CHAP 34

In Stage 4 sleep, the:

the deepest stage of sleep, during which we are least responsive to outside stimulation; pulse rate is slow

A nursing student is changing the client's bed. Which action requires intervention from the nursing instructor?

tossing soiled linens on the floor

An 82-year-old client is newly admitted to an assisted living facility. Which intervention promotes safety at night for the client?

use a night light

A client comes to the clinic and states to the nurse, "I am traveling overseas for a project frequently and am having a difficult time adjusting because of jet lag. What is the best response by the nurse?

"Light therapy can be beneficial and help ease the transition to a new time schedule or zone."

The nurse is promoting bedtime rituals with a family. Which statement indicates the nurse may need to provide further instructions to the mother?

"My boys love to roughhouse in their room right before bedtime"

factors affecting sleep ability

1. Adults juggling the demands of their job and family responsibilities often find little opportunity for rest and relaxation during a day. 2. Children involved in numerous extracurricular activities, as well as trying to excel academically, also do not have the opportunity to rest and relax during the day. 3. when rest is possible, one's environment is not always conducive to physical and mental relaxation.

A nurse is working with an older adult client who has been diagnosed with onset insomnia and informs the nurse about waking at least once during the night. What actions by the nurse can help promote adequate sleep? Select all that apply.

1. The nurse helps the client come up with a bedtime routine that can be implemented each night. 2. The nurse encourages the client to remove the television from the bedroom. 3. The nurse encourages the client to minimize caffeine intake several hours prior to bedtime.

A nurse is caring for a client who has been diagnosed with a disturbed sleep pattern. Which measures should the nurse implement to promote sleep? Select all that apply.

1. providing a back massage 2. Assisting with progressive relaxation 3. Promoting daytime exercises

Rapid Eye Movement (REM)

20% to 25% of a person's nightly sleep time Pulse, respiratory rate, blood pressure, metabolic rate, and body temperature increase; skeletal muscle tone and deep tendon reflexes are depressed.

A client with difficulty sleeping is prescribed ramelteon. The client asks the nurse, "How does this medicine work?" Which information would the nurse include in the response?

Activates the receptors for the hormone melatonin

Diagnosing

Assessment data actual or potential problems related to rest and sleep may identify alterations in rest and sleep as a primary problem. changes in rest and sleep may affect other areas of human functioning disturbed sleep pattern is the cause of another problem (etiology) Disturbed Sleep Pattern as the Problem Disturbed sleep: pattern if the problem is time limited Sleep deprivation: if the problem is prolonged Examples of NANDA-I Nursing Diagnoses p. 1216 for additional Common etiologies Impaired comfort or pain Changes in bedtime rituals or sleep environment Disruption of circadian rhythm Sleep apnea Sustained inadequate sleep hygiene Drug dependency and withdrawal Symptoms of physical illness Disturbed Sleep Pattern as the Etiology Insomnia related to inadequate sleep hygiene and anxiety Risk for injury related to somnambulism, narcolepsy, sleep apnea Deficient knowledge (e.g., nonpharmacologic remedies for insomnia) related to misinformation, lack of interest in learning, cognitive limitation

Non-rapid eye movement (NREM)

Consists of four stages Stages I and II: 5% to 50% of sleep, light sleep Stages III and IV—10% of sleep, deep-sleep states (delta sleep)

factors affecting sleep and rest

Developmental considerations Motivation Culture Lifestyle and habits Physical Activity and Exercise Dietary Habits Smoking Environmental factors Psychological stress Illness Gastroesophageal reflux Coronary artery diseases Epilepsy Liver failure and encephalitis Hypothyroidism End-stage renal disease Medications

Which interview question would be the best choice for the nurse to use to assess for recent changes in a client's sleep-wakefulness pattern?

Do you usually go to bed and wake up about the same time each day?

common sleep disorders

ICSD Classification of Sleep Disorders Insomnia Sleep-related breathing disorders Central disorders of hypersomnolence Circadian rhythm sleep-wake disorders Parasomnias Sleep-related movement disorders Sleep Deprivation

evaluating

Evaluate the effectiveness of the plan of care to promote rest and sleep by determining whether the patient has met the individualized expected outcomes specified in the plan Nursing care is considered effective if the patient is able to: Verbalize feeling rested or having had a restful night's sleep Identify factors that interfere with or disrupt the normal sleep pattern Use techniques that promote sleep and provide a restful environment Concentrate and function effectively during waking hours Eliminate behaviors related to sleep deprivation modify if need be

The nurse is caring for a client who reports insomnia. The client has recently moved from an area near a fire station in the inner city to the country. Which recommendation will the nurse make to facilitate sleep?

Find a phone app that plays sounds of the city.

The pediatric nurse teaches parents about normal sleep patterns in their children. Which education point should the nurse include?

Inform parents that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap.

ASSESSMENT

Obtaining a Sleep History Nature of problem Cause of problem Related signs and symptoms When the problem began and how often it occurs How the problem affects everyday living Severity of the problem and how it can be treated How the patient is coping with the problem and success of treatments attempted Sleep Characteristics to Assess Restlessness Sleep postures Sleep activities Snoring Leg jerking Screening Tools to Assess Sleep Disturbances The Epworth Sleepiness Scale The Pittsburgh Sleep Quality Index (PSQI) Sleep Disturbance QuestionnaireSleep Diary A sleep diary/log provides data on the patient's sleep-wakefulness patterns over a period of time. summarizes information about patterns indicating activities and behaviors that affect the quality and quantity of sleep kept for 14 days includes a graph of the total number of hours of sleep per day number of undisturbed hours of sleep number of awakenings, and so forth daily record is completed addressing the following: Time patient retires Time patient tries to fall asleep Approximate time patient falls asleep Time of any awakening during the night and resumption of sleep Time of awakening in morning Presence of any stressors affecting sleep Record of food, drink, or medication affecting sleep Record of physical and mental activities Record of activities performed 2 to 3 hours before bedtime Presence of worries or anxieties affecting sleep Physical Assessment -confirm patient is getting enough rest to provide energy for the day's activities -validate the existence of a sleep disturbance that is decreasing the quantity or quality of sleep Energy level presence of physical weakness, fatigue, lethargy, or decreased energy Facial characteristics narrowing or glazing of eyes, swelling of eyelids, decreased animation Behavioral characteristics yawning, rubbing eyes, slow speech, slumped posture Physical data suggestive of sleep problems obesity, enlarged neck, deviated nasal septum

Outcome identification and planning

Planning for patient care, especially in a health care facility, involves planning with the patient suitable measures to promote rest and sleep. Whenever nurses care for a patient, nursing measures support the following expected patient outcomes [S-M-A-R-T format] The patient will: Maintain a sleep-wake pattern that provides enough energy for the day's tasks Demonstrate self-care behaviors that provide a healthy balance between rest and activity Identify stress-relieving rituals that enable the patient to fall asleep more easily Demonstrate decreased signs of sleep deprivation Verbalize feeling less fatigued and more in control of life activities

nursing process for rest and sleep

Routine health assessment: identify the patient's sleep-wakefulness pattern effect of these patterns on everyday functioning presence of factors that may be affecting the sleep use of sleep aids sleep disturbances and contributing factors. If the patient's sleep is adequate and no problems, sleep history is brief When admitted to a care facility: assess the patient's usual times for retiring and waking bedtime rituals normal sleep environment so that these can be incorporated into the plan of care Patients in hospitals often receive fragmented sleep. Their sleep may be disrupted by routine care measures, noise in the environment, and lighting Paying attention to small matters can make the difference between a patient's having a good night of sleep or no sleep.

The nurse is completing an admission assessment for a client scheduled for back surgery after a construction accident. The nurse notes the client is having slowed speech and focus, irritability, yawning, and that he reports severe lumbar and right leg pain. The nurse suspects a nursing diagnosis of:

Sleep Pattern Disturbance related to acute pain

circadian rhythm

Sleep is one of the body's most complex biologic rhythms Predictable fluctuations in processes that occur in repeated cycles of time, completing a full cycle every 24 hours. Fluctuations in a person's heart rate, blood pressure, body temperature, hormone secretions, metabolism, and performance and mood display circadian rhythms. Light and dark regulate sleep

implement

Sleep problems are usually not the primary reason for a patient's interaction with the health care system. A key to detecting a patient's sleep problems is the use of appropriate communication skills while displaying a nonjudgmental, caring attitude. Patients who believe the nurse is generally concerned about their well-being are not reluctant to discuss their sleep concerns or problems. To correct a sleep problem, the patient needs to believe that the nurse cares and will provide extra help to promote rest and sleep. Nursing Interventions to Promote Sleep Prepare a restful environment clean linens, adjust lightening/temp, control noise, Promote bedtime rituals brush teeth, shower, reading/TV, prayer/quiet Offer appropriate bedtime snacks and beverages healthy protein/carbs, avoid alcohol/caffeine/fluids Promote relaxation and comfort deep breathing, caring presence and touch, back massage Respect normal sleep-wake patterns REM sleep is more common during morning naps NREM sleep is more common during naps later in the day plan naps to fir needs not interfere with nighttime sleeping Schedule nursing care to avoid disturbances Cluster care Use medications to produce sleep barbiturates, benzodiazepines, and nonbenzodiazepines short term use associated with drug dependence and drug tolerance. abrupt discontinuation should be avoided; taper to avoid withdrawal symptoms Use alternative nonpharmacologic measures to promote sleep when appropriate. OTC sleep medications most often contain antihistamines should only be used on a short-term basis potential for adverse effects lack of effectiveness over a lengthy time period CHA Herbal medicines may offer ways to improve sleep; it is important to include questions about use of these agents as part of a nursing assessment related to sleep, as some patients may not consider OTC herbs to be medication. Teach about rest and sleep Teach patients and their families about rest and sleep and their importance to well-being. normal variations in sleep patterns measures to promote relaxation and sleep Discuss sleep hygiene recommendations with the patient. Sleep hygiene refers to nonpharmacologic recommendations that help a person get a better night's sleep. Review and change lifestyles and environment. Sleep hygiene suggestions •Restricting the intake of caffeine, nicotine, and alcohol, especially later in the day •Avoiding mental and physical activities after 5 PM that are stimulating •Avoiding daytime naps •Eating a light carbohydrate/protein snack before bedtime •Avoiding fluid intake in the evening to minimize trips to the bathroom during night •Sleeping in a cool, dark room •Eliminating use of a bedroom clock •Taking a warm bath before bedtime •Trying to keep the sleep environment as quiet and stress-free as possible

Stages of Sleep

Studied and analyzed by sleep study or polysomnogram noninvasive, pain-free study usually conducted over one or two nights in a sleep study facility electroencephalograph (EEG), which receives and records electrical currents from the brain electrooculogram (EOG), which records eye movements electromyograph (EMG), which records muscle tone. T

Sleep Cycle

The person passes consecutively through four stages of NREM sleep. The pattern is then reversed. Return from stage IV to III to II Enter REM sleep instead of re-entering stage I The person re-enters NREM sleep at stage II and moves on to III and IV. A person awakened from sleep at any time will return to sleep by starting at stage I of NREM sleep

physiology of sleep

Two systems in the brainstem, the reticular activating system (RAS) and the bulbar synchronizing region, are believed to work together to control the cyclic nature of sleep. RAS extends upward through the medulla, the pons, the midbrain, and into the hypothalamus. It facilitates reflex and voluntary movements as well as cortical activities related to a state of alertness comprises many nerve cells and fibers; fibers have connections that relay impulses into the cerebral cortex and spinal cord During sleep, the RAS experiences few stimuli from the cerebral cortex and the periphery of the body Wakefulness occurs when this system is activated with stimuli from the cerebral cortex and from periphery sensory organs and cells an alarm clock awakens us from sleep to a state of consciousness, in which we realize that we must prepare for the day Sensations such as pain, pressure, and noise produce wakefulness by means of peripheral organs and cells Hypothalamus has control centers for several involuntary activities of the body, one of which concerns sleeping and wakings Injury to the hypothalamus may cause a person to sleep for abnormally long periods. Various neurotransmitters are involved with the sleeping process. Norepinephrine and acetylcholine—in addition to dopamine, serotonin, and histamine—are involved with excitation. Melatonin, a hormone, is thought to regulate the sleep-wake cycle and possibly circadian rhythms (see following discussion of circadian rhythms) It is also known that sleep and wake states are also characterized by distinct hormonal patterns that exert potential significant influences on metabolism and glucose homeostasis

An older adult client tells his home care nurse that he doesn't seem to sleep as well as he used to. The nurse is aware that the sleep changes that occur in the older adult client which cause a less restful sleep include:

a decrease in the deep sleep stage of the sleep cycle.

A nurse is reviewing the medication administration record. Which order does the nurse question?

a diuretic administered twice daily at 9 a.m. and 9 p.m.

Insufficient sleep in children

affect normal growth and development performance deficits and behavioral problems. risk of obesity during childhood or later in life adults and children who slept less than the recommended hours per night were more likely to be overweight.

The client is scheduled for a polysomnography to determine if the client has obstructive sleep apnea (OSA). The nurse instructs the client to:

anticipate sleeping overnight at a health care center

Adverse effects of sleeping difficulties from shift work

anxiety personal conflicts loneliness depression gastrointestinal symptoms increase in type 2 diabetes hypertension higher rates of cardiovascular disease including strokes, and substance abuse

A nurse is caring for a client with insomnia. Which teaching will the nurse provide to help the client improve sleep?

create a bedtime routine

what is sleep

state of rest accompanied by altered consciousness and relative inactivity. Sleep is part of what is called the sleep-wake cycle. Wakefulness is a time of mental activity and energy expenditure period of inactivity and restoration of mental and physical function. complex rhythmic state involving a progression of repeated cycles, each representing different phases of body and brain activity, and is crucial for physical, mental, and emotional well-being

A nurse at the health care facility is caring for an older adult client who complains of sleeplessness. Which condition is a manifestation of depression in an older client?

insomnia

When the newly admitted client with chronic obstructive pulmonary disease informs the nurse that she frequently awakens during the night, the nurse may notify the physician for which intervention?

low-flow oxygen

sleep health

multidimensional pattern of sleep-wakefulness, adapted to individual, social, and environmental demands, that promotes physical and mental well-being. characterized by subjective satisfaction, appropriate timing, adequate duration, high efficiency and sustained alertness during waking hours Many people can fall asleep easily and remain asleep until the desired waking time. Others rarely fall asleep without a struggle; then when they do, sleep is fragmented Insufficient sleep can seriously affect a person's physical and psychological health Nurses need promoting good sleep health and detect and address sleep disturbances

Sleep-weight link

possibly related to two hormones: leptin and ghrelin. Leptin signals the brain to stop eating, whereas ghrelin promotes continued eating. sleep deprivation lowers leptin levels and elevates ghrelin levels, thus increasing one's appetite. brain may interpret a drop in leptin as a sign of starvation. brain then signals the body to eat more while it simultaneously lowers the body's metabolic rate. When this happens, people are more likely to gain weight, even if food intake is decreased

Which factor necessitates the need for more sleep in the adolescent population?

rapid growth

short sleeper

someone who sleeps less than 6 hours a night