Kozier Ch 44 Sleep

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cswett
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101891
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Kozier Ch 44 Sleep
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2011-09-15 10:40:58
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Sleep
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Sleep
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  1. Lack of Sleep
    • •Problem in US is lack of sleep:
    • –Causes decreased concentration, sleepiness, fatigue,
    • distractibility

    • •Chronic lack of sleep puts person at risk:
    • –Hypertension
    • –Diabetes
    • –Heart attack
    • –Stroke
    • –Accidents, especially car
  2. Physiologly of Sleep
    •Sleep is altered state of consciousness where perception of and reaction to environment decreased

    • •Person is unaware of the environment & will respond
    • selectively to external stimuli
    • –Meaningful stimuli: Alarm clock, smoke alarm
    • –Non-meaningful stimuli: Everyday noises, soft light
  3. Sleep & Wake Cycle - Wake
    • •Melatonin- decreased
    • •Cortisol- the “stimulating hormone” is increased
    • •Neurotransmitters associated with wakefulness are high:
    • –Acetylcholine
    • –Dopamine - helps connections of brain for parkinsons
    • –Noradrenaline
  4. Sleep & Wake Cycle - Sleep
    • •Neurotransmitters
    • –Serotonin- lessens response to sensory stimuli
    • –GABA- shuts off RAS
    • •Darkness & preparing for sleep
    • –decreases stimulation of RAS
    • •Hormones
    • –Melatonin- secreted, person feels less alert
    • –Growth hormone (GH)- secreted
    • –Cortisol- the “stimulating hormone” is inhibited
    • - - higer risk for diabeties
  5. Circadian Rhythm
    • •Humans have many biological rhythms
    • •Circadian rhythm is one type
    • •Circadian-means “about day” & involves the sleep-wake cycle
    • •Circadian synchronization
    • –Person awake when body temp highest and asleep when body temp lowest
    • *why hospital feels colder at night
  6. Sleep Cycles
    • •Refers to basic organization of sleep
    • •Two types that alternate in cycles during sleep
    • –NREM: non-rapid-eye movement
    • –REM: rapid eye movement
  7. NREM Sleep
    • •Occurs when activity in RAS inhibited
    • •Constitutes 75% - 80% of sleep
    • •Consists of 4 stages
    • –As progress through the stages:
    • •body systems slow down (BP, P, HR, CO, RR, metabolic rate, temp)
    • •Harder to awaken
    • •Skeletal muscles relax
    • •Intracranial pressure decreases

    • •Stage 1: lasts few minutes, light sleep, easily awakened
    • •Stage 2: lasts only 10-15 minutes, more difficult to
    • awaken
    • •Stage 3 & 4: deeper sleep, involves delta waves,
    • very difficult to awaken, snoring. Essential for restoring energy and releasing important growth hormones
  8. REM Sleep
    • •Occurs every 90 minute
    • •Lasts 5 to 30 minutes
    • •Acetylcholine and dopamine increase
    • •Most dreams take place
    • •Brain is highly active
    • •Brain metabolism increases as much as 20%
    • •Distinctive eye movements occur
    • •Voluntary muscle tone decreased
    • •Deep tendon reflexes absent
    • •Gastric secretions increase
    • •HR and RR often are irregular
    • •Regions of brain associated with learning, thinking, organizing information stimulated
    • –Lack of REM: apathy, depression, irritability, confusion, impaired memory
  9. Sleep Cycles
    • •Cycle through NREM and REM
    • •Complete cycle lasting 90-110 minutes
    • •Length of time for each stages varies with each cycle
    • •Adult sleeper has 4-6 cycles per 7-8 hours
    • •If awakened during a stage- must start at stage 1 NREM
  10. Sleep Patterns: Infants & Toddlers
    • •Infant:
    • –Awaken every 3 to 4 hours
    • –Periods of wakefulness gradually increase
    • –By 6 months, most infants sleep through the night
    • and establish a pattern
    • –Establish a pattern of daytime naps

    • •Toddler (1-3 years):
    • –Require 12 to 14 hours
    • –Most still need an afternoon nap
    • –Nighttime fears and nightmares are also common
  11. Sleep Patterns: Pre-school & school age children
    • •Preschool child (3-5 years)
    • –Require 11 to 13 hours of sleep
    • –Sleep needs fluctuate in relation to activity and
    • growth spurts

    • •School-age child (aged 5 to 12)
    • –Require 10-11 hours of sleep
    • –Most receive less
  12. Sleep Patterns: Adolescents
    • •Require 9-10 hours of sleep each night
    • •Few actually get that much sleep
    • •Circadian rhythms tend to shift
    • –Tendency to stay up later and wake later
  13. Sleep Patterns: Adults & Elders
    • •Adults
    • –Most healthy adults need 7-9 hours of sleep
    • –Individual variations

    • •Elders
    • –Tendency toward earlier bedtime and wake times
    • –May show an increase in disturbed sleep
    • –Need to sleep does not decrease with age
  14. Factors that Effect Sleep
    • •Illness
    • –Pain
    • –Endocrine disorders- thyroid, low estrogen, increased body temp, frequent urination
    • •Environment- hospital
    • •Lifestyle
    • –Jobs
    • –kids
    • •Emotional stress-
    • –anxiety stimulates sympathetic NS
    • •Stimulants
    • –Caffeine
    • –Alcohol (disturbs REM)
    • –Smoking
    • •Diet
    • –Some food promote sleep
    • –Weight gain & loss
    • •Motivation- forcing self to stay awake or interest in activity
    • •Medications- page 1172, Box 45-2
  15. Drugs that Disrupt Sleep
    • Alcohol
    • Amphetamines
    • Antidepressants
    • Beta-Blockers
    • Broncodialators
    • Caffeine
    • Decongestants
    • Narcotics
    • Steroids
  16. Sleep Disorder: Insomnia
    • •Difficulty falling asleep or remaining asleep
    • •Waking up frequently
    • •Daytime sleepiness
    • •Difficulty concentrating
    • •Irritability
    • •Risk factors
    • –Older age due to medical conditions
    • –Female- hormone fluctuations
  17. Sleep Disorders: Excessive Daytime Sleepiness
    • •Insufficient sleep
    • •Hypersomnia
    • –Has sufficient sleep at night but cannot stay awake
    • during day
    • –Medical cause (hypothyroidism)

    • •Narcolepsy
    • –Cause: lack of hypocretin in CNS that regulates sleep
    • –Have excessive daytime sleepiness & have sleep
    • attacks
    • –Sleep at night usually begins with sleep-onset REM
  18. Sleep Apnea
    • •Frequent short breathing pauses during night
    • •More than 5 apneic episodes > 10 sec/hr considered abnormal
    • •Symptoms include snoring, frequent awakenings, difficulty falling asleep, morning headaches, memory and cognitive problems, irritability
    • •Types include obstructive (mouth), central (resp center of brain), mixed
  19. Parasomnia
    • •Behavior that may interfere with or occur during sleep
    • •Arousal disorders
    • –Sleepwalking, sleep terrors
    • •Sleep-wake transition disorders
    • –Sleep talking
    • •Associated with REM sleep
    • –Nightmares
    • •Others
    • –Bruxism- teeth grinding, jaw clenching
  20. Sleep Pattern Assessment
    • •Sleep history
    • •When does client usually go to sleep?•Bedtime rituals?•Does client snore?•Can client stay awake during day?•Taking any prescribed or OTC medications?
    • •Health history
    • •Obtain information about medical or psychiatric problems that may influence sleep
    • •Medication history
    • •Physical exam
    • •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)

    • •Sleep diary
    • •Client may be asked to keep track of
    • –Time factors associated with sleep
    • –Activities performed 2-3 hours prior to sleep
    • –Consumption of caffeine, alcohol
    • –Medications
    • –Bedtime rituals
    • –Difficulty remaining awake during day
    • –Any worries or fears that may be contributing

    • •Diagnostic studies
    • •Polysomnography done in lab. These done together with electrodes to measure muscle movement and
    • brain waves:
    • –EEG (electroencephalogram)
    • –EMG (electromyogram)
    • –EOG (electro-oculogram)
    • •Other
    • –Measure ECG, resp, O2, leg movement
  21. NANDA Nursing Diagnosis
    • •Sleep deprivation
    • •Insomnia

    • •Other ND from sleep pattern disturbances:
    • –Risk for injury
    • –Ineffective coping
    • –Fatigue
    • –Risk for impaired gas exchange
    • –Anxiety
    • –Activity intolerance
  22. Nursing Interventions for Sleep Disturbances
    • •Reducing environmental distractions
    • •Promoting bedtime rituals
    • •Providing comfort measures
    • •Scheduling nursing care to promote uninterrupted sleep
    • •Teaching stress reduction, relaxation techniques or good sleep hygiene
  23. Sleep Hygiene
    • •Reducing environmental distractions
    • •Promoting bedtime rituals
    • •Providing comfort measures
    • •Scheduling nursing care to promote uninterrupted sleep
    • •Teaching stress reduction, relaxation techniques or good sleep hygiene
  24. Client Education
    • •The importance of sleep
    • •Conditions that promote or interfer with sleep
    • •Safe use of sleep medications
    • •Effects of prescribed medications on sleep
    • •Effects of disease states on sleep
  25. Bedtime Rituals
    • •Routines promote sleep. Usually first nursing intervention to try. If interfered with, can affect one’s sleep
    • •Adults
    • –Listening to music
    • –Reading
    • –Soothing bath
    • –Praying
    • •Children- need to be socialized into rituals
    • –Bedtime stories, holding favorite toy
  26. Medications
    • •Prescribed as PRN
    • •Sedative-hypnotics (induce sleep)-
    • –General CNS depression
    • –Unnatural sleep- NREM & REM is altered
    • –May cause daytime sleepiness & hangover
    • –Rebound insomnia
    • –Table 45-1 (Ambien- not alter REM)
    • –Barbituates (alter REM) cannot be stopped abruptly
    • •Anti-anxiety or tranquilizers-
    • –Suppress CNS response to stimuli
    • •Using medications:
    • –Be aware of actions, effects, risks of specific medications
    • –Use smallest does possible
    • –Regular use can cause tolerance & rebound insomnia
  27. Medications for Insomnia
    • Chloral hydrate (Noctec) - Half-life 7-10 hours
    • Eszopilone (Lunesta) - 6 hours
    • Ethchlorvynol (Placidyl) - 10-20 hours
    • Flurazepam (Dalmane) 47-100 hours
    • Glutethimide (Doriden) 1-12 hours
    • Lorazepam (Ativan) 10-20 hours
    • Melatonin - 1 hour
    • Temazepan (

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