Sleep/Rest (knowledge check answers ch.33)

For each of the following patients, propose at least two factors that might affect sleep: 1. A newborn in the NICU 2. A preschooler being treated for pneumonia 3. An adolescent with cancer 4. A breastfeeding mother of a newborn 5. An older man who has fractured his hip

1. • Lights and noise and other unfamiliar stimuli • Pain and other noxious stimuli, such as needlestick and suctioning. • Physical illness symptoms (e.g., dyspnea, fever) • Handling by caregiver or parent 2. • Difficulty breathing, need to be awakened for treatments, experiencing new environmental stimuli, and so on • Usual factors associated with toddlers and preschoolers (e.g., frightened to go to bed because of imagined monsters or intruders or may waken frequently at night because of bad dreams, the need to use the bathroom, illness, heavy snoring, tossing off the bedclothes, or falling out of bed) 3. • Anxiety • Various medications that might interfere with sleep (e.g., opioids for pain) • Lifestyle factors commonly associated with adolescence (e.g., keeping up with the academic demands and other pressures at school; staying up late to watch television, text friends, surf the Internet, or study; dating; using alcohol or drugs; consuming large amounts of caffeinated colas and other beverages) can interfere with the quality or amount of sleep. 4. A breastfeeding mother typically suffers some degree of sleep deprivation because of nighttime feedings. Breastfed infants usually will feed every two to four hours in the first months of life before taking solid foods. 5. • Nocturia and discomfort or pain • Medications, such as opioids for pain • Unfamiliar environment

Describe the progression of a typical sleep cycle for a young adult.

A sleeping young adult progresses back and forth through lighter and deeper stages of sleep, about six times during an 8-hour sleep period. After falling asleep in stage I, a person progresses through successively deeper stages of NREM sleep from stage I to stage IV. Then the sequence reverses, and the person progresses through successively lighter stages to stage II, but instead of proceeding to stage I, the person enters the REM stage. After REM sleep, the person cycles back through NREM stages II, III, and IV and back again from IV to II to REM. If awakened at any time, however, the sleeper starts the cycle again at stage I.

What factors in the hospital environment may contribute to sleep deprivation?

Illness and hospital care are common causes of sleep deprivation, especially for patients in critical care units (CCUs). In the CCU, lights, equipment noise, and frequent interruptions for treatments and assessments, in addition to the client's fragile physical condition, combine to create sleep deprivation.

What is the most common dyssomnia?

Insomnia is the most common dyssomnia.

Why should people contact their prescriber before taking nonprescription sleep aids?

People should contact their healthcare provider before taking nonprescription (over the counter) sleep medications because they can interact with other medicines they may be taking. Also, they do have side effects, which may be dangerous for people with certain health conditions.

What is the stage that must be "made up" if not enough time is spent in it?

REM (stage V) sleep must be made up.

Compare and contrast sleep and rest. How are they different? Alike?

Sleep is a state of rest accompanied by altered consciousness and relative inactivity. Sleep is characterized by reduced skeletal muscle activity. Blood pressure and pulse rate decrease, and skin vessels dilate. The metabolism falls by 20% to 30%, so energy is conserved. At rest, the body is disturbed by all exterior noises, whereas in sleep, it is screened from them by altered consciousness. Rest is a condition in which the body is in a decreased state of activity, with the consequent feeling of being refreshed. Although necessary and beneficial, rest without sleep is inadequate. Sleep restores the normal levels of normal brain activity and "balance" in the central nervous system; rest alone cannot do this. Many organs that function during rest suspend their activities in sleep.

Why is promoting sleep an important nursing intervention?

Sleep is an important nursing intervention because it enhances wellness and speeds recovery from illness. Sleep and illness are interrelated. Prolonged lack of sleep can result in illness, and illness interferes with sleep. Sleep and rest are both essential to life and for keeping the body, mind, and spirit in excellent physiological shape. Rest and sleep restore energy, improve learning, and strengthen the immune system. Without the proper amount of sleep, the body ceases to function efficiently.

Why is snoring significant?

Snoring is a physical sign of obstructive sleep apnea. Also, snoring can significantly reduce the quality of sleep.

What is the classification of zolpidem (Ambien)? Why is it an especially desirable medication for sleep?

Zolpidem (Ambien) is classified as a sedative/hypnotic, nonbarbiturate. It is an especially desirable medication for sleep because it is short-acting and does not produce a hangover effect.

What are two other classes of medications that are sometimes prescribed for sleep?

• Benzodiazepines • Tricyclic antidepressants • Barbiturates

List two sleep-provoked disorders, and explain how the sleep stage affects the disease.

• Coronary artery disease. During REM sleep, dreams may increase heart rate and provoke angina and ECG changes. • Bronchial asthma. People with asthma may experience bronchospasm during REM sleep. In adults, asthma attacks may occur at any time during the night. In children, they occur mostly during the final two-thirds of the night, when there is less stage IV sleep. • Chronic obstructive pulmonary disease (COPD). Persons with COPD experience lowered oxygen tension and increased carbon dioxide retention during sleep, especially during REM sleep when neuromuscular control is normally depressed. This can result in pulmonary spasm and transient pulmonary hypertension. • Diabetes. Blood glucose levels vary during sleep. When diabetes is uncontrolled, it may profoundly affect the blood sugar during sleep when the person is not alert enough to deal with it. Therefore, a person with uncontrolled diabetes may need to have blood glucose levels monitored during sleep. • Duodenal ulcers. During REM sleep, people with duodenal ulcers secrete up to 20 times more gastric acid than do people who do not have duodenal ulcers. This increased acid often produces nocturnal epigastric pain and sleep loss.

What are the clinical signs of sleep deprivation in patients?

• Daytime drowsiness • Restlessness • Perceptual disorders • Impaired cognitive functioning • Irritability • Slowed reaction time • Somatic (body) complaints • General feeling of malaise • Changes in IgG, IgM, IgAm If sleep deprivation is severe and prolonged, delusions, paranoia, and other psychotic behaviors may occur.

Describe ways in which depression can affect sleep.

• Difficulty falling asleep • Less slow-wave (deep) sleep • Less time in REM sleep • Awaken early • Less total sleep time • Hypersomnia (excessive sleeping)

Describe three independent nursing interventions to promote sleep.

• Encourage use of relaxation exercise. • Allow visitors when needed for emotional security and relaxation, but limit visitors if the patient requires rest/sleep. • Explain procedures to decrease anxiety and promote healthy coping. • Listen attentively to decrease anxiety and convey compassion and caring. • Schedule nursing care to avoid interruption of sleep (e.g., don't awaken a patient to administer a sleeping pill, provide for rest periods). • Use nursing judgment to decide when a procedure must be done and when it is more important for your patient to sleep. • Alter routines; for example, allow the patient to sleep as long as he can in the morning and bring his breakfast later. • Unless the patient is critically ill, do not awaken him for morning vital signs when he is sleeping. • Create a restful environment; for example, be sure the bed linens are tight on the bottom and loose on top to allow movement; keep linens clean and free of irritants; use extra pillows, a blanket from home, or any other item that may help the patient rest; keep the patient in good body alignment; keep the room dark and quiet, unless the patient prefers a light; as much as possible, control the temperature of the room and provide good ventilation. • Promote comfort (e.g., be sure to offer pain medications at their scheduled times and before time to sleep; offer fluids, cool cloths, massage, or backrub). • Support bedtime rituals and routines (e.g., reading, watching TV, or praying; having warm milk, a favorite doll, blanket, or bedtime story; brushing teeth or hair). • Offer appropriate bedtime snacks/beverages (e.g., juice, crackers). • Teach the client to avoid alcohol and caffeine (e.g., tea, coffee, chocolate, colas.) • Advise the client to drink plenty of fluids during the day, but restrict large amounts of fluid close to bedtime. • Advise the person to not smoke after the evening meal. • Promote relaxation (e.g., guided imagery, progressive muscle relaxation, music therapy).

List the five stages of sleep.

• NREM (non-rapid eye movement, also called slow-wave sleep) is stages I, II, III, and IV • REM (rapid eye movement) is stage V

Name at least two nursing diagnoses that might have a sleep problem as the cause.

• Risk for Injury or Falls related to sleepwalking (or REM sleep behavior disorder or narcolepsy) • Fatigue (or Activity Intolerance) related to chronic insufficient quality or quantity of sleep (e.g., secondary to insomnia) • Ineffective Coping related to decreased cognitive functioning and awareness, secondary to lack of sleep • Disturbed Thought Processes related to decreased cognitive functioning, secondary to lack of sleep • Anxiety (or Fear) related to fear of death from sleep apnea

Identify at least three types of environmental stimuli that can disturb sleep.

• Room temperature (too cool, too warm) • Bedclothes (too heavy, too light) • Noise • Not having one's usual environment (e.g., no music) • Amount of light • Sleeping alone (or with someone)

For a chronic, long-term sleep problem would you use a diagnosis of Sleep Pattern Disturbance, Sleep Deprivation, or Readiness for Enhanced Sleep?

• Sleep Pattern Disturbance is NANDA nursing diagnosis defining a time-limited interruption in sleep resulting from external factors, such as room temperature and humidity, noise, lighting, noxious odors, sleep partner, unfamiliar sleep surroundings or bed, interruptions, lack of privacy, and physical restraints. A Sleep Pattern Disturbance can be reported as difficulty falling asleep, awakening with trouble getting back asleep, verbal complaint of not feeling rested after awakening, or dissatisfaction with sleep in general. • Sleep Deprivation is the NANDA nursing diagnosis when the patient has a decreased amount, consistency, or quality of sleep over prolonged periods of time. Defining characteristics of Sleep Deprivation are more severe than those for Sleep Pattern Disturbance, so nursing activities may focus as much on relieving symptoms (e.g., confusion, paranoia) as on sleep promotion. • Readiness for Enhanced Sleep is the NANDA diagnosis when a client has no particular sleep problem but desires improved quality of sleep.

List and define at least three parasomnias.

• Sleepwalking (somnambulism) occurs during stages III and IV of NREM sleep, usually 1 to 2 hours after falling asleep. The person who is sleeping leaves the bed and walks about with little awareness of surroundings. He may perform what appear to be conscious motor activities (e.g., opening doors, walking) but does not wake up. The person is not aware of sleepwalking and has no memory of the event on awakening. The event may last 3 to 4 minutes or longer. Children sleepwalk more often than adults. If the child does not outgrow the condition or serious safety risks exist, medications may be given to suppress stage IV sleep. Stress, fatigue, and some medications can cause sleepwalking. • Sleeptalking occurs during NREM sleep, just before the REM stage. It does not usually interfere with the person's rest. Speech is often nonsensical and garbled.. • Bruxism, grinding and clenching of the teeth, usually occurs during stage II NREM sleep. It can eventually erode tooth enamel, loosen the teeth, and lead to misalignment. • Night terrors are sudden arousals in which the person (usually a child) is physically active and expresses fear or strong emotion. The child is not awake, though, and is difficult to awaken. Once awakened, the child has no memory of the event. Unlike nightmares or highly disturbing state of confusion, which occur during REM, night terrors occur during stage IV (deep NREM) sleep. • REM sleep behavior disorders are associated with REM (or dreaming period) sleep, in which the sleeper violently acts out the dream. People have actually injured themselves or others without waking. • Enuresis (bedwetting) is nighttime incontinence. It has incorrectly been associated with dreaming; however, most incidents occur during NREM sleep, during the first third of the night when the child is difficult to arouse. It is distressing because of the stress society places on continence, the inconvenience of keeping bed linens clean, and the misconception that the child is bedwetting to act out against parents.

Name at least one nursing diagnosis that might have a sleep problem as the defining characteristic.

• Spiritual Distress related to challenges to belief system as manifested by nightmares, sleep disturbances, and verbalization of inner conflict about beliefs Other diagnoses that might cause symptoms of sleep difficulties include the following: • Anxiety • Chronic Sorrow • Death Anxiety • Decisional Conflict • Diarrhea • Dysfunctional Grieving • Impaired Gas Exchange • Nausea • Pain • Relocation Stress Syndrome

Describe the physiological activity characteristic of each stage of sleep.

• Stage I is a light sleep in which the sleeper can easily be awakened. The person is relaxed; breathing is regular and deep; the eyelids slowly open and close, and the eyes roll from side to side. The person feels groggy, the eyelids feel heavy, and suddenly without notice the person falls asleep. Within 5 to 10 minutes, sleep progresses to stage II. Stage I accounts for about 5% of our total sleep during the night. Brain activity consists of alpha waves with occasional low-frequency theta waves. • Stage II is also light sleep. Brain activity slows. The eyes are still, and body processes begin to slow down (e.g., temperature, pulse, and blood pressure decrease). The sleeper is easily aroused. Stage II, which usually lasts for 10 to 15 minutes, helps us disconnect from the outside world. • Stage III is a deeper sleep. Slow-wave activity begins to occur in this stage. The person is difficult to arouse, slow eye movement stops, skeletal muscles are very relaxed, and snoring may occur. This stage may last 5 to 15 minutes. A young adult spends about 8% of sleep time in stage III. • Stage IV is the deepest sleep. In this stage, the delta waves are highest in amplitude, slowest in frequency, and highly synchronized. The body, mind, and muscles are very relaxed. The heart rate is about 25% lower than when awake. It is difficult to awaken someone in stage IV slow-wave sleep, and if awakened, the person may appear confused and react slowly. Some dreaming may occur in stage IV, but dreams are less vivid than those that occur in REM sleep. A young adult spends about 11% of sleep time in stage IV. Stage IV sleep appears to be especially important for restorative processes such as protein synthesis, cell division, and tissue renewal. During this stage, the body releases human growth hormone, which is essential for repair and renewal of brain and other cells. • Stage V, REM sleep, is named because of its characteristic rapid eye movements, which can often be detected even though the sleeper's eyelids are closed. Metabolism, temperature, pulse, heart rate, and blood pressure increase, but muscle activity and deep tendon reflexes are depressed. Because most people awakened during REM sleep report that they have been dreaming, this loss of muscle tone is thought to be a protective response, to prevent the person from acting out the dreams. People are more difficult to arouse during REM sleep than during any other stage of sleep; however, more spontaneous awakenings occur during this stage than any other. When sleepers are successfully awakened during this stage, they are usually alert and can react normally, whereas those awakened during stages III or IV of slow-wave (NREM) sleep take a few moments to wake up and react.

Why are sleeping pills not recommended for chronic insomnia?

• They are habit-forming. • They become less effective with long-term use. • They can have serious side-effects. However, sedative-hypnotic treatment is justified in short-term insomnia to avoid the known consequences of insomnia on mood and performance. Short-term, aggressive treatment may prevent the development of chronic insomnia.