Chapter 42
Sleep
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Physiology of Sleep

Circadian rhythms


Affected by light, temperature, social activities,
and work routines.
The biological rhythm of sleep frequently
becomes synchronized with other body
functions.
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Physiology of Sleep: Sleep
Regulation




Regulated by a sequence of physiological
states integrated by central nervous system
(CNS) activity
Hypothalamus
Reticular activating system (RAS)
Bulbar synchronizing region (BSR)
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RAS and BSR
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Case Study


Walter Murphy is 82 years old and has resided in the
local nursing home for the past 3 months. His wife,
Mary, still lives at home but visits Walter on a daily
basis. Walter is confined to a wheelchair as a result
of osteoarthritis and a mild stroke he experienced 1
year ago. Even though he has physical limitations, he
is alert and oriented.
Over the past several weeks, Mary found her
husband to be very sleepy when visiting him just
before lunchtime. Walter tells Mary that he has
trouble falling asleep at night, and once he does fall
asleep, he reawakens frequently during the night.
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Stages of the Adult Sleep Cycle
NREM
Stage 2
REM
NREM
Stage 3
NREM
Stage 2
NREM
Stage 4
NREM
Stage 3
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Functions of Sleep

Purpose of sleep




Remains unclear
Physiological and psychological restoration
Maintenance of biological functions
Dreams


Occur in nonrapid eye movement (NREM) and
rapid eye movement (REM) sleep
Important for learning, memory, and adaptation to
stress
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Physical Illness

Physical illness can cause pain, physical
discomfort, anxiety, depression, and sleep
disturbances:

Hypertension
 Respiratory disorders
 Nocturia
 Pain
 Restless leg syndrome (RLS)
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Terminology





Hypersomnolence = Excessive sleepiness.
A polysomnogram involves the use of electroencephalography
(EEG), electromyography (EMG), and electro-oculography
(EOG) to monitor stages of sleep and wakefulness during
nighttime sleep.
Sleep hygiene = Practices that a patient associates with sleep.
Cataplexy is sudden muscle weakness during intense emotions
such as anger, sadness, or laughter; it can occur at any time
during the day.
Sleep paralysis is the feeling of being unable to move or talk
just before waking or falling asleep.
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Sleep Disorders
• Adjustment sleep disorder (acute
insomnia), Inadequate sleep hygiene,
Behavioral insomnia of childhood,
Insomnia caused by medical condition
Insomnia
Sleep apnea
• Primary central sleep apnea, Central
sleep apnea caused by medical condition,
Obstructive sleep apnea syndromes,
Excessive daytime sleepiness
• Cataplexy, Sleep paralysis
Narcolepsy
Sleep deprivation
• Emotional stress, Medications,
Environmental disturbances, Symptoms
Parasomnias
• Somnambulism (sleepwalking), Night
terrors, Nightmares, Nocturnal enuresis
(bed-wetting), Body rocking, Bruxism
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Quick Quiz!
1. During rounds on the night shift, you note that
a patient stops breathing for 1 to 2 minutes
several times during the shift. This condition
is known as
A. Cataplexy.
B. Insomnia.
C. Narcolepsy.
D. Sleep apnea.
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Sleep and Rest

Rest contributes to:




Mental relaxation
Freedom from anxiety
State of mental, physical, and spiritual activity
Bed rest does not guarantee that a patient
will feel rested.
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Normal Sleep Requirements
and Patterns
Neonates
Infants
16 hours a day
8 to 10 hours at night for a total
of 15 hours per day
Toddlers
Preschoolers
Total 12 hours a day
12 hours a night
School Age
Adolescents
9 to 10 hours
Get ~7½ hours
Young Adults
Middle and Older Adults
Get 6 to 8½ hours
Total number of hours declines
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Quick Quiz!
2. A 4-year-old pediatric patient resists going to
sleep. To assist this patient, the best action to
take would be
A. Adding a daytime nap.
B. Allowing the child to sleep longer in the
morning.
C. Maintaining the child’s home sleep routine.
D. Offering the child a bedtime snack.
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Factors Affecting Sleep
Physical illness
Drugs and substances
Hypertension, respiratory,
musculoskeletal, chronic illness,
GI, nausea
Hypnotics, diuretics, narcotics,
antidepressants, alcohol,
caffeine, beta-blockers,
anticonvulsants
Lifestyle
Usual sleep patterns
Work schedule, social activities,
routines
May be disrupted by social
activity or work schedule
Emotional stress
Environment
Worries, physical health, death,
losses
Noise, routines
Exercise and fatigue
Food and calorie intake
Moderate exercise and fatigue
cause a restful sleep
Time of day, caffeine, nicotine,
alcohol
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Quick Quiz!
3. A patient suffers from sleep pattern disturbance. To
promote adequate sleep, the most important nursing
intervention is
A. Administering a sleep aid.
B. Synchronizing the medication, treatment, and vital
signs schedule.
C. Encouraging the patient to exercise immediately
before sleep.
D. Discussing with the patient the benefits of beginning
a long-term night-time medication regimen.iok
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Case Study (cont’d)


Anna is a 23-year-old nursing student
assigned to the nursing home for her second
semester in nursing school. She has had
experience in nursing homes, having worked
in one center as a nurse assistant during the
last two summers. Anna’s assignment is to
care for Mr. Murphy over the next 4 weeks.
What factors could Anna consider when
preparing to care for Mr. Murphy?
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Nursing Process
Assessment
Diagnosis
Planning
Implementation
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Evaluation
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Case Study (cont’d)



As Anna prepares to conduct an assessment of Mr.
Murphy, she knows it is important to consider how
sleep is altered in older adults. Because they typically
have less deep sleep and more awakenings, it will be
important to consider what factors in the nursing
home disrupt sleep.
She has learned that his osteoarthritis pain is a
contributing factor to the sleep disturbances. His
immobility from the stroke adds discomfort.
Anna also plans to assess Mr. Murphy’s medications
carefully to determine whether any drugs are adding
to a sleep alteration.
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Assessment

Sleep assessment



Sources for sleep assessment = Patient, family
Tools for sleep assessment
Sleep history

Description of sleeping problems, usual sleep
pattern, current life events, physical and
psychological illness, emotional and mental status,
bedtime routines, bedtime environment, behaviors
of sleep deprivation
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Case Study (cont’d)

Assessment questions for Mr. Murphy:

Please describe the nature of your sleep problem.
 Do you awaken during the night?
 Can you rate the quality of last night’s sleep?
 Please describe your usual bedtime routine.
 Are you having any trouble that is contributing to
your sleep problem?

Assess Mr. Murphy for signs of sleep
problems.
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Nursing Diagnosis
Anxiety
Ineffective
breathing
pattern
Acute
confusion
Compromised
family coping
Ineffective
coping
Insomnia
Fatigue
Sleep
deprivation
Readiness for
enhanced sleep
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Case Study (cont’d)

Nursing diagnosis: insomnia


Related to excessive environmental stimuli
Goal

Mr. Murphy will attain a sense of restfulness after
sleep in 1 month.
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Planning

Goals and outcomes example


Goal: The patient will control environmental
sources disrupting sleep within 1 month.
Outcomes:
• Patient will identify factors in the immediate home
environment that disrupt sleep in 2 weeks.
• Patient will report having a discussion with family
members about environmental barriers to sleep in 2
weeks.
• Patient will report changes made in the bedroom to
promote sleep within 4 weeks.
• Patient will report having fewer than two awakenings per
night within 4 weeks.
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Implementation

Health promotion

Environmental controls
 Promoting bedtime routines
 Promoting safety
 Promoting comfort
 Establishing periods of rest and sleep
 Stress reduction
 Bedtime snacks
 Pharmacological approaches
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Implementation (cont’d)
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Case Study (cont’d)
Sit next to the window 30 to
60 minutes each morning.
Bright light in the morning helps
maintain a 24-hour circadian cycle.
Discourage daytime napping. Daytime napping interferes with
sleeping,
Have an egg-crate-type
mattress placed over his
normal mattress.
Increasing comfort of sleeping
position, enhancing relaxation will
promote sleep.
Encourage Mr. Murphy to
decrease his fluids 2 to 4
hours before sleep.
Decreases the number of times the
patient awakens to urinate.
Arrange for Mr. Murphy to
Soothing music blocks out sounds
have a CD player and
from the environment and
headphones when he goes to promotes relaxation.
sleep.
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Implementation (cont’d)

Acute care

Environmental controls
 Promoting comfort
 Establishing periods of rest and sleep
 Promoting safety
 Stress reduction

Restorative or continuing care



Promoting comfort
Controlling physiological disturbances
Pharmacological approaches
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Continuous Positive Airway
Pressure
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Case Study (cont’d)



Anna asked Mr. Murphy to use a rating scale for the
quality of his sleep at the end of each week. After 1
week, Mr. Murphy rates his night sleep at a 6 out of
10; after 2 weeks, an 8 out of 10.
Anna asked Mrs. Murphy to evaluate her perceptions
of Mr. Murphy’s level of fatigue. She says he is more
alert, awake, and talkative during her visits.
Anna asked Mr. Murphy at the end of 4 weeks to
keep a record for a week of the length of time he
estimates he is sleeping.
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Evaluation

Patient outcomes

Determine whether expected outcomes have been
met.
• Are you able to fall asleep within 20 minutes of getting
into bed?
• Describe how well you sleep when you exercise.
• Does the use of quiet music at bedtime help you to
relax?
• Do you feel rested when you wake up?
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