Ch. 42 Sleep
List the stages of sleep and describe each stage.
(NREM, Nonrapid eye movement; REM, rapid eye movement.) Stage 1: NREM -Stage 2: NREM -Stage 3: NREM -Stage 4: NREM -REM sleep Stage 1- Stage lasts a few minutes. It includes lightest level of sleep. Decreased physiological activity begins with gradual fall in vital signs and metabolism. Sensory stimuli such as noise easily arouses person. Awakened, person feels as though daydreaming has occurred. Stage 2- Stage lasts 10 to 20 minutes. It is a period of sound sleep. Relaxation progresses. Body functions continue to slow. Arousal remains relatively easy. Stage 3- Stage lasts 15 to 30 minutes. It involves initial stages of deep sleep. Muscles are completely relaxed. Vital signs decline but remain regular. Sleeper is difficult to arouse and rarely moves. Stage 4- Stage lasts approximately 15 to 30 minutes. It is the deepest stage of sleep. If sleep loss has occurred, sleeper spends considerable portion of night in this stage. Vital signs are significantly lower than during waking hours. Sleepwalking and enuresis (bed-wetting) sometimes occur. It is very difficult to arouse sleeper. REM sleep- Stage usually begins about 90 minutes after sleep has begun. Duration increases with each sleep cycle and averages 20 minutes. Vivid, full-color dreaming occurs; less vivid dreaming occurs in other stages. Stage is typified by rapidly moving eyes, fluctuating heart and respiratory rates, increased or fluctuating blood pressure, loss of skeletal muscle tone, and increase of gastric secretions. It is very difficult to arouse sleeper.
What are the normal sleep requirements and patterns for people across all age groups? (example newborns sleep more than 16 hours a day, older adult less than 6 hours)
-Neonates up to age 3- 16 hours a day -Infants -8 to 10 hours a night for a total of 15 hours per day -Toddlers (ages 2-4) - total 12 hours a day -Preschoolers (age 5)- 12 hours a night -School age- 9-10 hours -6 year old averages 11-12 hours of sleep nightly -11 year old sleeps about 9-10 hours Adolescents: get ~ 7 ½ hours. In adolescents, shortened sleep time often results in excessive daytime sleepiness, which frequently leads to reduced performance in school, vulnerability to accidents, behavior and mood problems, and increased use of alcohol. Young adults: get 6-8 ½ hours. -Middle adults: In middle age, the amount of stage 4 sleep begins to fall—a decline that continues with advancing age. -Older adult: Complaints of sleeping difficulties increase with age. More than 50% of older adults report sleep problems. The tendency to nap seems to increase progressively with age because of the frequent awakenings experienced at night.
What are sleep disorders?
Primary central sleep apnea, Central sleep apnea caused by medical condition, Obstructive sleep apnea syndromes, Excessive daytime sleepiness
What is the difference between sleep and rest?
Rest: when we give our body a period for relaxation. We relaxes our muscles, sometimes close our eyes for comfort. But, our brain can running his functions actively during resting phase too. We have our full consciousness about the surrounding during resting time. Sleep: In this condition our brain does not work actively. we don't have our full consciousness about the surroundings. Our brain here takes rest as well as our body muscles do.
Give the definitions of sleep and rest?
Sleep: Sleep is a cyclical physiological process that alternates with longer periods of wakefulness. The sleep-wake cycle influences and regulates physiological function and behavioral responses. Rest: When people are at rest, they usually feel mentally relaxed, free from anxiety, and physically calm. Rest does not imply inactivity, although everyone often thinks of it as settling down in a comfortable chair or lying in bed. When people are at rest, they are in a state of mental, physical, and spiritual activity that leaves them feeling refreshed, rejuvenated, and ready to resume the activities of the day.
What are steps in Nursing process for client with sleep disorders and describe each step?
• Assessment- -Sleep assessment -Sources for sleep assessment = Patient, family -Tools for sleep assessment -Sleep history -Description 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 •Diagnosis- -Sleep assessment -Sources for sleep assessment = Patient, family -Tools for sleep assessment -Sleep history -Description 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 •Planning- -It is important for a plan of care for sleep promotion to include strategies appropriate to the patient's sleep routines, living environment, and lifestyle. -When developing goals and outcomes, it is important for the nurse and patient to collaborate. -Address other health problems that interfere with sleep as a first priority. -Involve sleep partner as needed in the selection of interventions. -When patients have chronic sleep problems, the initial referral for a patient is often to a comprehensive sleep center for assessment of the problem. Consult with health professionals as needed. •Implementation- -When planning interventions to promote sleep, consider the usual characteristics of the patient's home environment and normal lifestyle. -Patients in acute care settings have their normal rest and sleep routine disrupted, which generally leads to sleep problems. In this setting, nursing interventions focus on controlling factors in the environment that disrupt sleep, relieving physiological or psychological disruptions to sleep, and providing for uninterrupted rest and sleep periods for the patient. -A regular bedtime routine of relaxing activities prepares a person physically and mentally for sleep. -An environment with a darkened room, reduced noise, a comfortable bed, and good ventilation promotes sleep. -The nursing interventions implemented in the acute care setting are also used in the restorative or continuing care environment. Controlling the environment, especially noise; establishing periods of rest and sleep; and promoting comfort are important considerations. •Evaluation- •Determine whether expected outcomes have been met. -Are you able to fall asleep within 20 minutes of getting into bed? -Describe how well you sleep when you exercise. -Does the use of quiet music at bedtime help you to relax? -Do you feel rested when you wake up?
*Key points in the text book.
• Sleep provides physiological and psychological restoration. • The 24-hour sleep-wake cycle is a circadian rhythm that influences physiological function and behavior. • The control and regulation of sleep depends on a balance among regulators within the CNS. • During a typical night's sleep a person passes through four to five complete sleep cycles. Each sleep cycle contains three NREM stages of sleep and a period of REM sleep. • The most common type of sleep disorder is insomnia. • The hectic pace of a person's lifestyle, emotional and psychological stress, and alcohol ingestion frequently disrupt the sleep pattern. • 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. • When planning interventions to promote sleep, considers the usual characteristics of the patient's home environment and normal lifestyle. • A regular bedtime routine of relaxing activities prepares a person physically and mentally for sleep. • An environment with a darkened room, reduced noise, comfortable bed, and good ventilation promotes sleep. • Important nursing interventions for promoting sleep in the hospitalized patient are establishing periods for uninterrupted sleep and rest and controlling noise levels. • Pain or other disease symptom control is essential to promoting the ability to sleep. • Long-term use of sleeping pills often leads to difficulty initiating and maintaining sleep.
What are the nurse's role in establishing periods of rest and sleep example: control of noise in room, control of room temperature etc.
•Cluster nursing activities to provide uninterrupted periods of sleep •Provide programs for staff on the effects of noise and noise-reduction strategies •Develop a designated quiet time period during the day that incorporates rest and reduction of noise on the unit •Reduce lighting, telephone volumes, and staff conversations in the halls during quiet time and nighttime •Use sleep hygiene measures with patients such as personal hygiene, adjusting room temperature, and relaxation methods
List examples of drugs affecting sleep? (example, alcohol etc)
•Hypnotics- Interfere with reaching deeper sleep stages. Provide only temporary (1 week) increase in quantity of sleep. Eventually cause "hangover" during day; excess drowsiness, confusion, decreased energy. Sometimes worsen sleep apnea in older adults •Antidepressants and Stimulants- Suppress REM sleep. Decrease total sleep time •Alcohol- Speeds onset of sleep. Reduces REM sleep. Awakens person during night and causes difficulty returning to sleep •Caffeine- Prevents person from falling asleep. Causes person to awaken during night. Interferes with REM sleep •Diuretics- Nighttime awakenings caused by nocturia •Beta-Adrenergic Blockers- Cause nightmares. Cause insomnia. Cause awakening from sleep •Benzodiazepines- Alter REM sleep. Increase sleep time. Increase daytime sleepiness •Nicotine- Decreases total sleep time. Decreases REM sleep time. Causes awakening from sleep. Causes difficulty staying asleep •Narcotics- Suppress REM sleep. Cause increased daytime drowsiness •Anticonvulsants- Decrease REM sleep time. Cause daytime drowsiness
What are the definitions of the different types sleep disorders? (Example: Narcolepsy, Insomnia, sleep apnea, parasomnias (Brusixm, Sleep walking etc.).
•Insomnia the most common sleep disorder, is a symptom patients experience when they chronically have difficulty falling asleep. Primary central sleep apnea, Central sleep apnea caused by medical condition, Obstructive sleep apnea syndromes, Excessive daytime sleepiness. •Sleep apnea is a disorder characterized by lack of airflow through the nose and mouth for periods of 10 seconds or longer. Three types of sleep apnea are known: central, obstructive, and mixed. The most common form is obstructive. Excessive daytime sleepiness is the most common complaint. •Narcolepsy is a dysfunction of mechanisms that regulate the sleep and waking states. (Cataplexy, Sleep paralysis) •Sleep deprivation is 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. •Parasomnias are sleep problems that are more common in children. These include sleepwalking, night terrors, nightmares, bed-wetting, body rocking, and tooth grinding. (Somnambulism (sleepwalking), Night terrors, Nightmares, Nocturnal enuresis (bed-wetting), Body rocking, Bruxism)
What are the nursing interventions for the different sleep disorders?
•Insomnia- Treatment is symptomatic, including improved sleep hygiene measures, biofeedback, cognitive techniques, and relaxation techniques. Behavioral and cognitive therapies have few adverse effects and show evidence of sustained improvement in sleep over time •Sleep Apnea- Treatment includes therapy for underlying cardiac or respiratory complications and emotional problems that occur as a result of the symptoms of this disorder. •Narcolepsy- Narcoleptic patients are treated with stimulants or wakefulness-promoting agents such as sodium oxybate, modafinil (Provigil) or armodafinil (Nuvigil) that only partially increase wakefulness and reduce sleep attacks. Patients also receive antidepressant medications that suppress cataplexy and the other REM-related symptoms. Brief daytime naps no longer than 20 minutes help reduce subjective feelings of sleepiness. Other management methods that help are following a regular exercise program, practicing good sleep habits, avoiding shifts in sleep, strategically timed daytime naps if possible, eating light meals high in protein, practicing deep breathing, chewing gum, and taking vitamins. Patients with narcolepsy need to avoid factors that increase drowsiness (e.g., alcohol; heavy meals; exhausting activities; long-distance driving; and long periods of sitting in hot, stuffy rooms). •Parasomnias- Specific treatment varies. However, in all cases it is important to support patients and maintain their safety.
What are the patient teaching to improve sleep hygiene habits across age groups example: bedtime story for preschoolers and school age. Teenagers no TV, no game or studying at bedtime, no food etc.?
•Instruct patient to try to exercise daily, preferably in the morning or afternoon, and to avoid vigorous exercise in the evening within 2 hours of bedtime. •Caution patient against sleeping long hours during weekends or holidays to prevent disturbance of normal sleep-wake cycle. •Explain that, if possible, patients should not use the bedroom for intensive studying, snacking, television watching, or other nonsleep activity besides sex. •Encourage patients to try to avoid worrisome thinking when going to bed and to use relaxation exercises. •If patient does not fall asleep within 30 minutes of going to bed, advise him or her to get out of bed and do some quiet activity until feeling sleepy enough to go back to bed. •Recommend that patient limit caffeine to morning coffee and limit alcohol intake (more than 1 to 2 drinks a day interrupts sleep cycle). •Ask patient to examine environment. Instruct that use of earplugs and eyeshades may be helpful. •Instruct patient to avoid heavy meals for 3 hours before bedtime; a light snack may help.
What are the non-pharmacological approach and pharmacological approach for sleep?
•Non-pharmacological- establish nighttime routine, prompting comfort (soft cotton clothes, loose- fitting, extra blanket, voiding before sleep), pursue relaxing activity such as sewing ot reading, bedtime snacks, (WARM MILK or cocoa that contains l-tryptophan ) •Pharmacological- Melatonin, Valerian, Kava, Chamomile -Medications that induce sleep are called hypnotics. Sedatives are medications that produce a calming or soothing effect -Benzodiazepines and nonbenzodiazepines are common classifications of drugs used to treat sleep problems. The nonbenzodiazepines have become the treatment of choice for insomnia because of improved efficacy and safety of use -The benzodiazepines cause relaxation, antianxiety, and hypnotic effects by facilitating the action of neurons in the CNS that suppress responsiveness to stimulation, thereby decreasing levels of arousal
What are the factors influencing sleep? (example illness etc.) Describe how each factor influences sleep?
•Physical illness- Hypertension, respiratory, musculoskeletal, chronic illness, GI, nausea •Lifestyle- Work schedule, social activities, routines •Emotional stress- Worries, physical health, death, losses •Exercise and fatigue- Moderate exercise and fatigue cause a restful sleep •Drugs and substances- Hypnotics, diuretics, narcotics, antidepressants, alcohol, caffeine, beta-blockers, anticonvulsants •Usual sleep patterns- May be disrupted by social activity or work schedule •Environment- Noise, routines •Food and calorie intake- Time of day, caffeine, nicotine, alcohol
What are the cultural aspects of sleep that must be considered?
•Sleep patterns, bedtime routines, sleep aids, and sleep arrangements are components of cultural practices related to the use of space and interaction distances. •Co-sleeping, in which infants and children sleep with their parents, is a culturally preferred habit; and the practice of co-sleeping varies between cultures .It is more common in non-industrialized countries. In some parts of the world co-sleeping practices are seen as part of the bonding process and warmth and protection for an infant (i.e., against the cold) . This practice is also common in the United States with Asian, Hispanic, and African American families
What are the nursing focus on sleep per older adults? Provide comfort, back rub, reposition, clean linen etc.
•Sleep-wake Pattern -Maintain a regular bedtime and wake-up schedule -Eliminate naps unless they are a routine part of the schedule. -If naps are taken, limit to 20 minutes or less twice a day -Go to bed when sleepy. -Use warm bath and relaxation techniques -If unable to sleep in 15 to 30 minutes, get out of bed. -Avoid stimulating activities before bedtime such as exercise or watching television •Environment -Sleep where you sleep best. -Keep noise to minimum; use soft music to mask it if necessary. -Use night-light and keep path to bathroom free of obstacles. -Set room temperature to preference; use socks to promote warmth. -Listen to relaxing music -Increase exposure to bright light during the day •Medications -Use sedatives and hypnotics with caution as last resort and then only short term if absolutely necessary -Adjust medications being taken for other conditions and assess for drug interactions that may cause insomnia or excessive daytime sleepiness. •Diet -Limit alcohol, caffeine, and nicotine in late afternoon and evening -Consume carbohydrates or milk as a light snack before bedtime -Decrease fluids 2 to 4 hours before sleep •Physiological/Illness Factors -Elevate head of bed and provide extra pillows as preferred -Use analgesics 30 minutes before bed to ease aches and pains. -Use therapeutics to control symptoms of chronic conditions as prescribed
What are the functions of sleep?
•The purpose of sleep remains unclear. Physiological and psychological restoration, and maintenance •Sleep is important to the preservation of cardiac function, as well as to decrease respirations and blood pressure and to relax muscle tone. During sleep, the body also conserves energy, and skeletal muscles relax. •The interpretation of dreams oftentimes will help patients resolve personal concerns or fears. Personality also influences the quality of dreams. Most dreams are forgotten. To remember a dream, a person must consciously think about it upon awakening.
What is the tool for sleep assessments called?
•Two effective subjective measures of sleep are the Epworth Sleepiness Scale and the Pittsburgh Sleep Quality Index •The Epworth Sleepiness Scale evaluates the severity of EDS •The Pittsburgh Sleep Quality Index assesses sleep quality and sleep patterns