Sleep
Rest and Sleep
Maggie Kimbrough, MSN, RN
Objectives
Compare and contrast common sleep disorders.
Compare and contrast sleep requirements for different age groups.
Analyze factors that promote and disrupt sleep.
Illustrate a sleep assessment for a patient.
Identify potential clinical problems appropriate for patients with alterations in sleep.
Select nursing interventions to promote a normal sleep cycle for different age groups and in the hospital setting.
Describe ways to evaluate nursing interventions for improving the sleep cycle.
Use the Clinical Judgment Measurement Model/nursing process as a framework to care for a patient with alterations in sleep.
Basics of Sleep
Sleep is a basic human need essential for functioning in our world.
Influences:
Concentration
Judgments
Healing & restoration
Physiology of Sleep
Sleep is defined as a cyclical physiological process that alternates with longer periods of wakefulness.
Circadian Rhythms:
The most familiar rhythm that operates on a 24-hour day-night cycle.
Influences major biological & behavioral functions, including:
Body temperature
Heart Rate (HR)
Blood Pressure (BP)
Hormone secretion
Mood
Sensory acuity
Biological clocks synchronize biological functions; interruptions (e.g., in hospitals) can affect cycles, leading to irritability, restlessness, anxiety, impaired judgments, and overall health issues due to lack of sleep.
Sleep Regulation
Controlled by the Central Nervous System (CNS).
Two systems in the brainstem control the cyclic nature of sleep.
Reticular Activating System (RAS):
Located in the upper brainstem, maintaining alertness & wakefulness.
Cerebral cortex activity (emotional or thought processes) stimulates RAS.
Wakefulness results from the release of catecholamines, such as norepinephrine.
During sleep, stimuli to RAS decline.
A quiet room enhances stimulation to RAS.
Non-Rapid Eye Movement (NREM) Sleep
Stages of NREM Sleep:
N1 (Light Sleep):
Lasts a few minutes.
Represents a gradual fall in vital signs (VS) & metabolism.
Easily aroused; feels like daydreaming if awakened.
N2 (Moderate Sleep):
Progression to deeper relaxation, with easy arousal.
Body functions slow.
N3 (Deep Sleep):
Known as “slow wave sleep.”
Deepest sleep stage; difficult to arouse.
Significant decline in brain and muscle activity, with regular vital signs.
Rapid Eye Movement (REM) Sleep
Characterized by:
Vivid, full-color dreaming
Occurs approximately 90 minutes after sleep has begun
Rapid eye movement, fluctuating heart & respiratory rates, and increased blood pressure.
Loss of skeletal muscle tone
Increased gastric secretions
Very difficult to arouse, with REM duration increasing with each cycle, averaging about 20 minutes.
Sleep Cycle Characteristics
A person typically goes through 4-6 complete sleep cycles each night.
With each cycle, NREM stages 2 & 3 shorten while REM duration lengthens.
Age Differences:
Newborns and children spend more time in deep sleep (N3).
As individuals age, they spend more time in lighter sleep stages.
Number of cycles influenced by total sleep time.
Functions of Sleep
Restoration:
Brain and body tissue restoration occurs during NREM sleep.
Biological processes slow to preserve and repair.
Memory Consolidation:
Important for learning, memory processing, and adapting to stress.
Energy Preservation:
Sleep helps to conserve body energy for times of wakefulness.
Adverse Effects of Sleep Loss:
Confusion, altered mood, motor performance, memory issues, and decreased immunity.
Dreams
REM dreams are vivid and elaborate; important for learning and memory processing.
Influenced by personality.
Dream analysis can aid psychotherapy, helping resolve fears or concerns.
Vivid recall typically occurs immediately after waking from REM sleep.
Normal Sleep Requirements & Patterns
Neonates (up to 3 months):
Average 16 hours/day; sleep cycle of 40-50 minutes.
First week typically almost continual sleep, 50% of which is REM, essential for development.
Infants (3 months and older):
Nighttime sleep begins; averages 8-10 hours/night and 15 hours total daily sleep.
REM constitutes about 30%.
Common to awaken early morning and at night.
Toddlers:
By age 2, should sleep through the night with daytime naps (averaging 12 hours/day).
Nighttime waking is common; bedtime resistance occurs, influencing routines.
Preschoolers:
Average 12 hours/night; by age 5, daytime napping is rare.
Bedtime fears and nightmares are common; require routines and rituals.
School-Age Children:
A 6-year-old averages 11-12 hours/night while an 11-year-old averages 9-10 hours/night.
Bedtime challenges require consistent approaches.
Adolescents:
Recommended to have 8-10 hours but often only achieve about 7 hours.
Sleep is affected by academic demands, social activities, and electronics leading to excessive daytime sleepiness (EDS).
Young Adults:
Typically sleep 6-8.5 hours/night, rarely taking naps.
Sleep changes occur due to lifestyle demands and pregnancy.
EDS can lead to accidents and decreased productivity.
Middle Adults:
Sleep time begins to decline; N3 (Stage 4) sleep also decreases.
Insomnia is common due to life changes (e.g., menopause).
Older Adults:
Increased sleeping difficulties, with shorter REM and reduced N3 sleep.
More frequent awakenings at night and longer time to fall asleep, often related to physical conditions (e.g., arthritis).
Increased napping due to nighttime awakenings.
Normal Sleep Requirements Summary
Neonates: 16 hrs/day
Infants: 8-10 hrs/night, total 15 hrs/day
Toddlers: 12 hrs/day
Preschoolers: 12 hrs/night
School Age: 11-12 hrs (6 yrs), 9-10 hrs (11/12 yrs)
Adolescents: ~7 hrs (recommendation exceeds)
Young Adults: 6-8.5 hrs
Middle and Older Adults: Sleep declines in total hours
Factors Affecting Sleep
Drugs & Substances:
Prescription medications can disrupt sleep and reduce daytime alertness (e.g., sedatives, antidepressants).
Older adults (polypharmacy) may face combined effects disrupting sleep.
Lifestyle and Sleep Patterns:
Rotating shifts can impair sleep and alertness; alterations in routines can aggravate sleep issues.
Activities like heavy labor, nighttime socializing, and mealtime changes can disrupt sleep patterns.
Emotional Stress:
Worry and emotional stress can exacerbate sleep disruption.
Life transitions (e.g., retirement, loss) particularly affect older adults.
Environment:
Conditions such as ventilation, bed quality, and noise affect sleep quality.
Hospitals often create sound disturbances that hinder patient sleep.
Lighting and room temperature (cold vs. warm) also play roles in sleep onset.
Exercise & Fatigue:
Regular exercise promotes relaxation but should not be vigorous right before bed.
Food & Caloric Intake:
Healthy eating habits support adequate sleep; heavy or spicy meals may impair it.
Caffeine, alcohol, and nicotine consumption in the evening can lead to insomnia.
Sleep Disorders
Untreated sleep disorders can cause:
Insomnia
Abnormal movements or sensations during sleep
Excessive daytime sleepiness (EDS)
Common Sleep Disorders
Insomnia:
Characterized by difficulty falling asleep, frequent wakening, and non-restorative sleep.
Often associated with excessive daytime sleepiness and underlying disorders.
Commonly affects women; transient insomnia may result from situational stresses.
Symptoms include feeling fatigued and anxious during the day.
Management includes treating underlying conditions, providing cognitive and relaxation techniques.
Sleep Apnea:
Defined as lack of airflow for periods of 10 seconds or longer.
Types include:
Central Sleep Apnea (CSA): Dysfunction in respiratory control center.
Obstructive Sleep Apnea (OSA): Most common; involves muscle relaxation obstructing airway.
Symptoms often include loud snoring, daytime fatigue, and headache.
Treatment may involve weight loss, CPAP devices, or surgical interventions if necessary.
Narcolepsy:
A neurological disorder affecting sleep regulation characterized by EDS.
Individuals may experience sudden sleep attacks; REM can begin within 15 minutes of sleep.
Symptoms may include cataplexy (sudden muscle weakness), vivid dreams, and sleep paralysis.
Treatment includes scheduled naps, medications like modafinil, and lifestyle modifications.
Sleep Deprivation:
Refers to reduced sleep quantity, consistency, or quality, often exacerbated in hospital settings.
Management involves correcting environmental or lifestyle factors causing disturbances.
Parasomnias:
Encompasses undesirable behaviors during sleep, such as:
Somnambulism (sleepwalking)
Sleep terrors
Nightmares
Sleep talking
Sleep bruxism (teeth grinding)
Sleep enuresis (bed-wetting)
Nursing Assessment
Sleep Assessment:
Sources for sleep history include the individual, bed partner, and parents.
Assess the following:
Nature of sleep problem
Signs & Symptoms (S&S)
Onset and frequency
Severity
Predisposing factors
Impact on the patient
Assessment Tools:
Common tools for sleep assessment:
Epworth Sleepiness Scale
Pittsburgh Sleep Quality Index
Physical Assessment:
Physical evaluation may provide crucial insights into sleep issues.
Sleep History:
Should include descriptions of sleeping problems, usual patterns, medical history, life events, emotional/mental status, bedtime routines, and indicators of deprivation.
Nursing Interventions
Control the Environment:
Considerations:
Temperature
Ventilation
Noise level
Comfort of bed
Lighting
Promote Bedtime Routines:
Encourage bedtime routines to wind down; suggest quiet activities.
Avoid stimulation before bedtime; reading or soft music may help.
Promote Comfort and Safety:
Recommendations include soft clothing, loose pajamas, and adequate bedding.
Ensure a clutter-free environment and provide night lights when necessary.
Establish Rest & Sleep Periods:
Encourage physical activity during the day; advise against vigorous exercise right before bed.
Suggest phone unplugging to minimize disturbances.
Stress Reduction:
Avoid forcing sleep; suggest engaging in relaxation activities.
Discuss children’s nightmares and fears to promote safety and comfort.
Diet & Bedtime Snacks:
Dairy snacks (e.g., warm milk) may promote sleep due to L-tryptophan.
Avoid heavy meals or stimulants (caffeine, alcohol) near bedtime.
Pharmacological Approaches:
Nonprescription sleep medications are generally not advisable.
Caution prescribed medications due to potential side effects (e.g., confusion, constipation).
Response to Hospital Environment:
Control noise levels by shutting doors and reducing phone/equipment volume.
Enforce quiet practices during nighttime hours and provide privacy for discussions.
Evaluation of Sleep
Assessment of patient understanding regarding effective interventions.
Collaborate with patient if sleep does not improve; adapt approaches based on individual needs.
Comparing current sleep patterns with baseline assessments will aid in evaluating sleep improvements.