Chapter 38: Physiological Integrity - Basic Care and Comfort

CHAPTER 38: PHYSIOLOGICAL INTEGRITY

SECTION: BASIC CARE AND COMFORT

Rest and Sleep
  • Importance of Sleep:
      - Adequate amounts of sleep and rest promote health.
      - Consequences of insufficient sleep:
        - Inability to concentrate
        - Poor judgment
        - Moodiness
        - Increased risk for accidents.
      - Chronic sleep loss linked to:
        - Obesity
        - Depression
        - Hypertension
        - Diabetes mellitus
        - Heart attack
        - Stroke.
SLEEP CYCLE

  • Components of the Sleep Cycle:
      - Composed of three stages of Non-Rapid Eye Movement (NREM) sleep and a period of Rapid Eye Movement (REM) sleep.
      - REM sleep constitutes 20% to 25% of total sleep time.

  • Stages of NREM Sleep:
      - Stage 1 NREM:
        - Very light sleep
        - Lasts only a few minutes
        - Characterized by:
          - Muscle relaxation
          - Loss of awareness of surroundings
          - Initial decrease in vital signs and metabolism
        - Easier to awaken; feels relaxed and drowsy.
      - Stage 2 NREM:
        - Deeper sleep lasting 10 to 20 minutes
        - Vital signs and metabolism continue to slow.
        - Requires slightly more stimulation to awaken; increased relaxation.
      - Stage 3 NREM:
        - Known as slow-wave sleep or delta sleep
        - Vital signs further decreasing
        - More difficult to awaken from this stage.

SLEEP DURATION
  • Variability by Developmental Stage:
      - Infants and toddlers: 9 to 15 hours/day
      - Adolescents: 9 to 10 hours/day
      - Adults: 7 to 8 hours/day.
COMMON SLEEP DISORDERS

  1. Insomnia:
       - Most common sleep disorder characterized by inability to obtain adequate sleep and feel rested.
       - Manifestations include:
         - Difficulty falling asleep
         - Difficulty staying asleep
         - Awakening too early
         - Lack of refreshing sleep.
       - Types of Insomnia:
         - Acute insomnia: lasts a few days, often due to situational stressors.
         - Chronic insomnia: lasts for a month or more.
         - Intermittent insomnia: periods of normal sleep followed by episodes of insomnia.
       - Increased risk factors: women and older adults.

  2. Sleep Apnea:
       - Characterized by more than five breathing cessations lasting longer than 10 seconds per hour of sleep, resulting in decreased arterial oxygen saturation levels.
       - Can be categorized into two types:
         - Central Sleep Apnea: dysfunction in the central nervous system which fails to initiate breathing during sleep.
         - Obstructive Sleep Apnea: relaxation of structures in the mouth and throat during sleep occludes the upper airway.

  3. Narcolepsy:
       - Sudden and uncontrollable attacks of sleep, potentially occurring at inappropriate times, increasing risk of injury.

  4. Hypersomnolence Disorder:
       - Characterized by excessive daytime sleepiness lasting at least 3 months affecting social and vocational activities.

  • REM Sleep Characteristics:
      - Vivid dreaming occurs approximately 90 minutes after falling asleep, recurring every 90 minutes with increased duration in each cycle.
      - Associated with increased risk for accidents or injuries related to sleepiness.
ASSESSMENT/DATA COLLECTION
  • Evaluate sleep patterns, history, and recent changes.
      - Identify usual sleep requirements.
      - Inquire about sleep problems: type, manifestations, timing, seriousness, related factors, aftereffects.
      - Use a visual scale to rate sleep from 0 (worst sleep) to 10 (best sleep).
      - Check for common factors interfering with sleep.

FACTORS THAT INTERFERE WITH SLEEP

  • Physiologic disorders (e.g., sleep apnea, nocturia).
  • Current life events such as travel demands or change in work hours.
  • Emotional stress or mental illness (e.g., anxiety, fear, grief).
  • Diet factors like caffeine consumption or heavy meals before bedtime.
  • Exercise: Can promote sleep if done at least 3 hours before bedtime, or disrupt if too close to sleep time.
  • Fatigue: Excessive or stressful activities hinder sleep onset.
  • Sleep environment: Disruptions from light, inappropriate temperatures, or noise (children, pets, loud noise, snoring partner).
  • Medications: Some may induce sleep but interfere with restorative sleep (e.g., bronchodilators, antihypertensives).
  • Substance use: Stimulants like nicotine and caffeine can disturb sleep.
NURSING ACTIONS
  • Assist clients in establishing and adhering to a bedtime routine.
  • Limit unnecessary awakenings during the night.
  • Encourage a quiet environment conducive to sleep.
  • Help with personal hygiene or back rubs before sleep to increase comfort.
  • For clients with sleep apnea, consider Continuous Positive Airway Pressure (CPAP) devices.
  • Consult healthcare providers regarding over-the-counter sleep aids (e.g., melatonin, valerian, chamomile).
  • As a last resort, propose pharmacological agents for insomnia, preferring benzodiazepine-like medications (e.g., zolpidem, eszopiclone, zaleplon).
  • Adjust inpatient routines to align more closely with clients' home sleep patterns (e.g., bathing, bedtime).
CLIENT EDUCATION
  • Encourage the establishment of a bedtime routine and consistent sleep pattern.
  • Advisable to complete exercise at least 3 hours before sleep.
  • Optimize sleep environment for comfort.
  • Advise limiting alcohol, caffeine, and nicotine intake at least 4 hours prior to sleep.
  • Encourage limitation of fluid intake 2 to 4 hours before bedtime.
  • Recommend engaging in muscle relaxation techniques if experiencing anxiety or stress.
Specific Recommendations for Disorders:
  • For Narcolepsy:
      - Maintain regular exercise, consume small protein-rich meals, avoid overly relaxing activities (e.g., sitting for long periods), and avoid potentially hazardous activities due to possible sleep episodes.
      - Take naps during times of drowsiness and utilize prescribed stimulants.
  • For Hypersomnolence Disorder:
      - Uphold a regular sleep-wake schedule, ensure ample sleep opportunities, and take prescribed stimulants when necessary.

CASE STUDY: NARRATIVE SCENARIO

Introduction
  • Scenario Context: John is a nurse at a provider's office caring for Mrs. Smith.
Scene 1
  • Dialogue:
      - John: "Hello, Mrs. Smith. How are you feeling?"
      - Mrs. Smith: "I have been having trouble sleeping at night. I'm having difficulty concentrating at work, and I'm feeling irritable."
Scene 2
  • Inquiry about Night Routine:
      - John: "What is your typical night routine?"
      - Mrs. Smith: "I have been traveling a lot for work, so my routine varies. By the time I have dinner, it's late in the evening. I usually eat a large meal with a glass of wine about one hour before bedtime. Work has been very stressful, and a glass of wine helps me relax. I try to take a warm bath before bed when I have time."
  • Exercise Inquiry:
      - John: "Do you exercise during the day?"
      - Mrs. Smith: "I walk my dog every morning when I am home."
Scene 3
  • Discussion on Improving Sleep:
      - John: "Let's talk about what you can do to improve sleep."
      - Mrs. Smith: "Thank you."
Scenario Conclusion
  • John provides education to Mrs. Smith on strategies for improving her sleep quality.