focal signs immediately	A decline can mean worsening brain injury or stroke and needs fast treatment.
Keep the head of the bed raised about 30 degrees with the head midline, unless ordered otherwise	This helps venous drainage from the brain.
Give oxygen as ordered to keep SpO2 at goal	The brain is very sensitive to low oxygen.

EVALUATION

GCS is stable or improving
Pupils are equal and reactive
Client is back to baseline

CARE PLAN 2 · NURSING DIAGNOSIS

Risk for Aspiration

Risk factors

Decreased level of consciousness
Weak gag or cough reflex
Impaired swallowing

PLANNING · EXPECTED OUTCOMES

Short-term goals

Client maintains a clear airway with no aspiration

Long-term goals

Client eats safely with no signs of aspiration pneumonia

ASSESSMENT

Airway, breath sounds, and respiratory effort
Gag reflex and swallow screen before oral intake
Temperature and lung sounds for signs of pneumonia

INTERVENTIONS AND RATIONALES

INTERVENTION	RATIONALE
Keep the client NPO until a swallow screen is passed	Eating with a poor swallow can send food into the lungs.
Position on the side or with head raised	This helps secretions drain out instead of into the airway.
Keep suction at the bedside	Lets the nurse clear the airway quickly.
Give oral care regularly	Clean mouths reduce bacteria that could be aspirated.

EVALUATION

Lungs remain clear
No fever or signs of aspiration
Client passes a swallow screen before eating

Practice this in Head-to-Toe

Practice neuro checks and spot changes in level of consciousness.

Play Head-to-Toe

Quick answers

What is the first thing to check in a client with sudden confusion?

Airway, breathing, and circulation first, then a quick blood glucose, since hypoglycemia is common and easy to reverse.

What is an early sign of a decline in neurologic status?

A change in level of consciousness, such as new restlessness or drowsiness, is often the earliest sign.

For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.