Chapter 45 Sleep

Sleep Diary

a sleep specialist may ask clients to keep a leep diary or log for 1-2 weeks in order to get a more plete picture of their sleep complaints.

Adolescents

(12-18 years old) require 9-10 hours of sleep each night.

School Age Children

(5-12 years old) needs 10-11 hours of sleep per night, but most receive less because of increasing demands

NREM

(non rapid eye movement) NREM sleep occurs when activity in the RAS is inhibited. About 75-80% of sleep during a night is NREM sleep. -*Stage 1* is the stage of very light sleep and lasts only a few minutes. During this stage, the person feels drowsy and relaxed, the eyes roll from side to side, and the heart and respiratory rates drop slightly. The sleeper can be readily awakened and may deny that they were sleeping. Low voltage brain waves are noted -*Stage 2* is the stage of sleep during which body processes continue to slow down. The eyes are generally still, the heart and respiratory rate decrease slightly and body temp falls. An individual in stage 2 required more intense stimuli than in stage 1 to awaken such as touching or shaking -*Stage 3* is the deepest stage of sleep, differing only in the percentage of delta waves recorded during a 30 second period. During deep sleep or delta sleep, the sleeps heart and respiratory rate drop 20-30% below those exhibited during waking hours. The sleeper is difficult to arouse. The person is not disturbed by sensory stimuli, the skeletal muscles are very relaxed, reflexes are diminished, and snoring is most likely to occur. This stage is essential for restoring energy and releasing important growth hormones.

Examples of parasomnias

-Bruxism (grinding of teeth, occurs during stage 2 of NREM sleep) -Enuresis (bed wetting, NREM stage 3) -Periodic limb movement disorder (the legs jerk twice or 3x per minute during sleep. -Sleep Talking (talking during sleep occurs during NREM sleep and before REM sleep) -Sleepwalking (occurs during stage 3 of NREM)

Diagnosising

-Insomnia (delayed onset of sleep r/t overstimulation prior to bedtime) -risk for injury r/t somnambulism -ineffective coping r/t insufficient quality and quantity of sleep -fatigue r/t insufficient sleep -impaired gas exchange r/t sleep apnea -deficient knowledge r/t misinformation -anxiety r/t sleep apnea and or the diagnosis of a sleep disorder -activity intolerance r/t sleep deprivation or excessive daytime sleepingess

Types of Sleep:

-NREM -REM

Physiological Changes during NREM sleep

-arterial BP falls -pulse rate decreases -peripheral blood vessels dilate -cardiac output decreases -skeletal muscles relax -basal metabolic rate decreases 10-30% -growth hormone levels peak

Clinical manifestations of Insomnia:

-difficult falling asleep -waking up frequently in the night -difficulty returning to sleep -waking up too early in the morning -unrefreshing sleep -daytima sleepiness -difficulty concentrating -irritability

Excessive Daytime Sleepiness

-hypersomnia -narcolepsy -sleep apnea -insufficient sleep

Assessing

-physical Examination (common findings among clients with sleep apnea include an enlarges and reddened uvula and soft palate, enlarged tonsils and adenoids, obesity, and in male clients a neck size greater than 17.5 inches.

Interventions for Older Adults to promote sleep:

-reduce or eliminate the consumption of caffeine and nicotine -be sure their environment is warm and safe -provide comfort measures -enhance the sense of safety and security by checking on clients frequently and making sure that the call light is within reach -if lack of sleep is caused by medications or certain health conditions -evaluate the situation and find out what the rest and sleep disturbances mean to the client.

Enhancing Sleep with Medications

-sedative hypnotic medications produce a general CND depression and an unnatural sleep (ambien), do not alter REM sleep or produce rebound insomnia when discontinued. -sleep medications affect REM sleep more than NREM sleep. Clients need to be informed that one or two nights of increasedd dreaming (REM rebound) are usual after the drug is discontinued after long term use. -Initial dose of medications should be low and increased added gradually -Regular use of any sleep medication can lead to tolerance over time and rebound insomnia. In some instances this may lead clients to increase the dosage. Clients must be cautioned about developing a pattern of drug dependency -abrupt cessation of barbiturate sedative hypnotics can create withdrawal symptoms such as restlessness, tremors, weakness, insomnia, increased HR, seizures, convulsions, and even death

Factors Affecting Sleep

-sleep quality (a subjective characteristic and is often determines by whether a person wakes up feeling energetic or not -quality of sleep (the total time the individual sleeps)

Adults

7-8 hours of sleep per night. Signs that may indicate that a person is not getting enough sleep include falling asleep or becoming drowsy during a task that is not fatiguing, not being able to concentrate or remember information, and being unreasonable irritable with other.

Older Adults

7-9 hours of sleep per night. Older adults may show an increase in disturbed sleep that can create a negative impact on their quality of life, mood and alertness. They may awaken an average of 6 times during the night. Although the ability to sleep becomes more difficult, the need to sleep does not decrease with age. During sleep, an older adult has flattened circadian rhythm. This is noted by *earlier bedtime and morning arousal, this is described as advanced sleep phase syndrome* The quality of sleep diminishes.

Diagnostic Studies

EEG, EMG, EOG. Electrodes transmits electric energy from the cerebral cortex and muscles of the face to pens that recor the brain waves and muscle activity on graph paper. Respiratory effort and airflow, ECG leg movement, and oxygen saturation are also monitored. Oxygen staturation are of particular importance if sleep apnea is suspected.

Insufficient Sleep

Individuals may develop attention and concentration deficits, reduced vigilance, distractibility, reduced motivation, fatigue, malaise, and occasionally diplopia and dry mouth. When clients report obtaining more sleep on weekends off, it usually indicates that they are not obtaining sufficient sleep.

Circadian Rhythme

Sleep and waking cycles are the best known of the circadian rhythms, body temp, BP, and many other physiolical functions also follow a circadian pattern. Sleep is a complex biologic rhythm. When a person's biologic clock coincides with the sleep/wake cycle, the person is said to be in circadian synchronization; that is, the person is awake when the body temp is at its highest, and asleep when the body temp is lowest.

Environment

The person must be able to achieve a state of relaxation prior to entering a period of sleep. Any change-for example, noise in the environment-can inhibit sleep. Discomfort from environmental temp and lack of ventilation can affect sleep. Light levels can be another factor. Another influence includes the comfort and size of the bed.

Motivation

a combination of boredom and lack of sleep can contribute to feeling tired.

Narcolepsy

a disorder of excessive daytime sleepiness caused by the lack of the chemical hypocretin in the area of the CNS that regulates sleep. Clients with narcolepsy have sleep attacks or excessive daytime sleepiness, and their sleep at night usually begins with a sleep onset REM period. The majority of clients also have cetaplexy or the sudden onset of muscle weakness or paralysis in association with strong emotion, sleep paralysis, hypnagogic hallucinations, and fragmented nighttime sleep. *Onset symptoms tend to occur between ages 15-30, and symptom severity usually stabilized within the first 5 years of onset.

Sleep

an altered state of consciousness in which the individual's perception of an reaction to the environment are decreased

Parasomnias

behavior that may interfere with sleep and may even occur during sleep. It is characterized by physical events such as movements or experiences that are displayed as emotions, perceptions, or dreams. 3 classes: -NREM -REM -micellaneous with no specific stage of sleep This may be anightmare disorder with exaggerated features of REM sleep.

Toddlers

between 12-14 hours of sleep are recommended for children 1-3 years of age.

Stimulants and Alcohol

caffeine containing beverages act as stimulants of the cns. People who drink an excessive amount of alcohol often find their sleep disturbed. While making up for lost REM sleep after some of the effects of the alcohol have worn off, people often experience nightmares.

Sleep Apnea

characterized by frequent short breathing pauses during sleep. Occur during REM or NREM sleep. Frequency of episodes range from 50-600 per night. 3 common types of sleep apnea are: -obstructive apnea (occurs when the structures of the pharynx or oral cavity block the flow of air. The diaphragm become stronger and stronger until the obstruction is removed) -central apnea (involve a defect in the respiratory center of the brain. all actions involved in breathing, such as chest movement and airflow cease.) -mixed apnea

Hypersomnia

conditions where the affected individual obtains sufficient sleep at night but still cannot stay awake during the day.

Key Factor to Sleep:

darkness

Duration of REM and NREM

during the early part of the night, the deep sleep periods are longer, As the night progresses, the sleeper spends less time in stage 3 of NREM sleep. REM sleep increases and dreams tend to lengthen. Before sleep ends, periods of near wakefulness occur, and stages 1 and 2 NREM and REM sleep dominate.

Biologic Rhythms

exist in plants, animals, and humans. In humans, these are controlled from within the body and synchronized with environmental factors, such as light and darkness. The most familiar biologic rhythm is the circadian rhythm. It is a sort of 24 hour internal clock.

Lifestyle

following an irregular morning and nighttime schedule can affect sleep. Moderate exercise in the morning or early afternoon usually is conducive to sleep, but exercise late in the day can delay sleep.

Illness

illnesses that causes pain or physical distress can result in sleep problems. -Respiratory conditions can disturb an individual's sleep -people who have gastric or duodenal ulcers may find their sleep disturbed b/c of pain -certain endocrine disturbances can also affect sleep. Hyperthyroidism lengthens presleep time, making it difficult for a client to fall asleep. Hypothyroidism, decreases stage 3 sleep. -Women with low estrogen often report excessive fatigue -Elevated body temp can cause some reduction in delta sleep and REM sleep

Functions of sleep:

individuals with inadequate amounts of sleep tend to become emotionally irritable, have poor concentration, and experience difficulty making decisions.

Sleep Hygiene

interventions used to promote sleep. Nursing interventions to enhace the quantity and quality of sleep involve largely nonpharmacologic measures. These involve health teaching about sleep habits, support of bedtime rituals, the provision of a restful environment, specific measures to promote comfort and relaxation, and appropriate use of hypnotic medications

Cyclic Nature of Sleep:

is thought to be controlled by centers located in the lower part of the brain. Neurons within the reticular formation, located in the brainstem, integrate sensory information from the peripheral nervous system and relay the information to the cerebral cortex. The upper part of the reticular formation consists of a network of ascending nerve fibers called the reticular activating system (RAS), which is invoved with the sleep/wake cycle.

Neurotransmitters in the brain:

located within the neurons in the brain affect the sleep/wake cyc;e. Serotonin is thought to lessen the repsonse to sensory stimulation and damma-aminbutyric acid (GABA) to shut off the activity in the neurons of the reticular activating system.

Medications

most hypnotics can interfere with deep sleep and suppress REM sleep. Beta blockers have been known to cause insomnia and nightmares. Narcotics, such as morphine, are known to suppress REM sleep and to cause frequent awakenings and drowsiness. Tranquilizers interfere with REM sleep. Although antidepressants suppress REM sleep, this effect is considered a therapeutic action. Selectively depriving a depressed client of REM sleep will result in an immediate but transient improvement in mood.

Smoking

nicotine has a stimulating effect on the body and smokers often have more difficulty falling asleep than nonsmokers

Newborns

sleep 12-18 hours a day on an irregular schedule with periods of 1-3 hours spent awake.

Emotional Stress

stress is considered by most sleep experts to be the one of the greatest causes of difficulties in falling sleep or staying asleep. Constant exposure to stress will increase the activation of the hypothalamic-pituitary-adrenal (HPA) axis leading to sleep disorders. Anxiety increases the norepinephrine blood levels through stimulation of the sympathetic nervous system. This chemical change results in less deep and REM sleep and more stage changes and awakenings.

Insomnia

the inability to fall asleep or remain asleep. Acute insomnia lasts one to several nights and is often caused by personal stressors or worry. If the insomnia persists for longer than a month, it is considered chronic insomnia. More often, people experience chronic intermittent insomnia, which means difficulty sleeping for a few nights, followed by a few nights of adequate sleep before the problem returns. *2 risk factors for insomnia are older age and female gender* Treatment for insomnia: -stimulus control (creating a sleep environment that promotes sleep -cognitive therapy (learning to develop positive thoughts and beliefs about sleep) -sleep restriction (following a program that limits time in bed in order to get to sleep and stay asleep throughout the night)

Preschoolder

the preschool age child (3-5 years old) requires 11-13 hours of sleep per night, particularly if the child is in preschool. Sleep needs fluctuate in relation to activity and growth spurts.

Sleep Cycles

typically pass through NREM and REM sleep, the complete cycle usually lasting about 90-110 minutes in adults. -1st sleep cycle, a sleep usually passes through the 1st 2 stages of NREM sleep in a total of about 20-30 minutes. -Stage 3 lasts about 50-60 minutes -After stage 3 NREM, the sleep passes back through stages 2 and 1 over about 20 minutes. -Thereafter, the 1st REM stage occurs, lasting about 10 minutes, completing the first sleep cycle. The healthy adult sleeper usually experiences 4-6 cycles of sleep during 7-8 hours. *the sleeper who is awkened during any stage must begin anew at stage 1 NREM sleep and proceed through all stages to REM sleep.

REM Sleep

usually recurs about every 90 min and lasts 5-30 minutes. Most dreams take place during REM sleep but usually will not be remembered unless the person arouses briefly at the end of REM period. During REM sleep, the brain is highly active, and brain metabolism may increase as much as 20%. Levels of acetylcholine and dopamine increase, with the highest levels of acetylcholine release occurring during REM sleep. This sleep is also called paradoxical sleep because EEG activity resembles that of wakefulness. Distinctive eye movements occur, voluntary muscle tone is dramatically decreased and deep tendon reflexes are absent.

Infants

usually takes 2 naps per day and should get about 14-15 hours of sleep in 24 hours

Diet

weight gain has been associated with reduced total sleep as well as broken sleep and earlier awakening. Wight loss, seems to be associated with an increase in total sleep and less broken sleep. *Dietary L trytophan found, in cheese and milk, may induce sleep*

Melatonin

with the beginning of daylight, melatonin is at its lowest level in the body and the stimulating hormone, cortisol, is at its highest. Wakefulness is also associated with high levels of acetylcholine, dopamine, and noradrenaline. Acetylcholine is released in the reticular formation, dopamine in the midbrain, and noradrenaline in the pons. These neurotransmitters are localized within the reticular formation and influence cerebral cortical arousal.