1. Comfort, Rest, and Sleep
Kozier C 45

2. Objectives Identify the characteristics of NREM and REM sleep
Identify the four stages of NREM sleep
Describe variations in sleep patterns throughout the life span
Identify factors that affect normal sleep
Describe common sleep disorders

3. Objectives Identify the components of a sleep pattern assessment
Develop nursing diagnosis, outcomes, and nursing interventions related to sleep problems
Describe interventions that promote normal sleep

4. Question 1
A client has a history of sleep apnea. The nurse should ask which of the following most appropriate questions?
Do you have a history of cardiac irregularities?
Do you have a history of any kind of nasal obstruction?
Have you had chest pain with or without activity?
Do you have difficulty with daytime sleepiness?

5. Rationales 1
Although cardiac arrhythmias may occur, they are usually only detectable during a sleep study, and thus the client would not be aware of them.
Nasal obstruction is rarely the cause of sleep apnea or a complaint of clients with sleep apnea.
There are many causes of chest pain, and this is unlikely to be something reported by clients with sleep apnea unless they have underlying cardiac disease.
Correct. Most clients with sleep apnea report excessive daytime sleepiness. If they don’t volunteer this, clients should be asked if they fall asleep or struggle to stay awake at work.

6. Physiology of Sleep
Darkness & preparing for sleep cause decrese in stimulation of the RAS
Pineal gland secretes melatonin
This results in person feeling sleepy
Growth hormone is secreted & cortisol inhibited.

7. Biorhythms Circadian Rhythms = “about a day”
Circadian Synchronization = awake when physiologic and psychological rhythms are most active and asleep when lest active.

8. Cicadian regularity Begins by 3rd week of life May be inherited
By 5th or 6th month more like parents sleep-wake pattern.

9. Question 2
Because of significant concerns about financial problems a middle-aged client complains of difficulty sleeping. Which of the following would be an appropriate outcome for the nursing care plan? “By day 5, the client will:
Sleep 8 to 10 hours per day.”
Report falling asleep within 20 to 30 minutes.”
Have a plan to pay all the bills.”
Decrease worrying about financial problems and will keep busy until bedtime.”

10. Rationales 2 Most adults do not need to sleep 8 to 10 hours per day.
Correct. Falling asleep within 20 to 30 minutes is normal for adults and would represent substantial improvement in the client’s difficulties.
Although it would be ideal to remove the source of the client’s stress, he is unlikely to have a plan to pay all his bills within 5 days.
Distraction or keeping busy until bedtime will not prevent the client from worrying about his bills at bedtime.

11. Types of Sleep
Two types of sleep
NREM-
REM

12. Stages of Sleep: NREM
Stage I- very light sleep (drowsy-relaxed) lasts a few mins.
Stage II- light sleep,
body process continue to slow
Eyes still
T, HR & RR decrease slightly
Lasts about 10 – 15 min
Makes up 44 – 55% of total sleep.

13. Stages of Sleep: NREM
Stage III-heart and respiratory rate are slower

14. Stages of Sleep: NREM
Stage VI-signals deep, restful sleep /w slower brain waves.
Thought to restore the body physically.
Some dreaming occurs.
Skeletal muscles relaxed
Reflexes diminished
Snoring most likely to occur

15. Physiologic changes during NREM sleep
Arterial BP falls
Pulse increases
Peripheral blood vessels dilate
Cardiac output decreases
Skeletal muscles relax
Basal metabolic rate decreases 10 – 30%
Growth hormone levels peak
Intracranial pressure decreases

16. REM-Rapid eye Movement-
Occurs about every 90 min & lasts 5-30 min
Not restful
Most dreams take place here
Brain metabolism increases 20%

17. Sleep Cycles Pass the four stages in 90 – 110 mins
Sleeper passes through the 1st 3 NREM stages in about min.
After stage IV NREM sleeper passes thru Stages III and II in about 20mins
Than the 1st REM occurs (lasts 10 mins)

18. Sleep Cycles
Healthy adult passes thru 4 – 6 cycles of sleep in 7 – 8 hrs

19. Functions of Sleep Restores normal levels of activity
Lack of sleep results in poor concentration, irritability, difficult decision making.
It use to be thought that a regular sleep pattern was more important than actual hours slept but sleep deprivation is associated
with cognitive & health problems.

20. Normal Sleep Patterns and Requirements
Newborns- sleep 16 to 18 hours a day, usually seven sleep periods & enter REM sleep immediately.
Infants at end of yr sleep hours a day
Toddlers hours a day.
Preschoolers hours of sleep per night
School Aged children (5 – 12 yrs) need hours at night.
REM sleep of children at this age is reduced to about 20 percent.

21. Normal Sleep Patterns and Requirements
Adolescents hours of sleep
Young adults hours may require less
Older Adults- 7-9 hours
Sundowner’s syndrome

22. Question 3
A client reports to the nurse that she has been taking barbiturate sleeping pills every night for several months and now wishes to stop taking them. The nurse advises the client to:
Take the last pill on a Friday night so disrupted sleep can be compensated on the weekend.
Continue to take the pills since sleeping without them after such a long time will be difficult and perhaps impossible.
Discontinue taking the pills.
Continue taking the pills and discuss tapering the dose with the primary care provider.

23. Rationales 3
Suddenly stopping barbiturate sleeping pills can precipitate a dangerous withdrawal.
Stopping requires a plan but can be done.
Correct. Doses should be tapered gradually and the tapering process supervised by the client’s primary care provider.

24. Sleep and the Elderly Video
Figure 1-2 Harriet Tubman (1820–1913) was known as “The Moses of Her People” for her work with the Underground Railroad. During the Civil War (1861–1865), she nursed the sick and suffering of her own race. (CORBIS Images)
Figure 1-3 Sojourner Truth (1797–1883), abolitionist, Underground Railroad agent, preacher, and women’s rights advocate, was a nurse for over 4 years during the Civil War and worked as a nurse and counselor for the Freedmen’s Relief Association after the war. (Randall Studio ( ) Sojourner Truth (c ), abolitionist. Copyright Photograph, Albumen Silver Print. Copyright National Portrait Gallery, Smithsonian Institution/Art Resources, NY.)
Figure 1-4 Dorothea Dix (1802–1887) was the Union’s Superintendent of Female Nurses during the Civil War. (CORBIS Images)
Figure 1-9 Considered the founder of modern nursing, Florence Nightingale (1820–1910) was influential in developing nursing education, practice, and administration. Her publication, Notes on Nursing: What It Is, and What It Is Not, first published in England in 1859 and in the United States in 1860, was intended for all women. (Bettman/CORBIS).
Figure 1-10 Clara Barton (1812–1912) organized the American Red Cross, which linked with the International Red Cross when the U.S. Congress ratified the Geneva Convention in 1882.
Click here to view a video on sleep and the elderly.
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25. Factors Affecting Sleep
Age- One of the most important factors affecting persons sleep and rest periods.
Illness- causing pain or physical distress can result in sleep problems.
Environment-Noise level
Fatigue- more tired the shorter the first (REM) sleep
Lifestyle-Shift work

26. Factors Affecting Sleep
Emotional Stress
Alcohol and Stimulants
Diet
Smoking
Motivation
Medications

27. Drugs That Affect Sleep
Alcohol Antidepressants
Beta-blockers Caffeine
Bronchial dilators Steroids
Decongestants Narcotics
Amphetamines

28. Common Sleep Disorders
Insomnia- most common sleep disorder, inability to obtain an adequate amount or quality of sleep.
Hypersomnia- Opposite of insomnia, excessive sleep, especially daytime.
Narcolepsy- Sudden wave of overwhelming sleepiness that occurs during the day. Referred to as “sleep attack”.

29. Primary Sleep Disorders
Sleep Apnea- periodic cessation of breathing during sleep.
Obstructive apnea
Central apnea
Mixed
>5 apneic episodes or 5 breathing pauses longer than 10 seconds/hour.

30. Primary Sleep Disorders
Sleep Apnea-
Load snoring
Nocturnal awakenings
Excessive daytime sleepiness
Difficulties falling asleep
Morning headaches
Memory/cognitive problems
Irritability.

31. Sleep Disorders
Parasomnias- Behavior that may interfere with sleep. (somnambulism, sleep talking, Nocturnal enuresis, nocturnal erections, bruxism).
Insufficient Sleep - prolonged disturbance resulting in decreases amount, quality, consistency of sleep.

32. Box Parasomnias

33. Assessment of Sleep Assessment of a client’s sleep includes:
a sleep history,
sleep diary,
physical examination,
a review of diagnostic studies.

34. Sleep History When does client usually go to sleep? Bedtime rituals?
Does client snore?
Can client stay away during day?
Taking any prescribed or OTC medications?

35. Sleep History What is the usual sleeping pattern, specifically:
sleeping and waking times
hours of undisturbed sleep, etc.
Bedtime rituals
Use of sleep medications
Sleep environment
Changes in sleep pattern

36. Sleep Diary Written record to be much more precise
Total number of sleep hours a day
Activities performed 2-3 hours before sleep
Bedtime rituals
Any worries that may affect client’s sleep
Factors that client believes to be positive or negative towards sleep

37. Physical Examination
Observation of clients facial appearance, behavior, and energy level.
Darkened areas around the eyes, puffy eyelids, reddened conjunctiva, glazed or dull appearing eyes.
Irritability, yawning, slumped posture, hand tremor, rubbing of eyes, confusion, fatigued, lethargic, etc.

38. Physical Examination
Rarely yields information unless client has obstructive sleep apnea
Enlarged and reddened uvula and soft palate
Enlarged adenoids and tonsils (children)
Obesity (adults)
Neck circumference > 17.5 inches (men)
Deviated septum (occasionally)

39. Diagnostic studies
Polysomnography – (EEG, electromyogram & electro-oculogram are recorded simultaneously).
May also include respiratory effort & airflow, ECG, leg movement & O2 sat.

40. NANDA Nursing Diagnoses
Disturbed Sleep Pattern
With specific descriptions such as “difficulty falling asleep” or “difficulty staying asleep”
Various etiologies may be involved and specified

41. NANDA Nursing Diagnoses
Sleep pattern disturbances as etiology of other diagnoses:
Risk for injury
Ineffective coping
Fatigue
Risk for impaired gas exchange
Deficient knowledge
Anxiety
Activity intolerance

42. Outcomes for Clients With Sleep Disturbances
Maintain (or develop) a sleeping pattern that provides sufficient energy for daily activities
Enhance feeling of well being
Improve the quality and quantity of the client’s sleep

43. Implementation
Nursing interventions are used to enhance the quantity and quality of sleep & involve largely non-pharmacologic measures. Interventions include-
guided imagery
therapeutic message
progressive muscle relaxation
uninterrupted sleep periods.

44. Implementation Client teaching Supporting bedtime rituals
Individuals need to learn the importance of rest and sleep in maintaining active and productive lifestyles.
Supporting bedtime rituals
Many are accustomed to rituals or pre-sleep routines and if altered can affect sleep.
Creating Restful Environment

45. Bedtime Rituals Altering or eliminating routines can affect sleep
Adults
Listening to music
Reading
Soothing bath
Praying
Children
Need to be socialized into presleep routine
Usually preceded by hygienic ritual

46. Implementation Promoting Comfort and Relaxation
Assist client with hygienic routines
Offer back message
Administer analgesics 30 min before sleep
Enhancing Sleep with Medications
Nurse responsible for making decisions with the client about when to administer sedative or hypnotics.

47. Effeurage massage consists of long, slow, gliding strokes.
Figure One suggested pattern for a back massage.
Effeurage massage consists of long, slow, gliding strokes.

48. Question 4
During a yearly physical, a 52-year-old male client mentions that his wife frequently complains about his snoring. During the physical exam, the nurse notes that his neck size is 18 inches, his soft palate and uvula are reddened and swollen, and he is overweight. The most appropriate nursing intervention for this client is to:
Recommend that he and his wife sleep in separate bedrooms so that his snoring does not disturb his wife.
Refer him to a dietician for a weight loss program.
Caution him not to drink or take sleeping pills since they may make his snoring worse.
Refer him to a sleep disorders center for evaluation and treatment of his symptoms.

49. Rationales 4 This does not address the client’s problem.
It would not be wrong to refer him to a dietician for weight loss counseling, but being evaluated by a sleep disorders specialist is more critical.
Drinking alcohol or taking sleeping pills is not advised in clients with sleep apnea because they reduce the client’s ability to get around.
Correct. The client’s symptoms, combined with his weight, suggest that he has obstructive sleep apnea and should be referred to a sleep disorders specialist for further evaluation.

50. Sedative-Hynoptic Meds
Medication Half-Life
Chloral hydrate hrs
Placidyl hrs
Dalmane hrs
Doriden hrs
Ativan hrs
Lunesta 6 hrs

51. Sedative-Hynoptic Meds
Medication Half-Life
Melatonin 1 hr
Restoril hrs
Halcion hrs
Sonata 1 hr
Ambien hrs

52. Reducing Environmental Distractions in Hospitals
Close window curtains if street lights shine through
Close curtains between clients in semiprivate and larger rooms
Reduce or eliminate overhead lighting: provide night light at the bedside or in the bathroom
Close the door of the client’s room

53. Reducing Environmental Distractions in Hospitals
Perform only essential noisy activities during sleeping hours
Ensure that all carts wheels are well oiled
Wear rubber soled shoes
Keep required staff conversations at low levels: conduct nursing reports or other discussions in a separate area away from clients rooms

54. Teaching to promote rest & sleep
Establish regular betime & wake up
Eliminate lengthy naps
Exercise just not 2 hrs before bedtime
Est regular bedtime routine – listen to music, warm bath,
Avoid heavy meals 3 hrs before bedtime

55. Teaching to promote rest & sleep
Avoid alcohol & caffeine at least 4 hrs before bedtime
Decrease fluid intake 2-4 hrs before bed
Use sleeping meds as last resort
Take analgesics before bedtime if needed

56. Question 5
A new nursing graduate’s first job requires 12-hour night shifts. Which of the following strategies will make it easier for the graduate to sleep during the day and remain awake at night?
Wear dark wrap-around sunglasses when driving home in the morning, and sleep in a darkened bedroom.
Exercise on the way home to avoid having to stand around as long waiting for equipment at the gym.
Drink several cups of strong coffee or 16 oz of caffeinated soda when beginning the shift.
Try to stay in a brightly lit area when working at night.

57. Rationales 5
Correct. Reducing exposure to bright light in the morning, driving home, and when going to sleep will make it easier to fall asleep after work.
Exercising before going to bed will increase arousal.
Caffeine consumed at the beginning of a 12-hour shift will not assist the nurse in remaining awake during the later part of the shift.
Although working in a brightly lit area will reduce drowsiness, this strategy is rarely available to nurses working the night shift; lights are often dimmed in hospital corridors and client rooms.