Rest and Sleep
Continuous positive airway pressure
(CPAP) is the definitive treatment for moderate or severe obstructive sleep apnea. Noise-related disturbances in a hospital setting can interfere with sleep and increase blood pressure, decrease oxygen saturation, and delay wound healing.
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 adults 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 older adults to discuss sleep concerns with their health care provider.
REM rebound
A person who is deprived of REM sleep for several nights generally will spend more time in REM sleep on successive nights. This phenomenon allows the total amount of REM sleep to remain fairly constant over time
Dietary habits
Combining foods that are high in tryptophan with healthy, complex carbohydrates improves sleep. A small protein- and carbohydrate-containing snack such as peanut butter on toast or cheese and crackers about an hour before bed may be more effective. Alcohol limit REM and delta sleep.
Identify variables that influence rest and sleep.
Developmental Considerations Motivation Culture Lifestyle and Habits -Physical Activity and Exercise -Dietary Habits -Smoking Environmental Factors: Sleeping in a strange or new environment tends to influence both REM and NREM sleep. Psychological Stress: (1) the person experiencing stress may find it difficult to obtain the amount of sleep needed; and (2) REM sleep decreases in amount, which tends to add to anxiety and stress. Illness Medications
Identify variables that influence rest and sleep.
Developmental Considerations Older adults often need more time to fall asleep and are less able to cope with changes in their usual sleep patterns compared to younger people. Many older adults nap during the day, which often results in sleeping fewer hours at night. Chronic illnesses in older adults may also affect their sleep patterns. For instance, many older men have enlargement of the prostate gland, which may cause them to awaken throughout the night to use the bathroom. Motivation: student who is bored and disinterested in a lecture or class may doze during the lecture. a tired person may be wakeful and alert when at a party Culture > bedtime rituals, position/place, include in plan of care
Develop nursing diagnoses that identify sleep problems that may be addressed using independent nursing interventions.
Disturbed Sleep Pattern as the Problem Disturbed sleep pattern if the problem is time limited; or Sleep deprivation if the problem is prolonged. Common etiologies for these nursing diagnoses may include the following: Impaired comfort or pain Changes in bedtime rituals or sleep environment Disruption of circadian rhythm Sleep apnea Sustained inadequate sleep hygiene Drug dependency and withdrawal Symptoms of physical illness
Medications
Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications are seen as additional common causes of sleep problems. timing of antihypertensive medication administration may need to be adjusted to provide peak protection during early-morning hours, when heart attacks are more common. Cancer chemotherapy appears to be less toxic when administered at certain times of the day
Preschoolers Nursing implications
Encourage parents to continue bedtime routines. Advise parents that waking from nightmares or night terrors (awakening screaming about 20 minutes after falling asleep) are common during this stage. Waking the child and comforting the child generally helps. Sometimes use of a night light is soothing.
Toddlers Nursing Implications
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.
REM Sleep
Eyes dart back and forth quickly. Small muscle twitching, such as on the face Large muscle immobility, resembling paralysis Respirations irregular; sometimes interspersed with apnea Rapid or irregular pulse
Perform a comprehensive sleep assessment.
Focused assessment assess the patient's usual times for retiring and waking, bedtime rituals, and preferences regarding sleep environment so that these can be incorporated into the plan of care, if possible. Patients in hospitals often receive fragmented sleep. A sleep diary or log provides more specific data on the patient's sleep-wakefulness patterns over a period of time. The Epworth Sleepiness Scale The Pittsburgh Sleep Quality Index (PSQI) STOP-Bang Questionnaire (OSA)
Preparing a Restful Environment
Good body alignment is conducive to relaxation. For patients who must assume unusual positions because of their illness, ingenuity and skill are necessary to minimize muscle strain and discomfort. For example, patients who must sleep with their head and torso elevated to aid breathing should be well supported in a manner that relieves muscle strain. A quiet and darkened room with privacy is relaxing for nearly everyone. In a strange environment, unfamiliar noises, such as people walking by or entering and leaving the room and the sounds of elevator doors, often bring complaints from patients in health care facilities. The temperature of the room, the amount of ventilation, and the amount of bed covering are matters of individual choice.
Sleep requirement
On average, infants require 12 to 15 hours each day; toddlers, 11 to 14 hours; and preschoolers 11 to 13 hours a day. School-aged children, aged 6 to 13, require from 9 to 11 hours of sleep, and teenagers 8 to 10 hours a day for adults is 7 to 9 hours for older adults 7 to 8 hours.
Parasosmnia
Patterns of waking behavior that appear during REM or NREM stages of sleep, commonly seen in children. Sleepwalking Sleep terrors Sleep enuresis Sleep related eating disorder
Describe nursing strategies to promote rest and sleep.
Physical activity increases both REM and NREM sleep. Moderate exercise is a healthy way to promote sleep, but exercise that occurs within a 3-hour interval before normal bedtime can hinder sleep. The fatigue that results from normal work activities or exercise is believed to contribute to a restful sleep, whereas excessive exercise or exhaustion can decrease the quality of sleep.
Newborns and Infants Nursing Implications
Teach parents to position infant on the back. This is the only safe sleeping position for infants less than 1 year old. Sleeping in the prone position increases the risk for sudden infant death syndrome (SIDS). Advise parents that eye movements, groaning, grimacing, and moving are normal activities at this age. Encourage parents to have infant sleep in a separate area rather than their bed. Caution parents about placing pillows, crib bumpers, quilts, stuffed animals, and so on in the crib because this may pose a suffocation risk
Stage III
The depth of sleep increases, and arousal becomes increasingly difficult. This stage composes about 10% of sleep.
Disturbed Sleep Pattern as the Etiology
The disturbed sleep pattern may affect many other areas of human functioning. In the nursing diagnoses that follow, the disturbed sleep pattern is the cause of another problem: Insomnia related to inadequate sleep hygiene and anxiety Risk for injury related to somnambulism, narcolepsy, sleep apnea Deficient knowledge (e.g., nonpharmacologic remedies for insomnia) related to misinformation, lack of interest in learning, cognitive limitation
Plan, implement, and evaluate nursing care related to alterations in rest and sleep.
The patient will: Maintain a sleep-wake pattern that provides sufficient energy for the day's tasks Demonstrate self-care behaviors that provide a healthy balance between rest and activity Identify stress-relieving rituals that enable the patient to fall asleep more easily Demonstrate decreased signs of sleep deprivation Verbalize feeling less fatigued and more in control of life activities In order to correct a sleep problem, the patient needs to believe that the nurse cares and will provide extra help to promote rest and sleep.
Stage II
The person falls into a stage of sleep. The person can be aroused with relative ease. This stage constitutes 50% to 55% of sleep.
Stage I
The person is in a transitional stage between wakefulness and sleep. The person is in a relaxed state but still somewhat aware of the surroundings. Involuntary muscle jerking may occur and waken the person. The stage normally lasts only minutes. The person can be aroused easily. This stage constitutes only about 5% of total sleep.
Stage IV
The person reaches the greatest depth of sleep, which is called delta sleep. Arousal from sleep is difficult. Physiologic changes in the body include the following:Slow brain waves are recorded on an EEG. Pulse and respiratory rates decrease.Blood pressure decreases. Muscles are relaxed.Metabolism slows and the body temperature is low. This constitutes about 10% of sleep.
Sleep Cycle
This pattern is then reversed, and the person returns from stage IV to stage III to stage II. Instead of reentering stage I and awakening, the person enters into the REM stage of sleep, after which the person reenters NREM sleep at stage II and returns to stages III and IV. A person awakened from sleep at any time will return to sleep by starting at stage I of NREM sleep
Describe the physiology of sleep.
Two systems in the brainstem, the reticular activating system (RAS) and the bulbar synchronizing region. The RAS extends upward through the medulla, the pons, the midbrain, and into the hypothalamus. It facilitates reflex and voluntary movements as well as cortical activities related to a state of alertness. The RAS comprises many nerve cells and fibers. The fibers have connections that relay impulses into the cerebral cortex and spinal cord. The hypothalamus has control centers for several involuntary activities of the body, one of which concerns sleeping and waking. Injury to the hypothalamus may cause a person to sleep for abnormally long periods.
insufficient sleep in adults and children
Various studies confirm that adults and children who slept less than the recommended hours per night were more likely to be overweight. This sleep-weight link is possibly related to two hormones: leptin and ghrelin. Leptin signals the brain to stop eating, whereas ghrelin promotes continued eating. Research suggests that sleep deprivation lowers leptin levels and elevates ghrelin levels, thus increasing one's appetite To compound the problem, the brain may interpret a drop in leptin as a sign of starvation Unfortunately, the brain then signals the body to eat more while it simultaneously lowers the body's metabolic rate. When this happens, people are more likely to gain weight, even if food intake is decreased
Restless legs syndrome
also known as Willis-Ekbom disease (WED), is a common sleep-related movement disorder that affects up to 15% of the population, most often middle-aged and older adults. Approximately 2% of children also suffer from RLS, and there appears to be a strong genetic component. Almost 75% of these children have a parent with RLS (NSF, 2011g). People with RLS cannot lie still and report unpleasant creeping, crawling, or tingling sensations in the legs. Usually, these sensations are in the calf, but they may occur anywhere from the ankle to the thigh. Nonpharmacologic measures to prevent or alleviate this discomfort include massaging the legs, walking, doing knee bends, and moving or gently stretching the legs.
Circadian rhythms
are predictable fluctuations in processes that occur in repeated cycles of time, completing a full cycle every 24 hours. When physiologic and psychological rhythms are high or most active, the person is awake; when these rhythms are low, the person is asleep. Light and dark are powerful regulators of the sleep-wake circadian rhythm; when there is interference with the normal cycle, circadian disruption (chronodisruption) occurs. The exposure to light at night during normal sleeping hours is termed night shift chronodisruption. physiology of sleep
Insufficient sleep
can seriously affect a person's physical and psychological health (see Physical and Psychological Effects of Insufficient Sleep). Consequently, nurses need to be vigilant in promoting good sleep health and detecting and addressing sleep disturbances Good sleep health may be characterized by subjective satisfaction, appropriate timing, adequate duration, high efficiency and sustained alertness during waking hours
People who suffer sleep difficulties
caused by working night shifts or constantly changing work shifts may experience adverse effects, including anxiety, personal conflicts, loneliness, depression, gastrointestinal symptoms, increase in type 2 diabetes, hypertension, and higher rates of cardiovascular disease including strokes, and substance abuse
Non-rapid eye movement (NREM) sleep
comprises about 75% of total sleep time, consists of four stages. Stages I and II, consuming about 5% and 50% of a person's sleep time, respectively, are light-sleep states. During these stages, the person can be aroused with relative ease. Stages III and IV, each representing about 10% of total sleep time, are deep-sleep states, termed delta sleep or slow-wave sleep. The arousal threshold (intensity of stimulus required to awaken) is usually greatest in stage IV NREM. Throughout the stages of NREM sleep, the parasympathetic nervous system dominates, and decreases in pulse, respiratory rate, blood pressure, metabolic rate, and body temperature are observed.
rest
condition in which the body is in a decreased state of activity, with the consequent feeling of being refreshed
Smoking
have a more difficult time falling asleep Avoiding nicotine in any substance close to bedtime is suggested as part of good sleep hygiene practices (NSF, n.d.e). People usually report improved sleep patterns after discontinuing nicotine use. Total withdrawal from smoking may be associated with temporary sleep disturbances. Patients who stop smoking often have more daytime sleepiness and report significantly more restlessness at night
Assess
include restlessness, sleep postures, and sleep activities such as snoring or leg jerking (RLS). Snoring is caused by an obstruction to airflow through the nose and mouth. snoring is not ordinarily a sleeping disorder. However, snoring accompanied by apnea can present a problem. When snoring changes from the characteristic sawing-wood sound to a more irregular silence followed by a snort, this indicates obstructive apnea. As mentioned earlier, the American Academy of Pediatrics states that snoring in children needs to be evaluated as a possible indication of OSA.
Insufficient sleep in children
may affect normal growth and development and could be a contributing factor in performance deficits and behavioral problems. Furthermore, short sleep duration in childhood is associated with an increased risk of obesity during childhood or later in life
non-rapid eye movement (NREM) sleep
non-rapid eye movement that characterizes four stages of sleep
sleep cycle
passage through the four stages of NREM sleep (I, II, III, IV), then reversal (IV, III, II), and finally, instead of reentering stage I and awakening, entering REM sleep and returning to stage II
Lifestyle and Habits
physical Activity and Exercise >work schedule, A person's ability to relax from work-related pressures and to put aside home stresses are also important factors in the ability to fall asleep. Nurses who role model good health behaviors are more effective teachers
rapid eye movement (REM) sleep
stage that constitutes 20% to 25% of a person's nightly sleep; person is difficult to arouse during this stage
sleep
state of altered consciousness throughout which varying degrees of stimuli preclude wakefulness
Older Adults Sleep Pattern
An average of 7 to 8 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. Older adults 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.
Using Medications to Promote Sleep
Assessment of stress and coping patterns and any underlying medical conditions, are required prior to the use of medications to induce or maintain sleep. The underlying cause for the sleep disturbance must be determined; nonpharmacologic interventions should be tried first or in combination with pharmacologic therapy Use of some hypnotic medications, including the barbiturates and benzodiazepines, should usually be short term, as these drugs are associated with drug dependence and drug toleranc
REM Sleep
Blood pressure increases or fluctuates Increase in gastric secretions Metabolism increases; body temperature increases Encephalogram tracings active REM sleep enters from stage II of NREM sleep and reenters NREM sleep at stage II: arousal from sleep difficult Constitutes about 20% to 25% of sleep
Preschoolers Sleep Pattern
Children in this stage generally sleep 11 to 13 hours at night. The REM sleep pattern is similar to that of an adult. Daytime napping decreases during this period, and by the age of 5 years, most children no longer nap. This age group may continue to resist going to bed at night.
Insomnia
Common medications that may result in insomnia include those taken for hypertension and cardiovascular disease, cold and allergies, attention-deficit hyperactivity disorder (ADHA), and depression Insomnia at least 3 times a week for 3 months considered chronic A growing number of health conditions have been associated with chronic insomnia. They include obesity; type 2 diabetes; psychiatric disorders such as depression; and cardiovascular disorders such as heart failure, stroke, hypertension, and myocardial infarction (heart attack). Cognitive behavioral therapy (CBT) is a safe, effective means of managing chronic insomnia and may include cognitive therapy, relaxation training, stimulus control therapy, or sleep restriction therapy
illness
Gastric secretions increase during REM sleep. (GERD) awaken at night with heartburn or pain. They find that using antacids to neutralize stomach acidity often relieves discomfort and promotes sleep. The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep. Epilepsy seizures are most likely to occur during NREM sleep and appear to be depressed by REM sleep. Liver failure and encephalitis tend to cause a reversal in day-night sleeping habits. Hypothyroidism tends to decrease the amount of NREM sleep, especially stages II and IV, while hyperthyroidism may result in difficulty falling asleep. End-stage renal disease (ESRD) disrupts nocturnal sleep and leads to excessive daytime sleepiness. Patients with ESRD who receive dialysis also have a higher incidence of RLS (discussed later in the chapter), which possibly is related to the iron deficiency common in ESRD.
Describe common sleep disorders and associated assessment criteria.
Insomnia Sleep-related breathing disorders Central disorders of hypersomnolence > hypersomnia xcessive sleep > Narcolepsy (rare) xcessive dt sleep - cataplexy Circadian rhythm sleep-wake disorders> jetlag Parasosmnia Sleep-related movement disorders It may result from decreased REM sleep or NREM sleep. Other sleep disorders
Rapid Eye Movement Sleep
It is more difficult to arouse a person during this sleep than during Non-REM sleep. In normal adults, the REM state consumes 20% to 25% of a person's nightly sleep time. People who are awakened during the REM state almost always report that they have been dreaming. During REM sleep, the pulse, respiratory rate, blood pressure, metabolic rate, and body temperature increase, whereas general skeletal muscle tone and deep tendon reflexes are depressed. REM sleep is believed to be essential to mental and emotional equilibrium and to play a role in learning, memory, and adaptation.
Central disorders of hypersomnolence
Low hypocretin levels (brain chemical responsible for alertness) CNS stimulants (Methlyphenidate) may be treatment
Physical assessment
Narrowed or glazing eyes, swelling of eyelids, signs of sleep apnea, fatigue, lethargy
Toddlers Sleep Pattern
Need for sleep declines as this stage progresses. May require two naps during the day and end this stage sleeping 11 to 14 hours a night and napping once during the day. Toddlers may begin to resist naps and going to bed at night. They may move from crib to youth bed or regular bed at around 2 years.
Newborns and Infants Sleep Pattern
Newborn: Sleeps an average of 16 hr/24 hr; averages about 4 hours at a time. Each infant's sleep pattern is unique. On average, infants sleep 12 to 15 hours at night, with several naps during the day. Usually by 8 to 16 weeks of age, an infant sleeps through the night. REM sleep constitutes much of the sleep cycle of a young infant.
Stages of Sleep
Non-Rapid Eye Movement Sleep (NREM) Rapid Eye Movement Sleep Sleep Cycle
Sleep-Related Breathing Disorder
Obstructive sleep apnea (OSA) Breathing may cease for 10 to 20 seconds and possibly as long as 2 minutes. During long periods of apnea, the oxygen level in the blood drops, the pulse usually becomes irregular, and the blood pressure often increases. This decrease in ventilation and associated physiologic response activates the fight-or-flight response of the sympathetic nervous system and the sleeper startles and awakens. The incidence of OSA (adult) increases with age, excess weight, large neck size, male, and family history and is associated with cardiovascular risk factors, cardiovascular disease, depression, increased risk of motor vehicle accidents, and increased mortality polysomnography
Describe the functions of rest and sleep.
Sleep is a period of inactivity and restoration of mental and physical function. It is a complex rhythmic state involving a progression of repeated cycles, each representing different phases of body and brain activity, and is crucial for physical, mental, and emotional well-being. Rest is a concept that is used in many disciplines; in this chapter, rest refers to a condition in which the body is in a decreased state of activity, with the consequent feeling of being refreshed.
