1. Lullaby and Good Night….
Lisa B. Flatt, RN, MSN, CHPN

2. Rest vs. Sleep Calm state Relaxation Physical activity
No physical activity
Altered state of consciousness
Perception and reaction are decreased
Varying levels of reaction (dog barking, lawn mower, smoke detector)

3. Types of Sleep Rapid Eye Movement (REM) Non-rapid Eye Movement (NREM)
25% of sleep in young adults
Recurs every 990 minutes and lasts 5-30 minutes
Increases as you become more rested
Active dreaming, remembered dreams, difficulty awakening, depressed muscle tone, irregular heart, respiratory rates and muscle movements, increased brain activity
Most sleep is non-REM
slow-waves
4 Stages
I:last few minutes; drowsy, relaxed, eyes roll side to side; RR and HR decrease
II: minutes, eyes still; HR, RR and T decrease
III: HR, RR, T decrease; MS relaxes; decreased reflexes; snoring
IV: deep sleep; HR and RR drop to 20-30% waking rate; some dreaming, eye rolling; decreased BP; blood vessels dilate; MS relax; decreased BMR; increased GI activity

4. How long do they last? Not Long enough!
REM – recurs every 990 minutes, lasts 5-30 minute
NREM - about one hour in adults
Stage II and III – minutes total
Stage IV – 30 minutes
Cycle REM, St I,II and III then IV – then III, II and REM cycle4-6 times every 7-8 hours
Each cycles lasts about 70 minutes
If you wake up, start all over again!
More rested, cycles last longer, less time in Stages II and IV and NREM
Different developmental levels, different time lengths

5. Circadian Rhythm – Not to be confused with Cicadas
24 hour – Daily cycle, all living things do it!
Biorhythms – humans only. These are controlled with light and darkness, gravity and electromagnetic stimuli.
Infants as young as 6
months have circadian rhythms very much like
adults!

6. How well do you sleep? What to assess and consider……
Age and developmental level
Individual preferences
Physical condition
Cultural, spiritual and religious practices
Living conditions and socioeconomic status
Environmental factors
Psychological factors
Medications

7. Age and Developmental Level – the need for sleep
Hours/day
Other
Newborns
16-18
50%REM mostly St III and IV NREM
Infants
12-22
Light sleep, end of 1st year 14 of 24 hrs with 1-2 naps
Toddlers
10-12
20-30%REM, 1 nap, bedtime resistance
Preschoolers
11-12
20-30%REM,less St I NREM, consistency, may need naps
School-age
8-12
20% REM
Adolescents
Young adult
7-8
Middle-age adult
6-8
St IV decreases, aroused more easily
Older adult
Awaken more frequently, longer to get back to sleep

8. Preferences Sleep patterns Lifestyle
Work schedule and changes – sleep pattern changes
Caffeine
Alcohol – speeds up REM sleep
Smoking – nicotine is a stimulant
Vigorous exercise at ‘wrong times’ – releases endorphins

9. What kind of shape are you in?
Illnesses – require more sleep
Altered health status
Obesity – difficulty breathing
Nocturia
Activity level
Ineffective breathing

10. And more……
Cultural, Spiritual, Religious
Socieeconomic, Living conditions, Environmental
Co-sleeping (babies and young children sleeping with parents)
Sanitation
Safety
Noise
Temperature extremes
ventilation

11. ….. And more…… Anxiety Stress Depression Beta blockers Sedatives
Psychiatric
Medications
Anxiety
Stress
Depression
Beta blockers
Sedatives
Narcotics
Diuretics
Amphetamines
Bronchodilators
Decongestants
Steroids

12. Disturbing my Sleep! Primary Sleep Disorders Secondary Sleep Disorders
Narcolepsy – excessively sleepy during day; could be in middle of driving, talking, etc..; starts with REM
Unknown, possible genetic defect
Insomnia – unable to fall asleep; psychological (anxiety, etc); pain; nocturia; environmental (lights, etc.); chemical (medicine, caffeine, etc.)
Full assessment needed, usually no med’s; modification of habits, etc.
Secondary Sleep Disorders
Hypersomnia – excessive sleeping during the day, r/t CNS damage, kidney, liver or metabolic disorders
Sleep apnea – periods of apnea during sleep; last 10 sec – 2 min; x/night; tired during day; middle-aged overwt males and post-menopausal women
Parasomnia-behaviors that interfere with sleep
Sleep deprivation – decrease in amount, consistency and quality of sleep

13. Sleep Apnea Three types Causes Treatments
_Obstructive – tongue, tonsils_
__Central Apnea- chest movement, air flow stops, respiratory center defect in brain__
__Mixed – both combined_____
Causes
___remove and hopefully correct__________
___modify reasons as above__________
Treatments
__CPAP_____
__BiPAP____________
___Surgery, adjust body habitus, sleep sitting up____

14. Parasomnia- behaviors
Somnambulism - ___sleep walking______
Sleeptalking - ___holler out, tell secrets_______
Nocturnal enuresis - __pee at night___
Nocturnal erections - ___speaks for itself_____
Bruxism - ___teeth grinding____

15. Assessment Medications Age Activity - patterns Diet Alcohol/drugs
Disease process - labs
Sleep patterns
Stress, anxiety, depression

16. Nursing Diagnosis Insomnia R/T ____anxiety, stress, depression
Impairment of normal sleep pattern R/T _____shift work, SOB, ________
Sleep deprivation R/T _____fan running at night for wife to sleep, dementia, nightmares, narcolepsy, sleep walking, idiopathic CNS disease_______

17. Plan Collaborate with team to get an ideas on how to promote sleep
Assess sleep pattern daily
Client will verbalize plan to sleep at night, wake in am
Reduce environmental noise
Monitor fluid intake after 6PM
Instruct family on sleep patterns and disease

18. Interventions Provide Calm environment by closing door at night
Rub lotion on back before bed at 10PM
Turn off tv at 8pm
Administer sleeping pill by 9pm
Keep sleep log
Educate family on need to give diuretic before 4pm

19. Evaluation 6 of 7 nights closed door before 9PM
Did not rub patient’s hairy back at all
Wife turned off tv at night before 11pm
Gave extra sleeping pills and benadryl to keep patient off call light 7 of 7 nights
Sleep log kept by nurse first two days, family kept last 5 days (instructed not to hit patient with sleep log)
Wife took patients diuretic related to her swollen ankles – discuss this with social work