Sleep & Pain
1. Know culture considerations and cultural characteristics regarding Sleep
BOX 43.10
CULTURAL ASPECTS OF CARE
Co-sleeping/Bed-sharing

Sleep patterns, bedtime routines, sleep aids, and sleep arrangements are
components of cultural practices related to the use of space and interaction
distances
(Giger and Haddad, 2021).
 Traditionally, experts recommend having infants and children sleep in their
own beds.
 Co-sleeping or bed-sharing, in which infants and children sleep with their parents, is a
culturally preferred habit that varies among cultures (Barry, 2019).
 In the United States, bed-sharing is more common in mothers who are younger
and less educated (Bombard et al., 2018; Stiffler et al.,
2018).
 Reasons for bed-sharing practices relate to breastfeeding, comfort, tradition, better
or more sleep, attachment and bonding with the infant, and protection for an
infant (i.e., to protect against the cold) (Marinelli et al., 2019; Barry, 2019). Health care
providers in the United States discourage it because of safety issues. One belief is that
co-sleeping does not promote independence (Barry, 2019).
 Research results indicate that co-sleeping or bed-sharing is a risk factor for sudden
infant death syndrome (SIDS) (Carlin and Moon, 2017).
 Research does not show that using a device to make bed-sharing safe reduces infant
suffocation or SIDS (AAP, 2016).
 Bed-sharing is not recommended for infants who were born prematurely or with parents
who use alcohol or drugs or smoke because of the increased risk for SIDS (Mitchell et
al., 2017; Carlin and Moon, 2017).
 Bed-sharing is often related to infant sleep problems such as frequent
awakenings, nighttime crying, increased time spent awake at night and less
nighttime sleep (Mindell et al., 2017).
 As a nurse, be culturally sensitive when discussing co-sleeping practices with parents
and developing sleeping plans for children.
Implications for patient-centered care
• Complete a thorough sleep assessment of the child and family.
• Discuss the risks of co-sleeping with parents. During the discussion remain culturally
sensitive and respectful of the parents’ views (Barry, 2019).
• Instruct parents who practice co-sleeping to avoid using alcohol or drugs that impair
arousal. Decreased arousal prevents the parents from waking if the child is having
problems (Mitchell et al., 2017).
• Recommend to parents that they share a room but not the bed with their infant
(Bombard et al., 2018).
• Encourage parents to use light sleeping clothes, to keep room temperature
comfortable, and to avoid bundling the child tightly or in too many clothes.
• Remove pillows and blankets from the infant’s bed (Gaw et al., 2017).
2.
Know the characteristics of each (NREM and REM) of the stages of sleep - Use Potter
& Perry
There are two sleep phases: nonrapid eye movement (NREM) sleep and rapid eye movement
(REM) sleep (Box 43.1). In the classical definition of NREM sleep, people progress through four
stages during a typical 90-minute sleep cycle. The American Academy of Sleep Medicine
defines three stages in NREM sleep, combining stages 3 and 4 (Kryger et al., 2017). The
quality of sleep from stage 1 through stage 3 becomes increasingly deep. Lighter sleep is
characteristic of stages 1 and 2, when a person is more easily arousable. Stage 3 (formerly
stages 3 and 4) involves a deeper sleep called slow-wave sleep, from which a person is more
difficult to arouse (Kryger et al., 2017). REM sleep is the phase at the end of each 90-minute
sleep cycle. During REM sleep there is increased brain activity associated with rapid eye
movements and muscle atonia.
Stages of the Sleep Cycle
NREM sleep (75% of night)
N1 (formerly stage 1)
• Stage of lightest level of sleep, lasting a few minutes.
• Decreased physiological activity begins with gradual fall in vital signs and metabolism.
• Sensory stimuli such as noise easily arouse sleeper.
• If awakened, person feels as though daydreaming has occurred.
N2 (formerly stage 2)
• Stage of sound sleep during which relaxation progresses.
• Arousal is still relatively easy.
• Brain and muscle activity continue to slow.
N3 (formerly stages 3 and 4)
• Called slow-wave sleep.
• Deepest stage of sleep.
• Sleeper is difficult to arouse and rarely moves.
• Brain and muscle activity are significantly decreased.
• Vital signs are lower than during waking hours.
REM sleep (25% of night)
• Vivid, full-color dreaming occurs.
• Stage usually begins about 90 minutes after sleep has begun.
• Stage is typified by autonomic response of rapidly moving eyes, fluctuating heart and
respiratory rates, and increased or fluctuating blood pressure.
• Loss of skeletal muscle tone occurs.
• Gastric secretions increase.
• It is very difficult to arouse sleeper.
• Duration of REM sleep increases with each cycle and averages 20 minutes.
3.
Know components of a sleep assessment – What Questions to ask
Do you feel rested?
Sleep assessment.
Usually patients are the best resource for describing sleep problems
In addition, bed partners can provide information about patients’ sleep patterns that help
reveal the nature of certain sleep disorders.
When caring for children, seek information about sleep patterns from parents or
guardians because they are usually a reliable source of information.
Tools for sleep assessment.
Two effective subjective measures of sleep are the Epworth Sleepiness Scale and the
Pittsburgh Sleep Quality Index.
The Epworth Sleepiness Scale contains eight questions about the likeliness of a patient
being sleepy during certain activities (e.g., watching television, reading, sitting and
talking with someone) on a scale of 0 (would never doze or sleep) to 3 (high chance of
dozing or sleeping). A score of 0 to 5 indicates lower normal daytime sleepiness; 6 to 10
is considered higher than normal daytime sleepiness; a score of 11 or 12 is mild
excessive daytime sleepiness; 13 to 15 is moderate excessive daytime sleepiness; and a
score of 16 to 24 is severe excessive daytime sleepiness (Johns, n.d.). The scale is
available at http://epworthsleepinessscale.com/about-the-ess/.
The second tool, the Pittsburgh Sleep Quality Index, assesses sleep quality and patterns
(Mollayeva et al., 2016). This scale is available at
https://www.opapc.com/uploads/documents/PSQI.pdf.
Another brief, effective method for assessing sleep quality is the use of a visual analog
scale. Draw a straight horizontal line 100 mm (4 inches) long. Opposing statements such
as “best night’s sleep” and “worst night’s sleep” are at opposite ends of the line. Ask
patients to place a mark on the horizontal line at the point corresponding to their
perceptions of the previous night’s sleep. Measuring the distances of the mark along the
line in millimeters offers a numerical value for satisfaction with sleep. Use the scale
repeatedly to show change over time. Such a scale is useful to assess an individual
patient, not to compare patients.
Another brief, subjective method to assess sleep is a numeric scale with a 0-to-10 sleep
rating. Ask individuals to separately rate the quantity and quality of their sleep on the
scale. Instruct them to indicate with a number between 0 and 10 their sleep quantity and
then their quality of sleep, with 0 being the worst sleep and 10 being the best.
Sleep history.
When you suspect a patient has a sleep problem, assess the quality and characteristics
of sleep in greater depth by asking the patient to describe the problem. This includes
recent changes in sleep patterns, sleep symptoms experienced during waking hours, the
use of prescribed or over-the-counter sleep medications, diet and intake of substances
such as caffeine or alcohol that influence sleep, and recent life events that have affected
the patient’s mental and emotional status.
Description of sleeping problems.
Conduct a more detailed history when a patient has a persistent or what appears to be a
serious sleep problem. Open-ended questions help a patient describe a problem more
fully. A general description of the problem followed by more focused questions usually
reveals specific characteristics that are useful in planning therapies. To begin, you need
to understand the nature of the sleep problem, its signs and symptoms, its onset and
duration, its severity, any predisposing factors or causes, and the overall effect on the
patient. Ask specific questions related to the sleep problem (Box 43.5).
BOX 43.5
Nursing Assessment Questions
Nature of the problem
• Describe the type of sleep problem you’re having.
• Why do you think you are not getting enough sleep?
• Describe a recent night’s sleep. Is this similar to your usual sleep? How is this sleep
different from your usual sleep?
Signs and symptoms
• Do you have difficulty falling asleep, staying asleep, or waking up?
• Have you been told that you snore loudly?
• Do you have headaches when awakening?
Onset and duration of signs and symptoms
• When did you notice the problem?
• What do you do to relieve the symptom?
• How long has this problem lasted?
Severity
• How long does it take you to fall asleep?
• How often during the week do you have trouble falling asleep?
• On average, how many hours of sleep a night did you get this week?
• How does this compare to your usual amount of sleep?
• What do you do when you awaken during the night or too early in the morning?
Predisposing factors
• What do you do just before you go to bed?
• Have you recently had any changes at work or at home?
• How is your mood? Have you noticed any changes recently?
• Which medications or recreational drugs do you take on a regular basis?
• Are you taking any new prescriptions or over-the-counter medications?
• Do you eat food (spicy or greasy foods) or drink substances (alcohol or caffeinated
beverages) that affect your sleep?
• Do you have a physical illness that affects your sleep?
• Does anyone in your family have a history of sleep problems?
Effect on patient
• How has the loss of sleep affected you?
• Do you feel excessively sleepy or irritable or have trouble concentrating during waking
hours?
• Do you have trouble staying awake? Have you fallen asleep at the wrong times (e.g.,
while driving, sitting quietly in a meeting)?
Proper questioning helps to determine the type of sleep disturbance and the nature of
the problem. Box 43.6 provides examples of additional questions for you to ask a patient
when you suspect specific sleep disorders. The STOP-BANG sleep assessment tool is a
reliable evidence-based tool used to screen for OSA and is frequently used in
preanesthesia and/or preoperative assessments (see Chapter 50) (Chung et al., 2016;
Kawada, 2019). The questions help to select specific sleep therapies and the best time
for implementation.
BOX 43.6
Questions to Ask to Assess for Specific Sleep Disorders
Impaired sleep
• How easily do you fall asleep?
• Do you fall asleep and have difficulty staying asleep? How many times do you awaken?
Do you awaken at the same time?
• What time do you awaken in the morning? What causes you to awaken early?
• What do you do to prepare for sleep? To improve your sleep?
• What do you think about as you try to fall asleep?
• How often do you have trouble sleeping?
Sleep apnea
• Do you snore loudly? Does anyone else in your family snore loudly?
• Has anyone ever told you that you often stop breathing for short periods during sleep?
(Spouse or bed partner/roommate may report this.)
• Do you experience headaches after awakening?
• Do you have difficulty staying awake during the day?
Narcolepsy
• Do you fall asleep at the wrong times? (Friends or relatives may report this.)
• Do you have episodes of losing muscle control or falling to the floor?
• Have you ever had the feeling of being unable to move or talk just before waking or
falling asleep?
• Do you have vivid, lifelike dreams when going to sleep or awakening?
To add to the sleep history, have the patient and bed partner keep a sleep-wake log for 1
to 4 weeks. The patient completes the sleep-wake log daily to provide information on
day-to-day variations in sleep-wake patterns over extended periods. Entries in the log
often include 24-hour information about various waking and sleeping health behaviors
such as physical activities, mealtimes, type and amount of intake (alcohol and caffeine),
time and length of daytime naps, evening and bedtime routines, the time the patient tries
to fall asleep, nighttime awakenings, and the time of morning awakening. A partner helps
record the estimated times the patient falls asleep or awakens. Although the log is
helpful, the patient needs to be motivated to participate in its completion.
Usual sleep pattern.
Normal sleep is difficult to define because individuals vary in their perception of
adequate quantity and quality of sleep. However, it is important to have patients describe
their usual sleep pattern to determine the significance of the changes caused by a sleep
disorder. Knowing a patient’s usual, preferred sleep pattern allows you to try to match
sleeping conditions in the health care setting with those in the home. Ask the following
questions to determine a patient’s sleep pattern:
1. What time do you usually get in bed each night?
2. How much time does it usually take to fall asleep? Do you do anything special to help
you fall asleep?
3. How many times do you wake up during the night? What do you think is the cause?
4. What time do you typically wake up in the morning?
Physical and psychological illness.
Determine whether the patient has any preexisting health problems that interfere with
sleep. Chronic diseases such as chronic obstructive pulmonary disease (COPD) and
painful disorders such as arthritis interfere with sleep. Also assess the patient’s
medication history, including a description of over-the-counter and prescribed drugs.
Assess individuals for polypharmacy, especially older adults, because polypharmacy
can cause sleep problems (Miner and Kryger, 2020). A history of psychiatric problems
also makes a difference. For example, a patient who is living with bipolar disorder sleeps
more when depressed than when manic. A patient who is depressed often experiences
an inadequate amount of fragmented sleep. If a patient takes medications to aid sleep,
gather information about the type and amount of medication and the frequency of its use.
Also assess the patient’s daily caffeine intake.
If a patient has recently undergone surgery with general anesthesia, expect that patient
to experience some sleep disturbance. Patients usually awaken frequently during the
first night after surgery and receive little deep or REM sleep. Depending on the type of
anesthesia, it takes several days to months for a normal sleep cycle to return.
Current life events.
In your assessment learn whether the patient is experiencing any changes in lifestyle
that disrupt sleep. A person’s occupation often offers a clue to the nature of the sleep
problem. Changes in job responsibilities, rotating shifts, or long hours contribute to a
sleep disturbance. Questions about social activities, recent travel, or mealtime schedules
help clarify the assessment.
Emotional and mental status.
A patient’s emotions and mental status affect the ability to sleep. For example, a patient
who is experiencing anxiety, emotional stress related to illness, or situational crises
such as loss of job or a loved one often experiences insomnia. Ask whether the
individual is a caregiver because caregiver stress, physical strain, and irregular
schedules of caregivers often contribute to sleep disruption (Miner and Kryger, 2020).
When a sleep disturbance is related to an emotional problem, the key is to treat the
primary problem; its resolution often improves sleep (Murawski et al., 2018; Miner and
Kryger, 2020). Patients with mental illnesses may need mild sedation for adequate rest.
Assess the effectiveness of any medication and its effect on daytime function.
Bedtime routines.
Ask patients what they do to prepare for sleep. For example, some patients drink a glass
of milk, take a sleeping pill, eat a snack, or watch television. Assess habits that are
beneficial compared with those that disturb sleep. For example, watching television
promotes sleep for one person, whereas it stimulates another to stay awake. Sometimes
pointing out that a habit is interfering with sleep helps patients find ways to change or
eliminate habits that are disrupting sleep.
Pay special attention to a child’s bedtime rituals. For example, the parents need to report
whether it is necessary to read a bedtime story, rock the child to sleep, or engage in
quiet play. Some young children need a special blanket or stuffed animal when going to
sleep.
Bedtime environment.
During assessment ask the patient to describe preferred bedroom conditions, including
preferences for lighting in the room, music or television in the background, or needing to
have the door open versus closed. Include questions about the presence of electronic
devices in the bedroom (e.g., phones, televisions), all of which have small lights that
remain on or have a light that blinks when the battery is low. Patients are often surprised
by how many of these devices are in the sleeping environment.
In addition, some children need the company of a parent to fall asleep. Environmental
distractions in a health care setting such as a roommate’s television, an electronic
monitor in the hallway, a noisy nurses’ station, or another patient who cries out at night
often interfere with sleep. Modify the environment whenever possible to promote sleep.
Behaviors of sleep deprivation.
Some patients are unaware of how their sleep problems affect their behavior. Observe for
behaviors such as irritability, disorientation (similar to a drunken state), frequent
yawning, and slurred speech. If sleep deprivation has lasted a long time, psychotic
behavior such as delusions and paranoia sometimes develops. For example, a patient
reports seeing strange objects or colors in the room or acts afraid when the nurse enters
the room.
4.
Know how sleep or lack thereof affects the client physiologically and psychologically
BOX 43.3
Sleep-Deprivation Symptoms
Physiological Symptoms
• Ptosis, blurred vision
• Fine-motor clumsiness
• Decreased reflexes
• Slowed response time
• Decreased reasoning and judgment
• Decreased auditory and visual alertness
• Cardiac arrhythmias
Psychological Symptoms
• Confused and disoriented
• Increased sensitivity to pain
• Irritable, withdrawn, apathetic
• Agitated
• Hyperactive
• Decreased motivation
• Excessive sleepiness
Sleep deprivation occurs when a client does not meet the body's biological sleep
requirements. Sleep deprivation can affect higher order cognitive projects, impair
judgment, decrease response time, and trigger seizure disorders, migraines, and tension
headaches.
Functions of sleep
Sleep restores biological processes. During NREM stage 3 sleep, the body releases
human growth hormone for the repair and renewal of epithelial and specialized cells
such as brain cells (Huether et al., 2020).
REM sleep appears to be important for early brain development, cognition, and memory.
Researchers associate REM sleep with changes in the brain, including cerebral blood
flow and increased cortical activity. In addition, there is increased oxygen consumption
and epinephrine release. These changes are associated with memory storage and
learning (Huether et al., 2020).
Sleep deprivation affects immune function, metabolism, nitrogen balance, and protein
catabolism. A loss of REM sleep often leads to confusion and suspicion. Prolonged sleep
loss alters various body functions (e.g., mood, motor performance, memory, equilibrium)
(National Sleep Foundation, 2020b). Individuals with sleep problems are also more likely
to have chronic diseases such as hypertension, cardiovascular disease, diabetes
mellitus, obesity, and depression (Jike et al., 2018; Tan et al., 2018). In addition, they may
experience poorer quality of life and productivity (Jike et al., 2018). Millions of health care
dollars are spent on indirect costs related to sleep deprivation, such as motor vehicle
and industrial accidents, litigation, property damage, hospitalization, medical errors, and
death (Hillman et al., 2018; Sleep Advisor, 2020).
Dreams.
Although dreams occur during both NREM and REM sleep, the dreams of REM sleep are
more vivid and elaborate, and some believe that they are functionally important to
learning, memory processing, and adaptation to stress (Kryger et al., 2017).
5.
Complications of sleep disorders know characteristics of each sleep disorder, i.e., S/S,
common, similarities and differences, safety issues related, nursing diagnosis and nursing
interventions related to them, evaluate outcomes, what to expect for treatment
Define:Insomnia is an ongoing inability to sleep despite having the opportunity to do so.
Safety:
Nursing diagnosis:
Interventions:
Outcomes:
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
Define:Apnea is a condition in which there is an absence of inspiratory airflow for a
minimum of 10 seconds.
Safety:
Nursing diagnosis:
Interventions:
Outcomes:
Treatment:
Define:Hypopnea is associated with a decrease in oxygen saturation and lasts 10
seconds or longer.
Safety:
Nursing diagnosis:
Interventions:
Outcomes:
Treatment:
Define:Obstructive sleep apnea (OSA) is related to the recurrent episodes of upper
airway collapse and obstruction while sleeping combined with waking from sleep.
Safety:
Nursing diagnosis:
Interventions:
Outcomes:
Treatment:
Define:Narcolepsy is a chronic sleep condition characterized by sudden sleepiness and
sudden periods of sleep.
Safety:
Nursing diagnosis:
Interventions:
Outcomes:
Treatment:
Define:Hypersomnia is a disorder of excessive daytime fatigue without improvement
after more sleep.
Safety:
Nursing diagnosis:
Interventions:
Outcomes:
Treatment:
Define:Restless leg syndrome (RLS), also called Willis-Ekbom disease, is an
uncontrollable urge to move the legs during sleep.
Safety:
Nursing diagnosis:
Interventions:
Outcomes:
Treatment:
Know sleep issues specific to the adult and the older adult
BOX 43.8
FOCUS ON OLDER ADULTS
Older adults.
Sleeping difficulties increase with age. Approximately 40% of older adults report problems with
sleep (Kryger et al., 2017; National Sleep Foundation, 2020a). Older adults spend more time
in stage 1 and less time in stages 3 and 4 (NREM sleep); some older adults have almost
no NREM stage 4 or deep sleep. Episodes of REM sleep tend to shorten. Older adults
experience fewer episodes of deep sleep and more episodes of lighter sleep (Miner and Kryger,
2020). They tend to awaken more often during the night, and it takes more time for them
to fall asleep. To compensate they increase the number of naps taken during the day.
Older adults often experience excessive daytime sleepiness, which can lead to
decreased physical abilities and falls (Miner and Kryger, 2020).
Older adults who have a chronic illness often experience sleep disturbances. For example, an
older adult with arthritis frequently has difficulty sleeping because of painful joints. Changes in
sleep patterns are often caused by changes in the CNS that affect the regulation of sleep.
Many older adults with insomnia have co-morbid mental health or medical conditions, take
medications that disrupt sleep patterns, or use drugs or alcohol. Sensory impairment
reduces an older person’s sensitivity to time cues that maintain circadian rhythms.
Promoting Sleep
Sleep-wake pattern
• Maintain a regular bedtime and wake-up schedule (Hedges and Gotelli, 2019).
• Eliminate naps unless they are a routine part of the schedule.
• If naps are taken, limit to 30 minutes and time them early in the day (Morris et al.,
2021).
• Go to bed when sleepy.
• Use warm bath and relaxation techniques (Touhy and Jett, 2020).
• If unable to sleep in 15 to 30 minutes, do a relaxing activity such as reading (Haynes et
al., 2018).
• Avoid stimulating activities such as exercise or watching television before bedtime
(Morris et al., 2021).
Environment
• Sleep where you sleep best.
• Keep noise to a 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 (Touhy and Jett, 2020).
• Sit in natural sunlight upon awakening if possible (Morris et al., 2021).
Medications
• Use sedatives and hypnotics with caution as last resort and then only short term if
necessary (Hedges and Gotelli, 2019).
• Adjust medications being taken for other conditions and assess for drug interactions
that may cause insomnia or excessive daytime sleepiness.
Diet
• Limit caffeine and nicotine in late afternoon and evening (Hedges and Gotelli, 2019).
• Avoid large meals and alcohol close to bedtime (Hedges and Gotelli, 2019)
• Consume carbohydrates or milk as a light snack before bedtime (Touhy and Jett,
2020).
• Decrease fluids 2 to 4 hours before sleep (Touhy and Jett, 2020).
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 (Morris et al.,
2021).
Know practices that hinder sleep and practices that promote sleep
BOX 43.12
Control of Noise in the Hospital
• Close doors to patients’ room when possible.
• Keep doors to work areas on unit closed when in use.
• Reduce volume of nearby telephone and paging equipment.
• Wear rubber-soled shoes. Avoid clogs.
• Turn off bedside oxygen and other equipment that is not in use.
• Turn down alarms and beeps on bedside monitoring equipment.
• Turn off room television and radio unless patient prefers soft music.
• Avoid abrupt loud noise such as flushing a toilet or moving a bed.
• Keep necessary conversations at low levels, particularly at night.
• Designate a time during the day for “quiet time” for patients
Promoting Sleep
 Avoid stimulants, such as caffeine, alcohol, and nicotine at least four to six hours before
bedtime.

Remove unnecessary light and noise.

Establish a bedtime routine, such as taking a warm shower or bath.
 Keep room dark, quiet, and at a comfortable, cold temperature.
 Go to bed only when tired.

If no sleep in 20 minutes, go to another room and read or listen to music.
 Turn the clock away from view.
 Go to bed and wake up at same time each day.
 Keep naps short and before 3 p.m.
 Complete exercise at least three hours before going to bed.
 Remove work items and televisions from bedroom when possible.
 The bedroom should be for sleep and sexual activity only.
Know circadian rhythm
Circadian rhythms.
People experience cyclical rhythms as part of their everyday lives. The most familiar
rhythm is the 24-hour, day-night cycle known as the diurnal or circadian rhythm (derived
from Latin: circa, “about,” and dies, “day”). The suprachiasmatic nucleus (SCN) nerve
cells in the hypothalamus control the rhythm of the sleep-wake cycle and coordinate this
cycle with other circadian rhythms (Huether et al., 2020). Circadian rhythms influence the
pattern of major biological and behavioral functions. The predictable changing of body
temperature, heart rate, blood pressure, hormone secretion, sensory acuity, and mood
depend on the maintenance of the 24-hour circadian cycle (Kryger et al., 2017).
Factors such as light, temperature, social activities, and work routines affect circadian rhythms
and daily sleep-wake cycles. All people have biological clocks that synchronize their sleep
cycles. This explains why some people fall asleep at 8 p.m., whereas others go to bed at
midnight or early in the morning. Different people also function best at different times of the day.
Health care agencies or extended-care centers usually do not adapt care to an individual’s
sleep-wake cycle preferences. Typical hospital routines interrupt sleep or prevent patients from
falling asleep at their usual time. Poor quality of sleep results when a person’s sleep-wake cycle
changes. Reversals in the sleep-wake cycle, such as when a person who is normally awake
during the day falls asleep during the day, sometimes indicate a serious illness.
The biological rhythm of sleep frequently becomes synchronized with other body functions. For
example, changes in body temperature correlate with sleep patterns. Normally, body
temperature peaks in the afternoon, decreases gradually, and drops sharply after a person falls
asleep. When the sleep-wake cycle becomes disrupted (e.g., by working rotating shifts), other
physiological functions usually change as well. For example, a new nurse who starts working
the night shift experiences a decreased appetite and loses weight. Anxiety, restlessness,
irritability, and impaired judgment are other common symptoms of sleep cycle disturbances.
Failure to maintain an individual’s usual sleep-wake cycle negatively influences a patient’s
overall health.
Know non- pharmacological interventions for sleep
Keep in mind priorities related to benzodiazepines
Understand all drugs for sleep and their potential side effects, safety issues related, nursing
diagnosis and nursing interventions related to them, evaluate outcomes, when to expect them to
be prescribed
Melatonin is a neurohormone produced in the brain that helps control circadian rhythms and
promote sleep (Kryger et al., 2017). It is a popular nutritional supplement that is found to be
helpful in improving sleep efficiency and decreasing nighttime awakenings. The recommended
dose is 0.3 to 3 mg taken 2 hours before bedtime. Older adults who have decreased levels of
melatonin find it beneficial as a sleep aid (Kryger et al., 2017). Short-term use of melatonin has
been found to be safe, with mild, infrequent side effects of nausea, headache, and dizziness. A
melatonin receptor agonist, such as ramelteon or tasimelteon, is well tolerated and appears to
be effective in improving sleep by improving the circadian rhythm and shortening the time
needed for sleep onset (Avidan and Neubauer, 2017; Patel et al., 2018). It is safe for long- and
short-term use, particularly in older adults. Common side effects include diarrhea, drowsiness,
tiredness and dizziness.
Several other herbal products help in sleep. Valerian has been shown to be effective in mild
insomnia by reducing the time to fall asleep and improving quality of sleep. Typically, individuals
who use valerian do not experience morning grogginess (WebMD, 2019). Lavender essential oil
may improve sleep quality (O’Malley, 2017). Passionflower (maypop) has mild sedative effects
and is used as a natural sleep aid (WebMD, 2019). Chamomile, an herbal tea, has a mild
sedative effect that may be beneficial in promoting sleep (WebMD, 2019). Caution patients
about the dosage and use of herbal compounds because the U.S. Food and Drug
Administration (FDA) does not regulate them. Herbal compounds may interact with prescribed
medications, and patients need to avoid using these together (Meiner and Yeager, 2019).
The use of nonprescription sleeping medications is not recommended. Patients need to learn
the risks of such drugs. Over the long term these drugs lead to further sleep disruption, even
when they initially seemed effective. Caution older adults about using over-the-counter
antihistamines because of their long duration of action, which can cause confusion,
constipation, urinary retention, and an increased risk of falls (Stewart et al., 2018). Help patients
use behavioral and proper sleep-hygiene measures to establish sleep patterns that do not
require the use of drugs.
The liberal use of drugs to manage insomnia is quite common in American culture. CNS
stimulants such as amphetamines, caffeine, nicotine, terbutaline, theophylline, and modafinil
need to be used sparingly and under medical management (Burchum and Rosenthal, 2019). In
addition, withdrawal from CNS depressants such as alcohol, barbiturates, tricyclic
antidepressants (amitriptyline, imipramine, and doxepin), and triazolam causes insomnia.
Consult with pharmacists and health care providers about managing doses.
Medications that induce sleep are called hypnotics. Sedatives are medications that produce a
calming or soothing effect (Burchum and Rosenthal, 2019). A patient who takes sleep
medications needs to know about their proper use and their risks and possible side effects.
Long-term use of antianxiety, sedative, or hypnotic agents disrupts sleep and leads to more
serious problems. The FDA requires that the product labels of all sleep medications contain
safety information related to the potential adverse effects of severe allergic reactions; severe
facial swelling; and complex sleep behaviors such as sleep-driving, making phone calls, and
preparing and eating food while asleep (USFDA, 2019).
Benzodiazepines and benzodiazepine-like drugs are commonly used to treat sleep problems
and are intended for short-term use (Avidan and Neubauer, 2017). The benzodiazepine-like
drugs are the treatment of choice for insomnia because of improved efficacy and safety of use
(Burchum and Rosenthal, 2019). Experts recommend a low dose of a short-acting medication
such as zolpidem for short-term use (no longer than 2 to 3 weeks) (Burchum and Rosenthal,
2019). These drugs cause fewer problems with dependence and abuse and fewer rebound
insomnia and hangover effects than benzodiazepines.
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 (Burchum and Rosenthal, 2019). Short-acting benzodiazepines (e.g., oxazepam,
lorazepam, or temazepam) at the lowest possible dose for short-term treatment of insomnia are
recommended. Initial doses are small, and increments are added gradually, based on patient
response, for a limited time. Warn patients not to take more than the prescribed dose, especially
if the medication seems to become less effective after initial use. The use of benzodiazepines in
older adults is potentially dangerous because of the tendency of the drugs to remain active in
the body for a longer time. As a result, they also cause respiratory depression; next-day
sedation; amnesia; rebound insomnia; and impaired motor functioning and coordination, which
leads to an increased risk of falls (Picton et al., 2018). If older patients who were recently
continent, ambulatory, and alert become incontinent or confused and/or demonstrate impaired
mobility, consider the use of benzodiazepines as a possible cause.
Administer benzodiazepines cautiously to children under 12 years of age. These medications
are contraindicated in infants less than 6 months old. Patients who are pregnant need to avoid
them because their use is associated with risk of congenital anomalies. Mothers who are
breastfeeding do not receive the drugs because they are excreted in breast milk. Raise these
issues with patients’ health care providers if you are concerned about the safety of a prescribed
medication.
Trazodone is a serotonin antagonist and reuptake inhibitor (SARI) antidepressant often used in
patients with depression or anxiety and insomnia. The most common side effects are daytime
grogginess and orthostatic hypotension. Low-dose trazodone is often used as an alternative to
benzodiazepines, especially in older patients.
Regular use of any sleep medication often leads to tolerance and withdrawal. Rebound
insomnia is a problem after stopping a medication, particularly the benzodiazepines (Avidan and
Neubauer, 2017). Immediately administering a sleeping medication when a hospitalized patient
is unable to sleep does the patient more harm than good. Consider alternative approaches to
promote sleep first. Routine monitoring of patient response to sleeping medications is important.
Know culture considerations and cultural characteristics regarding Pain
 Wong-Baker FACES® Pain Rating Scale, to assess
 Assess a patient’s health literacy
 Recognize variations in subjective responses to pain. Undertreatment, overtreatment, or
lack of trust in the health care provider might occur if members of the health care team
are unaware of the cultural norms associated with pain and pain expression, since pain
is subjective
 May under report due to culture or religious beliefs about pain
 Use knowledge of biological variations of pain. Significant differences in drug
metabolism, dosing requirements, therapeutic response, and adverse effects occur in
cultural groups.
 Check you own biases
Know components of a pain assessment – What Questions to ask
Refer to ATI chart on pg 236
What indicates effective pain management?
An indication of the success of a plan of care is determined through attainment of
outcomes. When complete pain relief is not achievable, reducing pain to a tolerable
level is a realistic outcome. For example, the following are possible outcomes:
• Reports that pain is at a tolerable level of 3 or less on a scale of 0 to 10
• Modifies activities that intensify pain
• Uses pain-relief measures safely
• Is able to complete ADLs independently
Understand all drugs for pain and their potential side effects, safety issues related, nursing
diagnosis and nursing interventions related to them, evaluate outcomes, when to expect them to
be prescribed Keep in mind priorities related to opioids
Herbal supplements may interact with prescribed analgesics and condition-specific medications.
For example, glucosamine and chondroitin supplements may interact with the anticoagulant
drug warfarin and increase the risk of bleeding. Thus it is important to ask patients to report to
their health care provider any type of herbal or dietary supplements taken to relieve pain (see
Chapter 32).
There are three types of analgesics: (1) nonopioids, including acetaminophen and nonsteroidal
antiinflammatory drugs (NSAIDs); (2) opioids (traditionally called narcotics); and (3) adjuvants or
coanalgesics, a variety of medications that enhance analgesics or have analgesic properties
BOX 44.13
Common Opioid Side Effects
Central nervous system (CNS) toxicity
• Thought and memory impairment
• Drowsiness, sedation, and sleep disturbance
• Confusion
• Hallucinations, potential for diminished psychomotor performance
• Delirium
• Depression
• Dizziness and seizures
Ocular
• Pupil constriction
Respiratory
• Bradypnea
• Hypoventilation
Cardiac
• Hypotension
• Bradycardia
• Peripheral edema
Gastrointestinal
• Constipation
• Nausea and vomiting
• Delayed gastric emptying
Genitourinary
• Urinary retention
Endocrine
• Hormonal and sexual dysfunction
• Hypoglycemia—reported with tramadol and methadone
Skin
• Pruritus
Immunological
• Immune system impairment possible with chronic use
Musculoskeletal
• Muscle rigidity and contractions
• Osteoporosis
Pregnancy and breastfeeding
• When at all possible, avoid opioid use during pregnancy to prevent fetal risks
Tolerance
• Over time, increased doses needed to obtain analgesic effect
Withdrawal syndrome
• Rapid or sudden cessation or marked dose reduction may cause rhinitis, chills, pupil dilation,
diarrhea, “gooseflesh”
Adapted from American Chronic Pain Association (ACPA) & Standford Medicine: ACPA and
Standford Resource Guide to Chronic Pain Management, 2021.
https://www.theacpa.org/resources/acpa-resource-guide/. Accessed October 25, 2021.
BOX 44.14
Patient Characteristics Associated with Higher Risk for Opioid-Related Adverse Drug Events
• Snoring and sleep apnea or sleep-disordered breathing
• Morbid obesity with high risk of sleep apnea
• Older age
• Significant co-morbidities (cardiac, pulmonary, or major organ failure)
• No recent opioid use
• Increased opioid dose requirement
• Receiving other sedating medications (e.g., antihistamines, antipsychotics)
• Recent surgery, especially thoracic or upper abdominal
• Prolonged general anesthesia
• Smoker
Adjuvants.
Coanalgesics or adjuvants are drugs originally developed to treat conditions other than pain but
that also have analgesic properties. For example, tricyclic antidepressants (e.g., nortriptyline),
anticonvulsants (e.g., gabapentin), and infusional lidocaine successfully treat chronic pain,
especially neuropathic pain. Corticosteroids relieve the pain from inflammation and bone
metastasis. Other examples of coanalgesics are bisphosphonates and calcitonin for bone pain.
Adjuvants have analgesic properties, enhance pain control, or relieve other symptoms
associated with neuropathic pain. You give adjuvants alone or with analgesics. Sedatives,
antianxiety agents, and muscle relaxants have no analgesic effect, although they may be
effective for their specific indications.
Know non- pharmacological interventions for pain
Evidence-based nonpharmacological therapies include acupuncture, massage, osteopathic and
chiropractic manipulation, cognitive-behavioral intervention, meditative movement and mindbody interventions, and dietary and self-management approaches to pain management
Distraction, prayer, mindfulness, relaxation, guided imagery, music, and biofeedback are
examples of therapies frequently initiated by nurses (U.S. Department of Veterans Affairs,
2017).
Physical therapies (e.g., applying hot or cold compresses, massage, exercise, transcutaneous
electrical nerve stimulation [TENS]) treat pain by improving physical function, altering
physiological responses, and reducing pain-related immobility. Complementary and alternative
medicine (CAM) therapies such as therapeutic touch and mindfulness meditation also help to
alleviate pain in some patients (see Chapter 32).
Aging
Vocabulary:
Presbycusis -age related hearing loss
Anosmia -loss of sense of smell
1. Gerontology-the scientific study of old age, the process of aging, and the particular problems of old
people.
1.
Geriatrics-the branch of medicine or social science dealing with the health and care of old people.
Osteoporosis- Osteoporosis is a bone disease that develops when bone mineral density and
bone mass decreases, or when the structure and strength of bone changes. This can lead to a
decrease in bone strength that can increase the risk of fractures (broken bones).
Cataracts -A cataract is a cloudy area in the lens of your eye (the clear part of the eye that
helps to focus light). Cataracts are very common as you get older. In fact, more than half of all
Americans age 80 or older either have cataracts or have had surgery to get rid of cataracts.J
Osteomalacia-Osteomalacia describes a disorder of “bone softening” in adults that is usually
due to prolonged deficiency of vitamin D. This results in abnormal osteoid mineralization..
Know age related changes in the body
Keep in mind everything goes down if the question answer says up it is more than likely not one
of the answers….
ATI CH 25 read over it but just notice all the things go down mainly
How you assess the older adult and use their functional status as a baseline
BOX 14.3
SPICES Tool for Overall Assessment of Older Adults
S: Sleep disorders
P: Problems with eating or feeding
I: Incontinence
C: Confusion
E: Evidence of falls
S: Skin breakdown
Use clinical judgment to conduct a more in-depth assessment when an older adult
demonstrates changes in any of these areas (Fulmer, 2019).
BOX 14.4
Examples of Altered Presentation of Illnesses in Older Adults Occurring in Various
Health Care Settings
Hospital
• Confusion is not inevitable. Look for an acute illness, presence of fever, neurological
events, new medication, or the presence of risk factors for delirium.
• Many hospitalized older adults have chronic dehydration exacerbated by acute illness
(Touhy and Jett, 2020).
• Not all older adults have fevers with infection. Symptoms instead include increased
respiratory rate, falls, incontinence, or confusion (Yeager, 2019c).
Nursing center
• Health care providers often undertreat pain in older adults, especially those with
dementia. Look for nonverbal cues of pain presence, such as grimacing or resistance to
care (Alderman, 2019).
• Decline in functional ability (even a minor one such as the inability to sit upright in a
chair) is a signal of new illness.
• Residents with less muscle mass—both the frail and the obese—are at a much higher
risk for toxicity from protein-binding drugs such as phenytoin and warfarin (Yeager,
2019b).
• New urinary and/or fecal incontinence is often a sign of the onset of a new illness.
Ambulatory care
• Fatigue or a decreased ability to do usual activities is often a sign of anemia, thyroid
problems, depression, or neurological or cardiac problems (Yeager, 2019c).
• Severe gastrointestinal problems in older adults do not always present with the same
acute symptoms seen in younger patients. Ask about constipation, cramping
sensations, and changes in bowel habits.
• Older adults reporting increased dyspnea and confusion, especially those with a
cardiac history, need to go to the emergency department because these are the most
common manifestations of myocardial infarction in this population (Yeager, 2019c).
• Depression is common among older adults with chronic illnesses. Watch for lack of
interest in former activities, significant personal losses, or changes in role or home life.
Home care
• Investigate all falls, focusing on balance, lower extremity strength, gait, and
neurological issues (e.g., loss of sensation).
• Monitor older adults with late-stage heart disease for loss of appetite as an early
symptom of impending heart failure (Yeager, 2019c).
• Drug-drug and drug-food interactions in older patients who are seeing more than one
provider and taking multiple medications are common. Watch for signs of interactions
(Yeager, 2019b).
What could change their functional status?
Functional changes
Physical function is a dynamic process. It changes as individuals interact with their
environments. Functional status in older adults includes the day-to-day ADLs involving
activities within physical, psychological, cognitive, and social domains. A decline in
function is often linked to illness or disease and the degree of chronicity. However, ultimately it
is the complex relationship among all of these factors that influences an older adult’s
functional abilities and overall well-being.
Keep in mind that it may be difficult for older adults to accept the changes that occur in all areas
of their lives, which in turn have a profound effect on functional status. Some deny the changes
and continue to expect the same personal performance, regardless of age. Conversely some
overemphasize them and prematurely limit their activities and involvement in life. The fear of
becoming dependent is overwhelming for an older adult who is experiencing functional decline
as a result of aging. Educate older adults to promote understanding of age-related changes,
appropriate lifestyle adjustments, and effective coping. Factors that promote the highest level of
function include a healthy, well-balanced diet; paced and appropriate regular physical activity;
regularly scheduled visits with a health care provider; regular participation in meaningful
activities; use of stress-management techniques; and avoidance of alcohol, tobacco, or illicit
drugs.
Functional status in older adults refers to the capacity for and the safe performance of
ADLs and instrumental ADLs (IADLs). It is a sensitive indicator of health or illness in the
older adult. ADLs (such as bathing, dressing, and toileting) and IADLs (such as the
ability to write a check, shop, prepare meals, or make phone calls) are essential to
independent living; therefore carefully assess whether an older adult performs these
tasks and how the illness either has changed or threatens to change the way these tasks
are completed. Occupational and physical therapists are your best resources for a
comprehensive assessment of functional impairment. A sudden change in function, as
evidenced by a decline or change in an older adult’s ability to perform any one or a
combination of ADLs, is often a sign of either an acute illness (e.g., pneumonia, UTI, or
electrolyte imbalance) or worsening of a chronic problem (e.g., diabetes or
cardiovascular disease) (Touhy and Jett, 2020). An online collection of functional
assessment tools used most commonly with older adults is available at the website of the
Hartford Institute for Geriatric Nursing, https://consultgeri.org/. When you identify a decline in a
patient’s functional status, focus your nursing interventions on maintaining, restoring, and
maximizing an older adult’s functional status to maintain independence while preserving safety
and dignity.
Nursing diagnosis and interventions related to the older adult maintaining maximal functioning
and
Independence
Healthy People 2030 (Office of Disease Prevention and Health Promotion, n.d.) has an
overarching goal to improve the health and well-being of older adults. More specifically,
Healthy People 2030 cites the following objectives for older adults:
• General health (improve physical activity for older adults with physical or cognitive
health problems, reduce rate of pressure injuries during hospitalization, reduce hospital
admissions among older adults with diabetes)
• Dementias (improved awareness and prevention of hospitalizations)
• Foodborne illness (reduce infections caused by Listeria, reduce rate of hospital
admissions for urinary tract infections)
• Injury prevention (reduce fall-related deaths, reduce the proportion of older adults who
use inappropriate medications, reduce emergency department visits due to falls)
• Oral conditions (reduce the proportion of older adults with untreated root surface
decay, loss of all teeth, and moderate and severe periodontitis
• Osteoporosis (reduce hip fractures among older adults, increase screening for
osteoporosis, increase the proportion of older adults who get treated for osteoporosis
after fractures)
• Respiratory disease (reduce the rate of hospital admissions for pneumonia and
asthma)
• Sensory or communication disorders (reduce vision loss from age-related macular
degeneration)