Foundations Chapter 33: Rest and Sleep

A school nurse is speaking to a group of parents regarding the sleep needs of adolescents. Which statement by a parent indicates a need for further education? -"Adolescents naturally develop an 'owl like' sleep pattern." -"Academic performance in adolescents is good when they sleep about 7 hours per night." -"Adolescents catch up on sleep on the weekends, when they typically sleep later." -"Adolescent girls are more likely to develop insomnia than boys."

"Academic performance in adolescents is good when they sleep about 7 hours per night." Adolescents need about 9 hours of sleep per night. Academic performance is negatively impacted when adolescents get less sleep. Due to irregular sleep patterns, adolescents typically sleep later on weekends in an attempt to catch up on sleep. Adolescent sleep patterns change to a more 'owl-like' pattern in which they rise later and go to sleep later. Adolescent girls have a higher risk of developing insomnia than adolescent boys.

The nurse knows that a client understands the purpose of a sleep diary when the client states: "I will only keep track of my sleep habits at home." "I will record the time I go to bed and how long it takes me to fall asleep." "I will keep track of my sleep information for 2 months." "I will write down all of my morning activities."

"I will record the time I go to bed and how long it takes me to fall asleep." Keeping notes of times of sleep and waking are important details to record in a sleep diary. The notes are usually maintained for 14 days and include specifics such as all wakeful activities and sleep patterns in strange environments.

REM behavior disorder (RBD)

"acting out" dreams while asleep

older adults nursing implications

-A comprehensive nursing assessment and individualized interventions may be effective in the long-term care of this age group. -Emphasize concern for a safe environment because it is not uncommon for older people to be temporarily confused and disoriented when they first awake. -Use sedatives with extreme caution because of declining physiologic function and concerns about polypharmacy. -Encourage people to discuss sleep concerns with their physicians.

older adults sleep pattern

-An average of 7 to 9 hours of sleep is usually adequate for this age group. -Sleep is less sound, and stage IV sleep is absent or considerably decreased. Periods of REM sleep shorten. -Elderly people frequently have great difficulty falling asleep and have more complaints of problems sleeping. -Decline in physical health, psychological factors, effects of drug therapy (e.g., nocturia), or environmental factors may be implicated as causes of inability to sleep.

nursing implications for toddlers

-Establish a regular bedtime routine (e.g., reading a story, singing a lullaby, saying prayers). -Advise parents of the value of a routine sleeping pattern with minimal variation. -Encourage attention to safety once child moves from crib to bed. If child attempts to wander out of room, a folding gate may be necessary across the door of the room.

middle-aged adults sleep pattern & nursing implications

-Total sleep time decreases during these years, with a decrease in stage IV sleep. -The percentage of time spent awake in bed begins to increase. -People become more aware of sleep disturbances during this period. Nursing Implications: -Encourage adults to investigate consistent sleep difficulties to exclude pathology or anxiety and depression as causes. -Encourage adults to avoid use of sleep-inducing medication on a regular basis.

non-rapid eye movement (NREM) sleep

-about 75% of total sleep -consists of 4 stages -parasympathetic system dominates -also called slow wave sleep

obstructive sleep apnea

-can result when the airway is occluded because of the collapse of the hypopharynx, enlarged tonsils or adenoids, deviated nasal septum, thyroid enlargement, or narrowing of nasal passageways caused by allergic rhinitis or nasal polyps -can lead to the development of heart failure

circadian rhythms

-complete a full cycle every 24 hours -fluctuations in a person's HR, BP, body temp., hormone secretions, metabolism, performance, & mood depend in part on circadian rhythms -*chronodisruption*: circadian disruption (working nights)

narcolepsy

-condition characterized by an uncontrollable desire to sleep -usually begins in adolescence or early adulthood & continues throughout life -sleepiness during the day is often the first symptom -most people with narcolepsy have low hypocretin levels -Ritalin (CNS stimulant); Provigil (wakefulness-promoting compound); Xyrem (sedative used for treating disturbed nocturnal sleep) used for treatment -avoiding heavy meals and alcohol may also help

mandibular advancement device (MAD)

-custom made oral appliance to treat mild OSA -hard, plastic device that is fitted by a dentist or orthodontist

stage III of NREM

-depth of sleep increases & arousal becomes increasingly difficult -10% of total sleep time

RAS

-facilitates reflex & voluntary movements & cortical activities related to a state of alertness -wakefulness occurs when the RAS is activated with stimuli from the cerebral cortex and periphery sensory organs and cells

stage II of NREM

-falls into a state of sleep -can be aroused with relative ease -50-55% of total sleep time

sleep patterns & nursing implications for preschoolers

-generally 9-16 hours at night, with 12 hours being the average -REM sleep pattern is similar to that of an adult -most children no longer nap by age 5 -may continue to resist going bed Nuring Implications: -advise parents that waking up from nightmare or night terrors is common; waking the child and comforting them generally helps; night lights

stage IV of NREM

-greatest depth of sleep (delta sleep) -arousal difficult -physiologic changes: slow brain waves recorded on EEG, pulse and respiratory rate decease, blood pressure decrease, muscles are relaxed, metabolism slows and body temp. is low -10% of sleep

nonpharmacologic measures to prevent/alleviate symptoms of RLS

-massaging legs -walking -knee bends -moving or gently stretching legs -eliminating use of caffeine, tobacco, and alcohol -taking a mild analgesic at bedtime -applying heat or cold to extremity -using relaxation techniques- biofeedback, TENS

adolescents sleep pattern

-need 9-10 hours but most get about 7 hours -excessive daytime sleepiness

toddlers sleep patterns

-need for sleep declines as this stage progresses -may initially sleep 12 hours at night with 2 naps during the day then at the end of this stage sleep 8-10 hours at night with 1 nap -may begin to resist naps -move from crib to bed at 2 years

newborns & infants sleep patterns

-newborns: average about 18 hours a day, about 4 hours at a time -infants: 10-12 hours a night, with naps during day -usually by 8-16 weeks, an infant sleep through the night -REM sleep constitutes much of the sleep cycle of a young infant

restless leg syndrome

-patients cannot lie still and report unpleasant cramping, crawling or tingling in legs -can occasionally occur in arms, face, or torso -seen in patients with end-stage renal disease, diabetes, iron deficiency, peripheral neuropathy, and pregnancy -antihistamines can exacerbate symptoms -no specific diagnostic test & no known cure

A client describes difficulty falling asleep and difficulty maintaining sleep, and reports daytime fatigue and inability to concentrate. The nurse suggests which noninvasive techniques that may help promote restful sleep? Select all that apply. -practicing relaxation techniques -removing bedtime distractions such as watching television in bed -taking alternative remedies such as melatonin or valerian root -waking at the same time every morning -twenty minutes on the treadmill or elliptical just before bedtime

-practicing relaxation techniques -removing bedtime distractions such as watching television in bed -waking at the same time every morning Maintaining a sleep/wake routine is essential to restful sleep. Promoting it by removing distractions and learning relaxation techniques can be beneficial. Exercising right before bed may promote wakefulness. Research has shown that melatonin and valerian do not help with insomnia.

rapid eye movement (REM) sleep

-pulse, RR, BP, metabolic rate, & body temp. increase -general skeletal muscle tone & deep tendon reflexes are depressed -believed to be essential for mental & emotional equilibrium & to play a role in learning, memory, and adaption -eyes dart back & forth quickly -small muscle twitching (face) -large muscle immobility, resembling paralysis -respirations irregular, sometimes interspersed with apnea -rapid or irregular pulse -increase in gastric secretions -encephalogram tracings active -arousal difficult -20-25% of sleep

cognitive behavioral therapy

-safe, effective means of managing chronic insomnia -may include progressive muscle relaxation, stimulus control, sleep restriction therapy, biofeedback, sleep hygiene measures -involves meeting with a therapist and working through maladaptive sleep beliefs -get up at the same time each day, retire at night only when sleepy, eliminate napping, and remain in bed only when sleeping

common features of narcolepsy

-sleep attacks -cataplexy: sudden loss of motor tone that may cause the person to fall asleep; usually experienced during a period of strong emotion -hypnagogic hallucinations: nightmares or vivid hallucinations -sleep-onset REM periods: during a sleep attack, the person moves directly to REM sleep -sleep paralysis

sleep apnea

-sleep-disorded breathing -condition in which a person experiences the absence of breathing or diminished breathing efforts (hyponea) during sleep between snoring intervals -breathing may cease for 10-20 seconds or up to 2 minutes -oxygen level in blood drops, pulse becomes irregular and blood pressure increases -patient startled and awakened -mostly middle aged men who are obese and have short necks

nursing implications for newborns & infants

-teach parents to position infant on back- only safe position for infants under 1 yr. -advise parents that eye movements, grimacing, groaning, and moving are normal -encourage parents to have infant sleep in separate area rather than their bed -caution about placing pillows, quilts, stuffed animals, etc. in crib

young adults sleep pattern

-the average amount of sleep required is about 8 hours, but most adults do not need 8 -REM sleep averages about 20% of sleep

stage I of NREM

-transitional stage between wakefulness and sleep -relaxed state but still somewhat aware of surroundings -involuntary muscle jerking may occur & waken the person -can be aroused easily -5% of total sleep time

continuous positive airway pressure machine (CPAP)

-used to treat moderate or severe OSA -noninvasive & consists of a mask connected to an air pump that is worn during sleep; delivers positive air pressure that holds the airway open -patient adherence inconsistent

sleep patterns & nursing implications for school-aged children

-younger: 10-12 hrs; older: 8-10 hours -sleep needs usually increase when physical growth peaks Nursing Implications: -discuss the fact that the stress of beginning school may interrupt normal sleep patterns -advise that a relaxed bedtime routine is most helpful at this age -inform parents about child's awareness of the concept of the death is possibly occurring at this age

During the first cycle of sleep, the client will be in REM sleep for:

3 minutes

The parents of a newborn ask when they can expect the baby to sleep through the night. The nurse responds that the baby will most likely sleep through the night by:

3 months of age Most infants sleep through the night by 3 months of age, but nocturnal awakenings continue to be frequent during the latter half of the first year.

A nurse caring for a client with hypersomnia investigates the cause of the sleep disorder. What are possible causes to consider? Select all that apply. Malnourishment Depression Some medications Another sleep disorder, such as apnea Eating disorders Alcohol abuse

Another sleep disorder, such as sleep apnea Depression Alcohol abuse Some medications The possible causes to hypersomnia could include another sleep disorder (such as sleep apnea), depression, alcohol abuse, or the effect of some medications, head trauma, obesity. Malnourishment and eating disorders would not be a cause of hypersomnia.

The nurse is instructing a parent on how to promote restful sleep for a child. The food that would serve as the best bedtime snack for the child is? Almonds Apple slices Chocolate bar Tuna salad

Apple slices Carbohydrates promote sleep by making tryptophan available to the brain. Simple carbohydrates such as fruit slices or juice are effective. Chocolate provides high sugar content and possibly caffeine exposure which will promote wakefulness. Tuna salad and almonds are protein, not carbohydrates.

What are characteristics of rapid eye movement sleep? Select all that apply. -Blood pressure and pulse rate show wide variations and may fluctuate rapidly. -A person is unable to move during this stage. -Muscles are relaxed but muscle tone is maintained. -Theta waves often have a sawtooth or notched appearance. -Sleepwalking and bed-wetting are most likely to occur during the this stage.

Blood pressure and pulse rate show wide variations and may fluctuate rapidly. A person is unable to move during this stage. Theta waves often have a sawtooth or notched appearance. During REM sleep, blood pressure and pulse rate show wide variations and may fluctuate rapidly, a person is unable to move, and theta waves often have a sawtooth or notched appearance. Muscles are relaxed but muscle tone is maintained. Sleepwalking and bed-wetting are most likely to occur during NREM.

During an orientation class for new RN graduates, the nurse educator identifies which conditions as potential risks for clients to experience sleep pattern disturbance? Select all that apply. Type 1 Diabetes Depression Stroke Constipation Substance abuse Glaucoma

Depression Stroke Constipation Substance abuse People engaged in changing shift work, particularly overnights, can be prone to higher risk of depression, loneliness, substance abuse, type 2 DM, and gastrointestinal and cardiovascular symptoms. Type 1 DM and glaucoma are not related to sleep-cycle disruption.

neurotransmitter involved with inhibition

GABA

A nurse is caring for a client diagnosed with sleep apnea. Which nursing diagnosis should the nurse include in her nursing care plan?

Impaired Gas Exchange The nurse should include the nursing diagnosis of Impaired Gas Exchange in her nursing care plan. During the apneic or hypopneic periods, ventilation decreases, and blood oxygenation drops. The accumulation of carbon dioxide and the fall in oxygen cause brief periods of awakening throughout the night. Relocation Stress Syndrome, Impaired Bed Mobility, and Risk For Injury are not appropriate diagnoses because the client's loss of sleep is not due to a new place; there is also no immobility or injury risk involved with sleep apnea.

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 The pattern of frequent arousals seen in people with chronic obstructive pulmonary disease may result from the body's adaptation to maintain adequate oxygenation. Usually, these clients require low doses of oxygen at night.

parasomnias

patterns of waking behavior that appear during REM or NREM stages of sleep; more commonly seen in children -somnambulism, REM behavior disorder, sleep terrors, bruxism, enuresis, nightmares, sleep-related eating disorder

The nurse is implementing nursing interventions to promote sleep on a busy hospital ward. Which intervention is the best choice for these clients?

Offer clients a small carbohydrate and protein snack before bedtime. Offering a client a small carbohydrate and protein snack before bedtime would be the best choice. Peanut butter on toast or cheese and crackers would be an example of an appropriate snack. The temperature of the room should be cool, not warm. An alarm clock would not be necessary for a client who is an inpatient in the hospital. A shower could possibly be helpful, but it is not the best answer.

A nurse working in a health clinic assesses sleep patterns during each health assessment. Based upon the nurse's knowledge regarding sleep needs, the nurse recognizes which age group as generally needing the least amount of sleep?

Older adults As people age, the number of hours of needed sleep decreases. An average of 5 to 7 hours of sleep is usually adequate for the older adult age group.

A nurse understands the client's stage of sleep that requires the greatest stimulus to awaken a client is:

REM sleep The NREM arousal threshold is usually greatest in stage IV NREM, but it is harder to arouse a person who is in REM sleep than NREM sleep. REM rebound is the term for accumulating REM sleep in balance over time.

The nurse is teaching a client with seasonal affective disorder about proper use of a full-spectrum light. Which teaching will the nurse include?

Sit within 3 ft (1 m) of the light for approximately 2 hours soon after awakening. The client should sit within 3 ft (1 m) of the artificial light for approximately 2 hours soon after awakening from sleep. Light exposure should begin in October or November, not April or May. Eyeglasses and contact lenses with ultraviolet filters should be removed before using the light. Other activities may take place, such as reading or handiwork, while periodically glancing at the light.

A client begins snoring and is sleeping lightly. The stage of sleep is:

Stage 2 Stage 2 is relatively light sleep from which the client is easily awakened. Rolling eye movements continue, and snoring may occur.

The nurse is caring for a client who experiences automatic behaviors associated with narcolepsy. What is the priority nursing intervention?

Teach client's spouse to keep car keys in an undisclosed location at night. The priority nursing intervention is to prevent the client from experiencing hazardous behaviors while asleep. Driving or taking part in occupational behaviors can lead to accidents; therefore, educating the client's spouse to keep car keys in another location enhances the chance of safety for the client. All other interventions can be undertaken after this.

sleep-related eating disorder

person eats while sleeping but has no recollection of eating in the morning

2 systems in the brain that control the cyclic nature of sleep

reticular activating system (RAS) & bulbar synchronizing region

REM rebound

a person who is deprived of REM sleep for several nights generally will spend more time in REM sleep on successive nights allows the total amount of REM sleep to remain fairly constant over time

enuresis

bedwetting; most commonly in males over 3 years of age

sleep terrors

more common in children & occur during the deepest stages of sleep

A nursing instructor is speaking to a group of students regarding the effects of shift work on sleep patterns. Which pattern of work shifts has been shown to enhance work production?

clockwise rotation of shifts Research has shown that clockwise rotation of shifts is preferable and that short naps during breaks enhance work performance. Recent studies have shown a negative relation between the number of consecutive night shifts worked and urinary levels of melatonin metabolites

A nurse working night shift understands the importance of enhancing the sleep patterns of his clients. In order to do so, he should: -allow the client to sit at the desk to enhance better rest. -cluster activities to allow 90 to 120 minutes of sleep. -evaluate the sleep response of the client with polysomnogram. -only wake them for the 12:00 AM and 4:00 AM vital signs.

cluster activities to allow 90 to 120 minutes of sleep. When possible, the nurse should cluster activities at night to provide periods of 90 to 120 minutes of uninterrupted sleep.

hypothalamus

contains inner biological clock injury may cause a person to sleep for abnormally long periods

neurotransmitters involved in excitation

norepinephrine, Ach, dopamine, seratonin, histamine

The nurse is performing an intake assessment of a 60-year-old client who admits to having a "nightcap" of 4 to 6 ounces of scotch whisky each night. What effect might this alcohol be having on the client's sleep?

decreased REM sleep Alcohol is known to decrease the amount of REM and delta sleep an individual experiences. Alcohol does not typically shorten sleep cycles or increase the total amount of sleep.

bruxism

grinding teeth in sleep; usually indicates stress

The nurse would recognize that an obese, male client who has been diagnosed with obstructive sleep apnea (OSA) faces an increased risk of:

heart disease. In healthy people, OSA may impair cardiac function over time and lead to the development of heart failure. If heart failure has already been diagnosed, OSA may result in progression of this condition. OSA is not directly associated with depression, respiratory acidosis, or seizure activity.

The nurse is caring for a client with narcolepsy. The client reports experiencing being unable to move upon awakening from sleep. The client's spouse states that the client makes sandwiches in the middle of the night, yet the client does not recall this behavior. How does the nurse document these concerns?

sleep paralysis and automatic behavior Sleep paralysis occurs when the person cannot move for a few minutes just before falling asleep or awakening. Cataplexy occurs with a sudden loss of muscle tone triggered by an emotional change such as laughing or anger. Hypnogogic hallucinations are dream-like auditory or visual experiences while dozing or falling asleep. Automatic behavior is the performance of routine tasks without full awareness, or later memory, of having done them. This client experiences sleep paralysis and automatic behavior.

somnambulism

sleepwalking, may range from sitting up in bed to walking around; sleepwalker is unaware of their surroundings

The nurse is completing a sleep history on a client who reports sleeping problems. Which of the client's regular behaviors will cause the client to have difficulty with sleep? -exercising immediately after getting off work at 5 p.m. -drinking two cups of coffee every morning -taking a diuretic at 9 a.m. and 5 p.m. daily -using a white noise machine to mask outside noise

taking a diuretic at 9 a.m. and 5 p.m. daily Various factors may affect sleep. Taking a diuretic, particularly late in the day, is a common cause for sleep problems. The diuretic may still affect the client at hours of sleep. The other behaviors are acceptable in promoting sleep: exercising more than 2 hours before sleep, ingesting caffeine early in the day, and using a white noise machine to keep the environment quiet.

The nurse is caring for a client who is having difficulty sleeping. Which medication does the nurse anticipate will be prescribed by the healthcare provider?

temazepam (Restoril) Benzodiazepines such as temazepam (Restoril) are often used to treat difficulty sleeping. Furosemid (Lasix) is a diuretic; amlodipine (Norvasc) is a calcium-channel blocker; and simvastatin (Zocor) is a HMG CoA reductase inhibitor ("statin") used to treat high cholesterol.

sleep cycle

wakefulness->NREM stage I->NREM stage II->NREM stage III->NREM stage IV->NREM stage III->NREM stage II->REM->NREM stage II -most people go through 4 or 5 sleep cycles each night -each cycle lasts about 90-100 min.