1. Chapter Five Sleep Alterations Chapter 5-1 Fourth Edition Linda D. Urden Kathleen M. Stacy Mary E. Lough Priorities in C RITICAL C ARE N URSING Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

2. Slide 2 Objectives  Define the stages of sleep.  Explain the three physiologic effects that occur during rapid eye movement (REM) sleep.  Describe changes in sleep resulting from the aging process.  Define dysfunctional sleep.  Name three commonly prescribed critical care medications that decrease REM sleep.  Describe evidence-based practice methods for promoting sleep in critical care.

3. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 3 Sleep Physiology Definition of Sleep A reversible behavioral state of perceptual disengagement from and unresponsiveness to the environment

4. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 4 Sleep Physiology  Research has involved simultaneous monitoring − Electrooculography (EOG) – measures eye movement activity. Helps determine when the patient is in rapid eye movement. It can also establish when sleep onset occurs as reflected by slow rolling eye movements. − Electromyography= involves leads placed over various muscle groups. Chin placed lead detects atonia associated with REM sleep. − Intercostal leads detect respiratory effort. − Leads over anterior tibialis detect leg movements that may be causeing the patient to wake up during sleep.

5. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Patient undergoing a sleep study Slide 5

6. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. − Electroencephalography (EEG) measures brain wave activity during sleep. Each stage of sleep is characterized by differing waveforms. − Electrocardiography (ECG) – shows cardiac abnormalities, oximetry monitors saturation levels during sleep. − Pizeoelastic bands around the chest and abdomen detect respiratory disorders suc as apnea − Thermocouples are used to monitor airflow through the nose and mouth. Slide 6

7. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Demonstrated two distinct stages of sleep  Nonrapid eye movement (NREM)  Rapid eye movement (REM) Slide 7

8. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 8 Sleep Stages: NREM Stages of Nonrapid Eye Movement (NREM) Sleep Stage 1 2%-5% Transitional lighter sleep Stage 2 45%-55% Deeper sleep Stage 3 3%-8% Slow wave activity 20% of EEG Stage 4 10%-15% Slow wave activity 50% of EEG (Continued)

9. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Sleep Stages: NREM (Continued) Stages 3 and 4 are referred to as slow-wave sleep or delta sleep Highest arousal threshold Highest arousal threshold Parasympathetic nervous system predominates Parasympathetic nervous system predominates Hormonal changes to promote anabolism Hormonal changes to promote anabolism Protein synthesis and tissue repair Protein synthesis and tissue repair Restorative period Restorative period Slide 9

10. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Sleep Stages: REM Rapid Eye Movement (REM) Sleep 20% to 25% in young adults 20% to 25% in young adults “Dream” stage “Dream” stage Sympathetic nervous system predominates Sympathetic nervous system predominates – Increased oxygen consumption – Increased BP, pulse, resp., cardiac output – Increased chance of plaque rupture due to surges in pressure and changes in coronary artery tone Slide 10

11. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11 Age-Related Sleep Changes  Excessive sleepiness or insomnia in elderly  Fewer episodes of stages 3 and 4 NREM and REM sleep  Fragmented sleep patterns with frequent awakening  Cardiac disease, diabetes, nocturia, restless legs, pain  Respiratory disorders and sleep apnea  Altered circadian rhythms  Social and physical changes

12. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12 Sleep and Disease  Failure to gain adequate sleep is linked to:  Impaired glucose tolerance  Weight gain in women  Hypertension  Increased levels of C-reactive protein, which is an increased risk factor for CHD (coronary heart disease)

13. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13 Sleep Apnea Syndromes  Definition: sleep-disordered breathing  Obstructive apnea (>10 seconds or more) Obstructive: Complete obstruction (location is the upper airway) Obstructive: Complete obstruction (location is the upper airway) Hypopnea: Partial obstruction Hypopnea: Partial obstruction  Central: Lack of ventilatory muscle effort  Mixed: Both types in one apneic event  Apnea-hypopnea index used to diagnose sleep apnea syndrome (Continued)

14. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14 Sleep Apnea Syndromes (Continued)  Consequences of Obstructive Sleep Apnea- Hypopnea Syndrome − Hypercapnia − Hypoxemia − Acidosis − Systemic and pulmonary hypertension − Cardiovascular changes (Continued) (Continued)

15. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15 Sleep Apnea Syndromes (Continued)  Assessment and diagnosis  Careful monitoring  Identify patients at risk Short neck, obesity, CVD, HTN, Short neck, obesity, CVD, HTN,  Medical management  Surgical management  Nursing management (Continued) (Continued)

16. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Central Sleep Apnea  Characteristics  Absence of airflow and respiratory effort for at least 10 seconds.  Absence of emg activity is present  Breathing resumes when CO2 levels become excessive Slide 16

17. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Medical Management Non-Invasive  Weight loss  Side sleeping  Avoid sedative medications  Avoid alcohol before bedtime  Sleep deprivation avoidance Slide 17

18. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Surgical Management  UPPP – large tonsillectomy is performed  Success has been measured in 40% to 60% of patients.  Complications  Speech impairment  Post-op bleeding  infection Slide 18

19. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. CPAP  Treatment of choice  Administered with a nasal mask  Effective if the patient is compliant  If the patient cannot tolerate or CPAP is not successful BIPAP provides separate pressures during inspiration and expiration can be used.  Proper mask fitting must be ensured. Slide 19

20. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nursing Care of patients  In the critical care unit who have a diagnosis of sleep apnea need CPAP should bring their own machine and use it in the critical care unit. Slide 20

21. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21 Sleep Apnea Syndromes (Continued)  Nursing management  Educating patient and family  Monitoring for apnea while in the ICU  Promote compliance with continuous positive airway pressure (CPAP) or bimodal positive airway pressure (BiPAP) devices  Postoperative monitoring for surgical interventions

22. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 22 Sleep Promotion in Critical Care  Massage  Relaxing sounds  Music therapy  Open visitation policies  Controlling noise and light