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Acute Mental Status Change Cheat Sheet (DRAFT) by [deleted]

Acute Mental Status Change

This is a draft cheat sheet. It is a work in progress and is not finished yet.

New Mental Status Change Noted

 

New symptoms or signs of increased confusion

(e.g. disori­ent­ation, change in speech)
Decreased level of consci­ousness
Inability to perform usual activities (due to mental status change)
New or worsened physical and/or verbal agitation*
New or worsened delusions or halluc­ina­tions*

Take Vital Signs

Temper­ature
BP, pulse, apical HR (if pulse irregular)
Respir­ations
Oxygen saturation
Finger stick glucose (diabe­tics)

New symptoms or signs of increased confusion

(e.g. disori­ent­ation, change in speech)

Decreased level of consci­ousness
Inability to perform usual activities (due to mental status change)
New or worsened physical and/or verbal agitation*
New or worsened delusions or halluc­ina­tions*

Vital Sign Criteria (any met?)

Vital Sign Criteria (any met?)
Apical heart rate > 100 or < 50
Respir­atory rate > 28/min or < 10/min
BP < 90 or > 200 systolic
Oxygen saturation < 90%
 

Further Nursing Evaluation

Mental Status
Functional Status
Cardio­vas­cular
Respir­atory
Gastro­int­est­ina­l/a­bdomen
Genito­urinary
Skin
Consider IV or subcut­aneous fluids
Update advance care plan and directives if approp­riate

Evaluate Symptoms and Signs**

Not eating or drinking
Acute decline in ADL abilities
New cough, abnormal lung sounds
Nausea, vomiting, diarrhea
Abdominal distension or tenderness
New or worsened incont­inence, pain with urination, blood in urine

Manage in Facility

Monitor vital signs, fluid intake­/urine output every 4-8 hrs for 24-72 hrs
If on diuretic, consider holding
Offer frequent small fluids (2-4 oz q 2h)
If on tube feeding, give more water with flushes