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connotes a condition in which the bodyis in a decreased state of activity, with the consequent feelingof being refreshed.
factors affecting ability to rest
- - job demands
- - family responsibilities
- - children w/numerous extracurricular activities
- - environment
a state of rest accompanied by altered consciousness and relative inactivity. A complex rhythmic state involving a progression of repeated cycles, each representing different phases of body and brain activity. (Although sensitivity to external stimuli is diminished during sleep, this sensitivity can be readily reversed.)
national sleep foundation 2005 American poll reported 60% of Americans admitted to driving while feeling drowsy. 37% admitted to falling asleep while driving. NHTSA (2005) reported driver's fatigue is responsible for:
- 100,000 police reported accidents
- 1,550 fatalities
- 71,000 injuries
- $12.5 million in monetary losses in a yr
The discomfort produced by illness and the need for hospitalization and treatment may interfere dramatically with a patient’s ability to sleep. Consequently, nurses need to be vigilant in detecting and treating sleep disturbances.
reticular activating system (RAS)
- - System in brainstem (one of two) believed to work w/bulbar synchronizing region to control the cyclic nature of sleep. The RAS extends upward through the medulla, the pons, the midbrain, and into the hypothalamus.
- - Facilitates reflex and voluntary movements as well as cortical activities related to a state of alertness.
- - Comprises many nerve cells and fibers. The fibers have connections that relay impulses into the cerebral cortex and spinal cord. During sleep, the RAS experiences few stimuli from the cerebral cortex and the periphery of the body. Wakefulness occurs when this system is activated with stimuli from the cerebral cortex and from periphery sensory organs and cells. For example, an alarm clock awakens us from sleep to a state of consciousness, in which we realize that we must prepare for the day. Sensations such as pain, pressure, and noise produce wakefulness by means of peripheral organs and cells. (Basically controls cortical activies r/t state of alertness)
has control centers for several involuntary activities of the body, one of which concerns sleeping and waking. Injury to the hypothalamus may cause a person to sleep for abnormally long periods.
NTs involved in sleep
Norepinephrine and acetylcholine, in addition to dopamine, serotonin, and histamine, are involved with excitation. Gamma-aminobutyric acid (GABA) appears to benecessary for inhibition. However, research has yet to proveexactly how biochemical changes and hormones function insleep.
Rhythm that completes a full cycle q.24h; synonym for diurnal rhythm. (“Circa” in Latin means “approximately”and “diem” is the Latin word for “day”; circadian represents approximately 1 day.) Rhythmic biologic clocks are known to exist in plants, animals,and humans. Influenced by both internal and external factors, they regulate certain biologic and behavioral functions in humans. Some cycles are monthly, such as a woman’s menstrual cycle. Fluctuations in a person’s heart rate, blood pressure, body temperature, hormone secretions, metabolism, and performance and mood depend in part on circadian rhythms.
Sleep is one of the body’s most complex biologic rhythms. Circadian synchronization exists when an individual’s sleep–wake patterns follow the inner biologic clock.When physiologic and psychological rhythms are high or most active, the person is awake; when these rhythms are low, the person is asleep. Although light and dark appear to be powerful regulators of the sleep–wake circadian rhythm,they do not exert primary control. The regulating mechanism is the person’s individual biologic clock, which is subject to numerous influences, such as occupational demands and social pressures. Problems of desynchronization occur when sleep–wake patterns are frequently altered and the person attempts to sleep during high-activity rhythms or to work when the body is physiologically prepared to rest.
name the two major stgs of sleep
- 1. non–rapid eye movement (NREM) sleep
- 2. rapid eye movement (REM) sleep
- These stages have been studied and analyzed with the help of the electroencephalograph (EEG),which receives and records electrical currents from the brain;the electrooculogram (EOG), which records eye movements; and the electromyograph (EMG), which records muscle tone.
non–rapid eye movement (NREM) sleep
- - (comprising about 75% of total sleep) consists of four stages.
- - Stages I and II, consuming about 5% and 50% of a person’s sleep time, respectively, are light sleep. During these stages, the person can be aroused with relative ease.
- - Stages III and IV, each representing about 10% of total sleep time, are deep-sleep states, termed delta sleep or slow-wave sleep. The arousal threshold (intensity of stimulus required to awaken) is usually greatest in stage IV NREM.
- - Throughout the stages of NREM sleep, the parasympathetic nervous system dominates,and decreases in pulse, respiratory rate, blood pressure, metabolic rate, and body temperature are observed.
rapid eyemovement (REM) sleep
- - is more difficult to arouse a person during REM sleep than during NREM sleep.
- - In normal adults, the REM state consumes 20% to 25% of a person’s nightly sleep time.
- - People who are awakened during the REM state almost always report that they have been dreaming. They can usually vividly recall their dreams even if they were absurd or have no sensible meaning for them. Everyone dreams.
- - pulse, respiratory rate, blood pressure, metabolic rate, and body temperature increase, whereas general skeletal muscle tone and deep tendon reflexes are depressed.
- - is believed to be essential to mental and emotional equilibrium and to play a role in learning, memory, and adaptation.
Phenomenon when a person who is deprived of REM sleep for several nights generally then spends more time in REM sleep on successive nights; allows the total amount of REM sleep to remain fairly constant overtime.
Characteristics of NREM sleep: Stg 1
- - 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.
Characteristics of NREM sleep: Stg 2
- - The person falls into a stage of sleep.
- - The person can be aroused with relative ease.
- - This stage constitutes 50% to 55% of sleep.
Characteristics of NREM sleep: Stg 3
- - The depth of sleep increases, and arousal becomes increasingly difficult.
- - This stage composes about 10% of sleep.
Characteristics of NREM sleep: Stg 4
- - 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.
Characteristics of REM Sleep
- - 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
- - a person passes consecutively through the four stages of NREM sleep. This pattern is then reversed, and the person returns from stage IV to stage III to stage II. Instead of reentering stage I and awakening, the person enters into the REM stage of sleep, after which he or she reenters NREM sleep at stage II and returns to stages III and IV. If a person is awakened from sleep at any time, he or she returns to sleep again by starting at stage I of NREM sleep.
- - Most people go through four or five cycles of sleep each night.
- - On average, each cycle lasts about 90 to 100 minutes.
- - The cycles tend to become longer as morning approaches.
- - Ordinarily, more deep sleep occurs in the delta stage (in stg 4 of NREM sleep) in the first half of the night, especially if one is tired or has lost sleep.
- - Variations in the sleep cycle occur according to age.
avg standard for sleep requirements for infants, children, and adults
- - infants: 14-20 hrs
- - children: 10-14 hrs
- - adults: 8 hrs has been the accepted standard, despite obvious variations seen in the general population. No rigid formula exists for the regular intervals and duration of sleep. It is important, however,that each person follows a pattern of rest that maintains well-being.
recommended hrs of sleep for adults is
7 to 9 hours
canbe considered a normal, protective body mechanism andnature’s warning that sleep is necessary
is abnormal and is often a symptom of illness
Sleep patterns of older adults vary, but 23% to 40% report recurring insomnia at least a few nights a month. Older people often need more time to fall asleep, wake earlier and more frequently during the night,and are less able to cope with changes in their usual sleep patterns than are younger people. Many older individuals nap during the day, which often results in sleeping fewer hours at night. 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.
factors affecting sleep
- - psychological stress
- - motivation (A desire to be wakeful and alert helps overcome sleepiness and sleep. The opposite is also true: When there is minimal motivation to be awake, sleep generally follows.)
- - culture
- - lifestyle and habits (Based on the circadian cycle, the body prepares for sleep at night by decreasing the body temperature and releasing melatonin. Working a night shift disrupts this natural process and can result in loss of sleep and other adverse effects, such as anxiety, personal conflicts, loneliness, depression, GI symptoms, and substance abuse. Nurses who work long hours and varying shifts have difficulty finding time to exercise and this can promote weight gain. The longer work hours have also been identified as a factor in an increase in the number of errors while at work. Sleep can be affected by watching some types of television shows, participating in stimulating outside activities, and taking part in activity or exercise. One’s abilities to relax from work-related pressures and to put aside home stresses are also important factors in the ability to fall asleep.)
- - developmental considerations (variations in sleep patterns are related to age.)
- - physical activity and exercise (Activity and exercise increase fatigue and, in many instances, promote relaxation that is followed by sleep. It appears that physical activity increases both REM and NREM sleep. Moderate exercise is a healthy way to promote sleep, but exercise that occurs within a 2-hour interval before normal bedtime can hinder sleep.)
- - age
- - physical stresses/illness/medications (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. For short-term use, zaleplon (Sonata) and zolpidem tartrate (Ambien) are often prescribed to promote sleep in older adults because there is less residual sleepiness. Eszopiclone (Lunesta) is prescribed for longer-term treatment of chronic insomnia.)
- - dietary habits (Protein may actually increase alertness and concentration, whereas carbohydrates appear to affect brain serotonin levels and promote calmness and relaxation. Therefore, a small protein- and carbohydrate-containing snack may be effective. Alcoholic beverages, when used in moderation, appear to induce sleep in some people. However, large quantities have been found to limit REM and delta sleep. No caffeine, such as coffee, tea, cola, and chocolate. Nicotine has a stimulating effect, and smokers usually have a more difficult time falling asleep. Eliminating cigarette smoking after the evening meal appears to improve the smoker’s ability to fall asleep.People usually report improved sleep patterns after discontinuing nicotine use.Total withdrawal from smoking may be associated with temporary sleep disturbances.)
Developmental Patterns of Sleep for Newborns and Infants
- Sleep Pattern:
- • Newborn: Sleeps an average of 16 hours/24 hours; averages about 4 hours at a time.
- • Each infant’s sleep pattern is unique. On average, infants sleep 10 to 12 hours at night with possibly 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. 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.
Developmental Patterns of Sleep for Toddlers
- Sleep Pattern:
- • Need for sleep declines as this stage progresses. May initially sleep 12 hours at night with two naps during the day and end this stage sleeping 8 to 10 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 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.
Developmental Patterns of Sleep for Preschoolers
- Sleep Pattern:
- • Children in this stage generally sleep 9 to 16 hours at night, with 12 hours being the average.
- • 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 him or her generally helps. Sometimes use of a night light is soothing.
Developmental Patterns of Sleep for School-Aged Children
- Sleep Pattern:
- • Younger school-aged children may require 10 to 12 hours nightly, whereas older children in this stage may average 8 to 10 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.
Developmental Patterns of Sleep for Adolescents
- Sleep Pattern:
- • Sleep needs of teenagers vary widely. 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.
- • Many adolescents do not get enough sleep.
- Nursing Implications:
- • Advise parents that 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.
Developmental Patterns of Sleep for Young Adults
- Sleep Pattern:
- • The average amount of sleep required is 8 hours, but in fact,many young adults require less sleep.
- • 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 an individual 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.
Developmental Patterns of Sleep for Middle-Aged Adults
- Sleep Pattern:
- • 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.
- • Individuals 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.
Developmental Patterns of Sleep for Older Adult
- Sleep Pattern:
- • An average of 5 to 7 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.
- • Elderly people 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 maybe 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 people 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 people to discuss sleep concerns with their physicians.
a natural chemical produced at night that decreaseswakefulness and promotes sleep
Illnesses affecting sleep
- • Gastric secretions increase during REM sleep. Many people with peptic ulcers awaken at night with pain. They find that eating a snack or using antacids to neutralize stomach acidity often relieves discomfort and promotes sleep.
- • The pain associated with coronary artery disease (CAD) and myocardial infarction (MI) 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 hyperthyroidismmay 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 restless leg syndrome, which possibly is related to the iron deficiency common in ESRD.
- • Epilepsy - sleep is sluggish
growing field of study that involves the strategic use of time in the administration of medicine. Researchers have determined that certain treatments for disease are more effective when body rhythms are taken into account. For example, a larger mid-afternoon dose of asthma medication may be more effective in preventing attacks that commonly occur at night during sleep. The timing of antihypertensive medication administration may need to be adjusted to provide peak protection during early-morning hours, when heart attacks are more common. Cancer chemotherapy appears to be less toxic when administered at certain times of the day. Paying attention to biologic rhythms may influence drug tolerance and medication effectiveness.
four major categories of sleep disturbances
- 1. Dyssomnias
- 2. Parasomnias
- 3. Sleep disorders associated with medical or psychiatric disorders
- 4. Other proposed disorders (sleep apnea)
sleep disorders characterized by insomnia or excessive sleepiness. (insomnia, hypersomnia, narcolepsy, sleep apnea, restless leg syndrome, sleep deprivation)
patterns of waking behavior that appear during sleep. (somnabulism, sleep talking, nocturnal erections, bruxism, enuresis, sleep-related eating disorder)
sleep related eating disorder
A type of parasomnia that is gaining more attention which is when the patient eats but does not remember eating in the morning. People with sleep-related eating disorder can gain weight and experience injury either from cooking in their sleep or eating potentially dangerous raw food. They also may experience sleep disruption.
talking in your sleep (type of parasomnia)
grinding of teeth during sleep (type of parasomnia)
urinating during sleep (type of parasomnia)
sleep walking (type of parasomnia)
screaming upon awakening due to a perceived threat (type of parasomnia)
- characterized by difficulty falling asleep, intermittentsleep, or early awakening from sleep. It is the mostcommon of all sleep disorders. People older than 60 years ofage, women (especially after menopause), and persons with a history of depression are more likely to experience insomnia.This sleep disorder can also occur during periods of stress, in situations involving some change in the normal environment,after traveling across time zones (jet lag), and as a result of the side effects of medications.
- Usually, people reporting insomnia have been observed tofall asleep more quickly and sleep more than they report theydo. However, the condition can lead to such distress that furtherwakefulness results. A person with insomnia oftenreports feeling tired, lethargic, and irritable during the day.Difficulty concentrating is also a common manifestation.
- Treatment of insomnia is usually unnecessary becausemost episodes last for only a short period. Insomnia that lastsless than 4 weeks is termed acute while chronic insomniapersists for 5 weeks to 6 months. Chronic insomnia is frequentlylisted as the motivating factor for a visit to a sleepdisorder clinic. Insomnia that lasts more than 6 months maybe termed persistent and may even continue throughout life.
- According to the Centers for Disease Control and Prevention(CDC) (2008), nearly 10% of the U.S. population suffersfrom chronic insomnia. Certain health conditions have beenassociated with chronic insomnia. They include obesity; type2 diabetes; psychiatric disorders, such as depression; and cardiovasculardisorders such as heart failure, stroke, hypertension,and myocardial infarction (heart attack). The misuse ofalcohol or caffeine can have an adverse effect on insomniaand stopping these behaviors may reduce or eliminate theinsomnia.
treatment of insomnia
- Nonpharmacological approaches should be attempted initiallyto resolve the insomnia. Cognitive Behavioral Therapy(CBT) is a safe, effective means of managing chronic insomniaand may include sleep hygiene measures, stimulus control,and sleep restriction therapy (NSF, 2008b). CBT involvesmeeting with a therapist and working through maladaptivesleep beliefs. It may also include biofeedback and relaxationtechniques. When used in conjunction with these other complementarytherapies, CBT is very successful. If, however,these measures prove ineffective, pharmacologic treatmentmay be necessary. Pharmacologic options include the use ofsedatives and hypnotics. However, only short-term use, atthe lowest dose, is recommended.
- Also, Sleep hygiene
- nonpharmacologic recommendationsthat help an individual get a better night’s sleep. Theseentail reviewing and changing lifestyles and environment.
- Sleep hygiene suggestions include the following:
- • Restricting the intake of caffeine, nicotine, and alcohol,especially later in the day.
- • Avoiding activities after 5 p.m. that are stimulating.
- • Avoiding naps.
- • Eating a light meal before bedtime.
- • 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 as possible
using the bedroom for sex andsleep only. People with insomnia who have problems initiating sleep should stay in the bedroom for only 15 to 20 minutes.If after this time they cannot fall asleep, they should leavethe room and return only when they feel sleepy. Getting upat the same time every day, no matter what time the personfell asleep, and refraining from napping during the day arerecommended.
- helps to determine sleep patterns. The focus of sleep restriction is to avoid naps and early bedtimes and, actually, change the way an individual sleeps.
- A sleep diary or log provides more specific data on the patient’s sleep–wakefulness patterns over a long period. It summarizes information about these patterns, possibly indicating activities and behaviors that affect the quality and quantity of sleep. Generally, the diary is kept for 14 days and typically includes a graph of the total number of hours of sleep per day. Depending on the nature of the problem, graphs may be made of the number of undisturbed hours of sleep, number of awakenings, and so forth. In addition, a daily record is completed addressing the following:
- • 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) -- caffeine gets in way *test question*
- • 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
- It is helpful if the patient has a bed partner who can assistwith the diary. The patient needs to understand that the diaryis simply a diagnostic tool. If keeping the diary causes toomuch stress for the patient and further interferes with his orher ability to sleep restfully, it should be discontinued.
involves any type of relaxation, such as progressive muscle relaxation, imagery training, or meditation.Not all relaxation methods are beneficial for all patients.
- a condition 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.Causes of hypersomnia are varied. They may include:
- • Another sleep disorder, such as sleep apnea
- • Drug or alcohol abuse
- • Head trauma or other injury to the central nervous system
- • Effect of certain medications
- • Depression
- • Obesity
- • Other medical conditions (multiple sclerosis, epilepsy).
- Some individuals may have a genetic predisposition to hypersomnia. It appears most often in adolescents and young adults.
treatment for hypersomnia
treatment of hypersomnia is symptomatic in nature. Stimulant drugs may prove effective, or in some cases, antidepressants may be prescribed. Attention to diet (avoidance of alcohol and caffeine) and behavioral changes (avoidance of night work and social activities later in the evening) mayoffer some relief from such episodes. Although not usually life threatening, hypersomnia can have some serious consequences, such as motor vehicle accidents that occur because of drowsiness or falling asleep while driving. These attacks may occur indefinitely.
condition characterized by an uncontrollable desire to sleep. A person with narcolepsy can literally fall asleep standing up, while driving a car, in the middle of a conversation, or while swimming. Individuals with narcolepsy tend to fall asleep quickly, find it difficult to wake up, sleep fewer hours than others, and sleep restlessly. Narcolepsy is considered a neurologic disorder. The condition usually begins in susceptible people during adolescence or early adulthood and continues through life. Sleepiness during the day is often the first symptom of narcolepsy, which usually occurs several years before experiencing any difficulty with nighttime sleep.
common features of narcolepsy
- • Sleep attacks: irresistible urge to sleep, regardless of thetype of activity in which the patient is engaged
- • Cataplexy: sudden loss of motor tone that may cause theperson to fall asleep; usually experienced during a periodof strong emotion
- • Hypnagogic hallucinations: nightmares or vivid hallucinations
- • Sleep-onset REM periods: during a sleep attack, the personmoves directly into REM sleep
- • Sleep paralysis: skeletal paralysis that occurs during the transition from wakefulness to sleep
- Presence of any two symptoms helps to confirm the diagnosis. Undiagnosed, a person with narcolepsy is potentially dangerous to himself or herself and others. In some countries, a person with a diagnosis of narcolepsy is not permitted to drive a motor vehicle. A central nervous system stimulant (e.g., methylphenidate [Ritalin]) that causes wakefulness may be used to control narcolepsy. Additional medications such as modafinil (Provigil), a wakefulness-promoting compound, and sodium oxybate (Xyrem), a sedative used for treating disturbed nocturnal sleep, have proved effective in treating narcoleptic symptoms. People using such drugs should take them faithfully because with discontinuation of use, the uncontrollable desire to sleep returns.
condition in which a person experiences theabsence of breathing (apnea) or diminished breathing efforts(hypopnea) during sleep between snoring intervals. Breathingmay cease for 10 to 20 seconds, possibly as long as 2 minutes.During long periods of apnea, the oxygen level in the blooddrops, the pulse usually becomes irregular, and the blood pressureoften increases. Many people experience sleep apneawithout symptoms, but excessive daytime sleepiness is commonlyreported. Although it occurs most commonly in middleagedmen who are obese and have short thick necks, womenand people of other ages may also experience it. Obstructive sleep apnea (OSA) can result when the airwayis occluded because of the collapse of the hypopharynx(Fig. 34-4) or from other structural abnormalities such asenlarged tonsils and adenoids, a deviated nasal septum, andthyroid enlargement. Narrowing of nasal passagewayscaused by allergic rhinitis or nasal polyps is another factorcontributing to OSA.Some investigators have theorized that sleep apnea mayexplain certain cases of death that occur during sleep.According to recent research, individuals with OSA had“more than twice the number of cardiac deaths during sleepinghours compared to the general population” (O’Brien,2007). In healthy people, OSA may impair cardiac functionover time and lead to the development of heart failure. Ifheart failure has already been diagnosed, OSA may result inprogression of this condition. Sleep apnea and heart failureare a dangerous combination, making it even more importantto recognize and treat OSA.Clinical information and polysomnography can confirmthe diagnosis of sleep apnea. This overnight sleep study consistsof an EEG recording of the stages of sleep and anyepisodes of apnea, an electrooculogram that detects eyemovements, and an electromyographic recording of musclemovement (Shields, 2008). Cardiopulmonary monitoring ofthe arterial oxygen saturation and an electrocardiogram(ECG) to detect any cardiac arrhythmias can also assist inthe diagnosis of obstructive sleep apnea.People with obstructive sleep apnea may become irritableduring the day, fall asleep during monotonous activities,have difficulty concentrating, and exhibit slower reactiontimes. They are also more likely to be involved in motor vehicleaccidents. Alcohol, tobacco, and sleeping pills increase thebreathing disruption that occurs in sleep apnea and should beavoided.
treatment of sleep apnea
Treatment of moderate obstructive sleep apnea may consistof removing the tonsils or using an oral appliance whensleeping. If this is ineffective, continuous positive airwaypressure (CPAP) may be recommended. CPAP is noninvasive and consists of a mask connected to an air pump that is wornduring sleep. This device delivers positive air pressure thatholds the airway open. Many patients discontinue use of CPAPbecause of a sensation of claustrophobia, discomfort exhalingagainst air inflow, or dryness and skin irritation. If conservativetreatment methods fail, surgery to remove soft tissue atthe back of the mouth may be an option. This surgery is notwithout risks and poses significant postoperative issues for thepatient. Individuals who opt for the procedure need continuedsupport and comprehensive teaching, including coping strategies,for the immediate postoperative period.
restless leg syndrome (RLS)
- cannot lie stilland report unpleasant creeping, crawling, or tingling sensationsin the legs. Usually, these sensations are in the calf, butthey may occur anywhere from the ankle to the thigh.Patients describe an irresistible urge to move the legs whenthese sensations occur, usually during the evening and night.In some cases, symptoms may affect both sides of the body.Almost one-fourth of the individuals diagnosed with RLShave an iron deficiency but the reason for this association isunclear. RLS is also seen in patients with end-stage renaldisease (ESRD) and in pregnant women. Over the countermedications such as antihistamines can exacerbate thesymptoms of RLS. This disorder has no cure.
- Although restless leg syndrome is a common sleep disorderthat affects up to 15% of the population, many healthcareworkers are unaware of its existence. The acronym URGEsummarizes the symptoms and criteria for diagnosis of RLS:
- U – urge to move the legs
- R – rest-induced
- G – gets better with activity
- E – evening symptoms more severe
treatment options for RLS
- Massaging the legs, walking, doing knee bends, and movingthe legs sometimes bring relief. Research continues into additionaltreatment options, but the following may prove effective:
- • Eliminating use of caffeine, tobacco, and alcohol.
- • Taking a mild analgesic at bedtime (provided it iscompatible with the current medical regimen).
- • Applying heat or cold to the extremity.
- • Using relaxation techniques. Biofeedback and transcutaneouselectrical nerve stimulation (TENS) may alsorelieve symptoms
- Ropinirole (Requip), a drug used to treat symptoms of Parkinson’s disease, has been approved by the FDA to treat restless leg syndrome. A newer drug in the same category, pramipexole dihydrochloride (Mirapex), has also proved effective for relief of the symptoms of RLS.
- The Restless Legs Syndrome Foundation (http://www.rls.org) is a support group available for the millions of peoplewith this disorder who experience chronic sleep loss.
decrease in the amount, consistency,or quality of sleep. It may result from decreased REMsleep or NREM sleep. Total sleep deprivation is rarely seen,other than in experimental settings. There are many causes,and the manifestations progress from irritability and impairedmental abilities to a total disintegration of personality. In general,the effects of sleep deprivation become increasinglyapparent after 30 hours of continual wakefulness.Partial sleep deprivation may result in loss of concentration,inattention, and impaired information processing and posesserious safety risks. Excessive daytime sleepiness, a form ofpartial sleep deprivation, impairs performance at times whenindividuals need to be alert. The strange environment of thehospital, physical discomfort and pain, the effects of medications,and the need for 24-hour nursing care may also contributeto sleep deprivation in hospitalized patients. It is unclear whether irreversible damage to body tissueresults from prolonged or chronic sleep deprivation. However,sleep deprivation clearly produces changes in physicaland mental functioning, supporting the belief that sleep isessential for well-being. Even mild OSA with its accompanyingdecreased quality of sleep and constant fatigue isthought to “put stress on the body equivalent to five years ofaging” Sleep deprivation may be caused byshorter periods of sleep, which over time can cause impairment.Whether it occurs as a result of a disorder or it is voluntarysleep curtailment, sleep deprivation has wide-rangingnegative consequences for human health and well-being.
The findings in the physical assessment may either confirmthat the patient is getting sufficient rest to provide energy forthe day’s activities or validate the existence of a sleep disturbancethat is decreasing the quantity or quality of sleep. Keyfindings include energy level (presence of physical weakness,fatigue, lethargy, or decreased energy), facial characteristics(narrowing or glazing of eyes, swelling of eyelids,decreased animation), or behavioral characteristics (yawning,rubbing eyes, slow speech, slumped posture). Physicaldata suggestive of potential sleep problems (e.g., obesity, enlarged neck, deviated nasal septum) may also be noted.
Observed in 10% to 20% of chronic insomniacs, involves marked muscle contractions thatresult in the jerking of one or both legs during sleep. Thejerking lasts about 28 seconds, on average; may arouse thesleeper; and contributes to insomnia.
caused by an obstruction to airflow through thenose and mouth. Other than disturbing others in the samebedroom, snoring is not ordinarily a sleeping disorder. However,snoring accompanied by apnea can present a problem.When snoring changes from the characteristic sawing-woodsound to a more irregular silence followed by a snort, thisindicates obstructive apnea.
Common etiologies for these nursing diagnoses may include the following:
- • Physical discomfort or pain
- • Emotional discomfort or pain caused by anxiety and stress
- • Changes in bedtime rituals or sleep environment
- • Disruption of circadian rhythm
- • Exercise just before sleep
- • Caffeine, nicotine, or alcohol intake after dinner
- • Drug dependency and withdrawal
- • Symptoms of physical illness
- Disturbed sleep pattern as the problem:
- - Anxiety
- - impaired gas exchange
- - risk for injury
- - low self esteem
- - impaired social interaction
- - disturbed thought process
- pt will
- - maintain sleep-wake pattern that provide sufficent energy for day tasks
- - demonstrate self-care behaviors that provide a healthy behavior between rest and activity
- - ID stress relieving rituals that enable one to fall asleep more easily
- - demonstrate decrease signs of sleep deprivation
- - verbalize feelings of less fatigue, more control of life activities
nursing interventions sleep promotion
- - prepare a restful environment
- - promote bedtime rituals
- - offer appropriate bedtime snacks and beverages (carbs)
- - promote relaxation and comfort
- - respect normal sleep-wake patterns
- - schedule nursing care to avoid disturbances
- - use meds to produce sleep
- - teach about rest and sleep
- - nurse evaluates the effectiveness of the plan of care (did it work?)
- - nurse checks to see whether the pt has met the individualized expected outcomes specified in the plan of care
- outcome achieved if:
- - pt verbalizes feelings of feeling rested/having a restful night's sleep
- - pt IDs factors that interfere w/ or disrupt the normal sleep pattern
- - pt uses techniques that promote sleep and a restful environment
- - the pt eliminates/minimizes behaviors r/t sleep deprivation
meds for sleep
The most commonly prescribed sleep aids belong to thesedative-hypnotic class of benzodiazepines. These drugsinclude flurazepam (Dalmane) and temazepam (Restoril).When used to induce sleep, both these drugs have the potentialto produce daytime drowsiness, a morning hangovereffect, and physical and psychological dependence. Drugs ina newer class of nonbenzodiazepines are less likely to cause adverse effects and have a lower risk of abuse. These morecommonly prescribed drugs include eszopiclone (Lunesta) and zolpidem (Ambien). The most recently approved sleepmedication is ramelteon (Rozerem). This drug is classified as a melatonin receptor agonist and it normalizes sleep cycles by enabling the body’s supply of melatonin to naturally promote sleep.
Variousstudies confirm that adults and children who slept less thantheir recommended hours per night were more likely to beoverweight. This sleep–weight link is possibly related to twohormones: leptin and ghrelin. Leptin signals the brain to stopeating, whereas ghrelin promotes continued eating. Researchsuggests that sleep deprivation lowers leptin levels and elevatesghrelin levels, thus increasing one’s appetite. To compound theproblem, a drop in leptin also can be interpreted by the brain asa sign of starvation. Unfortunately, the brain then signals thebody to eat more while it simultaneously lowers the body’smetabolic rate. When this happens, people are more likely togain weight, even if food intake is decreased. This informationappears to verify that lack of sleep affects not just the brain, butalso the entire body
involuntary muscle jerking occurs in stg 1 sleep in the other stgs, the muscles proceed from a relaxed state to large muscle immobility
During REM sleep, it's difficult to wake a person up and V/S increase. Delta sleep in NREM stgs III and IV sleep.
person goes through 4/5 cycles of sleep
chronic insomnia is the most common complaint of pts visiting sleep disorder clinics
hypothyrodism can interfere w/stg II and IV of NREM sleep. Chest pain occurs more frequently during REM sleep. Epileptic seizures occur more frequently during NREM sleep. Gastric secretions increase during REM sleep.
caffeine should be avoided 4/5 hrs before bedtime
A maternity nurse is instructing new parents on the proper sleeping position for their newborn child. In what position does the nurse instruct the parents to place the infant?
A patient reports that her naps after lunch often stretch to 3 hours in length and that she has great difficult rousing herself after a nap. This condition is best termed as which of the following?
Hypersomnia - a condition characterized by excessive sleep, particularly during the day.
The client is scheduled for a polysomnography to determine if the client has obstructive sleep apnea (OSA). The nurse instructs the client to
anticipate sleeping overnight at a healthcare center. - Polysomnography is a sleep study. The client will be scheduled for the study at a healthcare center and sleep overnight as part of the study. The client should avoid sedatives as this will aggravate OSA. Interventions for OSA include inserting an oral appliance or applying a facial mask for continuous positive airway pressure.
While instructing young adults about the need for adequate sleep, the nurse instructs the group that to improve sleep quality, individuals should
Have a consistent time for arising - A regular time of rising is one of the most effective means of improving sleep quality and synchronizing circadian rhythms with clock time.
A nurse is explaining the effect of a prescribed medication and the different phases of sleep to an insomniac client. Which of the following statements is true for non-rapid eye movement (REM) sleep?
It is called slow wave sleep. - Non-rapid eye movement sleep, which progresses through four stages, is also called slow wave sleep because during this phase, electroencephalographic (EEG) waves appear as progressively slower oscillations. The REM phase of sleep is referred to as paradoxical sleep because the EEG waves appear similar to those produced during periods of wakefulness but it is the deepest stage of sleep. NREM sleep is characterized as quiet sleep and REM sleep as active sleep.
A new mother calls the pediatric nurse to talk to the nurse about her baby who sleeps "all day long." The nurse informs the new mother that an infant requires how many hours of sleep?
14 to 20 hours of sleep each day
A patient in his 40s has asked the nurse how much sleep he should be getting in order to maximize his health and well-being. How should the nurse respond?
"Most adults need between 7 and 9 hours, but everyone is different."
The mother reports her 4-year-old child wakes frequently at night screaming. She also reports this occurs shortly after her son has fallen asleep. The nurse assesses the child takes a tub bath and the mother reads a story to her son prior to bedtime at 8 PM. The nurse intervenes by stating to the mother
- • "It is common for this to occur in this age group."
- • "Comforting your child when this occurs may help."
- • "You may find a night light in his room is helpful."
A patient has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning the patient complains of overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this patient's statement?
Assess the factors that the patient believes contribute to the problem.
Which of the following characteristics is associated with REM sleep?
The individual's facial muscles are twitching.
Name some chronic illnesses that
can affect sleep patterns
- Peptic ulcers- reflux, CAD hs
- angina, epilepsy seizure act, liver failure (enceph), hypothyroid (dec energy, inc sleep), meds/interactions
Dyssomnia that is an uncontrolled desire to sleep
What is somnabulism?
A parasomnia- sleep walking
What is the treatment for
obstructive sleep apnea?
CPAP @ hs to facilitate the flow of o2 forcing the airway to open by pos. pressure