sleep foundations

Rest definition

Awareness of environment is maintained by motor/cognitive response is decreased

Stages of the Adult Sleep Cycle

Four stages of NREM Sleep cycle lasts 90 to 100 minutes sleep goes through stages 1 to 4, then reversal from 4 to 3 to 3, followed by REM

when do you dream?

Occur in NREM and REM sleep Mostly rem

Assessment

Through the patient's eye Sleep assessment ØSources for sleep assessment = Patient, family ØTools for sleep assessment Sleep history ØDescription of sleeping problems, usual sleep pattern, current life events, physical and psychological illness, emotional and mental status, bedtime routines, bedtime environment, behaviors of sleep deprivation

Critical thinking

in the case of sleep, integrate knowledge from nursing and disciplines such as pharmacology and psychology USe personal experience professional standards

Ask the patient the following questions to determine a patients sleep pattern

•A general description of the problem followed by more focused questions usually reveals specific characteristics that are useful in planning therapies. To begin, you need to understand the nature of the sleep problem, its signs and symptoms, its onset and duration, its severity, any predisposing factors or causes, and the overall effect on the patient. •[Review Box 43-5, Nursing Assessment Questions, with the students.] •Proper questioning helps to determine the type of sleep disturbance and the nature of the problem. •[Review Box 43-6, Questions to Ask to Assess for Specific Sleep Disorders, with the students.] •As an adjunct to the sleep history, have the patient and bed partner keep a sleep-wake log for 1 to 4 weeks. •Ask the following questions to determine a patient's sleep pattern: •What time do you usually get in bed each night? •How much time does it usually take to fall asleep? Do you do anything special to help you fall asleep? •How many times do you awaken during the night? Why? •What time do you typically wake up in the morning? •On average, how many hours do you sleep each night? •Patients with sleep problems frequently show patterns drastically different from their usual one, or sometimes the change is relatively minor. Determine whether the patient has any preexisting health problems that interfere with sleep. A history of psychiatric problems also makes a difference. If the patient has recently had surgery, expect him or her to experience some sleep disturbance. Patients usually awaken frequently during the first night after surgery and receive little deep or REM sleep. Depending on the type of surgery, it takes several days to months for a normal sleep cycle to return. •In your assessment learn if the patient is experiencing any changes in lifestyle that disrupt sleep. A person's occupation often offers a clue to the nature of the sleep problem. •A patient's emotions and mental status affect the ability to sleep. When a sleep disturbance is related to an emotional problem, the key is to treat the primary problem; its resolution often improves sleep. •Ask patients what they do to prepare for sleep. •Pay special attention to a child's bedtime rituals. Some young children need a special blanket or stuffed animal when going to sleep. •Observe for behaviors such as irritability, disorientation (similar to a drunken state), frequent yawning, and slurred speech. If sleep deprivation has lasted a long time, psychotic behavior such as delusions and paranoia sometimes develop. •[Review Figure 43-3, Critical thinking model for sleep assessment, with students.] Common Pharmaceutical Categories That Impair Sleep • •• Antiarrhythmics • •• Antihistamines • •• Beta-blockers • •• Corticosteroids • •• Diuretics • •• Nicotine products • •• Selective serotonin reuptake inhibitors • •• Theophylline • •• Thyroid hormone

Consequences

Commonly occurring physiological consequences of poor sleep include: ØHypertension ØHeart disease and heart failure ØStroke ØObesity ØDevelopmental disorders such as alterations in growth hormone ØReproductive disorders due to disruption in hormonal regulation ØIncreased mortality How does sleep impact these? Effective weight management Diminished immune function

nursing diagnosis

-anxiety -ineffective breathing pattern -acute confusion -compromised family coping -ineffective coping -insomnia -fatigue -sleep deprivation -readiness for enhanced sleep

Implementation examples

Acute care ØEnvironmental controls ØPromoting comfort ØEstablishing periods of rest and sleep ØPromoting safety ØStress reduction

Physiology of sleep

Circadian rhythms- affected by light temperature, social activities, and work routines The biological rhythm of sleep frequently becomes synchronized with other body functions.

Common Diagnostic Tests

Definitive tests for sleep problems measure activity and events related to sleep and wakefulness Polysomnogram (PSG) Sleep journals

Populations at Risk

Every human being is at risk for sleep problems. Populations at risk: ØMiddle-aged and older adult ØWomen ØPregnant and perimenopausal women ØMen have highest risk for obstructive sleep apnea (OSA) ØObesity

Planning

Goals and outcomes example ØFollow professional standards ØCreate a concept map ØCollaborate Setting priorities Teamwork and collaboration ØPartner closely with the patient and sleep partner Collaborative Interventions ØSleep hygiene ØPharmacological Agents (Common Pharmacological Agents for Sleep Disorders Box 43-4 ØInvasive procedures •Professional standards are especially important to consider in developing a care plan. •As you plan care for a patient with sleep disturbances, creation of a concept map is another method for developing holistic patient-centered care. •When developing goals and outcomes, it is important for a nurse and patient to collaborate. •Patients are a helpful resource in determining which interventions hold priority. •When patients have chronic sleep problems, the initial referral for a patient is often to a comprehensive sleep center for assessment of the problem. The nature of the sleep disturbance then determines whether referrals to additional health care providers are necessary.

Implementation

Health promotion ØEnvironmental controls ØPromoting bedtime routines ØPromoting safety ØPromoting comfort ØEstablishing periods of rest and sleep ØStress reduction ØBedtime snacks ØPharmacological approaches

Healthy people 2020: objectives pertaining to sleep

Increase the proportion of adolescents obtaining adequate sleep Increase the proportion of adults obtaining adequate sleep Decrease the number of motor vehicle incidents attributed to drowsy driving Increase the proportion of adults with apnea symptoms seeking medical treatment

Normal Sleep Requirements & Patterns

Neonates- 16 hours a day Infants- 8 to 10 hours at night for a total of 15 hours per day Toddlers- total 12 hours a day Preschoolers -12 hours a night School age- 9 to 10 hours Adolescents- get 7 1/2 hours Young adults- get 6 to 81/2 hours Middle and older adults- total number of hours declines

Sleep apnea

Primary central sleep apnea, central sleep apnea caused by medical condition, obstructive sleep apnea syndromes, excessive daytime sleepiess •a disorder characterized by lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep. Three types of sleep apnea are known: central, obstructive, and mixed. The most common form is obstructive. •Obstructive sleep apnea (OSA) •The two major risk factors for OSA are obesity and hypertension. •OSA occurs when muscles or structures of the oral cavity or throat relax during sleep. The upper airway becomes partially or completely blocked, diminishing nasal airflow (hypopnea) or stopping it (apnea) for as long as 30 seconds. •Excessive daytime sleepiness is the most common complaint. •Feelings of sleepiness are usually most intense on awakening, right before going to sleep, and about 12 hours after the midsleep period. •Causes a serious decline in arterial oxygen saturation level. •Central sleep apnea (CSA) involves dysfunction in the respiratory control center of the brain. •The impulse to breathe fails temporarily, and nasal airflow and chest wall movement cease. •The oxygen saturation of the blood falls. The condition is common in patients with brainstem injury, muscular dystrophy, and encephalitis. Less than 10% of sleep apnea is predominantly central in origin. •People with CSA tend to awaken during sleep and therefore complain of insomnia and excessive daytime sleepiness (EDS). Mild and intermittent snoring is also present. •Treatment includes therapy for underlying cardiac or respiratory complications and emotional problems that occur as a result of the symptoms of this disorder.

Importance of sleep

Proper rest and sleep are as important to health as good nutrition and adequate exercise. Physical and emotional health depends on the ability to fulfill these basic human needs Identifying and treating patients sleep pattern disturbances are important goals. to help you need to understand the nature of sleep, the factors influencing it and the patients sleep habits. Sleep provides healing and restoration Some patients have preexisting sleep disturbances; other patients develop sleep problems as a result of an illness or hospitalization

Physiology of Sleep: Sleep Regulation

Regulated by a sequence of physiological states integrated by central nervous system (CNS) activity Hypothalamus Reticular activating system Homeostatic process

Sleep and Rest

Rest contributes to: Mental relaxation Freedom from anxiety State of mental, physical, and spiritual activity Bed rest does not guarantee that a patient will feel rested.

The concept of sleep

Sleep is natural, necessary, involves a shift in physiologic and neurological activity, and is intended to be restorative. Sleep is not a period of inactivity The scope of sleep ranges from restorative sleep, which results in an individual feeling rested, to impaired sleep which leaves the individual not feeling rested or refreshed. Impaired sleep can be intermittent or chronic with chronic sleep being associated with physical, cognitive, and social challenges. The most important idea is the first sentence.

Primary sleep disorders

Those that exist as an independent condition ex: •include insomnia, sleep-related breathing disorders, sleep-related movement disorders, parasomnias, circadian rhythm sleep disorders, and hypersomnia: • •• Insomnia exists when there is difficulty falling asleep or staying asleep. • •• Sleep-related breathing disorders involve either a problem with the airway, as seen in obstructive sleep apnea, or a problem with the neurologic drive to breathe during sleep (central sleep apnea). •Parasomnias include a variety of behaviors, such as sleepwalking, sleep terror, and REM behavior disorder. • •• Circadian rhythm sleep disorders occur when the drive to sleep does not occur according to what would be considered a normal sleep-wake pattern, such as someone who stays awake until early morning and does not have the drive to fall asleep as nighttime progresses. • •• Hypersomnia is characterized by excessive sleepiness or falling asleep at inappropriate times. Narcolepsy is an example of hypersomnia as a primary sleep disorder. •Secondary Sleep Disorders

A 45-year-old male patient snores loudly and his wife reports that he has periods where he stops breathing. He has gained a significant amount of weight in the past year. To assist this patient, the best action to take would be:

asking for a consult for a Sleep Study.

Circadian rhythms definition

cycle every 24 hours; fluctuations in HR, BP, temp, hormone, secretion, metabolism, performance, and mood

Narcolepsy

is a dysfunction of mechanisms that regulate the sleep and waking states. •During the day a person suddenly feels an overwhelming wave of sleepiness and falls asleep; REM sleep occurs within 15 minutes of falling asleep. Cataplexy, or sudden muscle weakness during intense emotions such as anger, sadness, or laughter, occurs at any time during the day. •Sleep paralysis is another symptom. Cataplexy, sleep paralysis

Sleep definition

naturally occurring altered state of consciousness characterized by decreased awareness and response to stimuli

1. During rounds on the night shift, you note that a patient stops breathing for 1 to 2 minutes several times during the shift. This condition is known as:

sleep apnea.

A patient suffers from sleep pattern disturbance. To promote adequate sleep, the most important nursing intervention is:

synchronizing the medication, treatment, and vital signs schedule.

Deeper assessment

•Assess patients' sleep patterns by using a nursing history to gather information about factors that usually influence sleep. Sleep is a subjective experience. Only the patient is able to report whether or not it is sufficient and restful. If the patient is satisfied with the quantity and quality of sleep received, you consider it normal, and the nursing history is brief. If a patient admits to or suspects a sleep problem, you need a detailed history and assessment. If a patient has an obvious sleep problem, consider asking if his or her sleep partner can be approached for further assessment data. •A poor night's sleep for a patient often starts a vicious cycle of anticipatory anxiety. •Usually patients are the best resource for describing sleep problems and how they represent a change from their usual sleep and waking patterns. •In addition, bed partners are able to provide information about patients' sleep patterns that helps reveal the nature of certain sleep disorders. •When caring for children, seek information about sleep patterns from parents or guardians because they are usually a reliable source of information. •Two effective subjective measures of sleep are the Epworth Sleepiness Scale and the Pittsburgh Sleep Quality Index. •Another brief subjective method to assess sleep is a numeric scale with a 0 to 10 sleep rating. •When suspecting a sleep problem, assess the quality and characteristics of sleep in greater depth by asking the patient to describe the problem. This includes recent changes in sleep pattern, sleep symptoms experienced during waking hours, use of sleep and other prescribed or over-the-counter medications, diet and intake of substances such as caffeine or alcohol that influence sleep, and recent life events that have affected the patient's mental and emotional status. •If a patient's sleep is adequate, assess his or her usual bedtime, normal bedtime ritual, preferred environment for sleeping, and usual preferred rising time. •When a patient has a sleep problem, conduct a complete sleep history. Diagnosing sleep problems depends on identifying factors that impair sleep.

Functions of sleep

•NREM sleep contributes to body tissue restoration. •During sleep the heart rate falls to 60 beats/min or less, which benefits cardiac function. Other biological functions decreased during sleep are respirations, blood pressure, and muscle tone. •The body needs sleep to routinely restore biological processes. During deep slow-wave (NREM stage 4) sleep, the body releases human growth hormone for the repair and renewal of epithelial and specialized cells such as brain cells. Protein synthesis and cell division for renewal of tissues such as the skin, bone marrow, gastric mucosa, or brain occur during rest and sleep. NREM sleep is especially important in children, who experience more stage 4 sleep. •Another theory about the purpose of sleep is that the body conserves energy during sleep. The skeletal muscles relax progressively, and the absence of muscular contraction preserves chemical energy for cellular processes. Lowering of the basal metabolic rate further conserves body energy supply. •REM sleep is necessary for brain tissue restoration and appears to be important for cognitive restoration and memory. •A loss of REM sleep leads to feelings of confusion and suspicion. •Although dreams occur during both NREM and REM sleep, the dreams of REM sleep are more vivid and elaborate; and some believe that they are functionally important to learning, memory processing, and adaptation to stress. •The ability to describe a dream and interpret its significance sometimes helps resolve personal concerns or fears. •Another theory suggests that dreams erase certain fantasies or nonsensical memories.

Nursing intervention

•Nursing interventions designed to improve the quality of a person's rest and sleep are largely focused on health promotion. Patients need adequate sleep and rest to maintain active and productive lifestyles. During times of illness, rest and sleep promotion are important for recovery. •[Review Box 43-8, Focus on Older Adults: Promoting Sleep, with students.] •In community health and home settings, help patients develop behaviors conducive to rest and relaxation. [Discuss each.] •[Review Box 43-9, Patient Teaching: Sleep Hygiene Habits, with the students.] •Patients benefit most from instructions based on information about their homes and lifestyles such as which types of activities promote sleep in a nightshift worker, or how to make the home environment more conducive to sleep. They will likely apply information that is useful and valued. •All patients require a sleeping environment with a comfortable room temperature and proper ventilation, minimal sources of noise, a comfortable bed, and proper lighting. Eliminate distracting noise so the bedroom is as quiet as possible. In the home the television, telephone, or the intermittent chiming of a clock often disrupts a patient's sleep. Patients vary in regard to the amount of light that they prefer at night. Bedtime routines relax patients in preparation for sleep. It is always important for persons to go to sleep when they feel fatigued or sleepy. •A bedtime routine (e.g., same hour for bedtime, snack, or quiet activity) used consistently helps young children avoid delaying sleep. •Adults need to avoid excessive mental stimulation just before bedtime. •For any patient prone to confusion or falls, safety is critical. •Night light •Beds set lower to the floor •Remove clutter •Sleepwalkers are unaware of their surroundings and are slow to react, increasing the risk of falls. Do not startle sleepwalkers but instead gently awaken them and lead them back to bed. •Infants' beds need to be safe. To reduce the chance of suffocation, do not place pillows, stuffed toys, or the ends of loose blankets in cribs. Loose-fitting plastic mattress covers are dangerous because infants pull them over their faces and suffocate. Parents need to place an infant on his or her back to prevent suffocation. •People fall asleep only after feeling comfortable and relaxed. •In the home, it helps to encourage patients to stay physically active during the day so they are more likely to sleep at night. Increasing daytime activity lessens problems with falling asleep. •The inability to sleep because of emotional stress also makes a person feel irritable and tense. When patients are emotionally upset, encourage them to try not to force sleep. Otherwise insomnia frequently develops, and soon bedtime is associated with the inability to relax. •Preschoolers have bedtime fears (fear of the dark or strange noises), awaken during the night, or have nightmares. •Cultural tradition causes families to approach sleep practices differently. •[Review Box 43-10, Cultural Aspects of Care: Co-sleeping, with students.] •Some people enjoy bedtime snacks, whereas others cannot sleep after eating. A dairy product such as warm milk or cocoa that contains L-tryptophan is often helpful in promoting sleep. A full meal before bedtime often causes gastrointestinal upset and interferes with the ability to fall asleep. •Warn patients against drinking or eating foods with caffeine before bedtime. •Melatonin is a neurohormone produced in the brain that helps control circadian rhythms and promote sleep. It is a popular nutritional supplement that is found to be helpful in improving sleep efficiency and decreasing nighttime awakenings. The recommended dose is 0.3 to 1 mg taken 2 hours before bedtime. •Several other herbal products assist in sleep. Valerian is effective in mild insomnia and RLS. It effects the release of neurotransmitters and produces very mild sedation. Kava helps promote sleep in patients with anxiety. It should be used cautiously because of its potential toxic effects on the liver. Chamomile, an herbal tea, has a mild sedative effect that may be beneficial in promoting sleep. •The use of nonprescription sleeping medications is not advisable. Patients need to learn the risks of such drugs. Over the long term these drugs lead to further sleep disruption, even when they initially seemed effective. •Common Pharmacologic Agents Used to Treat Sleep Disorders • •• Anticonvulsants• Gabapentin (Neurontin) • •• Antidepressants- Amitriptyline (Elavil)• Fluoxetine (Proxac) • •• Antihistamines• Diphenhydramine (Benadryl) • •• Benzodiazepines• Diazepam (Valium)• Lorazepam (Ativan)• Trazolam (Halcion) • •• Benzodiazepine receptor-like agents• Zolpidem (Ambien) • •• Melatonin-receptor agonists• Ramelteon (Rozerem)

Factors influencing sleep

•Often, several factors contribute to a sleep disorder. Physiological, psychological, and environmental factors inhibit sleep. •Sleepiness, insomnia, and fatigue often result as a direct effect of commonly prescribed medications. •Emotional stress causes a person to be tense and often leads to frustration when sleep does not occur. Stress also causes a person to try too hard to fall asleep, to awaken frequently during the sleep cycle, or to oversleep. Continued stress causes poor sleep habits. •Older patients frequently experience losses that lead to emotional stress such as retirement, physical impairment, or the death of a loved one. Older adults and other individuals who experience depressive mood problems experience delays in falling asleep, earlier appearance of REM sleep, frequent or early awakening, feelings of sleeping poorly, and daytime sleepiness. •Good ventilation is essential for restful sleep. The size, firmness, and position of the bed affect the quality of sleep. If a person usually sleeps with another individual, sleeping alone often causes wakefulness. On the other hand, sleeping with a restless or snoring bed partner disrupts sleep. •Following good eating habits is important for proper sleep. •Weight loss or gain influences sleep patterns. Weight gain contributes to OSA because of increased size of the soft tissue structures in the upper airway. •[Review Box 43-4, Drugs and Their Effects on Sleep, with students.]

extra information about circadian rhythms

•People experience cyclical rhythms as part of their everyday lives. •The most familiar rhythm is the 24-hour, day-night cycle known as the diurnal or circadian rhythm (derived from Latin: circa, "about," and dies, "day"). •The suprachiasmatic nucleus (SCN) nerve cells in the hypothalamus control the rhythm of the sleep-wake cycle and coordinate this cycle with other circadian rhythms. •Circadian rhythms influence the pattern of major biological and behavioral functions. The predictable changing of body temperature, heart rate, blood pressure, hormone secretion, sensory acuity, and mood depend on the maintenance of the 24-hour circadian cycle. •All persons have biological clocks that synchronize their sleep cycles. This explains why some people fall asleep at 8 p.m., whereas others go to bed at midnight or early in the morning. Different people also function best at different times of the day. •Failure to maintain an individual's usual sleep-wake cycle negatively influences the patient's overall health.

Successful Critical thinking

•Successful critical thinking requires a synthesis of knowledge, including information gathered from patients, experience, critical thinking attitudes, and intellectual and professional standards. Clinical judgments require you to anticipate the information necessary, analyze the data, and make decisions regarding patient care. You adapt critical thinking to the changing needs of the patient. •Personal experience with a sleep problem and experience with patients prepares you to know effective forms of sleep therapies. You use critical thinking attitudes such as perseverance, confidence, and discipline to complete a comprehensive assessment and develop a plan of care to provide successful management of the sleep problem. •Professional standards, such as the Nursing Scope and Standards of Practice, Clinical Guidelines for the Treatment of Primary Insomnia and "Excessive Sleepiness" in Evidence-based Geriatrics Nursing Protocols for Best Practice, provide valuable guidelines to assess and address the needs of patients with sleep disorders.

Stages of the adult sleep cycle Further information

•The normal sleep pattern for an adult begins with a presleep period during which the person is aware only of a gradually developing sleepiness. This period normally lasts 10 to 30 minutes; however, if a person has difficulty falling asleep, it lasts an hour or more. •Once asleep, the person usually passes through four or five complete sleep cycles per night, each consisting of four stages of nonrapid eye movement (NREM) sleep and a period of rapid eye movement (REM) sleep. •A person usually reaches REM sleep about 90 minutes into the sleep cycle. Seventy-five to 80% of sleep time is spent in NREM sleep. •With each successive cycle stages 3 and 4 shorten, and the period of REM lengthens. REM sleep lasts up to 60 minutes during the last sleep cycle. Not all people progress consistently through the stages of sleep. •Sleep becomes more fragmented with aging, and a person spends more time in lighter stages. •[Shown is Figure 43-2: Stages of adult sleep cycle.] •[Review Box 43-1, Stages of the Sleep Cycle, with students.]

Sleep Deprivation

•a problem many patients experience as a result of dyssomnia. Causes include fever, difficulty breathing, pain, emotional stress, medications, and disturbances in the health care setting. Owing to long work schedules and rotations, health care providers are prone to sleep deprivation. Hospitalization makes patients prone to sleep deprivation caused by environmental noises and interruptions for care. Emotional stress, Medications, Environmental disturbances, Symptoms

PArasomnials

•are sleep problems that are more common in children. These include sleepwalking, night terrors, nightmares, bed-wetting, body rocking, and tooth grinding. When adults have these problems, it often indicates more serious disorders. Somnambulism (sleepwalking), night terrors, nightmares, nocturnal enuresis (bed-wetting), body rocking, Bruxism

Secondary Sleep Disorders

•occur as the result of some other situation, and correcting that situation should resolve the problem with sleep. Secondary disorders are often caused by medical conditions, mental health conditions, and side effects of medical treatments. Box 11-1 presents medical conditions that are commonly known to interfere with sleep. A secondary sleep disorder may also be associated with use of any medication that has either a sedative or a stimulating effect because either of these actions can interfere with restorative sleep (Box 11-2). Prematurity in infants also may lead to problems with sleep secondary to the state of neurologic or cardiovascular development. •Many adults in the United States have significant sleep problems from inadequacies in either the quantity or quality of their nighttime sleep and experience hypersomnolence on a daily basis. •The American Academy of Sleep Medicine developed the International Classification of Sleep Disorders version 2 (ICSD-2), which classifies sleep disorders into eight major categories. •Individuals with sleep-related breathing disorders have changes in respirations during sleep. •Hypersomnias are sleep disturbances that result in daytime sleepiness and are not caused by disturbed sleep or alterations in circadian rhythms. •The circadian rhythm sleep disorders are caused by a misalignment between the timing of sleep and individual desires or the societal norm. •The parasomnias are undesirable behaviors that occur usually during sleep. •Sleep and wake disturbances are associated with many medical and psychiatric sleep disorders, including psychiatric, neurological, or other medical disorders. •In sleep-related movement disorders the person experiences simple stereotyped movements that disturb sleep. The category of isolated symptoms, apparently normal variants, and unresolved issues includes sleep-related symptoms that fall between normal and abnormal sleep. •The "other" sleep disorders category contains sleep problems that do not fit into other categories. •A polysomnogram involves the use of EEG, EMG, and EOG to monitor stages of sleep and wakefulness during nighttime sleep. The Multiple Sleep Latency Test (MSLT) provides objective information about sleepiness and selected aspects of sleep structure by measuring eye movements, muscle-tone changes, and brain electrical activity during at least four napping opportunities spread throughout the day. •[Review Box 43-2, Classification of Select Sleep Disorders, with students.]

Insomnia

•the most common sleep disorder, is a symptom patients experience when they chronically have difficulty falling asleep. Adjustment sleep disorder (acute insomnia), inadequate sleep hygiene, behavioral insomnia of childhood, insomnia caused by medical condition