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Rest and Sleep Chapter 34

Terms in this set (101)

What is rest?
a condition in which the body is in a decreased state of activity, with the consequent feeling of being refreshed.
What is sleep?
a state of rest accompanied by altered consciousness and relative inactivity.
What two systems work in the brainstem together to control the cyclic nature of sleep?
the reticular activating system (RAS) and the bulbar synchronizing region, are believed to work together to control the cyclic nature of sleep
What is melatonin?
a hormone, is thought to regulate the sleep-wake cycle and possibly circadian rhythms.
What are circadian rhythms?
are predictable fluctuations in processes that occur in repeated cycles of time, completing a full cycle every 24 hours.Fluctuations in a person's heart rate, blood pressure, body temperature, hormone secretions, metabolism, and performance and mood display circadian rhythms.
What are the two main stages of sleep?
non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep.
electroencephalograph (EEG)
which receives and records electrical currents from the brain
electrooculogram (EOG)
Records eye movements seen during rapid eye movement (REM) sleep
electromyograph (EMG)
records muscle tone
NREM Sleep
Stage I Characteristics
-The person is in a transitional stage between wakefulness and sleep.
-The person is in a relaxed state but still somewhat aware of the surroundings.
-Involuntary muscle jerking may occur and waken the person.
-The stage normally lasts only minutes.
-The person can be aroused easily.
-This stage constitutes only about 5% of total sleep.
NREM Sleep
Stage 2 Characteristics
-The person falls into a stage of sleep.
-The person can be aroused with relative ease.
-This stage constitutes 50% to 55% of sleep.
NREM Sleep
Stage 3 Characteristics
-The depth of sleep increases, and arousal becomes increasingly difficult.
-This stage composes about 10% of sleep.
NREM Sleep
Stage 4 Characteristics
-The person reaches the greatest depth of sleep, which is called delta sleep.
-Arousal from sleep is difficult.
-Physiologic changes in the body include the following:Slow brain waves are recorded on an EEG.Pulse and respiratory rates decrease.Blood pressure decreases.Muscles are relaxed.Metabolism slows and the body temperature is low.This constitutes about 10% of sleep.
REM sleep characteristics
-Eyes dart back and forth quickly.
-Small muscle twitching, such as on the face
-Large muscle immobility, resembling paralysis
-Respirations irregular; sometimes interspersed with apnea
-Rapid or irregular pulse
-Blood pressure increases or fluctuates
-Increase in gastric secretions
-Metabolism increases; body temperature increases
-Encephalogram tracings active
-REM sleep enters from stage II of NREM sleep and reenters NREM sleep at stage II: arousal from sleep difficult
-Constitutes about 20% to 25% of sleep
It is more difficult to arouse a person during ______ sleep than during ____ sleep
rapid eye movement (REM) , NREM
During REM sleep, what increases? What depresses?
During REM sleep, the pulse, respiratory rate, blood pressure, metabolic rate, and body temperature increase, whereas general skeletal muscle tone and deep tendon reflexes are depressed.
Normally during a sleep cycle, a person
passes consecutively through the four stages of NREM sleep. STUDY FIGURE 34-1
Newborns and Infants
Sleep Pattern & Nursing Implications
-Newborn: Sleeps an average of 16 hr/24 hr; averages about 4 hours at a time.
-Each infant's sleep pattern is unique. On average, infants sleep 12 to 15 hours at night, with several naps during the day.
-Usually by 8 to 16 weeks of age, an infant sleeps through the night.
-REM sleep constitutes much of the sleep cycle of a young infant.

**Nursing Implications**
-Teach parents to position infant on the back. This is the only safe sleeping position for infants less than 1 year old. Sleeping in the prone position increases the risk for sudden infant death syndrome (SIDS).
-Advise parents that eye movements, groaning, grimacing, and moving are normal activities at this age.
Encourage parents to have infant sleep in a separate area rather than their bed.
-Caution parents about placing pillows, crib bumpers, quilts, stuffed animals, and so on in the crib because this may pose a suffocation risk.
Toddlers
Sleep Pattern & Nursing implications
-Need for sleep declines as this stage progresses. May require two naps during the day and end this stage sleeping 11 to 14 hours a night and napping once during the day.
-Toddlers may begin to resist naps and going to bed at night.
-They may move from crib to youth bed or regular bed at around 2 years.

**NURSING IMPLICATIONS**
-Establish a regular bedtime routine (e.g., reading a story, singing a lullaby, saying prayers).
-Advise parents of the value of a routine sleeping pattern with minimal variation.
-Encourage attention to safety once child moves from crib to bed. If child attempts to wander out of room, a folding gate may be necessary across the door of the room.
Preschoolers
Sleep Pattern & Nursing Implications
-Children in this stage generally sleep 11 to 13 hours at night.
-The REM sleep pattern is similar to that of an adult.
-Daytime napping decreases during this period, and by the age of 5 years, most children no longer nap.
-This age group may continue to resist going to bed at night.

**NURSING IMPLICATIONS**
-Encourage parents to continue bedtime routines.
-Advise parents that waking from nightmares or night terrors (awakening screaming about 20 minutes after falling asleep) are common during this stage. Waking the child and comforting the child generally helps. Sometimes use of a night light is soothing.
School-Aged Children
Sleep Pattern & Nursing Implications
-Younger school-aged children may require 10 to 12 hours nightly, whereas older children in this stage may average 9 to 11 hours.
-Sleep needs usually increase when physical growth peaks.

**NURSING IMPLICATIONS**
-Discuss the fact that the stress of beginning school may interrupt normal sleep patterns.
-Advise that a relaxed bedtime routine is most helpful at this stage.
-Inform parents about child's awareness of the concept of death possibly occurring at this stage. Encourage parental presence and support to help alleviate some of the child's concerns.
Teenagers
Sleep Pattern & Nursing Implications
-Sleep needs of teenagers vary widely, but the average requirement is 8 to 10 hours. The growth spurt that normally occurs at this stage may necessitate the need for more sleep; however, the stresses of school, activities, and part-time employment may cause adolescents to have a restless sleep. Adolescents tend to go to bed later than younger children and adults, but early morning start times for high school frequently require an early awakening time. This can result in an average of only 7 to 7.5 hours of sleep a night.
-Many adolescents do not get enough sleep.

**NURSING IMPLICATIONS**
-Advise parents that their adolescents' complaints of fatigue or inability to do well in school may be related to not enough sleep. Excessive daytime sleepiness (EDS) may also make the teenager more vulnerable to accidents and behavioral problems.
Young Adults
Sleep Pattern & Nursing Implications
-The amount of sleep required is 7 to 9 hours.
-Sleep is affected by many factors: physical health, type of occupation, exercise. Lifestyle demands may interfere with sleep patterns.
-REM sleep averages about 20% of sleep.

**NURSING IMPLICATIONS**
-Reinforce that developing good sleep habits has a positive effect on health, particularly as a person ages.
If loss of sleep is a problem, explore lifestyle demands and stress as possible causes.
-Suggest use of relaxation techniques and stress-reduction exercises rather than resorting to medication to induce sleep. Sleep medications decrease REM sleep, may be habit forming, and frequently lose their effectiveness over time.
Middle-Aged Adults
Sleep Pattern & Nursing Implications
-Total sleep time decreases during these years, with a decrease in stage IV sleep.
-The percentage of time spent awake in bed begins to increase.
-People become more aware of sleep disturbances during this period.

**NURSING IMPLICATIONS**
-Encourage adults to investigate consistent sleep difficulties to exclude pathology or anxiety and depression as causes.
-Encourage adults to avoid use of sleep-inducing medication on a regular basis.
Older Adults
Sleep Pattern & Nursing Implications
-An average of 7 to 8 hours of sleep is usually adequate for this age group.
-Sleep is less sound, and stage IV sleep is absent or considerably decreased. Periods of REM sleep shorten.
-Older adults frequently have great difficulty falling asleep and have more complaints of problems sleeping.
-Decline in physical health, psychological factors, effects of drug therapy (e.g., nocturia), or environmental factors may be implicated as causes of inability to sleep.

**NURSING IMPLICATIONS**
-A comprehensive nursing assessment and individualized interventions may be effective in the long-term care of this age group.
-Emphasize concern for a safe environment because it is not uncommon for older adults to be temporarily confused and disoriented when they first awake.
-Use sedatives with extreme caution because of declining physiologic function and concerns about polypharmacy.
-Encourage older adults to discuss sleep concerns with their health care provider.
short sleeper
someone who sleeps less than 6 hours a night
Various studies confirm that adults and children who slept less than the recommended hours per night were more likely to be overweight. This sleep-weight link is possibly related to what two hormones?
leptin and ghrelin. Leptin signals the brain to stop eating, whereas ghrelin promotes continued eating. Research suggests that sleep deprivation lowers leptin levels and elevates ghrelin levels, thus increasing one's appetite.
People who suffer sleep difficulties caused by working night shifts or constantly changing work shifts may experience adverse effects, including?
anxiety, personal conflicts, loneliness, depression, gastrointestinal symptoms, increase in type 2 diabetes, hypertension, and higher rates of cardiovascular disease including strokes, and substance abuse
(Office of Disease Prevention and Health Promotion, 2017). The Joint Commission (2011) acknowledges the impact of fatigue on health care workers and urges greater attention to the issue, suggesting actions for health care facilities to reduce fatigue-related risks. These include:
-Assess work schedules and staffing to address extended work shifts and hours.
-Review hand-off processes and procedures to ensure safe transfer of information.
-Request staff input in designing work schedules to minimize staff fatigue.
-Develop and implement a fatigue management plan.
-Educate staff about sleep hygiene and the effects of fatigue on patient safety.
-Address staff concerns about fatigue.
-Encourage teamwork to support staff who work extended shifts.
=Keep the effects of fatigue in mind when reviewing adverse events.
Older adults developmental considerations
-Older adults often need more time to fall asleep and are less able to cope with changes in their usual sleep patterns compared to younger people.
-Many older adults nap during the day, which often results in sleeping fewer hours at night.
-Chronic illnesses in older adults may also affect their sleep patterns. For instance, many older men have enlargement of the prostate gland, which may cause them to awaken throughout the night to use the bathroom.
Certain illnesses are more closely related to sleep disturbances than others. For example:
-Gastric secretions increase during REM sleep. Many people with gastroesophageal reflux disease (GERD) awaken at night with heartburn or pain. They find that using antacids to neutralize stomach acidity often relieves discomfort and promotes sleep.
-The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep.
-Epilepsy seizures are most likely to occur during NREM sleep and appear to be depressed by REM sleep.
-Liver failure and encephalitis tend to cause a reversal in day-night sleeping habits.
-Hypothyroidism tends to decrease the amount of NREM sleep, especially stages II and IV, while hyperthyroidism may result in difficulty falling asleep.
-End-stage renal disease (ESRD) disrupts nocturnal sleep and leads to excessive daytime sleepiness. -Patients with ESRD who receive dialysis also have a higher incidence of RLS (discussed later in the chapter), which possibly is related to the iron deficiency common in ESRD.
-anxiety, depression, bipolar disorder and ADHD
Factors affecting rest & sleep
Developmental considerations
Motivation
Culture
Lifestyle and habits
Physical activity and exercise
Dietary habits
Environmental factors
Psychological Stress
Illness
Medications
Common sleep disorders
-Insomnia
-Sleep-related breathing disorders
-Central disorders of hypersomnolence
-Circadian rhythm sleep-wake disorders
-Parasomnias
-Sleep-related movement disorders
What is insomnia?
-difficulty falling asleep, intermittent sleep, or difficulty maintaining sleep, despite adequate opportunity and circumstances to sleep
•As many as 30 to 35 % of adults in the United States complain of insomnia.
•People older than 60, women (especially post menopausal), and people with a history of depression are more likely to experience insomnia.
•Older adults who have insomnia in the acute care setting may exhibit delirium as a symptom of their sleep deprivation.
•Many cases of insomnia are related to disruptions in circadian rhythms.
•Insomnia may be short-term or chronic in nature
•Always try nonpharmacologic treatments first
Obstructive sleep apnea (OSA)
-a potentially serious sleep disorder in which the throat muscles intermittently relax and block the airway during sleep, causing breathing to repeatedly stop and start. Obstructive sleep apnea occurs when the airway is occluded due to recurrent collapse of the upper airway. Normally, the airway remains open during sleep
•Characterized by five or more predominantly obstructive respiratory events
•The absence of breathing [apnea]
•Diminished breathing efforts [hypopnea]
•Respiratory effort-related arousals during sleep, accompanied by sleepiness, fatigue, insomnia, snoring
•Subjective nocturnal respiratory disturbance
•Observed apnea and associated health disorders (HTN, CAD, A fib, CHF, stroke, DM, cognitive dysfunction or mood disorder)
Hypersomnolence
excessive daytime sleepiness
Idiopathic hypersomnia
characterized by excessive sleep, particularly during the day. A person may fall asleep for intervals during work, while eating, or even during conversations. These naps do not usually relieve their symptoms. When they awake, they are often disoriented, irritated, restless, and have slower speech and thinking processes.
Narcolepsy
a condition characterized by excessive daytime sleepiness and frequent overwhelming urges to sleep or inadvertent daytime lapses into sleep. A person with narcolepsy can literally fall asleep standing up, while driving a car, in the middle of a conversation, or while swimming
•Up to 70% of people with narcolepsy also experience cataplexy, the sudden, involuntary loss of skeletal muscle tone lasting from seconds to one or two minutes.
Circadian rhythm sleep-wake disorders
are characterized by a chronic or recurrent pattern of sleep-wake rhythm disruption primarily caused by an alteration in the internal circadian timing system or misalignment between the internal circadian rhythm and the sleep-wake schedule desired or required; a sleep-wake disturbance (e.g., insomnia or excessive sleepiness); and associated distress or impairment, lasting for a period of at least 3 months (except for jet lag disorder) (Sateia, 2014). There are several disorders within this group of sleep disorders, with the most common being shift work disorder and jet lag disorder.
Parasomnias
patterns of waking behavior that appear during REM or NREM stages of sleep. They are more commonly seen in children.
Examples of parasomnias include:
Somnambulism or sleepwalking may range from sitting up in bed to walking around the room or the house to walking outside the house. The sleepwalker is unaware of his environment.
REM Sleep Behavior Disorder (RBD) is characterized by "acting out" dreams while asleep. While experiencing the dream episode, the sleeper can moan and thrash around in the bed, possibly causing harm to a bed partner or oneself (American Sleep Association, 2010).
Sleep terrors are more common in children and occur during the deepest stages of sleep. Typical behavior involves waking up screaming and sitting up in bed. They may appear to be awake and reasonable but are unable to communicate when they awaken from a sleep terror.
Nightmare disorder involves frightening dreams that are vivid and disturbing. They occur more frequently in children and represent a normal developmental process.
Sleep enuresis is urinating during sleep or bedwetting. It occurs most commonly in males who are over 3 years of age.
Sleep-related eating disorder occurs when a person eats while sleeping but has no recollection of eating in the morning. It can occur during sleepwalking and those affected can gain weight and experience injury either from cooking in their sleep or eating potentially dangerous raw food. They may also exhibit signs of sleep disruption during waking hours.
Parasomnias may be treated by
improving sleep habits, including maintaining a regular sleep schedule; good sleep hygiene, and obtaining an adequate amount of sleep. Medication may be used to control symptoms if the behaviors associated with the parasomnia cause a risk for injury to or disrupt the sleep of the patient or another person
Restless legs syndrome (RLS)
-a neurological disorder characterized by uncomfortable feelings in the legs, producing a strong urge to move them.
-affects up to 15% of the population(most common in middle aged and older adults)
•People with restless legs syndrome (RLS) cannot lie still and report unpleasant creeping, crawling, or tingling sensations in the legs.
•OTC meds such as antihistamines can exacerbate symptoms
Treatment options for RLS
-Eliminating use of caffeine, tobacco, and alcohol
-Taking a mild analgesic at bedtime (provided it is compatible with the current medical regimen)
-Applying heat or cold to the extremity
-Using relaxation techniques. Biofeedback and transcutaneous electrical nerve stimulation (TENS) may also relieve symptoms (see the accompanying Promoting Health Literacy display on page 1212).
Sleep deprivation
a decrease in the amount, consistency, or quality of sleep. It may result from decreased REM sleep or NREM sleep.
•Manifestations progress from irritability and impaired mental abilities to a total disintegration of personality
•Produces changes in physical and mental functioning
•Prolonged sleep deprivation associated with obesity, altered healing, depression, cancer, diabetes, and cardiovascular conditions
What is a sleep diary and what does it consist of?
A sleep diary or log provides more specific data on the patient's sleep-wakefulness patterns over a period of time.
-Time patient retires
-Time patient tries to fall asleep
-Approximate time patient falls asleep
-Time of any awakenings during the night and when sleep was resumed
-Time of awakening in the morning
-Presence of any stressors patient believes are affecting his or her sleep
-A record of any food, drink, or medication patient believes has positively or negatively influenced his or her sleep (include time of ingestion)
-Record of physical activities—type, duration, and time
-Record of mental activities—type, duration, and time
-Record of activities performed 2 to 3 hours before bedtime, bedtime rituals, changes in sleep environment
-Presence of any worries or anxieties patient believes are affecting his or her sleep
Disturbed sleep pattern if the problem is time limited; or Sleep deprivation if the problem is prolonged. Common etiologies for these nursing diagnoses may include the following:
Impaired comfort or pain
Changes in bedtime rituals or sleep environment
Disruption of circadian rhythm
Sleep apnea
Sustained inadequate sleep hygiene
Drug dependency and withdrawal
Symptoms of physical illness
In these nursing diagnoses , the disturbed sleep pattern is the cause of another problem:
Insomnia related to inadequate sleep hygiene and anxiety
Risk for injury related to somnambulism, narcolepsy, sleep apnea
Deficient knowledge (e.g., nonpharmacologic remedies for insomnia) related to misinformation, lack of interest in learning, cognitive limitation
Whenever nurses care for a patient, nursing measures support the following expected patient outcomes: The patient will:
Maintain a sleep-wake pattern that provides sufficient energy for the day's tasks
Demonstrate self-care behaviors that provide a healthy balance between rest and activity
Identify stress-relieving rituals that enable the patient to fall asleep more easily
Demonstrate decreased signs of sleep deprivation
Verbalize feeling less fatigued and more in control of life activities
Means for dealing with stress and anxiety
dealing with problems as they arise, conditioning yourself to consider stressful issues only at certain times, teaching yourself that worrying never solves problems and is counterproductive, and giving the worries over to another.A backrub, music, a warm bath, and washing the face if the patient is bedridden are nursing measures that may be used to help patients relax.
Offering Appropriate Bedtime Snacks and Beverages
combining foods that are high in tryptophan with healthy, complex carbohydrates improves sleep.An alcoholic beverage helps to promote sleep for some people. However, alcohol after dinner generally should be avoided because it may interrupt the normal sleep cycle and interfere with deep sleep. For most patients, beverages containing caffeine should be avoided for at least 4 to 5 hours before bedtime. Recommend that the patient take fluids during the day but avoid excessive fluid intake before bedtime to prevent the need to use the bathroom during the night.
Appropriate nursing measures for providing comfort
remaining with a lonely and frightened child or adult, using the simple strategy of caring presence and touch, offering a back massage, obtaining an extra blanket, or administering an analgesic.
Respecting Normal Sleep-Wake Patterns
Make every effort to allow patients to experience their normal period of sleep. The patient's normal napping habits should also be followed when possible. REM sleep is more common during morning naps, whereas NREM sleep is more common during naps later in the day. With this knowledge, help patients plan napping periods that best fit their needs and interfere the least amount with nighttime sleeping.
Nursing interventions to manage the level of light and sound, thus facilitating a more restful environment, include:
Maintaining a brighter room environment during daylight hours and dim lights in the evening
Decreasing the volume on alarms, telephones, overhead paging, and staff conversations
Closing doors to patient rooms
Scheduling procedures together so as not to awaken patients multiple times for vital signs, blood draws, bathing, or medication administration that can safely be postponed for a short time
Medicating for pain if needed
Keeping the room cool and providing earplugs and eye masks if requested and as appropriate
Sedative-hypnotic drugs
commonly prescribed for treatment of sleep disorders. These medications are used to induce sleep and maintain sleep, and include barbiturates, benzodiazepines, and nonbenzodiazepines, as well as some miscellaneous drugs.
short-acting hypnotics
inducing sleep and allowing the patient to awaken early in the morning without experiencing lingering side effects
Intermediate-acting hypnotics
are useful for sustaining sleep, but may be associated with residual drowsiness or hangover in the morning
Sleep hygiene suggestions include the following:
Restricting the intake of caffeine, nicotine, and alcohol, especially later in the day
Avoiding mental and physical activities after 5 PM that are stimulating
Avoiding daytime naps
Eating a light carbohydrate/protein snack before bedtime
Avoiding high fluid intake in the evening so as to minimize trips to the bathroom during the night
Sleeping in a cool, dark room
Eliminating use of a bedroom clock
Taking a warm bath before bedtime
Trying to keep the sleep environment as quiet and stress-free as possible
Stimulus control involves using the bedroom for
sex and sleep only
Sleep restriction is based on the theory of
limiting the time in bed to actual sleep time.
Nursing care is considered effective if the patient is able to:
Verbalize feeling rested or having had a restful night's sleep
Identify factors that interfere with or disrupt the normal sleep pattern
Use techniques that promote sleep and provide a restful environment
Concentrate and function effectively during waking hours
Eliminate behaviors related to sleep deprivation
____are powerful regulators of the sleep-wake circadian rhythm.
Light and Dark
Most people go through ____ cycles of sleep each night, alternating between REM and NREM sleep.
four or five
Health conditions that are associated with insomnia include
obesity, type 2 diabetes, psychiatric disorders, and cardiovascular disorders.
_______refers to nonpharmacologic recommendations that involve reviewing and changing lifestyles and environment in order to facilitate sleep.
Sleep Hygiene
characterized by five or more predominantly obstructive respiratory events (the absence of breathing [apnea] or diminished breathing efforts [hypopnea] or respiratory effort-related arousals) during sleep, accompanied by sleepiness, fatigue, insomnia, snoring, subjective nocturnal respiratory disturbance, or observed apnea and associated health disorders (hypertension, coronary artery disease, atrial fibrillation, congestive heart failure, stroke, diabetes, cognitive dysfunction or mood disorder)
OSA
_____ is the definitive treatment for moderate or severe obstructive sleep apnea.
Continuous positive airway pressure (CPAP)
Sleep deprivation can result in loss of
concentration, fatigue, excessive daytime sleepiness, and impaired performance, leading to serious safety risks.
A sleep diary and sleep screening tools can be used to assess
the quality of sleep and identify sleep disturbances.
Nursing diagnoses related to a disturbed sleep pattern can classify it as either
the problem or the etiology
______in a hospital setting can interfere with sleep and increase blood pressure, decrease oxygen saturation, and delay wound healing.
Noise-related disturbances
_______should be used to promote sleep before medications are prescribed.
Nonpharmacologic measures such as lifestyle changes
________ of the care plan necessitates the nurse's ongoing attention to the patient's sleep experience with modification of the care plan as needed.
evaluation
A nurse on a maternity ward is teaching new mothers about the sleep patterns of infants and how to keep them safe during this stage. What comment from a parent alerts the nurse that further teaching is required?
a.) "I can expect my newborn to sleep an average of 16 to 24 hours a day."
b.) "If I see eye movements or groaning during my baby's sleep I will call the pediatrician."
c.) "I will place my infant on his back to sleep."
d.) "I will not place pillows or blankets in the crib to prevent suffocation."
b. Eye movements, groaning, grimacing, and moving are normal activities at this age and would not require a call to the pediatrician. Newborns sleep an average of 16 to 24 hours a day. Infants should be placed on their backs for the first year to prevent SIDS. Parents should be cautioned about placing pillows, crib bumpers, quilts, stuffed animals, and so on in the crib as it may pose a suffocation risk.
A nurse observes involuntary muscle jerking in a sleeping patient. What would be the nurse's next action?
a.) No action is necessary as this is a normal finding during sleep.
b.) Call the primary care provider to report possible neurologic deficit.
c.) Lower the temperature in the patient's room.
d.) Awaken the patient as this is an indication of night terrors.
a. Involuntary muscle jerking occurs in stage I NREM sleep and is a normal finding. There are no further actions needed for this patient.
A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply.
a.) He is aware of his surroundings at this point.
b.) He is in delta sleep at this time.
c.) It would be most difficult to awaken him at this time.
d.) This is most likely an NREM stage.
e.) This stage constitutes around 20% to 25% of total sleep.
f.) The muscles are relaxed in this stage.
c, e. This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20% to 25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. Delta sleep is NREM stages III and IV sleep. In stage IV NREM sleep, the muscles are relaxed, whereas small muscle twitching may occur in REM sleep.
A nurse working in a sleep lab observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply.
a.) REM sleep constitutes much of the sleep cycle of a preschool child.
b.) By the age of 8 years, most children no longer take naps.
c.) Sleep needs usually decrease when physical growth peaks.
d.) Many adolescents do not get enough sleep.
e.) Total sleep decreases in adults with a decrease in stage IV sleep.
f.) Sleep is less sound in older adults and stage IV sleep may be absent.
d, e, f. Many adolescents do not get enough sleep due to the stresses of school, activities, and part-time employment causing restless sleep. Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older adults, and stage IV sleep is absent or considerably decreased. REM sleep constitutes much of the sleep cycle of a young infant, and by the age of 5 years, most children no longer nap. Sleep needs usually increase when physical growth peaks.
A nurse is discussing with an older adult patient measures to take to induce sleep. What teaching point might the nurse include?
a.)Drinking a cup of regular tea at night induces sleep.
b.)Using alcohol moderately promotes a deep sleep.
c.)Having a small bedtime snack high in tryptophan and carbohydrates improves sleep.
d.)Exercising right before bedtime can hinder sleep.
c. The nurse would teach the patient that having a small bedtime snack high in tryptophan and carbohydrates improves sleep. Regular tea contains caffeine and increases alertness. Large quantities of alcohol limit REM and delta sleep. Physical activity within a 3-hour interval before normal bedtime can hinder sleep.
A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply.
a.) A patient who has uncontrolled hypothyroidism.
b.) A patient with coronary artery disease.
c.) A patient who has GERD.
d.) A patient who is HIV positive.
e.) A patient who is taking corticosteroids for arthritis.
f.) A patient with a urinary tract infection.
a, b, c. A patient who has uncontrolled hypothyroidism tends to have a decreased amount of NREM sleep, especially stages II and IV. The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep, and a patient who has GERD may awaken at night with heartburn pain. Being HIV positive, taking corticosteroids, and having a urinary tract infection does not usually change sleep patterns.
A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply.
a.) A patient who is taking iron supplements for anemia.
b.) A patient with Parkinson's disease who is taking dopamine.
c.) An older adult taking diuretics for congestive heart failure.
d.) A patient who is taking antibiotics for an ear infection.
e.) A patient who is prescribed antidepressants.
f.) A patient who is taking low-dose aspirin prophylactically.
b, c, e. Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications are seen as additional common causes of sleep problems.
A nurse working the night shift in a pediatric unit observes a 10-year-old patient who is snoring and appears to have labored breathing during sleep. Upon reporting the findings to the primary care provider, what nursing action might the nurse expect to perform?
a.) Preparing the family for a diagnosis of insomnia and related treatments.
b.) Preparing the family for a diagnosis of narcolepsy and related treatments.
c.) Anticipating the scheduling of polysomnography to confirm OSA.
d.)No action would be taken, as this is a normal finding for hospitalized children.
c. OSA (pediatric) is defined by the presence of one of these findings: snoring, labored/obstructed breathing, enuresis, or daytime consequences (hyperactivity or other neurobehavioral problems, sleepiness, fatigue). According to the American Academy of Pediatrics children and adolescents with symptoms of OSA, including snoring, should have polysomnography to confirm the diagnosis. Although OSA may cause insomnia, this is not the primary diagnosis in this case. Narcolepsy is a condition characterized by excessive daytime sleepiness and frequent overwhelming urges to sleep or inadvertent daytime lapses into sleep. This scenario is not usually a normal finding in hospitalized children during sleep.
A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder?
a.) Circadian rhythm sleep-wake disorder
b.) Narcolepsy
c.) Enuresis
d.)Sleep apnea
b. Narcolepsy is an uncontrollable desire to sleep; the person may fall asleep in the middle of a conversation. Circadian rhythm sleep-wake disorders are characterized by a chronic or recurrent pattern of sleep-wake rhythm disruption primarily caused by an alteration in the internal circadian timing system or misalignment between the internal circadian rhythm and the sleep-wake schedule desired or required; a sleep-wake disturbance (e.g., insomnia or excessive sleepiness); and associated distress or impairment, lasting for a period of at least 3 months (except for jet lag disorder) (Sateia, 2014). Enuresis is urinating during sleep or bedwetting. Sleep apnea is a condition in which breathing ceases for a period of time between snoring.
A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply.
a.) Daily mental activities
b.) Daily physical activities
c.) Morning and evening body temperature
d.) Daily measurement of fluid intake and output
e.) Presence of anxiety or worries affecting sleep
f.) Morning and evening blood pressure readings
a, b, e. A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure is not usually kept in a sleep diary.
To promote sleep in a patient, a nurse suggests what intervention?
a.) Follow the usual bedtime routine if possible.
b.) Drink two or three glasses of water at bedtime.
c.) Have a large snack at bedtime.
d.) Take a sedative-hypnotic every night at bedtime.
a. Keeping the same bedtime schedule helps promote sleep. Drinking two or three glasses of water at bedtime will probably cause the patient to awaken during the night to void. A large snack may be uncomfortable right before bedtime; instead, a small protein and carbohydrate snack is recommended. Taking a sedative-hypnotic every night disturbs REM and NREM sleep, and sedatives also lose their effectiveness quickly.
A nurse is caring for an older adult who is having trouble getting to sleep at night and formulates the nursing diagnosis Disturbed sleep pattern: Initiation of sleep. Which nursing interventions would the nurse perform related to this diagnosis? Select all that apply.
a.)Arrange for assessment for depression and treatment.
b.) Discourage napping during the day.
c.) Decrease fluids during the evening.
d) Administer diuretics in the morning.
e.)Encourage patient to engage in some type of physical activity.
f.)Assess medication for side effects of sleep pattern disturbances.
a, b, e, f. For patients who are having trouble initiating sleep, the nurse should arrange for assessment for depression and treatment, discourage napping, promote activity, and assess medications for sleep disturbance side effects. Limiting fluids and administering diuretics in the morning are appropriate interventions for Disturbed Sleep Pattern: Maintaining Sleep.
A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. For what recommended treatment might the nurse prepare this patient?
A.)The use of a central nervous system stimulant
b.) Continuous positive airway pressure machine (CPAP)
c.) Chronotherapy
d.) The application of heat or cold therapy to promote sleep
c. Chronotherapy requires a commitment on the part of the patient to act over a period of weeks to progressively advance or delay the time of sleep for 1 to 2 hours per day. Over time, this results in a shift of the sleep-wake cycle. The use of a central nervous system stimulant is recommended for narcolepsy. Continuous positive airway pressure machine (CPAP) is used for OSA, and the application of heat or cold therapy to the legs is used to treat RLS.
A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep?
a.) Keep the room light dimmed during the day.
b.) Keep the room cool.
c.) Keep the door of the room open.
d.) Offer a sleep aid medication to patients on a regular basis.
b. The nurse should keep the room cool and provide earplugs and eye masks. The nurse should also maintain a brighter room environment during daylight hours and dim lights in the evening, and keep the door of the room closed. Sleep aid medications should only be offered as prescribed.
A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in older adults. Which action is recommended for these patients?
a.)Increase physical activities during the day.
b.)Encourage short periods of napping during the day.
c.)Increase fluids during the evening.
d.)Dispense diuretics during the afternoon hours.
a. In order to promote sleep in the older adult, the nurse should encourage daily physical activity such as walking or water aerobics, discourage napping during the day, decrease fluids at night, and dispense diuretics in the morning or early evening.
What is jet lag disorder?
a disruption of circadian rhythms due to crossing time zones
What is shift work disorder?
sleep deprivation and misalignment of the circadian rhythm secondary to nontraditional work hours
Treatment of dyssomnias
•Pharmacologic therapy
•Sedatives
•Hypnotics
•Nonpharmacologic therapy
•Cognitive Behavioral Therapy (CBT)
•Progressive muscle relaxation measures
•Stimulus control
•Sleep restriction; sleep hygiene measures
•Biofeedback and relaxation therapy
What are dyssomnias?
disorders that make it hard to fall asleep or stay asleep or avoid sleep.
Obtaining a Sleep History
Nature of problem
Cause of problem
Related signs and symptoms
When the problem began and how often it occurs
How the problem affects everyday living
Severity of the problem and how it can be treated
How the patient is coping with the problem and success of treatments attempted
(look at assessment 34-1) pg 1213
Screening Tools to Assess Sleep Disturbances
The Epworth Sleepiness Scale
The Pittsburgh Sleep Quality Index (PSQI)
Sleep Disturbance Questionnaire
What are the key findings physical assessment for sleep disorders?
•Energy level
•Facial characteristics
•Behavioral characteristics
•Physical data suggestive of sleep problems
Sleep Characteristics to Assess
Restlessness
Sleep postures
Sleep activities
Snoring
Leg jerking
Common Nursing Diagnoses for sleep
•Disturbed Sleep Pattern
•Sleep Deprivation
•Insomnia
•Risk for injury
•Deficient knowledge
Outcome Identification and Planning
•The patient will:
•Maintain a sleep-wake pattern that provides enough energy for the day's tasks
•Demonstrate self care behaviors that provide a healthy balance between rest and activity
•Identify stress-relieving rituals that enable the patient to fall asleep more easily
•Verbalize feeling less fatigued and more in control of life activities
Nursing Interventions to Promote Sleep
•Prepare a restful environment.
•Promote bedtime rituals.
•Offer appropriate bedtime snacks and beverages.
•Promote relaxation and comfort.
•Respect normal sleep-wake patterns.
•Schedule nursing care to avoid disturbances.
•Use medications to produce sleep.
•Teach about rest and sleep.
Teaching About Rest and Sleep
•Daily activity and exercise (at least 2 hours before bedtime)
•Avoid food, beverages, or OTC meds that contains caffeine in the evening
•Avoid heavy meals before bedtime
•Eat a light protein and carbohydrate containing snack at bedtime (if hungry)
•Keep usual wake patterns - even if go to bed later the night before
•Get out of bed if unable to fall asleep within 30 minutes and go into another room
•Limit fluids 2 - 4 hours before bedtime
•Engage in muscle relaxation if anxious or stressed.
•Limit alcohol and nicotine at least 4 hours before bedtime
•CBT may help with sleep
Sleep Hygiene. Nonpharmacologic recommendations that help a person get a better night's sleep
•Involve reviewing and changing lifestyles and environment
•Restrict caffeine, nicotine, and ETOH
•Avoid stimulating mental and physical activities after 5 pm
•Avoid daytime naps
•Eat light carbohydrate & protein snack before bedtime
•Avoid high fluid intake in the evening
•Sleep in a cool, dark room
•Eliminate use of a bedroom clock
•Warm bath before bedtime
•Keep sleep environment as quiet and stress free as possible
•Bedroom for sex and sleep only
•Relaxation exercises
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