Kozier C 45

Objectives
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Identify the characteristics of NREM and REM sleep
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Identify the four stages of NREM sleep
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Describe variations in sleep patterns throughout the life span
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Identify factors that affect normal sleep
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Describe common sleep disorders

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Identify the components of a sleep pattern assessment
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Develop nursing diagnosis, outcomes, and nursing interventions related to sleep problems
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Describe interventions that promote normal sleep

1.
2.
3.
4.
A client has a history of sleep apnea. The nurse should ask which of the following most appropriate questions?
Do you have a history of cardiac irregularities?
Do you have a history of any kind of nasal obstruction?
Have you had chest pain with or without activity?
Do you have difficulty with daytime sleepiness?

1.
2.
3.
4.
Although cardiac arrhythmias may occur, they are usually only detectable during a sleep study, and thus the client would not be aware of them.
Nasal obstruction is rarely the cause of sleep apnea or a complaint of clients with sleep apnea.
There are many causes of chest pain, and this is unlikely to be something reported by clients with sleep apnea unless they have underlying cardiac disease.
Correct. Most clients with sleep apnea report excessive daytime sleepiness. If they don’t volunteer this, clients should be asked if they fall asleep or struggle to stay awake at work.

 Darkness & preparing for sleep cause decrese in stimulation of the RAS
 Pineal gland secretes melatonin
 This results in person feeling sleepy
 Growth hormone is secreted & cortisol inhibited.

Circadian Rhythms = “about a day”
Circadian Synchronization = awake when physiologic and psychological rhythms are most active and asleep when lest active.

 Begins by 3 rd week of life
 May be inherited
 By 5 th or 6 th month more like parents sleep-wake pattern.

3.
4.
1.
2.
Because of significant concerns about financial problems a middle-aged client complains of difficulty sleeping. Which of the following would be an appropriate outcome for the nursing care plan? “By day 5, the client will:
Sleep 8 to 10 hours per day.”
Report falling asleep within 20 to 30 minutes.”
Have a plan to pay all the bills.”
Decrease worrying about financial problems and will keep busy until bedtime.”

1.
2.
3.
4.
Most adults do not need to sleep 8 to 10 hours per day.
Correct. Falling asleep within 20 to 30 minutes is normal for adults and would represent substantial improvement in the client’s difficulties.
Although it would be ideal to remove the source of the client’s stress, he is unlikely to have a plan to pay all his bills within 5 days.
Distraction or keeping busy until bedtime will not prevent the client from worrying about his bills at bedtime.

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Two types of sleep
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NREM-
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REM

NREM
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Stage I- very light sleep (drowsyrelaxed) lasts a few mins.
Stage II- light sleep,
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 body process continue to slow
Eyes still
T, HR & RR decrease slightly
Lasts about 10 – 15 min
Makes up 44 – 55% of total sleep.

NREM
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Stage III-heart and respiratory rate are slower

Stages of Sleep: NREM
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Stage VI-signals deep, restful sleep /w slower brain waves.
Thought to restore the body physically.
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Some dreaming occurs.
Skeletal muscles relaxed
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Reflexes diminished
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Snoring most likely to occur

Physiologic changes during NREM sleep
 Arterial BP falls
 Pulse increases
 Peripheral blood vessels dilate
 Cardiac output decreases
 Skeletal muscles relax
 Basal metabolic rate decreases 10 – 30%
 Growth hormone levels peak
 Intracranial pressure decreases

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Occurs about every 90 min & lasts 5-
30 min
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Not restful
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Most dreams take place here
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Brain metabolism increases 20%

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Pass the four stages in 90 – 110 mins
Sleeper passes through the 1 st 3
NREM stages in about 20-30 min.
After stage IV NREM sleeper passes thru Stages III and II in about 20mins
Than the 1 st REM occurs (lasts 10 mins)

 Healthy adult passes thru 4 – 6 cycles of sleep in 7 – 8 hrs

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Restores normal levels of activity
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Lack of sleep results in poor concentration, irritability, difficult decision making.
It use to be thought that a regular sleep pattern was more important than actual hours slept but sleep deprivation is associated with cognitive & health problems.

Normal Sleep Patterns and Requirements
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Newborns- sleep 16 to 18 hours a day, usually seven sleep periods & enter REM sleep immediately.
Infants at end of yr sleep 14 -15 hours a day
Toddlers- 12-14 hours a day.
Preschoolers- 11-13 hours of sleep per night
School Aged children (5 – 12 yrs) need 10- 11 hours at night.

Normal Sleep Patterns and Requirements
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Adolescents- 9-10 hours of sleep
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Young adults- 7-9 hours may require less
Older Adults- 7-9 hours
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Sundowner’s syndrome

3.
4.
1.
2.
A client reports to the nurse that she has been taking barbiturate sleeping pills every night for several months and now wishes to stop taking them. The nurse advises the client to:
Take the last pill on a Friday night so disrupted sleep can be compensated on the weekend.
Continue to take the pills since sleeping without them after such a long time will be difficult and perhaps impossible.
Discontinue taking the pills.
Continue taking the pills and discuss tapering the dose with the primary care provider.

2.
3.
1.
4.
Suddenly stopping barbiturate sleeping pills can precipitate a dangerous withdrawal.
Stopping requires a plan but can be done.
Suddenly stopping barbiturate sleeping pills can precipitate a dangerous withdrawal.
Correct. Doses should be tapered gradually and the tapering process supervised by the client’s primary care provider .

Click here to view a video on sleep and the elderly.
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Age- One of the most important factors affecting persons sleep and rest periods.
Illness- causing pain or physical distress can result in sleep problems.
Environment-Noise level
Fatigue- more tired the shorter the first
(REM) sleep
Lifestyle-Shift work

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Emotional Stress
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Alcohol and Stimulants
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Diet
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Smoking
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Motivation
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Medications

 Alcohol
 Decongestants
 Amphetamines
Antidepressants
 Beta-blockers Caffeine
 Bronchial dilators Steroids
Narcotics

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Insomnia- most common sleep disorder, inability to obtain an adequate amount or quality of sleep.
Hypersomnia- Opposite of insomnia, excessive sleep, especially daytime.
Narcolepsy- Sudden wave of overwhelming sleepiness that occurs during the day. Referred to as “sleep attack”.

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Sleep Apnea- periodic cessation of breathing during sleep.
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Obstructive apnea
Central apnea
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Mixed
>5 apneic episodes or 5 breathing pauses longer than 10 seconds/hour.

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Sleep Apnea-
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Load snoring
Nocturnal awakenings
Excessive daytime sleepiness
Difficulties falling asleep
Morning headaches
Memory/cognitive problems
Irritability.

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Parasomnias- Behavior that may interfere with sleep. (somnambulism, sleep talking,
Nocturnal enuresis, nocturnal erections, bruxism).
Insufficient Sleep - prolonged disturbance resulting in decreases amount, quality, consistency of sleep .

Box 43-3 Parasomnias

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Assessment of a client’s sleep includes:
 a sleep history,
 sleep diary,
 physical examination,
 a review of diagnostic studies.

 When does client usually go to sleep?
 Bedtime rituals?
 Does client snore?
 Can client stay away during day?
 Taking any prescribed or OTC medications?

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What is the usual sleeping pattern, specifically:
 sleeping and waking times
 hours of undisturbed sleep, etc.
Bedtime rituals
Use of sleep medications
Sleep environment
Changes in sleep pattern

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Written record to be much more precise
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Total number of sleep hours a day
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Activities performed 2-3 hours before sleep
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Bedtime rituals
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Any worries that may affect client’s sleep
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Factors that client believes to be positive or negative towards sleep

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Observation of clients facial appearance, behavior, and energy level.
Darkened areas around the eyes, puffy eyelids, reddened conjunctiva, glazed or dull appearing eyes.
Irritability, yawning, slumped posture, hand tremor, rubbing of eyes, confusion, fatigued, lethargic, etc.

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Rarely yields information unless client has obstructive sleep apnea
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Enlarged and reddened uvula and soft palate
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Enlarged adenoids and tonsils (children)
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Obesity (adults)
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Neck circumference > 17.5 inches (men)
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Deviated septum (occasionally)

 Polysomnography – (EEG, electromyogram & electrooculogram are recorded simultaneously).
 May also include respiratory effort
& airflow, ECG, leg movement &
O
2 sat.

 Disturbed Sleep Pattern
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With specific descriptions such as “difficulty falling asleep” or “difficulty staying asleep”
 Various etiologies may be involved and specified

 Sleep pattern disturbances as etiology of other diagnoses:
 Risk for injury
 Ineffective coping
 Fatigue
 Risk for impaired gas exchange
 Deficient knowledge
 Anxiety
 Activity intolerance

Outcomes for Clients
With Sleep Disturbances
 Maintain (or develop) a sleeping pattern that provides sufficient energy for daily activities
 Enhance feeling of well being
 Improve the quality and quantity of the client’s sleep

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Nursing interventions are used to enhance the quantity and quality of sleep & involve largely non-pharmacologic measures.
Interventions include-
 guided imagery
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 therapeutic message progressive muscle relaxation uninterrupted sleep periods.

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Client teaching
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Individuals need to learn the importance of rest and sleep in maintaining active and productive lifestyles.
Supporting bedtime rituals
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Many are accustomed to rituals or pre-sleep routines and if altered can affect sleep.
Creating Restful Environment

 Altering or eliminating routines can affect sleep
 Adults
 Listening to music
 Reading
 Soothing bath
 Praying
 Children
 Need to be socialized into presleep routine
 Usually preceded by hygienic ritual

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Promoting Comfort and Relaxation
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Assist client with hygienic routines
Offer back message
Administer analgesics 30 min before sleep
Enhancing Sleep with Medications
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Nurse responsible for making decisions with the client about when to administer sedative or hypnotics.

Figure 43.2 One suggested pattern for a back massage.
Effeurage massage consists of long, slow, gliding strokes.

2.
3.
1.
4.
During a yearly physical, a 52-year-old male client mentions that his wife frequently complains about his snoring. During the physical exam, the nurse notes that his neck size is 18 inches, his soft palate and uvula are reddened and swollen, and he is overweight. The most appropriate nursing intervention for this client is to:
Recommend that he and his wife sleep in separate bedrooms so that his snoring does not disturb his wife.
Refer him to a dietician for a weight loss program.
Caution him not to drink or take sleeping pills since they may make his snoring worse.
Refer him to a sleep disorders center for evaluation and treatment of his symptoms.

1.
2.
3.
4.
This does not address the client’s problem.
It would not be wrong to refer him to a dietician for weight loss counseling, but being evaluated by a sleep disorders specialist is more critical.
Drinking alcohol or taking sleeping pills is not advised in clients with sleep apnea because they reduce the client’s ability to get around.
Correct. The client’s symptoms, combined with his weight, suggest that he has obstructive sleep apnea and should be referred to a sleep disorders specialist for further evaluation.

 Medication Half-Life
 Chloral hydrate 7-10 hrs
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Placidyl
Dalmane
10-20 hrs
47-100 hrs
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Doriden
Ativan
Lunesta
1-12 hrs
10-20 hrs
6 hrs

 Medication
 Melatonin
 Restoril
 Halcion
 Sonata
 Ambien
Half-Life
1 hr
9-15 hrs
1.5-5.5 hrs
1 hr
2.6 hrs

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Close window curtains if street lights shine through
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Close curtains between clients in semiprivate and larger rooms
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Reduce or eliminate overhead lighting: provide night light at the bedside or in the bathroom
Close the door of the client’s room

Reducing Environmental
Distractions in Hospitals
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Perform only essential noisy activities during sleeping hours
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Ensure that all carts wheels are well oiled
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Wear rubber soled shoes
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Keep required staff conversations at low levels: conduct nursing reports or other discussions in a separate area away from clients rooms

 Establish regular betime & wake up
 Eliminate lengthy naps
 Exercise just not 2 hrs before bedtime
 Est regular bedtime routine – listen to music, warm bath,
 Avoid heavy meals 3 hrs before bedtime

 Avoid alcohol & caffeine at least 4 hrs before bedtime
 Decrease fluid intake 2-4 hrs before bed
 Use sleeping meds as last resort
 Take analgesics before bedtime if needed

1.
2.
3.
4.
A new nursing graduate’s first job requires 12-hour night shifts. Which of the following strategies will make it easier for the graduate to sleep during the day and remain awake at night?
Wear dark wrap-around sunglasses when driving home in the morning, and sleep in a darkened bedroom.
Exercise on the way home to avoid having to stand around as long waiting for equipment at the gym.
Drink several cups of strong coffee or 16 oz of caffeinated soda when beginning the shift.
Try to stay in a brightly lit area when working at night.

2.
3.
1.
4.
Correct. Reducing exposure to bright light in the morning, driving home, and when going to sleep will make it easier to fall asleep after work.
Exercising before going to bed will increase arousal.
Caffeine consumed at the beginning of a 12-hour shift will not assist the nurse in remaining awake during the later part of the shift.
Although working in a brightly lit area will reduce drowsiness, this strategy is rarely available to nurses working the night shift; lights are often dimmed in hospital corridors and client rooms.