Diagnostic Accuracy of the Disturbed Sleep

Pattern in Patients with Acute Coronary

Syndrome
Juliana Prado Biani Manzoli, RN, MsN , Marisa Dibbern Lopes Correia, RN, MsN , Micnéias Lacerda Botelho, RN,
MsE , Natanaellin Eydiane da Silva Begnami, RN , Paula Cristina Pereira da Costa, RN, PhD ,
and Erika Christiane Marocco Duran, RN, PhD
Juliana Prado Biani Manzoli, RN, MsN, is a Master in Nursing by Faculty of Nursing (FENF), University of Campinas (UNICAMP)
in Campinas, Sao Paulo, Brazil, Marisa Dibbern Lopes Correia, RN, MsN, is a Doctoral Student at FENF, UNICAMP in Campinas,
Sao Paulo, Brazil, Micnéias Lacerda Botelho, RN, MsE, is a Doctoral Student at FENF, UNICAMP in Campinas, Sao Paulo, Brazil,
Natanaellin Eydiane da Silva Begnami, RN, is a Master Student at FENF, UNICAMP in Campinas, Sao Paulo, Brazil, Paula
Cristina Pereira da Costa, RN, PhD, is a Doctor in Nursing by FENF, UNICAMP in Campinas, Sao Paulo, Brazil, and Erika
Christianne Marocco Duran, RN, PhD, is an Assistant Professor at FENF, UNICAMP in Campinas, Sao Paulo, Brazil

Search terms:
Acute coronary syndrome, nursing
diagnosis, sleep, Sono, Síndrome
Coronariana Aguda, Diagnóstico de
Enfermagem, Estudos de Validação,
Processo de Enfermagem
Author Contributions:
JPBM and ECMD have contributed to
the study conception. All authors
have contributed to the study design.
MDLC has contributed to data
collection. All authors have
contributed on data analysis. All
authors have contributed to the
paper review and approved the
manuscript final version.
OBJECTIVE: To clinically validate the nursing diagnosis, disturbed sleep pattern
(00198), in patients with acute coronary syndrome.
DATA COLLECTION: A clinical validation study using the patient history, Visual
Analog Sleep scale, and diagnostic inference. Accuracy techniques were performed.
SYNTHESIS OF DATA: There were 75 patients: 76.00% were men, and 82.66%
had a myocardial infarction. The defining characteristic, changes in sleep pattern,
presented a sensitivity of 0.900 and specificity of 0.9714.
CONCLUSION: Changes in sleep pattern was a predictor of the nursing diagnosis.
IMPLICATIONS FOR PRACTICE: Results will contribute to the identification of
sleep disturbances, by nurses, emphasizing the importance of improving sleep dur-
ing hospitalization.
OBJETIVO: Validar clinicamente o Diagnóstico de Enfermagem Padrão de Sono
Prejudicado (00198) em pacientes com Síndrome Coronariana Aguda.
MÉTODOS: Estudo de validação clínica, utilizando Histórico de Enfermagem, Es-
calas Visuais Análogas do Sono e inferência diagnóstica. Realizada medidas de
acurácia.
RESULTADOS: 75 pacientes, 76,00% homens e 82,66% com Infarto do Miocárdio.
A característica definidora Alteração do Padrão de Sono teve 0,900 de Sensibili-
dade e 0,9714 de Especificidade.
CONCLUSÕES: Alteração do padrão de sono foi preditora do diagnóstico de en-
fermagem.
IMPLICAÇÕES PARA A PRÁTICA: Contribuirá na identificação de distúrbios do
sono, pelos enfermeiros, ressaltando a importância da melhoria do sono durante a
internação.

Problem Identification Among the cardiovascular diseases is Acute coronary

Cardiovascular diseases represent the primary cause of
noncommunicable diseases and, in 2016, they accounted for
31% (17.9 million) of total deaths in the world (World Health
Organization [WHO], 2017), and 28% in Brazil (WHO, 2018).
Diseases of the circulatory system were responsible for hos-
pitalization of 1,116,362 people in 2016, with a higher rate in
the Southeast region, which registered 498,795 hospitaliza-
tions (Ministério da Saúde [BRAZIL], 2016).
syndrome (ACS), characterized by unstable angina (UA) and
acute myocardial infarction (AMI), with or without ST eleva-
tion, (Piegas et al., 2013). The acute phase after ACS (Schiza
et al., 2010), and the subsequent hospitalization (Dias, Re-
sende, & Diniz, 2015; Magalhães, de Jesus, Gois, & LLapa-
Rodríguez, 2014; Membrive et al., 2017), can lead to psy-
chological and physiological dysfunctions in the individual,
such as poor quality and quantity of sleep. The additional
stressors within the hospital environment, in addition to


C 2019 NANDA International, Inc. 1
International Journal of Nursing Knowledge Volume 00, No. 0, xxx 2019
Diagnostic Accuracy of the Disturbed Sleep Pattern in Patients
the disease itself, can contribute to sleep issues; therefore,
nurses should consider whether these patients’ responses
might indicate nursing diagnoses (ND) related to impaired
sleep.
Although recent studies have not been found in the lit-
erature that have identified ND related to sleep in patients
with ACS, there are studies that identify the presence of
sleep disorders in this population, and thus it can be inferred
that such ND are present in this population, for example,
Disturbed sleep pattern (000198) (Herdman & Kamitsuru,
2018).
As an example, a study that had, among its objectives, to
describe the sleep quality of patients with AMI by means of
a subjective instrument, identified that 60% of these had
a short duration of sleep and 48.7% of sleep fragmenta-
tion, which interfered with the quality of their sleep as well
as a high prevalence of bad sleepers (Andrechuk & Ceolim,
2015a).
Another study that aimed to evaluate the sleep of hospi-
talized patients with ACS using a specific questionnaire and
validating this questionnaire with the use of polysomnog-
raphy identified that among the 99 participants, 22% were
considered as bad sleepers, 43% were regular, and only 35%
were good sleepers (Storti et al., 2015).
The nursing process is composed of five interrelated and
interdependent stages; ND is the second stage (Conselho
Federal de Enfermagem [COFEN], 2009; Herdman & Kamit-
suru, 2014). According to NANDA International (NANDA-I),
ND is a “clinical judgment concerning a human response
to health conditions/life processes, or a vulnerability for
that response, by an individual, family, group or community”
(Herdman & Kamitsuru, 2017, p. 133). Nursing diagnosis is rel-
evant to nursing care, as it provides direction for, and the
ability to evaluate, the plan of care and implementation of
interventions that aim to achieve expected outcomes (Herd-
man & Kamitsuru, 2017; Matos & Cruz, 2009).
The validation of ND has been expanded in research,
which aims to contribute to a reduction in the existing in-
consistency in describing what is observed in clinical prac-
tice, and accuracy in identifying the ND that correspond to
the human response(s) presented by the patient (Lopes, da
Silva, & de Araújo, 2012).
Diagnostic accuracy studies are classified as validation
studies; these studies support the identification of defining
characteristics (DC) and related factors, also known as clin-
ical indicators, signs and symptoms, and etiological factors,
which best represent or contribute to the identified human
response, conferring legitimacy to the diagnostic inference
(Lopes, Silva, & Araujo, 2019; Pereira et al., 2015).
Disturbed sleep pattern (00198) is defined as “time-
limited interruptions of sleep amount and quality due to ex-
ternal factors,” and is one of the sleep-related ND within
NANDA-I (Herdman & Kamitsuru, 2014, p. 213). The DC pro-
vided for this NANDA-I diagnosis are alteration in sleep pat-
tern, difficulty in daily functioning, difficulty initiating sleep,
dissatisfaction with sleep, feeling unrested, and uninten-
tional awakening. The related factors are disruption caused
2
J. Prado Biani Manzoli et al.
by sleep partner, environmental barrier (e.g., ambient noise,
daylight/darkness exposure, ambient temperature/humidity,
and unfamiliar setting), immobilization, insufficient privacy,
and nonrestorative sleep pattern (i.e., due to caregiver re-
sponsibilities, parenting practices, and sleep partner) (Herd-
man & Kamitsuru, 2014, p. 213).
Disturbed sleep pattern can be attributed to patients with
ACS, due to changes in the quality and quantity of sleep
in this population, which can lead to worsening of the un-
derlying disease and the quality of life of these patients, in
both the short and long term (Schiza et al., 2010). Therefore,
this study aimed to perform a clinical validation of disturbed
sleep pattern in patients with ACS.
Data Source/Literature Search
This was a methodological, clinical validation study, rec-
ommended in the literature as the third step in the valida-
tion process of ND, and for diagnostic accuracy (Lopes et al.,
2019). It was conducted with patients experiencing ACS who
were hospitalized in clinical, emergency and coronary care
units of a large university hospital, in the interior of the State
of São Paulo (Brazil).
The inclusion criteria were patients aged 18 years or older,
with a confirmed diagnosis of ACS, exhibiting an alert level
of consciousness. The exclusion criteria included patients us-
ing sleep inhibitors or inducers, who were unable to respond
to an instrument at the time of data collection, or who pre-
sented clinical instability and/or risk of death. Convenience
sampling was used, with data collection occurring between
September of 2017 and January of 2018.
The diagnostic inference, considered as the reference
standard for this study, was performed by nurses from
the Group of Studies and Research on Nursing Care Man-
agement, included in the Process of Caring in Health and
Nursing research line, at the University of Campinas, São
Paulo/Brazil. The members of this research group are reg-
ularly exposed to discussions about nursing diagnosis and
the process of reflection.
Performing the diagnostic inference means determining
an ND that best represents a human response, observed in
the most diverse clinical situations presented by the patient.
Thus, the nurse should establish a clinical reasoning in order
to identify the clinical indicators and contributing factors of
a given ND, to infer it appropriately.
As there is no objective device available to measure or in-
vestigate the human response (Lopes, da Silva, & de Araujo,
2012), a training process is suggested to reduce the impact
of the bias of reference pattern, or imperfect gold standard,
due to the lack of patterns of Ideal reference for ND. Thus, it
is possible to identify whether the diagnostic inference was
performed correctly by the nurse, allowing the standardized
data collection as well as the minimized bias. This training
was also essential to increase the ability of the researchers’
cognitive system to detect and collect important information
(Dror, 2011).
J. Prado Biani Manzoli et al. Diagnostic Accuracy of the Disturbed Sleep Pattern in Patients
Training of the research team was precisely managed us-
ing the following process. These nurses received training
with regard to the ND, disturbed sleep pattern, and the pop-
ulation experiencing ACS, from the principal investigator
of the study, through an expositive class (Botelho, Correia,
Manzoli, Costa, & Duran, 2019). After the training, they were
evaluated using 12 clinical case studies, 50% which had this
ND present, and 50% in which this ND was absent. These
case studies were developed by the main researcher, and
reviewed by the other researcher on the study. The nurses
were required to evaluate the clinical case studies individu-
ally, and to perform the diagnostic inference on their own.
After the diagnostic inference was completed, the main
researcher evaluated the responses of each nurse, provid-
ing feedback, and performed a percentage calculation to de-
termine whether the nurses had attained acceptable levels
of successful inference in the assessments described above.
Those nurses who obtained an acceptable level of diagnostic
accuracy (>85% correct responses) were considered diag-
nosticians.
The methodology followed for this study (Hradesky, 1989)
suggests that three replicates of 12 clinical cases are per-
formed when there are three or more evaluators. However,
the Group of Studies and Research on Nursing Care Man-
agement (University of Campinas, São Paulo, Brazil) sug-
gests that clinical cases should be considered only once, be-
cause more complex and multifaceted activities, such as di-
agnostic reasoning, generally require reflection by the indi-
vidual, which does not happen during automatic processes
(Da Silva, Peixoto, Brandão, Ferreira, & Martins, 2011). The
inferential diagnostic process is not perfectly accurate and,
therefore, repetition of the activity may represent cognitive
memory, which could influence the diagnostic inference.
The nurse diagnosticians took turns with the patients
included in the study. Thus, only one diagnostician ad-
ministered the instruments and performed the diagnostic
inference for each patient. The data collection included
sociodemographic and clinical variables (Spagnol, 2013),
information obtained from the nursing assessment and
exam, and the results of the Visual Analogue Sleep Scale
(VASS).
The VASS (Bergamasco, 2005), translated into Por-
tuguese, is composed of 16 items: 15 are self-report, and one
is obtained by summing items 1 and 2, which should be com-
pleted by the patient himself, with the help of a nurse. These
items are distributed over three domains or subscales: the
Disturbance, Effectiveness, and Supplementation subscales.
The Disturbance subscale, which indicates descriptions of
sleep fragmentation and latency, includes items 1, 6, 7, 8, 9,
10, and 11, which total 700 points; the Effectiveness subscale
indicates characteristics of duration and quality of sleep,
and includes items 2, 12, 14, 15, and 16 (1+2), totaling 600
points; and the Supplementation subscale, which indicates
sleep supplementation, including items 3, 4, 5, 13, and totals
400 points (Bergamasco, 2005).
The final result is obtained through a sum that evaluates
each item of the subscales, based on the final score, and
can indicate low, moderate, or high levels of Disturbance, Ef-
fectiveness, and Supplementation. Higher scores in the Dis-
turbance and Supplementation subscales are indicators of a
poor sleep pattern. On the other hand, higher scores on the
Effectiveness subscale indicate a good sleep pattern (Berga-
masco, 2005).
The scores of the three subscales were categorized into
three levels. Low levels on the Disturbance subscale were
between 0 and 233, moderate levels were between 234 and
466, and high levels ranged from 467 to 700. For the Effec-
tiveness subscale, the low levels were between 0 and 200,
moderate levels were 201 to 399, and high levels ranged be-
tween 400 and 600. Finally, for the Supplementation sub-
scale, low levels were between 0 and 133, moderate levels
were between 134 and 266, and high levels ranged from 267
to 400.
After conducting the patient assessment including the
VASS, the nurse diagnosticians completed the diagnostic in-
ference to determine the presence or absence of disturbed
sleep pattern, using an individual worksheet on which they
described which DCs were identified during assessment, and
whether the ND was present or absent.
In addition to the DC described in disturbed sleep pattern
within the NANDA-I ND classification (Herdman & Kamitsuru,
2014), two other DCs were incorporated after performing the
first stage of the diagnostic validation process, the integra-
tive literature review: daytime sleepiness and sleep depriva-
tion. Conceptual and operational definitions were provided
to the nurse diagnosticians for all DCs.
The data collected were compiled and analyzed descrip-
R
tively, using Microsoft Excel Software (2013). For mean (M)
and standard deviation (SD) of the VASS, the Statistical Pack-
R
age for Social Sciences 20.0 program was used. The statisti-
cal tests for accuracy were based on measures of sensitivity
(Se), specificity (Sp), predictive positive (PPV), and negative
values (NPV); the Statistical Analysis Software R
version 9.4
was used, considering values above 0.5 by the power of dis-
crimination.
Thus, Se represents the probability of a particular DC be-
ing present when the ND is present, Sp represents the prob-
ability of the DC being absent when the ND is absent, PPV
represents the probability that the ND is present when the
DC is present, and NPV represents the probability that the
ND is absent when the DC is absent (Knottnerus & Buntinx,
2009).
For the purposes of statistical analysis, the DCs studied
were associated with the VASS. Thus, unintentional awaken-
ing and difficulty initiating sleep were associated with the
Disturbance subscale; alteration in sleep pattern, dissatis-
faction with sleep, feeling unrested, and sleep deprivation
were associated to the Effectiveness subscale; and difficulty
in daily functioning and daytime sleepiness were associated
with the Supplementation subscale.
Approval of the study was granted by the Research Ethics
Committee, under the number of opinion 2.220.033. The
data collection began after the subjects received clarifica-
tion on the objectives of the study and the procedures to be
3
Diagnostic Accuracy of the Disturbed Sleep Pattern in Patients J. Prado Biani Manzoli et al.

Table 1. Prevalence of the Defining Characteristics of ticenter Brazilian study that aimed to demonstrate clinical
the Nursing Diagnosis, disturbed sleep pattern, in characteristics, management, and hospital evolution of pa-
Hospitalized Patients with Acute Coronary Syndrome tients with ACS showed different findings, in which the ma-
(n = 75). Campinas, Sao Paulo, Brazil, 2018 jority of patients presented with UA (Piegas et al., 2013).
In terms of hospital length of stay, half of the patients
Defining characteristics N % p* were hospitalized for more than 72 hr. Thus, they were ex-
posed to the hospital environment for a longer period and,
Alteration in sleep pattern 37 49.33 .49 consequently, to its stressors. This can interfere with the
Unintentional awakening 31 41.33 .41
Difficulty in daily functioning 02 2.67 .02 quality and quantity of sleep (Costa & Ceolim, 2013), con-
Difficulty initiating sleep 23 30.67 .30 sidering both extrinsic and associated intrinsic factors. This
Dissatisfaction with sleep 27 36.00 .36 may be a limiting factor in the study; however, a consensus
Feeling unrested 23 30.67 .30 was not found on the best time for sleep assessment in hos-
Daytime sleepiness 12 16.00 .16
Sleep deprivation 05 6.67 .06
pitalized patients with ACS, because previous studies per-
formed this evaluation at different times (Andrechuk & Ce-
*
Prevalence olim, 2015a; Storti et al., 2015).
To evaluate the quality and quantity of sleep, the use
of instruments such as polysomnography is considered to
performed, with subsequent signature of the Terms of Free be the gold standard; however, the cost and its restricted
and Informed Consent form. access in daily practice are obstacles to use. Associated with
this fact, the diagnostic inference of nurses considers cog-
Findings nitive aspects that cannot be reliably measured by instru-
ments. Thus, instruments that evaluate sleep in a subjective
The sample consisted of 75 participants with a mean age way, such as self-reports, questionnaires, and scales such
of 62.41 years, (SD = 10.95), ranging from 40 to 86 years. as the VASS are effective, and have been used by other
Fifty-seven participants were male (76%), 53 (70.66%) were researchers (Bergamasco, 2005; Buysse, 2014; Mashayekhi,
married, 12 (16%) were widowers, six (8%) were single, and Pilevarzadeh, Amiri, & Rafiei, 2013).
five (6.66%) were divorced. Regarding the medical diagno- The VASS was used in this study to support the assess-
sis, 62 (82.66%) had AMI with or without ST elevation, and 10 ment of the patients’ previous night of sleep within the
(13.33%) presented with UA. Regarding hospitalization time, hospital, that is, the night before data collection, together
only one patient (1.33%) was hospitalized for less than 24 hr, with observation, verbal reports, and patient assessment.
19 (25.33%) were hospitalized for 24–72 hr, and 38 patients Using such a scale can support the care and subsidiary re-
(50.66%) were hospitalized for more than 72 hr. There was search related to inpatient sleep (Bergamasco, 2005). In this
a lack of data regarding marital status (n = 2, 2.66%), medi- study, the findings identified by the VASS showed that the
cal diagnosis (n = 3, 4%), and length of hospital stay (n = 17, majority of patients presented with moderate level scores
22.66%) in a few of these patients. on the Disturbance, Effectiveness and Supplementation
The VASS was used to support the judgment of nurses di- subscales.
agnosing the sleep pattern of hospitalized patients with ACS. With regards to accuracy, the DC of alteration in sleep
Disturbance subscale scores ranged from 39 to 595, with a pattern obtained statistically significant values and was con-
mean of 329.51 (SD =133.13); Effectiveness subscale scores sidered the predictive DC of the disturbed sleep pattern ND.
ranged from 100 to 509, with a mean of 305.36 (SD = 76.38); Likewise, the absence of the DC determined the absence of
and the Supplementation subscale scores ranged from 0 to the ND. This DC is related to the presence of alterations in
344, with a mean of 161.03 (SD = 92.20). the amount and quality of sleep of hospitalized patients with
Disturbed sleep pattern was identified in 40 (53.33%) ACS, and several studies present data that corroborate this
participants, and the prevalence of DCs is described in Ta- finding (Alcântara, Peacock, Davidson, Hiti, & Edmondson,
ble 1; Table 2 describes the diagnostic accuracy tests. Table 3 2014; Andrechuk & Ceolim, 2015a; Schiza et al., 2010). An-
presents the accuracy measurements performed, showing a other study demonstrated that patients with ACS who had
relationship between the presence and absence of the DC of less than 7 hr of sleep were associated with short sleep du-
disturbed sleep pattern and the three subscales of the VASS. ration, with a high risk (greater than 50%) of death after 1
year of initial or recurrent ACS (Alcántara et al., 2014).
Discussion The analysis of the relationship between worsening of
clinical indicators and sleep quality was an element of a
Regarding gender and marital status, other sleep assess- study that identified that 71.7% of patients hospitalized with
ment studies in this population also presented similar re- AMI had poor sleep quality. This variable was the only one
sults. (Andrechuk & Ceolim, 2016; Araújo et al., 2014; Storti that was associated with worsening of the clinical indicators
et al., 2015). of the patients; that is, the worse the quality of sleep, the
In relation of the medical diagnosis, there was a predomi- higher the chances of the worsening of clinical indicators
nance of AMI with or without ST elevation. Data from a mul- (Andrechuk & Ceolim, 2015a).

4
J. Prado Biani Manzoli et al. Diagnostic Accuracy of the Disturbed Sleep Pattern in Patients

Table 2. Accuracy of the Defining Characteristics of the Nursing Diagnosis, disturbed sleep pattern, in Hospitalized
Patients with Acute Coronary Syndrome (n = 75). Campinas, Sao Paulo, Brazil, 2018

Defining characteristics Se Sp PPV NPV p

Alteration in sleep pattern 0.9000 0.9714 0.9730 0.8947 <.0001*

Unintentional awakening 0.4250 0.6000 0.5484 0.4773 .8264*
Difficulty in daily functioning 0.0500 1.0000 1.0000 0.4795 .4955**
Difficulty initiating sleep 0.5000 0.9143 0.8696 0.6154 .0001*
Dissatisfaction with sleep 0.6750 1.0000 1.0000 0.7292 <.0001*
Feeling unrested 0.5500 0.9714 0.9565 0.6538 <.0001*
Daytime sleepiness 0.2000 0.8857 0.6667 0.4921 .3124*
Sleep deprivation 0.1000 0.9714 0.8000 0.4857 .3636**

*
p-value obtained by chi-square test.
**
p-value obtained by means of Fisher’s exact test.
Sensitivity (Se); Specificity (Sp); Positive predictive value (PPV); Negative predictive value (NPV).

Table 3. Accuracy Diagnóstica Related to the Defining Characteristics of the Nursing Diagnosis, disturbed sleep
pattern, with the Visual Analogue Sleep Scale in Hospitalized Patients with Acute Coronary Syndrome (n = 75).
Campinas, Sao Paulo, Brazil, 2018

VASS subscales Defining characteristics Se Sp PPV NPV P

Disturbance Unintentional awakening 0.7742 0.2500 0.4211 0.6111 .8091*

Difficulty initiating sleep 1.0000 0.3462 0.4035 1.0000 .0012*
Effectiveness Alteration in sleep pattern 0.1351 0.9737 0.8333 0.5362 .1075**
Dissatisfaction with sleep 0.1481 0.9583 0.6667 0.6667 .1800**
Feeling unrested 0.1739 0.9615 0.6667 0.7246 .0675**
Sleep deprivation 0.2000 0.9286 0.1667 0.9420 .3488**
Supplementation Difficulty in daily functioning 1.0000 0.3836 0.0426 1.0000 .5258**
Difficulty initiating sleep 1.0000 0.4444 0.2553 1.0000 .0026**

*
p-value obtained by chi-square test.
**
p-value obtained by means of Fisher’s exact test.
Visual analog sleep scale (VASS); Sensitivity (Se); Specificity (Sp); Positive predictive value (PPV); Negative predictive value (NPV).

Although the findings regarding the DC, unintentional
awakening, did not indicate good predictive capacity for the
ND, this was the second most prevalent DC. There is litera-
ture that indicates the occurrence of nocturnal awakenings
by patients hospitalized with AMI. For example, one study
aimed to describe the sleep quality of these patients, and
demonstrated that sleep fragmentation was present in ap-
proximately half of the sample; the main sleep disturbance
was the need to go to the bathroom (Andrechuk & Ceolim,
2015a).
Intervening sleep factors of patients hospitalized with
ACS, such as luminosity, were also considered, as well as
noise levels due to informal staff member conversations, and
the patient’s apprehension about his disease (Storti et al.,
2015). Other factors such as lack of self-control, inability to
play a role in the family, pain, and fear can also be identi-
fied as contributing factors to sleep fragmentation and un-
intended arousals (Dias et al., 2015; Magalhães et al., 2014;
Membrive et al., 2017).
The data found in the present study corroborate the find-
ings in the literature regarding the DC, dissatisfaction with
sleep, which showed statistically significant results. A study
that sought to assess the quality of sleep and the associated
factors causing sleep disruption identified that even when
sleep efficiency and duration were decreased, most partic-
ipants reported satisfaction with their sleep. This demon-
strates that the patient himself can undervalue the quality
of his sleep (Andrechuk & Ceolim, 2015a), and may feel sat-
isfied even when indicators suggest that he did not obtain a
good night’s sleep.
Feeling unrested presented significant statistical differ-
entiation in comparing the inference of diagnosticians and
opinions of patients. It is known that poor quality and
quantity of sleep can generate important physical, occu-
pational, cognitive, and social changes in the individual.
Such changes can be biological, and are related to fa-
tigue; lack of memory, attention, and concentration; changes
in mood; increased sensitivity to light and sounds; and
tachycardia. Functional and behavioral changes in every-
day activities can also be present (Müller & Guimarães,
2007).
Some daily behavioral changes cannot be observed in
hospitalized patients. Generally, individuals diagnosed with
ACS require prolonged rest (Hospital Sírio-Libanês, 2013)

5
Diagnostic Accuracy of the Disturbed Sleep Pattern in Patients
and have their daily activities restricted due to the dis-
ease and the hospital environment. This may explain the low
prevalence of the DC, difficulty in daily functioning, among
the participants studied.
Although sleep deprivation, which refers to insufficient
sleep, showed a low prevalence among patients in this study,
patients with ACS can present with it. It is known that pa-
tients deprived of sleep can have significant impairments
(Alcántara et al., 2014; Tobaldini et al., 2017) that could lead
to deterioration in their health situation.
One study that evaluated the sleep of patients with ACS
in the acute phase, and at 1 and 6 months after the event,
found that the amount and quality of sleep can reflect on
patients’ quality of life (Schiza et al., 2010). Another study,
conducted with hospitalized patients, demonstrated that de-
spite the fact that they had increased sleep latency, that
is, difficulty initiating sleep, they still rated their sleep as
good. This was explained by the fact that these patients re-
lated quality to quantity, as they slept during the day, and
therefore considered themselves to be good sleepers (Da
Silva, de Oliveira, & Inaba, 2011).
The aforementioned study aimed to identify sleep com-
plaints in hospitalized patients, and to propose improve-
ments for sleep quality. Most of the patients indicated that
they did not feel the need to sleep while performing ac-
tivities, but they presented daytime sleepiness, as daytime
naps occurred with the majority of the sample, ranging
from 2 to 4 times per day, demonstrating that they needed
sleep supplementation, even when they said they did not.
However, inpatients frequently spend the majority of their
time lying down, and a lack of distractions can lead to
frequent naps (Da Silva et al., 2011). Supporting this find-
ing, a study that aimed to characterize daytime sleepi-
ness in patients with AMI, and associated sociodemographic
and clinical characteristics, identified that 29.2% of 113 pa-
tients presented excessive daytime sleepiness (Andrechuk &
Ceolim, 2015b).
Although the VASS was focused on hospitalized patients,
and considered easy to administer, the nurse diagnosticians
perceived difficulty from the patients in understanding and
completing the scale items, which may also have limited the
study. Schooling was not the data collected in this study,
but in this public institution, the hospitalization of patients
with little study time is frequent, which could have influenced
even in the difficulty of understanding the filling of the VASS
in which it should be pointed out on a continuous line with
two extremes of opinion. In addition, the instrument used,
as well as other subjective sleep assessment instruments,
although quantitatively evaluating the patient’s perception
of his or her own sleep, may be influenced by sources of bias
and inaccuracies, but should not be considered imprecise,
since undergo validation studies that demonstrate their ef-
fectiveness (Ibáñez, Silva, & Cauli, 2018).
Thus, it was decided to relate the patient’s personal opin-
ion (VASS) with the interpretation given by the nurse di-
agnosticians based on the DCs, and divergence was noted
(Table 3). In addition, the divergence of the relationship be-
6
J. Prado Biani Manzoli et al.
tween the patients’ responses to the VASS and the pres-
ence of DCs can be attributed to the patients’ lack of under-
standing of problems related to sleep, and therefore their
responses may not present an adequate perception of these
disturbances (Santos, Cruz, & Barbosa, 2011). The literature
points out that differences between the perception that the
patient has and the objective data collected by professionals
about sleep evaluation (Barreto, 2011; Ravagnani & Crivelaro,
2010; Santos et al., 2011) may lack understanding and good
insight into sleep disorders themselves (Da Silva et al., 2011).
These facts demonstrate the importance of the stages
of the NP in the detection of problems related to Disturbed
sleep pattern, as the instrument used for sleep assessment
(VASS) was a tool used to help the nurse diagnosticians with
decision-making. However, one should not take into account
only the results of the scales. Other findings should be iden-
tified, using patient history, physical examination, and di-
rect observation, in order to support nurses’ decisions on
the presence of signs, symptoms, and etiological factors,
clinical indicators that suggest the presence or absence of a
given ND.
Conclusions
The defining characteristic, alteration in sleep pattern,
was the most predictive of the diagnosis, disturbed sleep pat-
tern, followed by dissatisfaction with sleep and feeling un-
rested. The lack of difficulty in daily functioning proved to be
effective in determining the absence of the ND.
This study can aid in the identification of sleep pattern dis-
turbance presented by hospitalized patients with ACS, and
their possible intervening factors, because changes in the
quantity and quality of sleep can worsen the patient’s clin-
ical condition, leading to a longer hospital stay and, conse-
quently an increase in health costs. In addition, it will con-
tribute to raising the visibility of the nursing approach to in-
patient sleep care, as sleep is still neglected by the entire
health care team, and limited interventions are directed to
minimize such problems.
It is important to note that the present ND has undergone
minor changes in the latest edition of the NANDA-I (Herdman
& Kamitsuru, 2018), which occurred after this study was in
process. However, these changes were primarily editorial in
nature (removal of “e.g.” and “i.e.” statements within the re-
lated factors), and therefore should not substantially affect
the results of this study.
Implications for Nursing Knowledge and Language
Development
Validation studies can promote a better understanding of
ND, such as Disturbed sleep pattern, and can also provide
a more effective and uniform method for communication.
Furthermore, they can contribute to diagnostic accuracy,
the plan of nursing care, and support research in the area,
J. Prado Biani Manzoli et al. Diagnostic Accuracy of the Disturbed Sleep Pattern in Patients
supporting nursing education and strengthening the knowl-
edge of the nursing discipline.
In addition, the present study exposes the importance of
the need for knowledge, understanding, and perception that
the patient should have in relation to his/her own sleep so
that this facilitates the early identification of sleep disorders
as well as their intervention.
Additional studies, more distinctly focused on sleep-
related ND in individuals with ACS, must be conducted in
order to give visibility to the ND in practice and to enable
improvement in clinical nursing care practice and patient
outcomes. Additionally, credence must be given to the im-
portance of adequate quality and quantity of sleep in this
population.
Knowledge Translation
The present study will enable early identification of sleep
pattern disturbance in patients hospitalized with ACS, as well
as the factors that interfere with sleep. Faced with this iden-
tification, measures to maximize the amount and the qual-
ity of sleep of these patients can be undertaken, decreasing
the chances of complications resulting from poor sleep, and
avoiding increases in health care costs.
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