Copyright © 2006 Mosby, Inc. All rights reserved.

Slide 1
Fifth Edition
Linda D. Urden
Chapter 6
Kathleen M. Stacy
Mary E. Lough Sleep Alterations and
Management

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Overview

• Characteristics of normal human sleep

and chronobiology
• Changes in sleep associated with aging
and pharmacology
• Abnormal sleep patterns affecting critically
ill patients
• Research-based nursing care for critically
ill patients with sleep disturbances

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Objectives

• Identify the stages of sleep.

• Explain the physiologic effects of rapid eye
movement (REM) sleep.
• Describe circadian desynchronization and
its primary effects.
• Depict the changes in sleep resulting from the
aging process and chronic illness.
• Name the commonly prescribed medications
that affect REM sleep.
• Delineate the consequences of disrupted sleep.
• Describe nursing interventions that are essential
in the treatment of disturbed sleep patterns.
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Sleep Physiology

Definition of Sleep
A reversible behavioral state of perceptual
disengagement from and unresponsiveness to the
environment
• Electroencephalography (EEG)
• Electrooculography (EOG)
• Electrocardiography (ECG)

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Sleep Stages

Non-rapid eye movement (NREM) sleep

• Stage 1: 2-5% Transitional lighter sleep
• Stage 2: 45-55% Deeper sleep
• Stage 3: 3-8% Slow wave activity 20% of
EEG
• Stage 4: 10-15% Slow wave activity 50% of
EEG

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Sleep Stages (cont’d)

Stages 3 and 4 are referred to as slow-wave sleep

or delta sleep
• Parasympathetic nervous system predominates
• Hormonal changes to promote anabolism
• Protein synthesis and tissue repair
• Restorative period

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Sleep Stages (cont’d)

Rapid Eye Movement Sleep

• 20-25% in young adults
• “Dream” stage
• Sympathetic nervous system predominates
– Increased oxygen consumption
– Increased BP, pulse, respirations, CO
– Increased chance of plaque rupture due to surges
in pressure and changes in coronary artery tone

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Sleep Changes in Aging

• Less restful sleep

• Fragmented sleep patterns
 Cardiac disease, diabetes, nocturia,
restless legs, pain
 Respiratory disorders and sleep apnea
 Altered circadian rhythms
• Social and physical changes

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Elderly Sleep in Critical Care

Altered sleep patterns

 Pain, stress, respiratory insufficiency
 Accommodate age-related changes

Interventions
• Control of environmental noise and light
• Use of white noise, music, massage
• Allow blocks of time for sleep

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Chronobiology

Circadian Rhythms from Suprachiasmatic Nucleus

(SCN) in Hypothalamus
• Internal controls
– Body temperature
– Sleep/wake cycle

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Chronobiology (cont’d)

Circadian Rhythms
• External controls
– Posture
– Exercise
– Light
• Homeostatic mechanisms of sleep
regulation

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Chronobiology (cont’d)

• Models of sleep regulation

 Two-process model
 Two-oscillator model

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Pharmacology of Sleep

Hypnotics
• Lighter sleep stages and higher lipophilicity
– Night tremors, nightmares, agitation in elderly
– Decreased metabolism by steroids
– Increased metabolism if smokers
• Antegrade amnesia
• May affect breathing in COPD

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Pharmacology of Sleep (cont’d)

Stimulants: High Abuse Potential

• Irritability, PNS symptoms, insomnia,
GI complaints, dyskinesias
• Euphoria, dysphoria, paranoia, psychosis
• Sustained use: cognitive and behavior
problems can occur
• TRY ALTERNATIVES!

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Pharmacology of Sleep (cont’d)

Alcohol
• Suppresses REM sleep
• >2 drinks increases Stage 1 and 2 NREM sleep
and decreases onset of slow-wave sleep
• May cause shallow fragmented sleep
• May aggravate airway maintenance
Look for alternative medicine (herbs, etc.)

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Abnormal Sleep: Disturbances in
Critically Ill Patients

• Definition: Insufficient duration or stages of sleep

that result in discomfort and interfere in quality of life
• Lack of sleep in critical care
 Disturbance in sleep architecture
 Diminished daytime performance

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Abnormal Sleep: Disturbances in
Critically Ill Patients (cont’d)

• Lack of sleep in critical care

 Residual daytime fatigue
 Dependence, tolerance
 REM suppression and rebound sleep

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Abnormal Sleep: Disturbances in
Critically Ill Patients (cont’d)

Etiology
• Psychological stress/anxiety
• Environment stressors
• Surgical stress
• Noise, interruptions for care/lack of sleep
• Painful procedures
• Excessive light
• Bed rest
• Isolation

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Abnormal Sleep: Disturbances in
Critically Ill Patients (cont’d)

Pathophysiology
• Physiologic and psychologic exhaustion
• Hormonal changes
• Changes in mood and performance
• Increased pain due to decreased somatostatin and
increased substance

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Assessment and Diagnosis of Sleep
Problems in Critical Care

• Description of normal sleep pattern

• Habits to enhance sleep
• Recent changes in normal sleep pattern
• Recent problems during sleep hours
• History of chronic illnesses (e.g., COPD, arthritis, GI
problems)
• Assess psychological response to critical care

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Management of Sleep
Problems in Critical Care

• Medical management
 Sedative/hypnotics
 Nonbenzodiazepine, short-acting hypnotics

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Management of Sleep
Problems in Critical Care (cont’d)

• Nursing management
 Nursing interventions
• Massage
• Audiotapes
• Promote caring, relaxing environment
• Limit interruptions
• Reduce environmental noise
• Maintain lighting according to circadian rhythms
 Assess results
 Design units to support rest

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Sleep Apnea Syndrome

• Definition: sleep-disordered breathing

 Obstructive apnea (>10 seconds or more)
• Hypopnea: partial obstruction
 Central: lack of muscle effort
 Mixed: both types in one apneic event
• Apnea-hypopnea index

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Sleep Apnea Syndrome

• Obstructive sleep apnea

 Definition and etiology
 Pathophysiology
• Hypoxemia
• Hypercapnia
• Acidosis
• Systemic and pulmonary hypertension
• Cardiac dysrhythmias: fast and slow

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Sleep Apnea Syndrome (cont’d)

• Obstructive sleep apnea

 Assessment and diagnoses
 Medical management
 Nursing management

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Sleep Apnea Syndrome (cont’d)

• Central sleep apnea

 Definition, etiology, and pathophysiology
 Assessment and diagnoses
 Medical management
 Nursing management

Copyright © 2006 Mosby, Inc. All rights reserved. Slide 27