Ch 33: Sleep

Physiologic and psychological changes surrounding the sleep cycle

• The heart beats 10 to 20 fewer times per minute when sleeping, and respirations, blood pressure, and muscle tone all decrease during sleep

• Rapid eye movement (REM) sleep

• Non-rapid eye movement (NREM) sleep

• Effect of lack of sleep

• Physiologic rhythms

-Physiologic Clear waste and get rid of toxins

-Psychological store important memerioes and get rid of others

Rapid eye movement (REM) sleep

• occurs during deep sleep and is manifested by quick scanning movements of the eyes that are associated with dreaming.

• REM sleep is associated with altered vital signs, muscle relaxation, increased cerebral blood flow, and steroid release

Non-rapid eye movement

in which REM does not occur, physiologic activity is reduced; brain waves, breathing, and heart rate slow; and blood pressure drops

Non–rapid eye movement (NREM) 1

• Lightest level of sleep, between sleep and wakefulness

• Vital signs and metabolism begin to decrease/slow down

• Easy arousal by external stimuli, such as noise

• Feeling of drowsiness

• Lasts a few minutes

• May occur during the day as “resting my eyes”

NREM 2

• Relaxation increases

• Sleep becomes deeper

• Snoring may occur

• Relatively easy arousal

• Physiologic functions continue to slow

• Accompanied by occasional small muscle jerks

• Lasts 10–20 min

NREM 3

• Deepest stage of sleep, called slow-wave or delta-wave sleep for the type of brain waves seen during this type of sleep

• More difficult arousal and rare movement

• Muscles relaxed

• Vital signs decrease, but regular rhythms/patterns maintained

• Restorative processes (such as the release of growth hormone) occur

• Sleep walking, somnambulism, and nocturnal enuresis may occur

• Strong stimuli needed for arousal

• Amount of time spent in slow-wave sleep depends on how long since a person slept

• Lasts approximately 30–60 min

somnambulism

• the medical term for sleepwalking, a sleep disorder where a person performs motor acts

Rapid eye movement (REM) “paradoxical sleep”

• Occurrence of vivid, colorful dreaming (less vivid dreaming may occur in other stages)

• Starts approximately 90 min after sleep is initiated

• Autonomous response causes rapid eye movements, fluctuating heart rate and respirations, and increased blood pressure

• Muscle tone decreased

• Gastric secretions increased

• Very difficult arousal

• Duration of REM sleep increases with each sleep cycle and averages 20 min

Psychological

• the diminished mental functioning associated with sleep deprivation.

• People with too little sleep have difficulty making decisions, experience decreased concentration, and become emotionally irritable.

• Accident and injuries are more common

Physiologic

• Rhythms fluctuate in preparation for activity or rest.

• Body temperature, cortisol, and melatonin levels change in preparation for waking or sleeping.

Sleep

is a naturally occurring altered state of consciousness regulated by the central nervous system

Neurotransmitters and the reticular activating system (RAS)

• Regulate sleep

  • REM sleep: acetylcholine and norepinephrine- network in the brainstem

  • NREM sleep: serotonin(regulate sleep cycle) and gamma aminobutyric acid (main)

RAS:

-controls wakefulness, attention, and filters incoming sensory information

The Reticular Activating System (RAS)

• Receives sensory impulses from the spinal cord and relays motor impulses to the thalamus and all parts of the cerebral cortex

Circadian rhythms

• influence patterns of biologic and behavioral functions

• Day-night, 24-hour cycle (when u feel awake and go to sleep)

  • Controlled by nerve cells within the hypothalamus (and RAS ) promote wakefulness

    • affect body temperature, endocrine functions, blood pressure, sleep, and other functions.

Sleep cycles

• Polysomnography: is the recording of brain waves, blood oxygen level, and other physiologic variables, such as muscle activity and eye and leg movements, during sleep

  • Four sleep stages

  • 3-5 cycles per night

1 full cycle last 90 mins

Sleep rhythms

• Last about 90 minutes

• The usual sleep sequence for a person is a fairly rapid progression through NREM stages 1 through 3, back through NREM stage 2, and then into REM sleep. During the early hours of sleep, NREM stage 3 is longer; in the later hours of sleep, REM sleep may last as long as 45 minutes of the cycle.

Sleep patterns

Newborns: mostly sleep 14- to 17-hour sleep duration each day

Elderly: least sleep’ 7-9 hours a night

Dyssominias just understand the differences

are disorders associated with getting to sleep, staying asleep, or being excessively sleepy.

-Causes of dyssomnias include too much napping, anxiety, depression, high levels of stimulation at bedtime, medication use, shift work, and hyperthyroidism.

• Circadian rhythm sleep disorders: when the person cannot sleep when sleep is wanted, needed, or expected.

  • potential consequences of circadian rhythm disturbances include sexual dysfunction, memory difficulties, high blood pressure, obesity, and an increased risk for asleep

• Insomnia: Difficulty in falling asleep or staying asleep

• Narcolepsy- day sleeping; cataplexy, or the sudden loss of voluntary muscle tone; vivid hallucinations during sleep onset or on awakening; and brief episodes of total paralysis at the beginning or end of sleep

• Hypersomnia: excessive daytime sleepiness

• Sleep apnea (OSA): absence of breathing

  • lack of airflow through the mouth and nose for at least 10 seconds, lasting up to 2 minutes

  • frequent snoring, morning headache

• Sleep deprivation: Lack of sleep

  • Factors: aging or may result from hospitalization, drug and substance abuse, emotional stress, medications, environmental factors (e.g., noise, light), and disruption of normal sleep patterns, such as with shift rotations or changes in lifestyle patterns.

• Restless legs syndrome: leg movement through out sleep

Parasomnias

are sleep behaviors

• Somnambulism: Sleepwalking

• Nocturnal enuresis: bed-wetting

• Sleep terrors and nightmares: intense fear, don’t remember

• Bruxism: Clenching or grinding teeth during sleep

Secondary sleep disorders

➢ Disabling symptoms of underlying medical or psychiatric disorders

-Affects the sleep-wake cycle
• Conditions such as heart failure, chronic obstructive pulmonary disease, pain, and gastric reflux disease all may affect sleep.
• Up to 90% of patients with depression report disturbed sleep.
• Anxiety, which may be situational (due to hospitalization, recent diagnosis, serious illness) or a chronic mental health condition, also interferes with sleep.

Factors causing sleep alterations

➢ Lifestyle( habits, too much screen time)
➢ Diet and exercise (recommended complex carbohydrates for bedtime snacks)
➢ Smoking
➢ Alcohol
➢ Stimulants and other medications
➢ Environmental factors
➢ Illness and hospitalization
➢ Anxiety and stress
➢ Relationships
➢ Poor sleep hygiene (large meals before bed or caffeine)

Heath History

➢ Sleep assessment
➢ Sleep instruments (not have to know must about it)
• Epworth Sleepiness Scale
• Pittsburgh Sleep Quality Index
• Sleep Hygiene Index
➢ Focused assessment
• Used if sleep problems are identified

Physical assessment

➢ Findings can be used to validate the presence or absence of sleep disturbances
➢ Key assessment findings
• Energy level, physical weakness, fatigue, lethargy, decreased affect, and behavioral signs (yawning)
➢ Physical signs
• Obesity, thick neck, nasal polyps, deviated septum, and shortness of breath
➢ Signs that can be assessed during hospitalization
• Muscle contractions, snoring, sleep apnea, and OSA

Diagnostic tests

• Polysomnography- records eye movements, muscle movement and activity, heart and respiratory rates, oxygen levels, airflow, and brain activity

• Multiple sleep latency test: How quicky someone fasts asleep

Nursing Diagnosis

Examples:

➢ Sleep Deprivation
• Supporting Data: Trouble falling asleep and staying asleep, daytime sleepiness, sleeps 4 to 5 hours per night, pale skin, puffy eyes, yawns frequently, poor sleep hygiene
➢ Impaired Sleep
• Supporting Data: Lighting and noise in the hospital, reports of being awakened at night, changes in normal sleep pattern
➢ Fatigue
• Supporting Data: Sleep deprivation, daytime drowsiness

Goals and outcome statements

• Potential goals that support the nursing diagnoses related to sleep and rest include the following:

  • Patient will remain asleep for 6-7 hours for 5 out of 7 nights within 1 month

  • Patient will sleep for at least 90 minutes at a time during hospitalization

  • Patient will take two 20-minutes naps daily

Interventions for specific sleep disorders

• Insomnia: stimulus control, sleep restriction, sleep hygiene, and cognitive therapy

• Narcolepsy: no cure; can improve by regular exercise routine, regular sleep routine, and daytime naps, light meals

• OSA: weight loss, avoid alcohol

• Restless leg syndrome: exercise, walk, decrease caffine, alcohol, and tobbaco use

Nonpharmacologic interventions

• Bedtime routines

• Bedtime snacks; eat complex carbs

• Exercise

• Relaxation; massage, music, warm bath

• A comfortable bed with no wrinkles

• Decrease Nosie sounds

Sleep medications look at symptoms

• Antianxiety: calm the central nervous system

• Antihistamines: block it

• Tricyclic antidepressants: block neurotransmitters

• Sedative-hypnotics: help remain alseep

Home care considerations

• Encourage self-care

• Teach patients

  • Normal variations in sleep patterns

  • Common measures to promote relaxation and sleep

  • How to keep a sleep diary

Outcomes are likely to be achieved if the patient is able to:

• Rest in an environment that promotes sleep

• Follow bedtime rituals as much as possible

• Report feeling rested after sleeping

• Maintain adequate energy and mental alertness to complete necessary tasks

• Identify factors that interfere with sleep and measures to improve sleep habits

• Use a variety of techniques to promote sleep