1. Chapter 40 Rest and Sleep

2. Physiology of Sleep Reticular activating system (RAS)
Facilitates reflex and voluntary movements
Controls cortical activities related to state of alertness
Bulbar synchronizing region
Hypothalamus — control center for sleeping and waking
RAS and the bulbar synchronizing region work together to control the cyclic nature of sleep.
If the hypothalamus is injured, one may sleep for abnormally long periods.
Circadian rhythms (24h) hr, bp, temp, hormone secretion, metabolism and performance and mood depend on circadian rhythms.
Synchronization is when sleep-wake patterns follow inner biologic clock.

3. Stages of Sleep Non-rapid eye movement (NREM) Consists of four stages
Stage I and II — 5% to 50 % of sleep, light sleep
Stage III and IV — 10% of sleep, deep-sleep states (delta sleep)
Rapid eye movement (REM)

4. Sleep Cycle
The person passes consecutively through four stages of NREM sleep.
The pattern is then reversed.
Return from stage IV to III to II
Enter REM sleep instead of reentering stage I
The person reenters NREM sleep at stage II and moves on to III and IV.

5. Factors Affecting Sleep
Developmental considerations
Psychological stress
Motivation
Culture
Lifestyle and habits
Physical activity and exercise

6. Factors Affecting Sleep (continued)
Dietary habits
Environmental factors
Illness
Medications

7. Illnesses Associated With Sleep Disturbances
Peptic ulcers
Coronary artery diseases
Epilepsy
Liver failure and encephalitis
Hypothyroidism
Gastric secretions increase during rem sleep. Wake up at night with pain. May need to eat a snack or take antacid
CAD pain and IM more likely with REM sleep
Epilepsy seizures most likely occur NREM sleep and depressed by REM sleep

8. Dyssomnias Insomnia Hypersomnia Narcolepsy Sleep apnea
Restless leg syndrome
Sleep deprivation
Dyssomnias — characterized by insomnia or excessive sleepiness
Insomnia – difficulty falling asleep, intermittent sleep, or early awakening from sleep. Most common.
Can result from depression. Excessive alcohol or caffiene may cause. Tx the cause if known. Chronic insomina may be treated pharmacologically with use of sedatives and hypnotics. Use only short term and at lowest dose.
Hypersomnia – excessive sleep, particularly during the day. Can be a result of medical condition or as a coping mechanism in someone who has no desire or energy to face a new day.
Narcolepsy uncontrollable desire to sleep. Fall asleep while standing up, driving, middle of conversation, swimming. Pt fall asleep quickly, find it difficult to wake up, sleep fewer hours than others and sleep restlessly. Considered a neurologic disorder. First symptom is sleepiness during the day and usually precedes by several yrs of any difficulty with nightime sleep.
Sleep apnea pt experiences absence of breathing between snoring intervals. Breathing may cease for 10 to 20 seconds, may be as long as 2 minutes. During periods of apnea, o2 level in blood drops, pulse irregular, bp incrases. Some pts have no symptoms. Middle aged men obese and short thick necks.
Obstructive sleep apnea airway is occluded due to the collapse of the hypopharynx or ther structural abnormalities such as enlarged tonsils and adenoids, deviated nasal septum, and thyroid enlargement, narrowing of nasal passageways from allergic rhinitis. Can result in death.
Polysomnography only method confirm dx of sleep apnea. (Overnight sleep study) EEG records stages of sleep and episodes of apnea, electroloculogram detects eye movements and electromyographic recording of muscle movement. Cardioppulmonary o2 sats and ECG monitor cardiac arrhythmias.
TX remove tonsils ror using oral appliance when sleeping. CPAP – continous positive airway pressure. Mask connected to an air pump that is worn during sleep. It delivers positivie air pressure that holds the airway open. Noncompliance- claustrophobia, discomfort exhaling against air inflow, dryness, etc.
Restless leg syndrome- can’t lye still and report unpleasant creeping, crawling, or tingling sensations in the legs. Usually in the calf but maybe from anle to thigh. S/S irresistible urge to move the legs, pts will try to massage, walk, knee bends, or move the leg for relief.
Tx eliminate caffeine, tobacco, and alcohol, mild analgesisc, and antiemboliam stockings
Sleep deprivation decrease in the amount, consistency, or quality of sleep. May result from decreased REM or NREM sleep.

9. Parasomnias Somnambulism Sleep talking Nocturnal erections Bruxism
Enuresis
Sleep-related eating disorder
Parasomnias — patterns of waking behavior that appear during sleep
Somnambulism – sleep walking; sleeeptalking; nocturnal erections; bruxism (grinding of teeth during sleep) and enuresis (urinating during sleep)

10. Nursing Interview Identify patient’s sleep-wakefulness patterns
Identify effect of these patterns on everyday functioning
Assess patient’s use of sleep aids
Assess the presence of sleep disturbances and contributing factors

11. Sleep Disturbance Assessment Parameters
Nature and cause of problem
Accompanying signs and symptoms
Date of occurrence and effect of everyday living
Severity of the problem
Treatment of problem
How the patient is coping with the problem

12. Information Recorded in a Sleep Diary
Time patient retires
Time patient tries to fall asleep
Approximate time patient falls asleep
Time of any awakening during the night and resumption of sleep
Time of awakening in morning
Presence of any stressors affecting sleep

13. Information Recorded in a Sleep Diary (continued)
Record of food, drink, or medication affecting sleep
Record of physical and mental activities
Record of activities performed 2 to 3 hours before bedtime
Presence of worries or anxieties affecting sleep

14. Key Findings of Physical Assessment
Energy level
Facial characteristics
Behavioral characteristics
Physical data suggestive of sleep problems

15. Sleep Characteristics to Assess
Restlessness
Sleep postures
Sleep activities
Snoring
Leg jerking

16. Common Etiologies for Nursing Diagnoses
Physical or emotion discomfort or pain
Changes in bedtime rituals or sleep environment
Disruption of circadian rhythm
Exercise and diet before sleep
Drug dependency and withdrawal
Symptoms of physical illness

17. 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