221: Sleep

Somnambulism

"Sleepwalking" affects up to 4% of adults and constitutes one of the leading causes of self-injury and sleep-related violence, which may include injury of others and even homicide *Sleepers may sit up with glassy eyes and get up and walk around; generally, they will avoid anyone who attempts to talk to them.

Restless Legs Syndrome

(Also known as Willis-Ekbom disease) is a familial sleep disorder characterized by disagreeable-feeling leg movements resulting from intense, abnormal, lower-extremity sensations of crawling or tingling. The sensations cause delay in sleep onset. This disorder affects as many as 12 million Americans and leads to constant leg movement during the day and insomnia at night. **Restless legs syndrome can occur at any age but is more common in elderly people.

Nocturnal Enuresis

(Bedwetting at night) Caused by socially disruptive and stressful condition that is common in childhood. **Bed alarms are the treatment that currently appears to work best in the long term. These alarms sound when moisture is present, waking the child. *Behavioral therapy may be used either alone or in conjunction with a bed alarm

Interventions for obstructive sleep apnea (OSA)

**Treatments for OSA include lifestyle changes for good sleep practices, decreased alcohol use, no use of tobacco products, and weight loss. Additional treatment consists of surgical procedures to correct abnormalities of the soft tissue or bone structure that is obstructing the patient's airway, use of an oral appliance while sleeping to keep the airway open, or *continuous positive airway pressure (CPAP)*. CPAP is noninvasive and consists of a face or nasal mask, connected to an air pump, that is worn during sleep and maintains pressure to hold the airway open. *Some patients report discomfort, skin irritation, or claustrophobia sensations; however, continued use of CPAP should be encouraged*

Risk factors for OSA

*Obesity, large neck circumference, smoking, alcohol use, and a family history of OSA. Structural abnormalities such as a recessed chin, abnormal upper airway structures, deviated septum, nasal polyps, or enlarged tonsils can predispose the affected person to OSA. The disorder is more common in adult males, but it can affect adult females and children as well. *The diagnosis of OSA is confirmed with polysomnography to measure respirations, heart rate, and muscle movements.

How often do infants normally sleep?

10 to 12 hours at night, with naps during the day (half of their sleep is in lighter stages)

Newborns should sleep in ____ to ____ -hour blocks between feedings

2 to 4

How many hours of sleep do adults normally get each night?

7 to 9

How many hours of sleep do adolescents need?

8-10 hours

How many hours of sleep to school-age children need?

8-12 hours

**Sleep apnea; obstructive sleep apnea (OSA)

A condition in which the person experiences the absence of breathing (apnea) or diminished breathing during sleep between snoring intervals. It is characterized by a lack of airflow through the mouth and nose for at least 10 seconds, lasting up to 2 minutes, during sleep. The most common type is obstructive sleep apnea (OSA), which affects 12 million to 18 million people in the United States. OSA involves collapse of the upper airway despite respiratory effort. The affected person continues to try to breathe, evidenced by chest and abdominal movements with loud snoring or snorting sounds. Diaphragmatic movements become stronger until the obstruction is relieved. Increased carbon dioxide levels in the blood that accumulate during the apneic episodes cause the person to awaken, and these awakenings can occur hundreds of times each night. Prolonged sleep apnea can cause an increase in blood pressure, leading to cardiac arrest. Cardiac arrhythmias, pulmonary hypertension, and left-sided heart failure can result from prolonged sleep apnea. The affected person's sleep partner's sleep may be disrupted by the snoring or by the abrupt cessation of breathing occurring with periods of apnea. Sleep partners often report staying awake to be sure the patient starts breathing again after each apnea period.

melatonin

A hormone manufactured by the pineal gland that produces sleepiness.

Lifestyle & sleep

A work schedule that does not match the person's biologic rhythms (as can occur with rotating shifts or periodic assignment to a night shift) frequently interferes with sleep. Younger adults may adjust to shift work more easily than older adults who are more set in sleep patterns. Accumulated sleep loss may affect decision making as well as patient safety in health care. The stress of a fast-paced life with multiple demands can prevent a person from relaxing and falling easily to sleep.

A father explains to the nurse that his infant's eyes seem to be moving while the infant is sleeping, what will the nurse tell the father

The nurse will tell the father that eye movements, grimacing, and body movements are normal features of sleep at this age

Home Care Considerations

Activity • Activity promotes sleep. Find physical activity that can be done daily, such as walking, swimming, or exercising. • Relaxation is difficult after vigorous exercise. Avoid exercise within 2 hours of bedtime. • Multiple interventions increase sleep success by promoting physical and mental relaxation. Implement complementary relaxation strategies before attempting sleep, including music, massage, or aromatherapy. Diet • Carbohydrates affect serotonin levels in the brain, inducing relaxation. Therefore eat a light bedtime snack with carbohydrates if hungry in the evening. • Heavy meals interfere with sleep. Avoid heavy meals within 3 hours of bedtime. • Central nervous system stimulants interfere with sleep. Limit caffeine, alcohol, and tobacco use, especially in the evening. Sleep Pattern • Using the bedroom only for sleep and sex helps the mind associate the room with these activities. Use the bedroom for sleep and sex only; do not watch television, read, study, or eat in this space. • Getting out of bed if unable to sleep trains the mind to sleep when in bed. If unable to fall asleep within 20 minutes, get out of bed and engage in a relaxing activity such as reading or listening to music until sleepy. • Maintaining a regular sleep pattern helps maintain circadian rhythms. Continue the regular sleep pattern on weekends and on holidays. • A consistent bedtime routine signals to the mind and body that it is time to go to sleep. Follow a consistent routine. • Identify lifestyle factors (e.g., long work hours, late meals, family stress) that may interfere with sleep, and change those factors. Environment • Comfort and security, along with decreased sensory input, promote sleep. - Adjust the environment to enhance sleep: Darken the room; decrease noise or wear earplugs; adjust the temperature to a comfortable level; and wear loose, comfortable clothing.

How does gender affect sleep?

Adult males are at a higher risk for development of obstructive sleep apnea. Children and adult females are at a lower risk for the disorder.

At what age can a toddler move out of the crib to a bed?

Approximately 2 years old.

How many hours of sleep do older adults get each night?

Approximately 6 hours

Secondary sleep disorders

Can be disabling symptoms of underlying medical or psychiatric disorders. The physiologic effect of medical conditions affects the sleep-wake cycle. **For example, heart failure, chronic obstructive pulmonary disease, pain, and gastric reflux disease all may affect sleep. Mental health disorders cause changes in sleep-wake regulation. Up to 90% of patients with depression report disturbed sleep. Anxiety, which is common in people who are hospitalized or who have a serious illness, also interferes with sleep. • Physiologic effect of medical conditions: heart failure, chronic obstructive pulmonary disease, pain, or gastric reflux disease • Hospitalization with a serious illness • Mental health disorders: -Depression -Anxiety -Fear

**Narcolepsy

Chronic neurologic disorder caused by the brain's inability to regulate the sleep-wake cycle normally, resulting in an uncontrollable desire to sleep. This sleep starts with the *REM phase*. At various times throughout the day, people with narcolepsy experience *overwhelming sleepiness* and *fall asleep* for periods of seconds to several minutes. These sleep episodes can occur at any time; accordingly, the disorder can be very disabling. People may involuntarily fall asleep while at work or at school, or when having a conversation, playing a game, eating a meal, or, *most dangerously, driving an automobile* or operating other types of potentially hazardous machinery. In addition to daytime sleepiness, three other major symptoms frequently characterize narcolepsy: *cataplexy, or the sudden loss of voluntary muscle tone; vivid hallucinations during sleep onset or on awakening; and brief episodes of total paralysis at the beginning or end of sleep.* Scientists now believe that narcolepsy results from disease processes affecting brain mechanisms that regulate REM sleep. For normal sleepers, a typical sleep cycle begins with NREM sleep and undergoes transition to REM sleep. People with narcolepsy frequently enter REM sleep within a few minutes of falling asleep. *The diagnosis of narcolepsy is confirmed by sleep diagnostic tests: the polysomnogram and the multiple sleep latency test.

Bruxism

Clenching of teeth or the grinding of teeth from side to side. This often occurs during sleep and may be due to stress. Pain can result if the clenching is tight or occurs over an extended period of time

Environmental Factors and sleep

People tend to sleep best in familiar settings where they feel comfortable and secure. Sleeping in new environments influences both NREM and REM sleep stages. People accustomed to the noise associated with living in a city may not rest well in country locales, whereas those accustomed to the quiet of the country may find it difficult to sleep in a city. Temperature and light are other variables that affect the ability to sleep.

Parasomnias

Disorders associated with abnormal sleep behaviors, rather than disorders of sleep itself. The behaviors come from activation of the autonomic nervous system, motor system, or cognitive processes during sleep or during the transitions between sleep and wakefulness. **These disorders are more common in children and adolescents. ***Attempts to awaken the person from a parasomnia should be discouraged. Although safety needs must be met, help should be given to the extent the person will accept it, which includes encouraging the person to return to sleep as the event ends. * Nocturnal enuresis (bed wetting) • Somnambulism (sleep walking) • Sleep terrors • Bruxism (excessive teeth grinding/clenching)

Dyssomnias

Disorders associated with getting to sleep, staying asleep, or being excessively sleepy. • Insomnia • Obstructive sleep apnea • Shift-work sleep disorder • Time zone change (jet lag) • Hypersomnia • Restless legs syndrome • Narcolepsy • Sleep deprivation

A mother tells you her infant's aunt made the infant a baby blanket with the child's name on it, how should you as the nurse respond to the mother?

Educate the mother on keeping the baby blanket as well as pillows, and bumpers out of the crib in order to decrease suffocation risk

Care of patients before bed time

Evening care, or h.s. ("hour of sleep"—at bedtime) care, is provided to prepare the patient for an uninterrupted period of sleep. Activities to prepare for sleep that the nurse may delegate to unlicensed assistive personnel (UAP) include: • Providing oral care • Doing partial bathing, to cleanse the face and hands • Providing skin care • Giving a back rub • Straightening or changing bed linen • Offering the opportunity for toileting • Offering a snack or water

Hypersomnia

Excessive daytime sleepiness lasting at least 1 month that causes impairment in the ability to function in occupational or other areas of the affected person's life. Even after 8 to 12 hours of sleep each night, the person still experiences trouble awakening in the morning. Hypersomnia can be caused by medical conditions such as some kidney or liver disorders, diabetic acidosis, central nervous system damage, or hypothyroidism.

Nonpharmacologic Interventions

Feeling comfortable and safe when attempting to sleep is important. A comfortable bed with linens that are not wrinkled and allow freedom of movement helps promote relaxation. Body alignment should prevent muscle strain and discomfort. A quiet, darkened room with privacy is helpful for most people, but a night light may be needed in unfamiliar surroundings. Infants and older adults may sleep best in softly lit rooms, but not with light shining directly in their eyes. Noise is a common sleep disrupter in the hospital; equipment sounds and staff conversations should be modified, as possible, to decrease noise. *Room temperature and the use of extra clothing or blankets should be at the discretion of the patient. It is not unusual for hospitalized patients to be awakened for sleeping pills or long before it is time for a meal or procedure. *When possible, treatments and care should be scheduled for when a patient normally is awake. *Scheduling of medications and treatments that can disrupt sleep (e.g., nebulizer treatments) should be carefully considered. It is best to reserve at least 90 to 120 minutes of "sleep windows," to allow progression through all stages of sleep.

illness and hospitalization

Illness and hospitalization are both physiologic and psychological stressors that influence sleep. Any illness that results in pain, discomfort, or mood changes can result in sleep problems. Sleep disturbances are more common with certain illnesses. Hospitalization is a stressor that disrupts sleep. Hospitals and residential care facilities usually do not adapt care routines to the person's sleep-wake cycle. When possible, health care providers should cluster care activities to provide 90- to 120-minute blocks of uninterrupted sleep time. This schedule allows for completion of all sleep stages. Maintaining a regular routine as much as possible enhances sleep for the hospitalized patient. **When the sleep-wake cycle is disrupted, the patient may experience anxiety, restlessness, impaired judgment, and irritability, along with other negative effects on overall health. **During a hospitalization, factors that affect sleep include unfamiliar surroundings, sounds, and smells; proximity to other patients; lack of privacy; increased light levels; medical technology; and underlying medical illnesses.

Sleep diary

Information to be recorded daily in the sleep diary includes: • Activities and food within 2 hours of going to bed • Time of retiring • Time of awakening • Required time to fall asleep • Number of times aroused during the night • Length of time awake if aroused during the night • Degree of restfulness in the morning • Use or nonuse of an alarm • General comments regarding sleep

Physical Assessment for sleep

Key assessment findings include an adequate energy level for tasks, physical weakness, fatigue, lethargy, decreased affect, and behavioral signs such as yawning or slow speech. Physical signs that may indicate potential sleep problems include obesity, thick neck, nasal polyps or deviated septum, or shortness of breath. Other signs that can be assessed during hospitalization include the presence of muscle contractions and jerks that arouse the patient from sleep, snoring, sleep apnea, or the irregular periods of silence followed by an abrupt snort indicative of OSA.

stimulants and other medications

Many prescription and over-the-counter medications can affect the quality of sleep, causing sleepiness, restlessness, or insomnia. ***Medications that decrease REM sleep include barbiturates, amphetamines, and some antidepressants. Other medications that affect sleep patterns include diuretics, antiparkinsonian medications, antihypertensives, steroids, decongestants, and asthma drugs. ***Beta blockers have been reported to cause nightmares and insomnia. **Narcotics suppress REM sleep, cause frequent awakening, and may cause excessive daytime sleepiness. ***Short-term use of medications such as *zaleplon (Sonata)* and *zolpidem (Ambien)* may be indicated to improve sleep patterns. *Eszopiclone (Lunesta)* has been approved by the U.S. Food and Drug Administration (FDA) for *longer-term* treatment of insomnia.

Relationships and sleep

New parents often report sleep disturbance as they adjust to the parenting role and associated frequent nightly awakenings. The sleep disturbance may become chronic if young children in the home do not establish regular sleep patterns or have ongoing care needs. Similarly, caregivers of persons with chronic illnesses living at home may become sleep-deprived. People whose primary relationships are disrupted often suffer from sleep disorders. A person going through the grieving process after a loss commonly may have difficulties sleeping; children away from home and suffering from homesickness often have trouble sleeping as well. Marital problems contribute to sleep disorders in both the involved adults and the children in the home. Sleep also is disrupted for those with a partner who has a sleep disorder. This can lead to sleep deprivation consequences for both partners.

Smoking and sleep

Nicotine has a stimulating effect, and smokers may have more trouble falling asleep and arouse more easily once asleep. *Long-term smoking can lead to permanent lung damage, which in turn is associated with hypoxia, requiring an increased need for rest. ***People who quit smoking usually report improved sleep, although temporary sleep disturbance may occur immediately after complete withdrawal from nicotine

QSEN Focus!

Patient-centered care requires that the nurse provide physical comfort and emotional support. When addressing sleep disturbances, the nurse elicits the patient's preferences and expressed needs as part of the clinical interview, implementation of the care plan, and evaluation of care.

Implementation and Evaluation regarding sleep

Nursing interventions to improve sleep quality are based on health-promotion principles. *During illness, sleep is important for recovery. The nurse should have a caring attitude when implementing strategies to improve sleep. *Addressing the sleep environment, maintaining sleep routines, providing light snacks if allowed, instituting relaxation measures, and carefully using medications can enhance sleep in both hospital and home settings. *Medications do not reset the circadian rhythms. These rhythms can be adjusted by progressing through shift rotation in a forward motion (days to evenings to nights), implementing sleep hygiene practices (evening routine diet, alcohol, tobacco, and activity restrictions), **and arising at the same time each day.

SAFE PRACTICE ALERT

OSA can cause fragmented sleep and low blood oxygen levels to the body, including the heart, leading to hypoxia, acidosis, and hypercapnia (increased carbon dioxide).

Diagnostic Tests

Objective data regarding sleep characteristics are obtained in a sleep disorder laboratory and are interpreted by a sleep specialist. *Polysomnography records eye movements, muscle movement and activity, heart and respiratory rates, oxygen levels, airflow, and brain activity while the patient sleeps. The results of polysomnography include the apnea-hypopnea index, or the number of apneic or hypopneic episodes per hour. ***The normal number of these episodes for an adult is fewer than 5 per hour; mild *OSA ranges from 5 to 15 episodes per hour; moderate OSA ranges from 15 to 30 episodes per hour; and *severe OSA is more than 30 apneic or hypopneic episodes per hour* **Another test is the multiple sleep latency test. The patient is monitored for brain waves, heartbeat, and eye movement during several 20-minute naps during the day. This test is used for patients suspected of having narcolepsy, and it shows whether they enter REM sleep shortly after falling asleep.

Obesity predisposes affected people to _________ __________ _______.

Obstructive sleep apnea

Rapid eye movement (REM) sleep

Occurs during deep sleep and is manifested by quick scanning movements of the eyes that are associated with dreaming. REM sleep is associated with memory storage, learning, increased cerebral blood flow, and epinephrine release

Sleep Deprivation

Occurs from prolonged lack of sleep of good quality and adequate quantity. Disturbances of sleep leading to deprivation can be associated with aging or may result from hospitalization, drug and substance abuse, emotional stress, medications, factors in the environmental (e.g., noise, light), and disruption of normal sleep patterns such as with shift rotations or changes in lifestyle patterns. **Sleep deprivation can cause symptoms of fatigue, headache, nausea, increased sensitivity to pain, decreased neuromuscular coordination, irritability, and difficulty concentrating. Eventually, disorientation and hallucinations may occur. *Sleep deprivation can have negative health effects on blood pressure (hypertension), glucose metabolism, and hormone regulation and leading to inflammation, increased frequency of seizures in patients with seizure disorders, and increased weight gain contributing to obesity. ***Florence Nightingale's nursing theory work discussed environmental adaptation with appropriate noise, hygiene, light, comfort, socialization, hope, nutrition, and conservation of patient energy. Many of these adaptations have been found to promote sleep and rest. People respond variably to sleep deprivation. The most effective treatment is correction of the factors interrupting the sleep patterns. Hospitalization, especially in acute care units such as intensive care or cardiac care units, puts patients at risk for sleep deprivation. *This is secondary to the unfamiliar noises from staff and equipment, necessary care by medical staff, constant light, and poor physical condition.

What should parents be taught regarding their newborns/infants in relation to sleep?

Position newborns and infants on the back for sleeping, to decrease the risk of sudden infant death syndrome or (SIDS)

Anxiety and stress regarding sleep

Psychological stress decreases REM sleep and can prevent a person from getting enough sleep. Anxiety, including the stress associated with work, finances, illness, and family, can cause intrusive thoughts, muscular tension, and *increased norepinephrine levels*, all of which may interfere with being able to go to sleep and stay asleep.

non-rapid eye movement (NREM) sleep

REM does not occur, growth hormone is released to repair epithelial and brain cells, cell division for skin and bone marrow renewal occurs, and energy is conserved

The use of long-term sleep medications --->

Should be STRONGLY discouraged

Sleep Terrors

Sleep terrors, or night terrors, are a parasomnia in which a person quickly awakens from sleep in a terrified state. Sleep terrors occur during deep sleep, usually during the first third of the night. *The cause is unknown, but they may be triggered by fever, lack of sleep, use of alcohol, or periods of emotional stress or conflict. *Night terrors are fairly common in children age 3 to 7 years of age, but they are most common in **boys 5 to 7 years old. Night terrors may run in families. By contrast, nightmares are more common in the *early morning. They may occur after the affected person watches a frightening movie or television program or has a strong emotional experience. The person may remember the details of a dream on awakening and will not be disoriented after the episode

Alcohol and sleep

Small amounts of alcohol may help some people fall asleep, but alcohol increases wakefulness in the last half of the night. **Ingesting large quantities of alcohol creates difficulty falling asleep and limits REM sleep. These effects may cause a restless sleep, contributing to any "hangover" experienced on arising. **Alcohol ingested when taking sleeping pills can cause dangerous side effects.

What stage of sleep is decreased in older adults?

Stage 4 sleep is decreased, resulting in less restorative sleep.

Interventions for insomnia

Stimulus control (using the bedroom for only sleep and sex), sleep restriction (staying in bed only if asleep), sleep hygiene, and cognitive therapy (relaxing and changing thought patterns). A combination of nonpharmacological methods is often necessary to change sleep patterns. Treatment for hypersomnia is aimed at correcting any underlying conditions contributing to the hypersomnia.

What are some ways nurses can "prepare" themselves regarding rest before working night shifts

Taking power naps, eliminating overtime on 12-hour shifts, and completing challenging tasks early in the shift to reduce patient care errors. Other strategies that can help adaptation to shift work include: • Take responsibility for obtaining a minimum of 6 hours of sleep each 24-hour period. • Maintain a regular sleep schedule when working and on nights off. • Include a 4-hour "anchor" sleep time during which sleep is scheduled whether on or off work. For example, after working, sleep from 8:30 a.m. to 4:30 p.m., and on days off, sleep from 4:30 a.m. to 12:30 p.m. The anchor sleep time is from 8:30 a.m. to 12:30 p.m. • Wear dark glasses that block blue light when driving home after night work. • Seek exposure to bright light (sunlight is best) as soon as possible after waking. • Before the first night shift, power-nap 30 to 90 minutes before leaving for work.

Evaluation of sleep

The effectiveness of the plan of care to promote sleep is evaluated by determining whether the identified outcomes have been reached. Outcomes are likely to be achieved if the patient is able to: • Rest in an environment that promotes sleep • Follow bedtime rituals as much as possible • Report feeling rested after sleeping • Maintain adequate energy and mental alertness to complete necessary tasks • Identify factors that interfere with sleep and measures to improve sleep habits • Use a variety of techniques to promote sleep -Follow-up assessment of the effectiveness of the interventions is an important step in ensuring healthy sleep patterns for patients in hospital and home settings.

Insomnia

The most common dyssomnia and is characterized by difficulty in falling asleep or staying asleep, sleep that is too light, or early-morning awakenings. Concern with the problems related to not getting enough sleep further interferes with sleep, contributing to an ongoing cycle of sleep disturbance. The occurrence of insomnia increases with age, and the disorder affects more women than men. Short-term insomnia usually can be traced to acute stress or lifestyle changes and often is self-limiting. Insomnia can lead to symptoms of sleep deprivation and daytime fatigue, which can cause impairment in work, social, and other areas of functioning. Medications for insomnia do not deal with the cause of the sleep problem, and prolonged use can create drug dependency.

Goals and Outcome Statements regarding sleep disturbances

The primary goal for the patient with a sleep disorder is to improve the quality and quantity of sleep. * It should be recognized that it may take weeks to achieve outcomes for sleep problems. Potential goals that support the nursing diagnoses related to sleep and rest include the following: • Patient will remain asleep for 6 to 7 hours consistently within 1 month. • Patient will sleep for at least 90 minutes at a time during hospitalization. • Patient will take two 20-minute naps daily. • Patient will fall asleep within 15 minutes of going to bed within 2 weeks. • Patient will report the ability to concentrate during the workday within 1 week. • Patient will repeat medication instructions upon discharge. • Parents will keep a sleep journal showing increased periods of sleep nightly at the next well-child visit. • Patient will remain injury-free during hospitalization.

Diet and exercise regarding sleep

The type and amount of food and liquid consumed both are recognized to affect sleep. Highly caffeinated substances such as coffee, cola, and chocolate are central nervous system stimulants that can disrupt the sleep cycle. Going to bed hungry or eating a large, heavy, or spicy meal just before going to bed can interfere with sleep. ** Bedtime snacks that contain complex carbohydrates are recommended to promote calmness and relaxation. *Sleep and rest are important in addressing the rise in obesity in the United States. Both children and adults who sleep less than the recommended number of hours each night are more likely to be overweight (NIH, 2011). **Exercise can assist with weight loss efforts and promote relaxation, but excessive exercise, especially in the evening, interferes with sleep.

Interventions for narcolepsy

There is no cure for narcolepsy at present. Treatment includes a regular exercise routine, a regular sleep routine, daytime naps if possible, light meals high in protein to maintain alertness, and vitamins. Avoiding alcohol, heavy meals, long-distance driving, and long periods of sitting is helpful. *Medications for narcolepsy include central nervous system stimulants, the nonamphetamine wake-promoting drug *modafinil*, and *tricyclic* and *selective serotonin reuptake inhibitor antidepressants*. *In 2002, the FDA approved Xyrem, which is the trade name for gamma hydroxybutyrate (GHB), for treating people with narcolepsy who experience episodes of cataplexy*

How can drinking caffeinated beverages and the use of technology at night affect adolescents, specifically

They may experience daytime sleepiness with impaired alertness and functioning.

Interventions for restless leg syndrome

Treatment for restless legs syndrome includes lifestyle changes of decreased caffeine, alcohol, and tobacco use, as well as maintaining a regular sleep pattern. *Massaging the legs, walking, or doing deep knee bends may temporarily relieve symptoms. *Supplements to correct deficiencies in iron, folate, and magnesium may be helpful*. No one medication is effective for restless legs syndrome, but drugs such as *dopaminergic* agents (largely used to treat Parkinson's disease), *ropinirole (Requip)*, *benzodiazepines*, *opioids*, and *anticonvulsants* may be prescribed

Safe Practice Alert!

When administering medications that affect sleep, be sure beds are in the low position, night lights are on, and call lights are within reach to help prevent patient falls. No alcohol products should be ingested with sleeping medications.

What does a normal polysomnography show?

a sleep sequence of four NREM stages and one REM stage

When is less sleep in a child "okay"?

around 11 to 12 years of age

The heart beats 10 to 20 fewer times per minute when sleeping, and respirations, blood pressure, and muscle tone all ___________ during sleep

decrease

The potential consequences of circadian rhythm disturbances include

depression, sexual dysfunction, memory difficulties, high blood pressure, obesity, and an increased risk for accidents. Most often happens in shift workers and people experiencing "jet lag"

People who sleep less than average are more likely to be

overweight, develop diabetes, and eat a high-calorie, high-carbohydrate diet

Polysomnography

test to monitor brain waves, muscle tension, eye movement, and oxygen levels in the blood as the patient sleeps

Causes of dyssomnias include

too much napping, anxiety, depression, high levels of stimulation at bedtime, medication use, shift work, and hyperthyroidism

NREM 4

• Deepest stage of sleep • Strong stimuli needed for arousal • Vital signs decreased much more than during wake time • Restorative processes continue • Somnambulism and nocturnal enuresis (bed wetting) may occur • May be lengthy period of sleep if sleep deprivation has occurred • Lasts 15-30 min

Questions to ask patient during a health assessment regarding narcolepsy

• Do you fall asleep unexpectedly at random times? (Family or coworkers may report such episodes.) • Do you have episodes of weakness, causing you to fall to the floor? • Do you have vivid dreams when falling asleep?

Questions to ask patient during a health assessment regarding sleep apnea

• Has anyone told you that you snore loudly or stop breathing while you sleep? • Do you have headaches when you wake up? • Do you have trouble staying awake during the day? • Do you feel tired all the time?

Questions to ask patient during a health assessment regarding insomnia

• How long does it take you to go to sleep? • How often do you have trouble falling asleep? • Do you have trouble staying asleep? waking up early and not getting back to sleep? • What time do you wake up in the morning? Do you use an alarm clock? • What do you do to prepare for sleep? • What have you tried to improve your sleep?

NREM 3

• Initial stage of deep sleep • More difficult arousal and rare movement • Muscles relaxed • Vital signs decrease, but regular rhythms/patterns maintained • Restorative processes such as the release of growth hormone occur *** • Lasts 15-30 min

NREM 1

• Lightest level of sleep, between sleep and wakefulness • Vital signs and metabolism begin to decrease/slow down • Easy arousal by external stimuli, such as noise • Feeling of drowsiness • Lasts a few minutes • May occur during the day as "resting my eyes"

REM

• Occurrence of vivid, colorful dreaming (less vivid dreaming may occur in other stages) • Starts approximately 90 min after sleep is initiated • ** Autonomous response causes rapid eye movements, fluctuating heart rate and respirations, and increased blood pressure • Muscle tone decreased • Gastric secretions increased • Very difficult arousal • Duration of REM sleep increases with each sleep cycle and averages 20 min

Sleep disturbances associated with illness

• Peptic ulcers cause pain at night, which may be related to the normal increase in gastric secretions during REM sleep. - Antacids that neutralize gastric acidity may relieve the pain and help sleep patterns. • Pain associated with coronary artery disease is more likely to occur during REM sleep. • Hypertension often causes early morning awakening and fatigue. • Epileptic seizures are more likely in NREM sleep stages. • Hypothyroidism tends to decrease the amount of NREM sleep. • Hyperthyroidism makes it difficult for a person to fall asleep. •** Low estrogen levels in women cause daytime fatigue, hot flashes, or night sweats, any of which may interfere with sleep. • *End-stage renal disease disrupts sleep and leads to daytime sleepiness* • Shortness of breath impairs the ability to sleep, and sinus drainage may cause difficulty breathing. • Any illness or injury associated with pain may disrupt sleep. • Anxiety, fear, or stress may cause problems with falling and staying asleep

Ways to control noise in the hospital

• Provide visual cues to decrease noise by dimming lights and closing curtains, but provide a night light for safety. • Provide privacy by drawing curtains between patients or closing room doors, if possible. • Negotiate times to mute television, radios, and music on hospital units. • Limit overhead pages to emergencies only at night. • Lower volume of telephone ringtones. • Limit staff conversations in hallways and at nursing stations . • Conduct shift reports in areas away from patient rooms, unless the facility requires bedside reporting. If the patient is asleep during change-of-shift rounds, the nurses can check the patient and then step away and speak in soft voices. • Move equipment quietly, without hitting other objects. • Monitor equipment frequently to prevent alarm tones as much as possible.

NREM 2

• Relaxation increases • Sleep becomes deeper • Snoring may occur • Relatively easy arousal • Physiologic functions continue to slow • Accompanied by occasional small muscle jerks • Lasts 10-20 min

Examples of nursing diagnosis for sleep

• Sleep Deprivation related to lifestyle factors and sleep apnea as evidenced by poor sleep patterns, daytime sleepiness, and snoring • Disturbed Sleep Pattern related to lighting and noise in the hospital as evidenced by reports of being awakened at night and by changes in normal sleep pattern • Fatigue related to sleep deprivation as evidenced by daytime drowsiness • Insomnia related to anxiety as evidenced by difficulty falling asleep • Anxiety related to inability to fall asleep as evidenced by inability to concentrate • Risk for Injury with risk factor of sleepwalking

Bed time routines that promote sleep

• Take a warm bath. • Eat a light snack that contains carbohydrates. • Drink warm milk. • Avoid caffeine, tobacco, and excessive alcohol. • Get a back massage. • Relax using aromatherapy and music therapy. • Adjust the environment for temperature, noise, and light. • Elevate the head of the bed for patients diagnosed with gastroesophageal reflux disease (GERD). • Avoid large meals and certain medications in the evening.

Questions to ask patient during a health assessment regarding sleeping disorders

• Why do you think you are having sleep problems? • Have you recently had any changes at home or at work? • Have you started any new medications? • Is there anyone else at home who does not sleep well?

How is the concept of sleep defined and described?

• sleep is natural, necessary, involves a shift in physiological and neurologic activity, and is intended to be restorative