Sleep Deprivation
Dr. Abdul-Monim Batiha
Assistant Professor
Critical Care Nursing
Philadelphia University
Outlines:
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DEFINITION.
STAGES OF SLEEP.
CIRCADIAN RHYTHM.
CIRCADIAN DESYNCHRONIZATION.
DYSFUNCTIONAL SLEEP.
SLEEP DEPRIVATION IN CRITICAL CARE
UNITS.
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EFFECTS OF SLEEP DEPRIVATION
IN CRITICAL CARE UNITS
SIGNS AND SYMPTOMS OF SLEEP
DEPRIVATION.
NURSING ROUTINES AND
INTERVENTIONS.
PHARMACOLOGY AND SLEEP.
NURSING’S CHALLENGE.
PREPARING THE PATIENT FOR SLEEP.
Definition
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Sleep is a state of unconsciousness from
which a person can be aroused by
appropriate sensory or other stimuli.
(Guyton 1991(
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It is a reversible behavioral state of
perceptual disengagement from and
unresponsiveness to the environment.
(William 2004)
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Sleep is the state of natural rest observed in
most mammals .It is characterized by a
reduction in voluntary body movement,
decreased reaction to external stimuli ,an
increased rate of anabolism the synthesis of
cell structures, and a decreased rate of
catabolism( the breakdown of cell structures(.
regular sleep is necessary for survival.
(Free encyclopedia 2007)
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Adults normally spend Approximately one
third of their lives asleep .
Research involving the
simultaneous monitoring of the
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Electroencephalogram (EEG)
Electrooculogram (EOG)
Electromyogram (EMG)
STAGES OF SLEEP
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Non-rapid eye movement (NREM)
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Consists of four stages
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Stage I and II — 50% to 60 % of sleep, light sleep
Stage III and IV — 20% of sleep, deep-sleep states
(delta sleep)
Rapid eye movement (REM)
20-25% of total sleep
In Stage 1
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The individual may not even be aware that he
has begun to sleep.
Still aware of his surroundings,
The individual is relaxed and drowsy,
His thoughts are aimless and begin to drift
Thinking is less reality-oriented.
Amplitude of brain waves low.
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The individual is less reactive to outside
stimuli, but can still be aroused easily.
Body temperature and vital signs start to
drop as metabolism slows.
Stage 1 is a brief stage, lasting no more
than 7 minutes.
Lasts 2% to 5% of total sleep time.
Stage 2 of NREM sleep
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Is a slightly deeper sleep and is a transition
or “door” stage to deeper NREM stages or to
REM sleep.
The individual is no longer aware of his
surroundings,
Amplitude of brain waves higher.
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and is a little harder to awaken.
Fragments of dreams may occur,
Eyes slowly roll from side to side.
Metabolism and vital signs continue to
decrease.
Sleep spinder.
Lasts 5-15 minutes.
This is the most stable and predominant
NREM sleep stage in adults.
NREM Stage 3 sleep
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Is much deeper than that of Stage 2, and the
individual is now more difficult to arouse.
Snoring may begin to occur
Because of decreased muscle tone. Vital
signs, body temperature, and metabolism are
decreased.
Roughly 15 to 20 minutes after falling asleep.
Stage 4 NREM sleep
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Deepest sleep stage, and the individual is
very difficult to awaken.
Sometimes referred to as “weary sleep," it is
at this time that sleep walking and bedwetting can occur.
The individual rarely moves at this time
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vital signs and metabolism are at their lowest,
with the parasympathetic system dominant.
Elevated GH and other anabolic hormones,
such as prolactin and testosterone, imply that
anabolism is taking place, particularly in
tissues with a high protein content.
Thus activities include protein synthesis and
tissue repair.
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When people speak of having had a good
night’s sleep, it is likely primarily Stage 4
sleep that they are referring to.
NREM Stages 3 and 4 are the deepest stages
of sleep and are often reported together as
delta-wave sleep, for the amplitude of waves
seen on the EEG during these stages.
20% to 25% of sleep for the adult, but this
percentage decreases with age.
REM sleep
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REM sleep is sometimes referred to as
paradoxical sleep.
REM sleep is a very active stage with a high
degree of cerebral and physiologic activity.
REM sleep continues to facilitate protein
anabolism, but during this same time there is
great fluctuation in autonomic nervous
system activity, causing heart rate variability.
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Increases in parasympathetic tone.
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Sympathetic stimulation.
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There is increased cerebral blood flow during
REM sleep .
Evidence suggests that the adrenalin surge
that more than doubles during REM sleep
may be responsible for episodes of ischemia,
sudden cardiac death, and strokes in the
early morning hours.
Most dreams occur during REM sleep
REM sleep can last from 5 to 35 minutes
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REM sleep is of great importance to nurses
because as the patient is entering this stage
of sleep, the nurse may notice a change in
vital signs and become concerned that the
patient's condition is worsening.
Walking
↓
NREM
(Stage 1)
NREM (Stage 2)
NREM ( Stage 3)
NREM ( Stage 4)
REM
NREM (Stage 2)
NREM ( Stage 3)
The cyclic Nature of sleep
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The cyclic nature of sleep and wakefulness is
thought to be regulated by complex
neurochemical reactions arising in the tissues
of the brain stem known as the reticular
formation.
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The sleep-wakefulness cycles, as well as the
REM/nonREM cycle, are throughout be
mediated by the neurotransmitters serotonin,
dopamine, norepinephrine, and epinephrine.
Current research suggests that the control of
sleep is a very complex process not confined
to one localized part of the brain.
Circadian rhythm
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The sleep-wake cycle follows the circadian
rhythm in a 24-hour cycle synchronized with
other biologic rhythms. Nighttime sleep is
the normal pattern for most adults.
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When sleep occurs during the low phase of
the
circadian
rhythm,
circadian
synchronization is present . Sleep that occurs
during normal waking hours is out of phase or
desynchronized
--------------------------------8AM
2PM
8PM
2AM
8AM-
T
i
m
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8
a
m
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Sleep desynchronization
Fig. 10-8 Sleep synchronization and desynchronization
with circadian rhythm.
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Desynchronized sleep is rated as poor-quality
sleep and causes a decreased arousal
threshold; therefore frequent awakenings are
more likely. Irritability, restlessness,
depression, anxiety, and decreased accuracy
in task performance are characteristic effects
of desynchronized sleep.
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Resynchronization with the circadian
rhythm must occur whenever sleep has
become desynchronized for the individual to
establish a normal sleep-activity pattern.
Although variable among individuals, the
resynchronization
process
is
thought
to
require a minimum of 3 days with a consistent
sleep-wake schedule.
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During resynchronization, the individual often
feels fatigued and unable to perform all of his
or her activities of daily living.
CIRCADIAN
DESYNCHRONIZATION
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The loss of rhythmicity may result from
external stressors, which then alters the
timing relationships of neural, hormonal, and
cellular systems.
Humans respond to stressors, such as
surgery, immobilization, and pain, with
increased levels and altered timing of adrenal
and other hormones.
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Farr and other reported that circadian
levels; the timing of temperature, blood
pressure, and heart rate; and urinary
excretion of catecholamines, sodium, and
potassium were altered after surgery in
hospitalized patients.
Nursing
interventions that maintain normal
rhythmicity of the day-night cycle.
SLEEP DEPRIVATION IN
CRITICAL CARE UNITS
Patients in critical care units often experience
a lack of sleep or frequent disruptions to their
sleep, further compounding their illness.
 Psychological stress alone can temporarily
affect an individual’s sleep patterns.
 More time is spent trying to initiate sleep, and
when sleep occurs, it mainly consists of
lighter sleep in Stages 1 and 2
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Research has shown that patients in critical
care units may spend 40% to 50% of their
sleep time awake, and of the remaining sleep
time only 3% to 4% in REM sleep.
Psychological stressors may cause an
individual to need more REM sleep and may
cause the individual to feel that they dreamed
more than usual and had less restful sleep.
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Illness and hospitalization certainly increase
psychological stress, but unfortunately
hospitalization makes it less possible for the
individual to obtain adequate REM sleep.
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Novaes and colleagues (1997)conducted a
study to evaluate physical and psychological
stressors in the intensive care unit (ICU)
patients. Fifty patients were asked to complete
the Intensive Care Unit Environmental
Stressor Scale, ranking the 40 items from not
stressful to very stressful. Of these 40 items,
not being able to sleep was ranked as the
second most important stressor, second only
to pain.
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Using EEGs, Hilton documented quantity and
quality of sleep of nine patients in a
respiratory critical care unit. Total sleep time
ranged from 6 minutes to 13.3 hours. Only
50% to 60% of the sleep occurred at night, and
no patients had complete sleep cycles. NREM
stage 1 sleep predominated, to the deprivation
of all other stages. Significant deprivation of
restorative sleep (NREM stages 3 and 4) was
demonstrated with only 4.7% to 10.5% of
sleep time being spent in these stages
(normally 30% to 35%).
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Shaver, in a review of sleep research, notes
that sleep deprivation is considered to be a
contributing factor in postoperative psychosis.
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There is substantial evidence to support the
fact that 4 days of sleep deprivation results in
a decreased production of ATP, the critical
energy substance.
EFFECTS OF SLEEP DEPRIVATION
IN CRITICAL CARE UNITS
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Sleep deprivation has been shown to induce
a catabolic state and negatively affect the
immune system and healing.
There is decreased ability to resist and fight
infection, further impacting the healing
process and hospitalization.
Immunosuppression
and decreased tissue repair
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studies report decreased pain tolerance and
profound fatigue of the sympathetic nerve
centers.
Cortisol secretions are normally diminished
during sleep and rise in the morning following
circadian rhythms.
Sleep deprivation in critical care patients
prolongs cortisol secretion and results in
decreased healing, making patients more
susceptible to infection and a prolonged
recovery process.
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Lack of sleep has also been shown to
contribute to upper airway musculature
dysfunction
and
hypoxic
ventilatory
responsiveness, adversely affecting gas
exchange. This could have a significant
impact on patients with respiratory problems,
particularly those who are being weaned
from the ventilator or those who have just
been extubated
Signs and symptoms of sleep
deprivation
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The signs and symptoms of sleep deprivation
may not be so apparent, at least initially.
Behavioral changes such as restlessness
and irritability may occur within 48 hours.
Disorientation
slurred speech may precede psychotic
behavior, which can occur within 96 hours
If a patient is deprived
primarily of NREM sleep
He may experience:
- fatigue, apathy, speech deterioration, poor
judgment, and lack of energy.
- ptosis and lack of facial expression.
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Deprivation of REM sleep
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May cause the patient to feel continually tired
and have difficulty concentrating. When
deprived of REM sleep for greater than 24 to
48 hours, the patient may experience
irritability, confusion, poor impulse control,
paranoia, and hallucination, or exhibit
aggressive behavior
If an individual does not obtain enough
sleep to meet his biological needs, this sleep
deprivation will accumulate over time until the
brain signals the body to obtain sleep.
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If sleep deprivation is prolonged, when the
patient finally enters sleep, it consists of
predominantly Stage 2 and the deep recovery
sleep of Stage 4. REM sleep usually does not
occur until the second or third night
CAUSES OF SLEEP DEPRIVATION
IN CRITICAL CARE UNITS
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Related to patient:
1- Age.
2- physical condition (underlying disease).
3- Pain.
4- Anxiety, and stress.
Related to staff:
1- Procedures are interrupting the sleep time.
Related to the environment
1- Noisy,
2- Unfamiliar environment,
3- Lighting,
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Dlin and others showed that the chief deterrents
to sleep in the critical care unit in order of
importance were (1) activity and noise, (2) pain
and physical condition, (3) nursing procedures,
(4) lights, (5) vapor tents, and (6) hypothermia.
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Woods and Falk20 found that 10% to 17% of
noises in the critical care unit were of a level
capable of arousing patients from sleep (greater
than 70 decibels).
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Sleep-disturbing events validated by EEG
were mainly staff and environmental noise,
which occurred on the average of every 20
minutes. Quality and quantity of sleep were
reported as poor in all subjects. Nightmares,
hallucinations, restlessness, or other
behavioral changes were observed in 60% of
the patients in the sample.
ASSESSMENT OF SLEEP
PATTERN DISTURBANCE
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Description of the normal sleep pattern
ِAny recent changes in the patient's normal
pattern resulting from the acute illness.
Recent and more distant history of sleep
disturbances.
The severity, duration, and frequency of the
problem.
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History of chronic illnesses and physical
conditions that may disturb sleep.
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The critical care nurse should elicit history of
snoring because of its relationship to sleep
apnea and sleep disturbances.
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The scientific standard for the measurement
of sleep is the polysomnogram (PSG).
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Sleep efficiency is an important sleep
variable defined as the proportion of actual
sleep time in the total sleep period.(95%
versus 65%)
Nursing routines and
interventions
-In order to have early morning laboratory work
and test results available when physicians
make rounds, most critical care units wake
Patients at 5 AM or 6 AM to draw blood and do
electrocardiograms.
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In a study of 203 patients from 4 ICU’s,
patients were given a questionnaire on the
day of discharge to evaluate their sleep
during their stay in the ICU. The questions
assessed perceived sleep quality and
daytime sleepiness,
perceived sleep
disruption caused by environmental activities,
and perceived sleep disruption caused by
specific environmental noises. They that
nursing interventions such as checking of
vital signs were more disruptive to sleep
than were other factors such as noise and
light.
(Friedman,1999)
One study reported that nurses generally
agreed that sleep was important to their
patients, but found it difficult to organize their
assessment routines and tasks to even
Accommodate 2-hour periods of quiet time.
(Olson,2001)
PHARMACOLOGY AND SLEEP
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Hypnotic drugs have been found to promote
the lighter stages of sleep (i.e., NREM stage
2) and may, paradoxically, be the cause of
night terrors, hallucinations, and agitation in
the elderly.
If hypnotics are indicated, it is wise to first
evaluate the medications that the patient is
receiving, to make certain that none of them
are contributing to the patient’s inability to
sleep. Consulting with the pharmacist may
help identify these medications so that
discussion can be initiated with the physician.
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Barbiturates e.g amobarbital they increases
NREM2, and suppress REM
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Benzodiazepines e.g. Diazepam increases
NREM stage 1 and reduces both NREM
stages 3 and 4 and REM.
Morphine increases spontaneous arousals
during sleep and shortens the sleep time by
reducing both REM and NREM stages 3 and
4, resulting in overall lighter sleep.
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It is the responsibility of the critical care
nurse to assess the need for sedative and
analgesic medications, to administer them in
the most effective manner to promote sleep,
and to monitor their effectiveness
NURSING’S CHALLENGE
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The sleep process and effects of deprivation
need to be incorporated into critical care
education programs and continuing education
programs, and encouraged as nursing
research topics.
Sleep requirements need to become part of
the written multidisciplinary plan of care, to
allow for care and assessment of patients, but
incorporating blocks of uninterrupted sleep.
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It needs to be discussed in shift to shift
report, and may need to be discussed in
Health Team Conference. Nursing activities
should be organized to make sleep a priority
for patients in critical care units.
Nursing
interventions
promoting and preparing
patient for sleep
for
the
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If the patient has a pulmonary artery
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and/or arterial line, make sure the transducer
is leveled to right atrium with the patient’s
head of the bed in the desired position.
Leveling the transducer at the phlebostatic
axis, with the patient in position for sleep, will
assure that the assessment readings taken
throughout the night are accurate to guide
decision-making. Assess the patient and the
intravenous lines for patency.
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The proper location of the phlebostatic axis
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Assess the patient for any pain or discomfort.
If pain medication is required, try to give it
early enough so that it takes effect before
bedtime and the patient will be pain-free and
more relaxed. If sleep medication is ordered,
offer it only after pain is relieved, so that the
hypnotic will be more effective.
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Offering a bedtime snack or a glass of warm
milk may encourage sleep. Nursing activities
such as freshening the bed linen and allowing
the patient to brush his teeth, wash his face,
and void before sleep are helpful.
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Providing an extra pillow or blanket,
arranging the pillows in a certain way, and
assisting the patient to a comfortable position
for sleeping may be helpful. A back massage
can be very relaxing and therapeutic, and
provides the patient with his nurse’s
undivided attention for the moment.
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For many patients, privacy or private room
and providing the patient with his covering,
pillows, and pajamas are all traditionally
promote sleep .
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Touch can be very therapeutic, and may
provide an opportunity for the patient to ask
questions or share concerns that might not
otherwise have been verbalized.
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If the patient has a tendency to nap during the
day, morning naps should be encouraged rather
than afternoon naps because afternoon naps
consist mostly of deep sleep (Stage 4) and short
periods generally leave the patient feeling tired.
(Hayter J, 2003)
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(Richards, 2002) tested the effect of a back
massage and combination of muscle
relaxation, mental imagery, and music on the
sleep of 69 older men with a cardiovascular
illness who were hospitalized in a critical care
unit. Her study showed significant differences
between the back-massage and the control
group, in the percentage of Stage 2 and REM
sleep, with the back-massage group sleeping
longer than the control group.
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When giving a hypnotic, make that the final
trip to the patient’s room for the shift. Before
leaving, make sure the patient has fresh
water, and that the call light is within reach.
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Titrate environmental stimuli: turn down light,
alarms, and decrease noise from TV and
talking.
Activity during day time should be increased .
Limiting caffeine intake after early afternoon
will promote sleep in the evening.
Make sure the intermittent suction machine
is turned off, the oxygen tubing is free of water,
faucets are not dripping, and the urinal is
empty and within reach. Pull the patient’s
curtain closed to help block out light from the
unit. If there is a door to the room, close it.
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During the night, take note of any patient who
appears not to be sleeping. Turning and
wakefulness can often be detected on the
monitor by movement. By checking on the
patient, you may find that he is having pain, is
anxious, or in some distress that need further
assessment.
If it is necessary to assess the patient, perform
procedures during the night, or bathe the
patient, do so as quietly as possible. Since
critically ill patients sometimes cannot tolerate
a lot of activity at one time, try to space
procedures to allow a minimum of 2 hours of
uninterrupted sleep at a time.
Noise and interruptions should be kept to a
minimum, to allow the patient to obtain the
much needed NREM Stages 3 and 4 sleep and
REM sleep.
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Have the patients use earplugs.
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At bet time , provide information to lower
anxiety. Do review of the day and remind
patient of the progress made toward
recovery, then add what to expect for the
next day.
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Institute “PM” care back to basics, brushing
teeth, washing face, before “ bedtime”.
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Allow family to be with the patient.
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Post sign at designated times” patient
sleeping”.
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Document amount of uninterrupted sleep per
shift, especially sleep episodes lasting longer
than 2 hours.