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Sleep and Rest Nursing Review (Video Notes)

Introduction to Sleep and Health

  • Sleep is essential for health and healing of the human body; without quality sleep, rejuvenation is impaired and multiple systems can be affected, potentially leading to chronic conditions such as depression, heart disease, hypertension, and diabetes. In the short term, sleep deprivation impairs memory, reaction time, concentration, and coordination.
  • Rest and sleep contribute to physical and mental health; Nurses assist clients in reducing sleep deprivation and sensory overload and promoting restful sleep.
  • Sleep and rest have broad implications for learning, memory consolidation, mood, and overall functioning; rest is beneficial even when a person is not asleep.

Scope of Practice and Roles (PN vs RN)

  • Fundamentals include call-out boxes focused on PN practice considerations; PN scope varies by state.
  • Some states allow PN to contribute directly to a plan of care; others limit PN participation to assisting the RN in plan development.
  • Most states require PN to be under RN supervision.
  • PN students should align discussions with their state’s scope of practice and safety guidelines.
  • Ultimately, the PN is responsible for operating within their scope by knowing and following state guidelines for safe practice.

The Brain and Sleep: Brief Overview

  • The brain consists of four major regions: cerebrum, cerebellum, diencephalon, and brain stem.
  • Cerebral cortex: outer layer of the cerebrum; processes sensory information and transfers information from short-term to long-term memory.
  • Brain stem: includes midbrain, pons, and medulla oblongata; supports motor functions and arousal.
  • Diencephalon: above the brainstem; contains the thalamus, hypothalamus, and pineal gland; regulates body temperature and autonomic nervous system.
  • Suprachiasmatic nucleus (SCN): located in the hypothalamus; helps regulate the circadian rhythm via light exposure.
  • Pineal gland: produces melatonin, a sleep hormone.
  • Damage to the SCN can cause erratic sleep-wake cycles due to disrupted circadian regulation.

Physiology of Sleep: Core Mechanisms

  • Circadian rhythm: internal biological clock that makes people sleepy at night and wake naturally in the morning; it typically aligns with environmental cues like light and temperature but can operate without prompts.
  • Sleep-wake homeostasis: drives the body to sleep after a period of wakefulness; sleep depth increases with sleep deprivation.
  • Factors affecting circadian rhythm include lighting (bright light can disrupt), medications, caffeine, foods, sleep environment, and stress.
  • Key brain structures involved in sleep regulation include the hypothalamus, SCN, brain stem, thalamus, and pineal gland.
  • Hypothalamus: commands sleep/arousal-regulating nerve cell groups; houses the SCN; regulates autonomic functions and body temperature.
  • SCN: communicates with the eyes to regulate the circadian rhythm via light exposure; damage leads to an erratic sleep cycle.
  • Brain stem (including pons and medulla): influences REM sleep; sends signals to relax muscles to prevent acting out dreams; REM is characterized by muscle atonia.
  • GABAergic sleep-promoting neurons in the hypothalamus and brain stem reduce arousal center activity, aiding sleep onset and maintenance.
  • Thalamus: during most sleep stages blocks external stimuli to protect sleep; during REM sleep it transmits sensory information that influences dream content and content recall (though the cortex continues processing).
  • Pineal gland and melatonin: melatonin helps prepare the body for sleep and contributes to sleep-wake regulation.

Stages of Sleep: NREM and REM

  • Sleep cycles: typically 4–6 cycles per night; each cycle includes NREM stages (1–3) and REM sleep, with REM increasing in duration as the night progresses.
  • EEG patterns help define stages; eye and body movements and vital sign changes also contribute.

REM Sleep

  • Characteristics: rapid eye movements, low muscle tone (atonia), dreaming stage; brain activity resembles wakefulness (beta waves).
  • Breathing can be irregular; heart rate may elevate.
  • Occurs multiple times per night, increasing in duration across cycles.

NREM Sleep

  • Stage 1 (N1): lightest sleep, transition from wakefulness; >50% alpha activity shifts to low-amplitude, mixed-frequency activity; lasts about 1-5\text{ minutes}; ~5\% of total sleep time; easy to awaken; muscle tone present; sensations of drowsiness.
  • Stage 2 (N2): deeper sleep; features sleep spindles (11-15\text{ Hz}) lasting ~0.5-1.5\text{ seconds} and K-complexes; heart rate and body temperature decrease; ~50\% of total sleep time; harder to awaken; longer as the night progresses.
  • Stage 3 (N3): deep sleep; delta waves (low frequency, high amplitude; 0.5-4\text{ Hz}); immune system strengthens; tissue and bone repair; lowest pulse and respiration rates; durable restorative stage; age-related decline with fewer stage 3 cycles.
  • Stage 4: REM sleep is sometimes referred to as stage 4 in older literature; however, modern staging typically treats REM as its own stage. In this content, REM is described as a sleep stage following stage 3 with EEG showing beta-like activity but with atonia.
  • Stage distribution (approximate for adults):
    • Stage 1: 5\%
    • Stage 2: 50\%
    • Stage 3: 10\% - 20\% (commonly around 15\% in some references)
    • REM: 20\% - 25\% of total sleep time
  • Each stage cycle lasts across the night, with REM periods lengthening and stage 3 diminishing as age increases.

Sleep Patterns Across the Lifespan

  • Infants (birth to 28 days; 1 month to 1 year): sleep in multiple sessions; NREM and REM occur roughly every 45-60\text{ minutes}; up to about stage 3 predominates in early months; about half of infant sleep is REM.
  • Adults (20-35 years): distribution roughly as above; cycles repeat ~4–5 times per night.
  • Older adults (65+): reduced stage 3 sleep, increased stage 2 sleep; wake more frequently and take longer to fall asleep; longer time in bed may occur, potentially affecting health issues such as musculoskeletal and pulmonary problems.

Recommended Sleep Durations by Age (CDC)

  • Birth to 3 months: 14-17\text{ hours}
  • 4 months to 1 year: 12-16\text{ hours}
  • Toddlers (1-2 years): 11-14\text{ hours}
  • Preschool (3-5 years): 10-13\text{ hours}
  • School age (6-12 years): 9-12\text{ hours}
  • Adolescents (12-18 years): 8-10\text{ hours}
  • Adults (18-60 years): 7+\text{ hours}
  • Adults 61-64 years: 7-9\text{ hours}
  • Adults 65+ years: 7-8\text{ hours}

Physiological Benefits of Sleep and Rest

  • Sleep supports development and maintenance of learning pathways, memory encoding, and concentration.
  • Sleep enables brain and cellular communication and toxin clearance in the brain during sleep.
  • Rest and sleep require intact internal mechanisms for optimal outcomes; sleep promotes learning, memory consolidation, and mood regulation.
  • Sleep supports immune function, muscle/tissue/bone repair, and hormonal balance.
  • Sleep influences weight regulation via ghrelin (hunger hormone) and leptin; sleep helps reduce cortisol (stress hormone), which affects insulin efficiency and glucose metabolism.
  • Adequate sleep is linked to improved concentration, mood, memory, productivity, reaction time, hand-eye coordination, strength, and power.
  • Drowsy driving is a major risk associated with sleep deprivation.

Sleep Deprivation: Types, Effects, and Management

  • Total sleep deprivation: no sleep for a full period (e.g., 24 hours or longer).
  • Partial sleep deprivation: reduced sleep hours over time.
  • Selective sleep deprivation: loss of a specific sleep cycle(s).
  • Causes include hospital interruptions, stress, pain, illness, medications, aging, and lifestyle factors (e.g., newborn care, heavy workload).
  • Cognitive and safety consequences: impaired judgment, slower reaction times, memory lapses, increased risk of seizures and headaches, mood disturbances, depression, and worse blood sugar control in diabetes. Sleep deprivation can contribute to obesity and type 2 diabetes through hormonal and metabolic pathways.
  • Treatment approaches depend on cause and severity; nonpharmacologic strategies (e.g., caffeine avoidance, exercise, and reducing alcohol/nicotine intake) and pharmacologic options under clinician guidance.

Promoting Sleep: Nonpharmacologic Interventions (NPI)

  • Education, lifestyle changes, calm environment, rituals, relaxation, and comfort are central to sleep promotion.

  • Nonpharmacologic nursing interventions:

    • Avoid stimulants (caffeine, alcohol, nicotine) 4–6 hours before bedtime: 4-6\text{ hours}
    • Minimize light and noise; provide white noise if needed.
    • Establish a bedtime routine (e.g., warm bath/shower before bed).
    • Maintain a dark, quiet, cool room; keep room comfortably cold.
    • Only go to bed when tired; if restless, engage in a quiet activity in another room (e.g., reading, listening to music).
    • Maintain a consistent sleep-wake cycle (regular bed and wake times).
    • Keep daytime naps short (less than 30\text{ minutes}).
    • Regular exercise and healthy eating; complete exercise at least 3\text{ hours} before bed.
    • Remove work items and electronics from the bedroom; associate the bedroom with sleep and sexual activity only.
    • Use a sleep diary to track habits and tailor a personalized plan with the client; evaluate and adjust with follow-up.

  • In-hospital considerations: address sensory overload and interruptions; reduce noise, dim lights at night, coordinate care to minimize awakenings, and provide comfort aids (blindfolds, earplugs) when appropriate; manage pain and monitor medications for sleep impact.

Sensory Overload and the Hospital Sleep Environment

  • Sensory overload occurs when stimuli exceed the brain’s processing capacity; common in acute care settings and linked to poorer sleep quality.

  • Contributing factors in hospitals: pain, frequent interruptions, noise, lighting, and medications that affect sleep cycles.

  • Nursing strategies to minimize sensory overload:

    • Develop a care plan that coordinates tasks and minimizes disruptions.
    • Dim lights and designate quiet times; lower alarms when feasible.
    • Provide blindfolds and earplugs as appropriate.
    • Control pain and monitor medication effects on sleep.

  • Additional contributing factors to poor sleep:

    • Cell phone use at night associated with shorter sleep, poorer quality, and daytime sleepiness; risk of depression and anxiety.
    • Night shift work with rotating duties linked to higher cardiovascular risk, obesity, diabetes, and job dissatisfaction.
    • Menopause: ~46\%-48\% report sleep difficulties; ~38\% of perimenopausal women experience sleep challenges.

Common Sleep Disorders: Characteristics and Nursing Considerations

  • Insomnia: ongoing difficulty sleeping despite opportunity; may include trouble falling asleep, staying asleep, waking early, or non-restorative sleep; can affect physical, emotional, and mental health; treatment can include medications, behavioral strategies, lifestyle changes, and cognitive behavioral therapy.

  • Sleep Apnea (OSA and CSA):

    • Obstructive Sleep Apnea (OSA): recurrent upper airway collapse/ obstruction during sleep; snoring common; diagnosed via polysomnography (sleep study); CPAP is first-line treatment; lifestyle changes (weight management, avoiding back-sleeping, smoking cessation, avoiding alcohol) can help.
    • Central Sleep Apnea (CSA): reduced brain signaling to respiratory muscles; causes include opioid overdose and heart failure; may lead to cessation of breathing events.

  • Narcolepsy: chronic sleep disorder with sudden sleepiness and episodes of sleep; nocturnal hallucinations, sleep paralysis, vivid dreams; cataplexy (brief loss of muscle tone) may occur; NT1 (with cataplexy) and NT2 (without cataplexy); hypocretin deficiency in NT1 is implicated.

  • Hypersomnia: excessive daytime fatigue not improved by additional sleep; may involve memory problems, depression, irritability, and attention deficits; underlying autonomic dysfunction or CNS trauma may contribute.

  • Restless Legs Syndrome (Willis-Ekbom Disease): urge to move legs with uncomfortable sensations; symptoms worsen in the evening and with inactivity; more common in older adults; may be associated with iron/vitamin deficiencies or MS; caffeine, nicotine, and alcohol may worsen symptoms; family tendency suggests heredity.

  • Night Terrors (Sleep Terrors): parasomnia, common in children; occur in the first third of the night; episodes last 10–40 minutes; child may appear panicked with poor recall; safe-handling strategies include not waking the child and implementing safety measures (mattress on floor, locks, alarms) to prevent injury; medical evaluation often includes sleep study; treatment focuses on adequate sleep, avoiding triggers (alcohol, caffeine), and treating underlying disorders; adults can experience night terrors too, sometimes more violent; could require medication in severe cases.

  • Diagnostic tool: Polysomnography documents heart rate, blood pressure, breathing, oxyhemoglobin saturation, brain wave patterns, body movements, and snoring.

  • Pharmacologic interventions (sleep therapy):

    • GABA agonists (benzodiazepines): e.g., alprazolam, clonazepam, lorazepam; provide sedation, muscle relaxation, anxiolysis, and potential retrograde amnesia; caution in older adults due to liver/kidney function; risk of dependence; not ideal for long-term use.
    • Non-benzodiazepine hypnotics (Z-drugs): e.g., zolpidem, zaleplon, eszopiclone; commonly prescribed; risks include gastric discomfort, hallucinations, memory impairment; potential for abuse and dependence at higher doses.
    • Melatonin: first-line for various ages; generally cost-effective, non-habit forming, few adverse effects; effectiveness may vary.
    • Antidepressants and antihistamines: used in some sleep disorders; potential sedative effects.
    • Over-the-counter (OTC) sleep aids: doxylamine succinate, diphenhydramine; may cause daytime drowsiness, dry mouth, blurred vision, urinary retention, and constipation; recommended to discuss with a physician before use.

  • Nonpharmacologic interventions (NPI) for sleep disorders and sleep promotion:

    • Acupuncture, dermotherapy, massage (relaxes muscles, improves circulation, reduces fatigue; watch for risks such as clots or injury in certain populations).
    • Guided imagery, mindfulness, meditation, music therapy, and CAT therapies (complementary and alternative therapies) to promote relaxation and sleep; yoga can reduce stress and improve health.
    • Education on sleep hygiene and creation of individualized sleep plans; collaborative care planning with the client and family; maintaining sleep diaries helps tailor interventions.
    • Community-based options: encourage group yoga classes or home-based routines; support groups for narcolepsy or other sleep disorders.

  • Sleep promotion and safety in nursing practice:

    • Avoid extended use of sleep medications; emphasize long-term behavioral changes and sleep hygiene.
    • Educate clients about sleep-promoting lifestyle changes and the role of relaxation techniques.

Nursing Process for Practical Sleep Care (PN Focus)

  • PN nursing process steps: data collection, planning, implementation, evaluation; emphasis on promoting comfort and facilitating restful sleep.
  • Practical nursing considerations:
    • Assess client comfort and emotional state; determine preferences for caregiver gender or consistent care providers when possible.
    • Explore openness to holistic treatments and cultural/spiritual beliefs; integrate feasible practices into the plan of care.
    • Conduct thorough history and assessment to identify sleep problems and contributing factors.
    • Plan strategies to minimize interruptions: controlling lights, noise, and visitor schedules; monitor vital signs and procedures to avoid disrupting sleep.
    • Implement a coordinated plan with other providers to organize tasks and protect sleep periods.
    • Provide ongoing assessment, support, and education to promote a healthy sleep lifestyle.

Comfort Promotion and Patient-Centered Care

  • Comfort is relief from pain, negativity, and emotional/physical distress; comfort promotes acceptance, safety, and reassurance.
  • Nursing actions to promote comfort:
    • Listen to patient concerns and address them honestly.
    • Involve patients in decisions about their care to foster trust and reduce fear.
    • Provide empathetic care; small acts (adjusting a pillow, offering a distraction such as TV or music) can ease distress.
    • Maintain presence and responsiveness to patient needs; ensure safety and privacy while supporting comfort.
    • Use nonverbal and verbal reassurance; explain what to expect to reduce anxiety.

Key Takeaways for Exam Preparation

  • Sleep physiology and regulation involve circadian rhythms (SCN in hypothalamus, light input) and sleep-wake homeostasis; REM and NREM stages alternate in cycles, with REM increasing toward the end of the night.
  • Sleep stages have characteristic EEG patterns and physiological changes; spindles and K-complexes in Stage 2 support memory processing; delta waves in Stage 3 reflect deep restorative sleep; REM sleep features beta-like activity with muscle atonia.
  • Sleep needs vary by age; CDC-recommended hours provide a framework for healthy sleep across the lifespan.
  • Sleep promotes physical health, immune function, metabolism, memory, mood, and safety; sleep deprivation can impair cognition and increase health risks.
  • In clinical settings, sleep can be disrupted by pain, interruptions, noise, environment, and medications; nursing interventions should minimize disturbances and promote rest.
  • Common sleep disorders include insomnia, various forms of sleep apnea (CSA and OSA), Narcolepsy, Hypersomnia, Restless Legs Syndrome, and Night Terrors; each has distinct etiologies, diagnostic tools (e.g., polysomnography), and treatment strategies.
  • Pharmacologic options include GABA agonists (benzodiazepines), non-benzodiazepine hypnotics, melatonin, antidepressants, and antihistamines; OTC options exist but carry risks of daytime drowsiness and other side effects.
  • Nonpharmacologic interventions (CAT) such as relaxation techniques, massage, guided imagery, mindfulness, and yoga can improve sleep quality and are commonly encouraged as first-line strategies.
  • The PN scope of practice varies by state; PNs typically work under RN supervision and must operate within state guidelines when contributing to care plans.
  • The nursing process for PN emphasizes data collection, planning, implementation, evaluation, and promoting comfort—integrating patient preferences, cultural considerations, and coordinated care to improve sleep and overall well-being.