1. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Chapter 42 Sleep

2. 2Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Physiology of Sleep  Circadian rhythms  Affected by light, temperature, social activities, and work routines.  The biological rhythm of sleep frequently becomes synchronized with other body functions.

3. 3Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Physiology of Sleep: Sleep Regulation  Regulated by a sequence of physiological states integrated by central nervous system (CNS) activity  Hypothalamus  Reticular activating system (RAS)  Bulbar synchronizing region (BSR)

4. 4Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. RAS and BSR

5. 5Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study  Walter Murphy is 82 years old and has resided in the local nursing home for the past 3 months. His wife, Mary, still lives at home but visits Walter on a daily basis. Walter is confined to a wheelchair as a result of osteoarthritis and a mild stroke he experienced 1 year ago. Even though he has physical limitations, he is alert and oriented.  Over the past several weeks, Mary found her husband to be very sleepy when visiting him just before lunchtime. Walter tells Mary that he has trouble falling asleep at night, and once he does fall asleep, he reawakens frequently during the night.

6. 6Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Stages of the Adult Sleep Cycle NREM Stage 2 NREM Stage 3 NREM Stage 4 NREM Stage 3 NREM Stage 2 REM

7. 7Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Functions of Sleep  Purpose of sleep  Remains unclear  Physiological and psychological restoration  Maintenance of biological functions  Dreams  Occur in nonrapid eye movement (NREM) and rapid eye movement (REM) sleep  Important for learning, memory, and adaptation to stress

8. 8Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Physical Illness  Physical illness can cause pain, physical discomfort, anxiety, depression, and sleep disturbances:  Hypertension  Respiratory disorders  Nocturia  Pain  Restless leg syndrome (RLS)

9. 9Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Terminology  Hypersomnolence = Excessive sleepiness.  A polysomnogram involves the use of electroencephalography (EEG), electromyography (EMG), and electro-oculography (EOG) to monitor stages of sleep and wakefulness during nighttime sleep.  Sleep hygiene = Practices that a patient associates with sleep.  Cataplexy is sudden muscle weakness during intense emotions such as anger, sadness, or laughter; it can occur at any time during the day.  Sleep paralysis is the feeling of being unable to move or talk just before waking or falling asleep.

10. 10Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Sleep Disorders Adjustment sleep disorder (acute insomnia), Inadequate sleep hygiene, Behavioral insomnia of childhood, Insomnia caused by medical condition Insomnia Primary central sleep apnea, Central sleep apnea caused by medical condition, Obstructive sleep apnea syndromes, Excessive daytime sleepiness Sleep apnea Cataplexy, Sleep paralysis Narcolepsy Emotional stress, Medications, Environmental disturbances, Symptoms Sleep deprivation Somnambulism (sleepwalking), Night terrors, Nightmares, Nocturnal enuresis (bed-wetting), Body rocking, Bruxism Parasomnias

11. 11Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Quick Quiz! 1.During rounds on the night shift, you note that a patient stops breathing for 1 to 2 minutes several times during the shift. This condition is known as A. Cataplexy. B. Insomnia. C. Narcolepsy. D. Sleep apnea.

12. 12Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Sleep and Rest  Rest contributes to:  Mental relaxation  Freedom from anxiety  State of mental, physical, and spiritual activity  Bed rest does not guarantee that a patient will feel rested.

13. 13Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Normal Sleep Requirements and Patterns

14. 14Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Quick Quiz! 2. A 4-year-old pediatric patient resists going to sleep. To assist this patient, the best action to take would be A. Adding a daytime nap. B. Allowing the child to sleep longer in the morning. C. Maintaining the child’s home sleep routine. D. Offering the child a bedtime snack.

15. 15Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Factors Affecting Sleep Physical illness Hypertension, respiratory, musculoskeletal, chronic illness, GI, nausea Drugs and substances Hypnotics, diuretics, narcotics, antidepressants, alcohol, caffeine, beta-blockers, anticonvulsants Lifestyle Work schedule, social activities, routines Usual sleep patterns May be disrupted by social activity or work schedule Emotional stress Worries, physical health, death, losses Environment Noise, routines Exercise and fatigue Moderate exercise and fatigue cause a restful sleep Food and calorie intake Time of day, caffeine, nicotine, alcohol

16. 16Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Quick Quiz! 3. A patient suffers from sleep pattern disturbance. To promote adequate sleep, the most important nursing intervention is A. Administering a sleep aid. B. Synchronizing the medication, treatment, and vital signs schedule. C. Encouraging the patient to exercise immediately before sleep. D. Discussing with the patient the benefits of beginning a long-term night-time medication regimen. iok

17. 17Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Anna is a 23-year-old nursing student assigned to the nursing home for her second semester in nursing school. She has had experience in nursing homes, having worked in one center as a nurse assistant during the last two summers. Anna’s assignment is to care for Mr. Murphy over the next 4 weeks.  What factors could Anna consider when preparing to care for Mr. Murphy?

18. 18Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process Assessment Diagnosis Planning Implementation Evaluation

19. 19Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  As Anna prepares to conduct an assessment of Mr. Murphy, she knows it is important to consider how sleep is altered in older adults. Because they typically have less deep sleep and more awakenings, it will be important to consider what factors in the nursing home disrupt sleep.  She has learned that his osteoarthritis pain is a contributing factor to the sleep disturbances. His immobility from the stroke adds discomfort.  Anna also plans to assess Mr. Murphy’s medications carefully to determine whether any drugs are adding to a sleep alteration.

20. 20Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Assessment  Sleep assessment  Sources for sleep assessment = Patient, family  Tools for sleep assessment  Sleep history  Description of sleeping problems, usual sleep pattern, current life events, physical and psychological illness, emotional and mental status, bedtime routines, bedtime environment, behaviors of sleep deprivation

21. 21Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Assessment questions for Mr. Murphy:  Please describe the nature of your sleep problem.  Do you awaken during the night?  Can you rate the quality of last night’s sleep?  Please describe your usual bedtime routine.  Are you having any trouble that is contributing to your sleep problem?  Assess Mr. Murphy for signs of sleep problems.

22. 22Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Diagnosis Anxiety Ineffective breathing pattern Acute confusion Compromised family coping Ineffective coping Insomnia Fatigue Sleep deprivation Readiness for enhanced sleep

23. 23Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Nursing diagnosis: insomnia  Related to excessive environmental stimuli  Goal  Mr. Murphy will attain a sense of restfulness after sleep in 1 month.

24. 24Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Planning  Goals and outcomes example  Goal: The patient will control environmental sources disrupting sleep within 1 month.  Outcomes: Patient will identify factors in the immediate home environment that disrupt sleep in 2 weeks. Patient will report having a discussion with family members about environmental barriers to sleep in 2 weeks. Patient will report changes made in the bedroom to promote sleep within 4 weeks. Patient will report having fewer than two awakenings per night within 4 weeks.

25. 25Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation  Health promotion  Environmental controls  Promoting bedtime routines  Promoting safety  Promoting comfort  Establishing periods of rest and sleep  Stress reduction  Bedtime snacks  Pharmacological approaches

26. 26Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation (cont’d)

27. 27Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d) Sit next to the window 30 to 60 minutes each morning. Bright light in the morning helps maintain a 24-hour circadian cycle. Discourage daytime napping.Daytime napping interferes with sleeping, Have an egg-crate-type mattress placed over his normal mattress. Increasing comfort of sleeping position, enhancing relaxation will promote sleep. Encourage Mr. Murphy to decrease his fluids 2 to 4 hours before sleep. Decreases the number of times the patient awakens to urinate. Arrange for Mr. Murphy to have a CD player and headphones when he goes to sleep. Soothing music blocks out sounds from the environment and promotes relaxation.

28. 28Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation (cont’d)  Acute care  Environmental controls  Promoting comfort  Establishing periods of rest and sleep  Promoting safety  Stress reduction  Restorative or continuing care  Promoting comfort  Controlling physiological disturbances  Pharmacological approaches

29. 29Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Continuous Positive Airway Pressure

30. 30Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Anna asked Mr. Murphy to use a rating scale for the quality of his sleep at the end of each week. After 1 week, Mr. Murphy rates his night sleep at a 6 out of 10; after 2 weeks, an 8 out of 10.  Anna asked Mrs. Murphy to evaluate her perceptions of Mr. Murphy’s level of fatigue. She says he is more alert, awake, and talkative during her visits.  Anna asked Mr. Murphy at the end of 4 weeks to keep a record for a week of the length of time he estimates he is sleeping.

31. 31Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Evaluation  Patient outcomes  Determine whether expected outcomes have been met. Are you able to fall asleep within 20 minutes of getting into bed? Describe how well you sleep when you exercise. Does the use of quiet music at bedtime help you to relax? Do you feel rested when you wake up?