Trisha Economidis, MS, ARNP
Lake-Sumter Community College
Fall, 2012
Sleep Quiz
 How many Americans suffer from sleep
disorders?
 A. 100,000
 B. 1 million
 C. 50-70 million
 How many sleep disorders have been
identified?
 A. 10
 B. 50
 C. 90
 Who has a greater incidence of
insomnia?
 A. Men
 B. Women
 For women, sleep disturbances are
often related to hormonal hallmarks
(menstruation, pregnancy,
menopause).
 A. True
 B. False
 Sleep patterns of the older adult include
which of the following: (Select all that
apply)
 A. Need more sleep than younger adults
 B. Take longer to fall asleep than younger
adults
 C. Awake more frequently and stay awake
longer than younger adults
 D. Frequent awakening is often due to
physical discomfort and nocturia
Physiology of sleep
 Biorhythms – Biological
 Controlled within the body
 Environmental
 Circadian rhythm- Biorhythm
 Day-night 24 hour clock
Types of sleep
 Non-Rem
 REM (Rapid Eye Movement)
 Occurs in 90-100 minute cycles
Sleep Cycle
Factors Affecting Rest & Sleep
 Comfort
 Anxiety
 Environment
Factors Affecting Rest and Sleep
 Lifestyle
 Work
 Exercise
 Travel
 Diet
 Drugs
 Medications
Average Sleep Requirements
 Table 33-1 Page 814
Alterations in Sleep patterns
Dyssomnias
 Dyssomnias
 Insomnia
 Sleep-wake Schedule
 Restless Leg Syndrome
 Sleep Deprivation
 Hypersomnia
 Narcolepsy
Dyssomnias
 Sleep Apnea- airway occlusion
 Hypercapnia and hypoxemia
 May have increased heart rate, increased bp
 S/S: excessive sleepiness, fatigue, snoring, nocturia
 Diagnosis: Made by sleep study
 Untreated can lead to :
 Hypertension
 Dysrhythmias
 Angina
 MI
 Stroke
 Mood swings
 Impotence
 Personality changes
Sleep Apnea
 Obstructive Sleep Apnea – caused by
occlusion of the airway during sleep.
 TX: CPAP – Continuous Positive Air
Pressure
 Central Sleep Apnea – Dysfunction in
central respiratory control
 Mixed Apnea – combination of Obstructive
and Central Sleep Apneas
CPAP
Altered Sleep Patterns
Parasomnias
 Sleepwalking (Somnambulism)
 Occurs during Stage 3-4 of sleep
 Sleep talking
 Bruxism-teeth grinding or clenching
 Night Terrors
 Nocturnal Enuresis
What is the Risk?
Sleep Hygiene Practices
 Assessment of Sleep Patterns and rituals
 Relaxation
 Eliminate stressful situations before bed
 Muscle relaxation
 Activities that relax rather than stimulate
 Warm bath
Sleep Hygiene
 Environment
 Adjust light, noise, temp to promote
sleep
 Use bedroom for sleep & sex only
 Go to bed at same time each night
 Help client to understand what
things can affect sleep patterns
Pharmacologic Interventions for
Sleep
Be aware of potential side effects
and possible dependency issues
 Shouldn’t mix with alcohol and
most are not recommended for
long-term use
Pharmacologic Interventions
 Non-benzodiazepines: Ambien,
Sonata, Lunesta
 Benzodiazepines: Valium, Ativan,
Klonopin, Xanax
 Caution: Hazardous in elderly; must
use cautiously in children; can cause
ADDICTION
Pharmacologic Interventions, cont.
 Barbiturates: sedative/hypnotic/anticonvulsants;
Seconal, Luminal, Nembutal
 Tricyclic Antidepressants: major side effect is
drowsiness. Elavil, Tofranil
 OTC Sleep aids
 Antihistamines
 Herbal remedies
 Melatonin
Nutrition Impact on Sleep
 No large fatty meals before sleep
 L-tryptophan increases sleep (milk &
cheese)
 Protein – increases alertness (not a
good before bed snack)
 Carbohydrates promote sleep
 crackers, bread, cereal
Nursing Diagnoses for Sleep
 Sleep Deprivation: Occurs over long periods of time
and symptoms more severe (confusion, even
psychosis)
 Disturbed Sleep Pattern: time limited sleep pattern.
Ex.: related to hospitalization – can be treated by
nursing therapy
 A patient is diagnosed with narcolepsy. The
nurse’s primary intervention should address
the patient’s:
 A. Inability to provide self-care
 B. Impaired thought processes
 C. Potential for injury
 D. Excessive fatigue
Correct Answer: C
 Narcolepsy is excessive sleepiness in the
daytime that can cause a person to fall
asleep uncontrollably at inappropriate times
(sleep attach) and result in physical harm to
self or others
 The nurse is planning a teaching program for a
patient with a diagnosis of obstructive sleep apnea.
Which is the most common intervention that the
nurse should plan to discuss with this patient?
 A. Encouraging sleeping in the supine position
 B. Using devices that support airway patency
 C. Positioning two pillows under the head
 D. Administering sedatives
Answer: B.
 A continuous positive airway pressure
(CPAP) mask worn over the nose when
sleeping keeps the upper airway patent
through continuous positive airway
pressure.
 Which is the most important nursing
intervention that supports a patient’s ability
to sleep in the hospital setting?
 A. Providing an extra blanket
 B. Limiting unnecessary noise on the unit
 C. Shutting off lights in the patient’s room
 D. Pulling curtains around the bed at night.
Answer: B
 Noise is a serious deterrent to sleep in a hospital.
The nurse should limit environmental noise
(distributing fluids, providing treatments, rolling
drug and linen carts) and staff communication
noise.
 (Turning off the lights is unsafe. You may dim the
lights or put a night light on to provide enough
illumination for safe ambulation to the bathroom)
 What concept associated with sleep should
the nurse consider to best plan nursing care
for a hospitalized patient?
 A. People require eight hours of
uninterrupted sleep to meet energy needs
 B. Frequency of nighttime awakenings
decreases with age
 C. Fear can contribute to the need to stay
awake.
 D. Bed rest decreases the need for sleep.
Answer: C
 Fear of loss of control, the unknown, and
potential death results in the struggle to stay
awake, which interferes with the ability to
relax sufficiently to fall asleep.
Comfort/Pain
 True or False?
 The nurse is the best judge of a
patient’s pain
Answer: False
Pain is SUBJECTIVE – only the
client can judge the level and
severity of pain
TRUE OR FALSE?
 You should wait until pain has reached
the maximum amount bearable before
medicating.
Answer: False
Pain control/relief is much more
effective when given when pain
begins
True or False?
True pain always produces
observable signs/symptoms such as
grimacing or moaning
Answer: False
Many people are stoic when it
comes to expressing pain. One’s
culture may also have an impact on
the expression of pain.
True or False?
 If the patient doesn’t look like he’s in
pain, it’s ok to withhold medications or
decrease the dose.
Answer: False
Pain is a subjective experience.
Only the patient knows how much
pain he/she is experiencing.
True or False?
 Clients taking pain medications will
become addicted.
Answer: False
While it does happen, it is unlikely
when analgesics are administered
and monitored carefully
So….What IS Pain?
 A sensation that HURTS
 A SUBJECTIVE experience
 An interference : a multi-dimensional
experience and impact
 Protective
Types or Origins of Pain
 Cutaneous - superficial
 Somatic - ligaments, joints, muscles
 Visceral – internal organs/body cavities
 Neuropathic – nerve pain
 Radiating – Starts at origin, but extends to
other locations
 Referred – Pain felt distant to origin
 Phantom
Phantom
Duration of Pain
 Acute Pain - Sudden onset/short
duration (up to 6 months)
 Chronic Pain –Has lasted 6 months or
longer
 Intractable Pain – Chronic and very
resistant to relief
 http://www.youtube.com/watch?v=Hs
kbfhiVJro
Quality of Pain
 What does it feel like?
 Sharp?
 Dull?
 Aching?
 Stabbing?
 Burning?
 Crushing?
 Tingling?
Intensity or Severity of Pain
 How much does it hurt?????
 Pain Rating Scales imperative –
Allows assessment of level of pain
and effectiveness of interventions
 0-10 scale
 Faces Pain Rating Scale
 Poker Chips - “pieces” of pain
Faces
Numeric
.
Assessment of Pain: The Who,
What, When, Where, and How
Who?
 The patient self-report is the most
reliable indicator of pain
 What if it’s a child? The
parent/caregiver knows the child
best
What?
 What the patient says AND
 Your observations which may include:
 Physiological responses: Acute pain - Increased blood
pressure, pulse and respirations; dilated pupils, rapid
speech
 Behavioral responses: Moaning, facial grimacing,
crying, agitation, guarding, withdrawing from painful
stimuli
 Psychological responses: Anxiety, depression, anger,
fear, exhaustion, irritability
When?
 On admission
 Before and after procedures or treatments
 With each assessment/vital signs
 When the patient is resting as well as during
activity
 Before you give pain meds and 30 minutes
after
 When the patient complains of pain
Where?
 Where ever the patient is and whatever is
going on?
 Resting in bed
 Ambulating
 Before, during, after procedures whether
in the patient’s room or in another
location
How?
 Begin with a pain history
 Do you have pain now?
 When did the pain begin? (Onset)
 Where is the pain located? (Location)
 How do you rate your pain? (use a pain
scale) (Intensity)
 How would you describe your pain?
(Quality)
How? (Pain History)
 How often do you have pain? (Frequency)
 What makes the pain better? (Alleviating
Factors)
 What makes it worse? (Aggravating
Factors)
 Do you have any other symptoms when you
are experiencing pain, i.e. nausea/vomiting?
(Associated Factors)
How? (Pain History)
 Have you experienced this type of pain in
the past? If so, how did you manage/cope
with it? (History of Previous Pain
Experience)
 Have you used any medications to treat the
pain? If so, what have you used and was it
effective?
 What, if any, alternative treatments have
you used for pain?
Review: Assessing Pain
How do we assess?
 Onset of symptoms
 Alleviating Factors
 Location
 Aggravating Factors
 Intensity
 Associated Factors
 Quality
 History of Previous
 Frequency
Pain Experience
How?
 Combine your pain history with your
observations of:
 Physiological responses
 Behavioral responses
 Psychological responses
Factors That May Affect Perception
of Pain
 Age
 Child – may not recognize sensation of
pain or may have paradoxical reaction
 Adolescent – may be expressed as
“attitude,” anger, aggression
 Older adult – may have trouble
verbalizing because of perception that
pain is “normal” part of aging
Factors that may Affect Pain
 Culture
 May impact level of pain one is willing to
endure
 Need to use assessment tools that are
culturally sensitive
 Perception of pain is impacted by age
and culture.
Analgesics Used for Pain
 3 common groups of drugs used for
pain management
 Opioids
 Nonopioids
 Adjuvants
Pain Medications: Opioid
Analgesics
 Work on pain by blocking receptors in the Central
Nervous System
Opioid Analgesics
 morphine sulfate
 methadone
 meperidine HCl (Demerol)
 hydromorphone (Dilaudid)
 Fentanyl
 oxycodone (Percocet)
 hydrocodone (Vicodin)
Opioid Analgesics
 Indications/Uses: More effective for
visceral pain
 Side/Adverse Effects: Respiratory
depression N/V, constipation,
drowsiness, pruritis (itching), dry
mouth, difficulty urinating,
tachy/bradycardias, hypotension
Opioid Analgesics
 Nursing Considerations:
 Assess respiratory status frequently. If
respiratory depression occurs, administer
Narcan to reverse effects. Monitor blood
pressure.
 Monitor for constipation and make
appropriate interventions (pg 741)
 Treat other symptoms as indicated
Nonopioid Analgesics
 Used to relieve mild to moderate pain, acute or chronic
(also may relieve inflammation and fever)
 Acetaminophen (Tylenol) (minimal anti-inflammatory
effect)
 NSAIDS (nonsteroidal anti-inflammatory drugs)
 aspirin
 ibuprofen (Motrin, Advil)
 naproxen (Aleve)
 Prescription NSAIDS: Celebrex, Voltaren, Indocin and
others
Side/Adverse Effects of Nonopioids
 Acetaminophen – Can cause liver toxicity especially
in patients who consume alcohol or who have liver
disease. Current recommendation: maximum of 3000
mg (3g) per day as of July, 2011
 Aspirin – regular use can cause prolonged clotting
time (bruise easily and bleed more)
 Other NSAIDS – gastric irritation and bleeding, use
with caution in patients with impaired clotting and
renal disease
Nursing considerations for
Nonopioids
 Tylenol – teaching regarding maximum
daily dose. Importance of reporting
overdose (liver damage occurs rapidly)
 NSAIDS – importance of taking with food.
Use of enteric-coated pills if gastric
irritation occurs. Monitor for gi bleeding.
Be aware of the possibility for drug
interactions.
Adjuvant Medications
 Enhance the analgesic effect of
opioids
 Anticonvulsants
 Antidepressants
 Sedatives
 Steroids
Non-pharmacological Interventions
for Pain Management(see pgs. 736738)
 Relaxation
 Guided imagery
 Distraction
 Therapeutic Touch
 Hypnosis
 Cutaneous Stimulation: TENS units, PENS units,
Spinal Cord stimulator, Acupuncture, Acupressure,
Massage, Heat/Cold Application, Contralateral
stimulation
 A patient has a total abdominal
hysterectomy for Stage 4 ovarian cancer.
What should the nurse do first when on the
second postoperative day this patient
reports abdominal pain at level 5 on a 1 to 10
pain scale?
 A. Reposition the patient
 B. Offer a relaxing back rub
 C. Use distraction techniques
 D. Administer the prescribed analgesic.
Answer: D
 Major abdominal surgery involves extensive
manipulation of internal organs and a large
abdominal incision that require adequate
pharmacological intervention to provide
relief from pain
 A patient states, “The pain moves from my
chest down my left arm.” Which
characteristic of pain is associated with this
statement?
 A. Pattern
 B. Duration
 C. Location
 D. Constancy
Answer: C
 This is a description of referred pain, which
is pain felt in a part of the body that is at a
distance from the tissues causing the pain.
Referred pain is related to location of pain.
 A patient has a history of severe chronic pain.
Which is one of the most important guidelines
associated with providing nursing care to this
patient?
 A. Asking what is an acceptable level of pain
 B. Providing interventions that do not precipitate
pain
 C. Determining the level of function that can be
performed without pain
 D. Focusing on pain management intervention
before pain becomes excessive
Answer: D
 Administration of analgesics around the
clock at regularly scheduled intervals or by
long-acting controlled-release transdermal
patches maintains therapeutic blood levels
of analgesics, which limit pain at levels of
comfort acceptable to patients.