Chapter 21: Comfort and Rest
Consequences of a Lack of Rest and Sleep
A lack of adequate rest and sleep has profound negative effects on an individual's physical and mental well-being. These results include:
Decreased ability to handle pain.
Increased risk for illness.
Prolonged healing process for existing injuries or conditions.
Impaired coping skills.
Impaired cognitive function.
Increased fatigue.
Decreased physical ability.
Characteristics and Benefits of Normal Sleep
Normal sleep is essential for the restoration of the body and mind. It is defined by the following characteristics and benefits:
Allows the body and the brain to relax and recover.
Reenergizes brain cells.
Strengthens the immune system.
Heals and repairs bodily tissues.
Physical markers including a slowed heart rate, slowed respiration, closed eyes, and relaxed muscles.
The Human Sleep Cycle and Biological Stages
Sleep is divided into two primary types that alternate throughout the night:
Nonrapid Eye Movement (NREM) Sleep: This type consists of four distinct stages. Each stage typically lasts between and minutes.
Rapid Eye Movement (REM) Sleep: This type is characterized by increased brain activity. During REM, breathing rate, heart rate, and eye movement all increase.
Cycle Frequency: On average, a person completes to full sleep cycles during a night’s sleep. A complete cycle transitions through NREM Stage I, Stage II, Stage III, Stage IV, and then REM sleep.
Sleep Requirements Across the Lifespan
Sleep needs vary significantly based on the age of the individual:
Newborns: Require an average of hours of sleep per day.
Children: Sleep needs gradually decrease as the child grows older.
Adults: Most adults require to hours of sleep per -hour period.
Older Adults: Often have difficulty acquiring uninterrupted sleep. They frequently find daytime napping helpful to supplement their rest.
Factors Affecting the Quality of Sleep
Multiple factors can disrupt a person's ability to achieve restful sleep:
Environment: Factors like noise (excessive, loud, or strange), light (artificial light needed for care or a lack of natural sunlight), room temperature, and unfamiliar surroundings (different beds or the presence of a roommate).
Pain: Both acute and chronic pain can prevent rest.
Chronic Health Conditions: Conditions causing shortness of breath, coughing, or frequent urination (nocturia) interfere with sleep, as can the side effects of certain medications.
Emotional Concerns: Physical illness often brings worries regarding a clinical condition, awaiting diagnosis from a biopsy or medical test, financial concerns (healthcare costs, loss of time at work), and worry about family members or pets at home.
Sleep Disorders: Specific medical conditions that inherently disrupt the sleep cycle.
Concerns for Sleep in Long-Term Care
Older adults in long-term care settings face unique challenges regarding sleep:
They take longer to fall asleep and awake more frequently.
They are more sensitive to ambient noise.
They may require regular daytime naps.
Chronic health conditions such as restless leg syndrome or frequent urination impact sleep.
Lack of sleep in this population contributes to an increased risk of anxiety, delirium, depression, and a higher risk of falls due to fatigue.
Clinical Sleep Disorders and Care Procedures
Insomnia
Definition: Difficulty falling asleep or staying asleep.
Care: Nursing assistants should report any complaints of insomnia, maintain awareness of the increased risk for falls, and provide an environment that promotes sleep.
Sleep Apnea
Definition: A disorder where breathing is interrupted, resulting in intermittent sleep.
Symptoms: Chronic loud snoring, gasping or choking during sleep, excessive daytime sleepiness, mood changes, and cognitive changes.
Care: Support the patient in weight management and the avoidance of alcohol and smoking. Assist with sleeping positions and the use of a continuous positive airway pressure (CPAP) machine.
CPAP Monitoring: Report to the nurse if the person refuses the mask, if there is a hissing noise from the seal or tubing, if the machine is malfunctioning, or if the mask/straps cause skin irritation.
Nursing Assistant Interventions to Promote Rest and Sleep
To help clients achieve better sleep, nursing assistants should:
Respect individual sleep preferences; do not insist on a strict, identical routine for everyone.
Maintain a quiet, restful environment and use appropriate night lighting.
Assist the client into a comfortable sleeping position and help with basic hygiene and elimination at bedtime.
Offer a bedtime snack.
Limit daytime naps while encouraging physical activity and sunlight exposure during the day.
Avoid serving caffeinated beverages in the afternoon or evening.
Promote relaxation with warm baths, back massages, or soft music.
Turn off the television or radio unless the individual uses them specifically to relax.
Observations to Report: Frequent nighttime awakenings, difficulty falling or staying asleep, daytime sleepiness, frequent nighttime urination, signs of pain, anxiety, or environmental stressors.
Understanding and Classifying Pain
Pain is a subjective experience and is generally categorized into two types:
Acute Pain: Sharp, sudden pain resulting from injury. This type typically lessens as the body heals.
Chronic Pain: Pain that lasts longer than generally expected and interferes with the ability to rest, relax, and sleep.
Response to Pain: This is influenced by the pain threshold (the point of awareness) and pain tolerance (the level where help is sought). It is also affected by culture, upbringing, age, and experience.
Assessing and Identifying Pain
Nursing assistants must actively identify pain, even if not reported:
Never assume a client is pain-free or exaggerating.
Indicators include sudden personality changes or refusal to participate in activities.
Nonverbal Signs: Facial expressions, moaning, crying, restlessness, calling out, rubbing or guarding an area, resisting care, redness, swelling, profuse sweating, change in behavior, or changes in vital signs.
Specific Inquiries: Ask the client about the location (one place or radiating), characteristics (burning, aching, throbbing, stabbing), intensity (using a scale), and circumstances (what makes it better or worse).
Tools for Measuring Pain Intensity
Healthcare providers use various scales to quantify pain:
Verbal Scale: Uses words like "no pain," "mild," "moderate," "severe," "burning," or "throbbing."
Numeric Scale: A series of numbers from to (or to ), where is "no pain" and is "the worst pain imaginable."
Visual Scales: A bar (Visual Analogue Scale or VAS) that includes words, colors, or numbers.
Wong-Baker FACES Scale: Consists of six faces ranging from "No Hurt" to "Hurts Worst." It uses alternate coding such as .
Treatment and Management of Pain
Pain management involves a combination of medical and physical therapies:
Medication: Over-the-counter (OTC) meds for mild/moderate pain; narcotics for severe pain. Breakthrough pain (felt before the next dose is due) must be reported immediately.
Physical Therapy: Includes exercise (for musculoskeletal injuries), ultrasound therapy (to increase circulation and relax muscles), and Transcutaneous Electrical Nerve Stimulation (TENS).
The Nursing Assistant Role: Be gentle, provide distractions, help the person relax, pay attention to positioning, and provide massages where appropriate.
Heat and Cold Applications
Applications of heat and cold can be moist or dry and are highly effective for musculoskeletal pain.
Safety Protocol: Applications must be monitored. Check the site every minutes and remove after minutes. Immediately report redness, pale skin, stinging, burning, or pain.
Risks: Children, older clients, and those with fair skin, impaired sensations, or impaired consciousness are at highest risk for injury (burns, tissue death).
Heat Benefits: Relaxes muscles, increases blood flow, speeds healing, reduces swelling, and provides warmth. Accelerates the inflammatory response and decreases stiffness.
Cold Benefits: Reduces pain and swelling through vasoconstriction (narrowing of blood vessels). Controls bleeding, reduces fevers, and numbs sensations. Often used for sprains and strains.
Procedures: Nursing assistants may apply dry heat using an Aquamatic pad (Procedure 21-1) or apply moist/dry cold (Procedures 21-2 and 21-3).