Nursing Fundamentals Pages 339-349

SLEEP & REST

Are you sleeping enough?

• No matter how comfortable you try and make the environment, alterations in sleep patterns have serious physical and emotional consequences

Functions of sleep

• Sleep plays a role in:• Reducing fatigue• Stabilizing mood• Improving blood flow to the brain• Increasing protein synthesis• Maintaining the disease-fighting mechanisms of the

immune system• Promotion of cellular growth and repair• Improving the capacity for learning and memory

storage

Sleep Phases

• Sleep is divided into 2 phases:• NREM – nonrapid eye movement – the EEG

waves are in slow wave sleep. Characterized as quiet sleep. There are 4 different steps to NREM sleep

• REM – rapid eye movement. EEG waves are similar to those of being awake, this is the deepest wave of sleep. Usually a person goes into REM sleep after 1 hour of being in NREM (not earlier)

So when do you sleep?

• Upon falling asleep, you go into NREM sleep, stages 1-4

• Then you go into REM sleep, this is the dream stage of sleep

• People alternate between the 4 stages of NREM and REM about 4-6xs during the night

Sleep Requirements

• The need for sleep decreases as you get older and the older adults stay in REM longer than younger adults do

• Most older adults sleep more during the weekdays while younger adults sleep more on the weekends

• Older adults nap more than younger adults, probably d/t older adults having inactivity during the day

Sleep Requirements

• Newborns sleep between 16-20 hrs/day

• Preschoolers sleep between 9-12hr.night

• Adolescent-adult sleep 7-9 hrs. night

Factors Affecting Sleep

• Older adults awaken more during the night and they rate their sleep as fair to poor

• Older adults awaken more due to:• Pain• smaller bladder capacity• Dementia-related problems• Side effects from meds as in increased urination• Some have diminished neurochemicals like

melatonin that promotes sleep

Circadian Rhythm

• Our body has the ability to run on a 24 hr cycle. It knows to awaken during day light and to sleep during dark

Activity

• Activity, especially exercise, increases fatigue and the need for sleep

• Activity increases the length of time one stays in both NREM and REM

• However…• If you perform physical activities right before

sleep, activity levels are increased and you will not be fatigued

Environment

• People have rituals that they swear by to help them sleep, some of the sleep rituals include:

• Eating a light snack watching T.V.• Performing hygiene Reading• Drinking milk• Now put the patient in an unfamiliar setting, they

may still perform some of their rituals but still cannot sleep

Motivation

• When a person has no reason to stay awake, they sleep

• If something important is happening, they can overcome the need to sleep

Emotions & Moods

• Depression or anxiety can stop a person from sleeping

• Being anxious floods the brain with neurotransmitters that interfere with relaxation

• Relaxation is a prerequisite for natural sleep

L-tryptophan

• Sleep is facilitated by this chemical

• L-tryptophan is found in protein foods such as milk and dairy products

• Also found in poultry (turkey), fish, eggs and some legumes

Alcohol

• Is a depressant that promotes sleep but it reduces REM sleep and the deep 4 stages of NREM

• Usually people awaken early after drinking because the chemicals that were earlier sedated, now surge forward from neurons

Caffeine

• Is a CNS stimulant and causes wakefulness• Caffeine is present in:• Coffee• Tea• Chocolate• Most dark cola drinks, clear sodas are

usually caffeine-free, root beer is usually caffeine-free

Illness

• Especially stomach ulcers, symptoms arise at night d/t HCL increases during the night during REM sleep

• If you are having trouble sleeping d/t pain, when there are less distractions, the pain is more distressing

• Conditions may worsen by laying flat in bed

Drugs that aid in sleep

• Sedatives- produce a relaxing and calming effect such as the barbituate Phenobarbital or the antihistamine Benadryl

• Tranquilizers – produce a relaxing and calming effect such as benzodiazepines like Xanax and Valium

•

Stimulants (that will not help you sleep)

• Amphetamines – like Dexedrine used for weight loss

Drug Tolerance

• If you take certain drugs over a period of time such as sedatives, a person can develop a drug tolerance. When this happens, there is a diminished effect from the drug at it’s usual dosage range. So the person takes even more and when they build up a drug intolerance to that higher dosage, they will need to increase the dose again. Before you know it, they need to take overdosing amts of the med to get the relief they are looking for and some meds cause addiction

What to do when a patient tells you he is having trouble

sleeping?• The nurse needs to obtain a more accurate

sleep pattern assessment using:

• Questionnaires

• Sleep diary

• Nocturnal polysomnography

Questionnaires

• Asking a series of questions will tell the nurse that the pt may be experiencing sleep apnea or having some other problems, she passes this information on to the Dr. for further assessment

Sleep Diary

• It’s a daily account of sleeping and waking activities

• The sleep diary is usually done in a sleep clinic

• This type of information can be inaccurate and other tests are ordered to detect sleep disorders

Nocturnal Polysomnography

• A pt is monitored for a whole nights sleep

• A technician can come to the home to conduct the study by using a computerized recording system from up to 60 feet away

• Dime-sized sensors are attached to the head and body

Polysomnography

• Records:• Brain waves chest and abd resp. effort.• Eye movements snoring sounds• Muscle tone pulse oximeter• Limb movement• Body position• Nasal and oral airflow• The results of this test are compared to normal

sleep patterns

Multiple sleep latency test

• People who c/o sleep difficulties are asked to take 20 minute naps a few times a day while being connected to the sensors

• Well-rested people take up to 15 minutes to fall asleep, people with sleep disorders fall asleep in 5 minutes or less, this is an indicator that sleep problems occur. REM should not occur in this 20 minute nap time test, if so, sleep disorder can be diagnosed

Sleep Disorders

• 40 million Americans have some type of sleep disorder

• There are 4 categories of sleep disorders:

• 1. Insomnia

• 2. Hypersomnias

• 3. Wake-cycle disturbances

• 4. parasomnias

Insomnia

• Means difficulty falling asleep, awakening frequently during the night or awakening early

• Person feels tired the next day, most of us have experienced this

• Should resolve in 3 weeks, if not leads to chronic insomnia, hypnotic drugs are used such as Nembutal or Restoril

Hypersomnia

• A sleep disorder characterized by feeling sleepy even after getting normal sleep, this includes :

• Narcolepsy

• Sleep apnea

Sleep apnea

• The sleeper stops breathing or breathing slows for 10 seconds or longer 5 or more times/hour

• Causes hypoxia (decreased cellular oxygenation) of the heart, brain and other organs, can cause M.I., stroke or sudden death

Treatment of sleep apnea

• Diet. Exercise, wt loss

• Avoid sleeping on your back

• Avoid alcohol or other sleeping aides

• C-pap is wearing a mask and receiving continuous positive pressure through a face or nose mask

• Surgery to remove tonsils, adenoids, uvula

Narcolepsy

• Characterized by sudden onset of daytime sleep, where the person goes into short NREM then REM

Sleep-wake cycle disturbances

• Results from a sleep schedule that involves daytime sleeping and interferes with biologic rhythms

• Changes in the intensity of light triggers sleeping

Shift work

• This happens to people who stay awake all night or work the evening shift

• The indoor lighting is not bright enough to suppress melatonin and these people fight to stay awake (melatonin helps you sleep)

• People usually don’t adapt to evenings or nights

Jet travel

• People find it difficult to change from time zones. It usually takes them 1 day to adjust, their sleep-wake cycle is off for a short time

Seasonal Affective Disorder (SADD)

• Symptoms begin during the darker winter months and disappear as daylight hours increase in the spring

• There may be an increase in melatonin, photo therapy suppresses melatonin, pt uses the light for 2-6hrs /day

• Disorder is characterized by lack of energy when awake, increased appetite, esp. sweets and wt gain

Parasomnias

• Are conditions that are associated with arousal or partial arousal during NREM

• These are not life threatening but they disturb others in the household

Parasomnias

• These include:• Bedwetters – nocturnal eneuresis• Sleep walkers - somnambulism• Grinding of teeth - bruxism• Nightmares or night terrors• Or those with restless leg syndrome - RLS• All of these symptoms keep people awake or

prevent sleep

How to care for the sleep deprived patient

• After reviewing the sleep patterns, nurse can come up with several NANDA diagnoses:

• Fatigue

• Disturbed sleep pattern

• Sleep deprivation

• Risk for injury

Promotion

• Nurse can promote measures as in:

• Maintaining sleep rituals

• Reducing the intake of stimulating chemicals

• Daytime exercise

• Maintain a regular schedule

• Offer a back massage for relaxation

MEDICATIONS

• When do you give your sleepless pt sleeping meds?• Give them before the pt turns in for the night• Do not allow the pt to fall off to sleep and wait until he

awakens to give him meds. He will have had a nap then and will not likely be able to fall back to sleep

• Also, do not give meds late, he’ll dose off and you’ll wake him to give his sleeping pill and then he may not fall back asleep

• You don’t want him to then take his sleep his and sleep all through the next day

The End