SEMINAR ON

REST AND
SLEEP
 Rest and Sleep

Introduction

Rest and sleep are two fundamental human needs that contribute to the
physical well-being and quality of life of every individual. Maslow’s hierarchy of
needs indicates sleep as one of our physiological requirements. Getting
enough quality of sleep at the right times according to our circadian rhythms
can protect mental and physical health, safety and quality of life. Nurses can
help clients recognise the importance of rest and learn how to promote it at
home or any health care facility.

Definitions

Rest
Rest is a “condition in which the body is in a decreased state of activity without
physical, emotional stress and freedom from anxiety.”

Sleep
Sleep can be defined as “a normal state of altered consciousness during
which the body rests; it is characterised by decreased responsiveness to
the environment, but a person can be aroused from sleep by external
stimuli”

Functions of sleep
 Conservation of energy

 Restoration of tissues and growth

 Thermoregulation

 Regulation of emotions

 Improve memory, learning, attention span

Types/stages/ phases of sleep
Brain activity can be recorded in the form of electroencephalogram,
EEG, which measures electrical activities in the superficial layers of the
cerebral cortex. Different stages of consciousness correspond to different
types of brain waves. A fully awake and alert brain produces high-frequency
low-voltage beta-waves. As consciousness decreases, brain waves become
progressively slower in frequency and higher in voltage.

Sleep is described as being of two major types,

 Non-rapid eye movement sleep (NREM)
 Rapid eye movement sleep (REM)

There ae several different stages of sleep that people go through each

night in which REM and NREM sleep occurs. By EEG we can see the brain
wave activities as person passes through delirious stages of sleep.
A person who is wide awake and mentally active will show a brain wave
pattern on the EEG called Beta waves are very small and very fast. As the
person relaxes, and gets drowsy slightly larger and slower alpha waves
appear. The alpha waves are eventually replaced by even slower and larger
waves, theta waves.

Non-rapid eye movement sleep (NREM)

First stage of sleep is known as NREM sleep. About 75 to 80% sleep during
night is NREM sleep. It consist of four stages: -

a) Stage 1 NREM
 This is the traditional stage between wakefulness and sleep last
about 10 to 15 minutes.
 Lightest level of sleep, gradual fall in vital signs and metabolism.
 The person can still be woken by any slight stimulus.
 Slowing of EEG waves.
 Sleeper may deny he is sleeping.
 Eyes tend to roll slowly from side to side.

b) Stage 2 NREM
 Usually last for 10 to 20 minutes.
 Greater relaxation than first stage, muscle relaxation intensifies,
body functions are slowing down.
 Absent eyeball moments, further slowing of EEG.
  It is a period of sound sleep.
 Arousal remains relatively easy.

C) Stage 3 NREM
 Stage last 15 to 30 minutes. This stage occurs about 30 minutes
after the person goes to sleep.
 It involves initial stages of deep sleep.
 Complete relaxation of muscles.
 Large slow waves in EEG.
 Vital signs declined because of the domination of parasympathetic
nervous system, but remains regular.
 Sleeper is difficult to arouse and rarely moves.

D) Stage 4 NREM
 Last approximately 15 into 30 minutes.
 It is the deepest stage of sleep.
 Body is relaxed and body functions are markedly decreased.
 This stage is also known as slow wave sleep.
 It is associated with the physical repair and restoration.
 Further slowing of an EEG.
 It is very difficult to arouse sleeper.
 Sleep walking and enuresis sometimes occur.

Rapid eye movement sleep (REM)

 It constitutes about 25 % of sleep.

 Period of light sleep, during which most of dreaming is thought to occur
and these dreams usually remembers that is they are consolidated in the
memory.
 Stage usually begins about 90 minutes after sleep has begun, recurs about
every 90 minutes and lasts 5 to 30 minutes.
 Stage is typified by rapidly moving eyes, fluctuating heart and respiratory
rates.
 When a person is very tired, the duration of each REM sleep is very short
or even absent. As the person becomes more rested through the night, the
duration of REM sleep increases.

 Sleep cycle
The usual sleeper experiences 4 to 6 cycles of sleep during 7 to 8
hours. Each cycle last at least about 70 minutes. During a sleep cycle, people
pass through four stages of NREM sleep, from 1 through 2 and 3 to stage 4 in
about 20 to 30 minutes. Fourth stage last about 30 minutes. These stages are
followed by stage 3 and 3 in that order. Thereafter the 1 st REM stage occurs,
lasting about 10 minutes. This sequence completes the first sleep cycle.

NREM STAGE I NREM STAGE II

(Lightest Level (Light Sleep)
of Sleep)

REM SLEEP NREM STAGE III

(Sound Sleep)

NREM STAGE IV
NREM STAGE II (Deepest Stage
of Sleep)

NREM STAGE III

Physiology of sleep
The amount and timing of sleep is regulated by 2 major factors:
homeostatic drive and circadian rhythm. Homeostatic drive is
basically the body’s need for sleep, or pressure to sleep. The part of
brain most important in regulating sleep is the hypothalamus. Human
have a sleep centre in the anterior hypothalamus and basal forebrain
and a wake centre in the posterior thalamus. The onset of sleep of each
subsequent stage is an active process involving delicate shifts in the
balance of several neuro transmitters.
According to metabolite theory of sleep, wake promoting area of
posterior hypothalamus, Tuberomammillary nucleus (TMN) produces
histamine, which activate Locus Coeruleus and Raphe nucleus of
Ascending Reticular Activating System (ARAS). These releases
Norepinephrine and Serotonin to activate thalamocortical fibres to
promote awake state. The sleep-promoting region is located in the
ventrolateral preoptic nucleus, VLPO (is a small cluster of neurons
situated in the anterior hypothalamus). The VLPO is activated by
Adenosine which is thought to be a substance that accumulates with
waking hours and drives the pressure to sleep. The VLPO releases
inhibitory neurotransmitter, GABA which inhibit neurons of the
ascending arousal system that are involved in wakefulness. As the
VLPO is also inhibited by neurotransmitters released by components of
the arousal systems, such as acetylcholine and norepinephrine and
serotonin. The hypocretin neurons, also called Orexin neurons in the
posterior lateral hypothalamus potentiate neurons in the ascending
arousal system and help stabilize the brain in the waking state and
consolidated wakefulness, which builds up homeostatic sleep drive,
helps stabilize the brain during later sleep. The TMN also produces
GABA that inhibits VLPO in return. This mutual inhibition is the basis of
the “switch” between sleep and wake. VLPO and the arousal system
form a "flip-flop" circuit. The hypocretin neurons stimulate the TMN, and
are crucial for maintaining wakefulness.
Circadian rhythm is the body’s biological clock for the sleep-wake
cycle. It determines the timing of sleep. The master clock is controlled by
the Suprachiasmatic nucleus (SCN, is the central pacemaker of
circadian rhythm) in the anterior hypothalamus. It receives light inputs
from the retina and resets the clock everyday accordingly to the day-
night cycle. During darkness the SCN controls the production of pineal
hormone melatonin which is believed to be a potent sleep inducer by
inhibiting RAS (Reticular Activating System). The RAS is believed to
contain diffuse network of neurones that cause arousal from sleep and
maintains alertness and wakefulness.
 Norepinephrine
Neurotransmitte Acetylcholine Serotonin GABA
r Histamine

Awake
/
NREM

REM

Normal sleep requirements

New-born - 16 to 18 hours per day
Infants - 12 to 15 hours per day
Toddlers - 11 to 14 hours per day
Preschool - 10 to 13 hours per day
School age - 9 to 11 hours per day
Adolescents- 8 to 10 hours per day
Young adults- 7 to 9 hours per day
Adults - 6 to 8 hours per day
Elders - 6 hours per day
Neonates
For the first week, the neonate sleeps almost constantly to recover from
birth. Approximately 50% of the sleep is REM sleep. This is essential for
development because the neonate is not awake long enough for significant
external stimulation.
Infants
Infants usually develop a night time pattern of sleep during 3 to 4
months of age. The infants may take several naps during daytime. Awakening
commonly occurs early in the morning although its not unusual for an infant to
be awakened during the night. A large infant sleep longer than a smaller one
because of greater stomach capacity. REM sleep is predominant.
Toddler
By the age of 2, children usually sleep through the night and take daily
naps. Total sleep averages 11-14 hrs hours/day. Naps may be eliminated at 3
years. Its common for toddlers to awaken during the night. The percentage of
REM sleep begins to fall because toddler have access to variety of meaningful
external stimuli.

Pre-schooler
 The pre-schoolers usually have difficulty relaxing after long active days.
Pre-schoolers rarely takes daily naps and also has problem with bedtime fears
and nightmares. Parents are most successful in getting a pre-schooler to bed
by establishing a consistent bedtime ritual. A child should not be allowed to
become manipulated with by sleeping with parents.
School age children
The amount of sleep needed during the school years is highly
individualised because of varying states of activity and level of health. The
school age child usually does not require a gap.
Adolescents
An adolescent’s day is usually active and mentally and physically
exhausting. Often the desire to spend time with peers prevents adolescents to
sleep. Because of staying up late, an adolescent frequently sleeps late in the
morning.
Young adults
Healthy young adults require rest and sleep to participate in the busy
activities that fill their days. However, it is common for busy lifestyles to
interrupt. Approximately 20% of sleep time is spent in REM sleep, which
remains consistent through life.
Middle adults
During adulthood, the total time spent sleeping at night begins to
decline. Also the amount of stage begins to fall continuing through out older
age. Sleep disturbances are common. Insomnia is particularly common
because of the changes and stresses of middle age. Sleep disturbances can
be caused by anxiety, depression, or certain physical ailments. Women
experiencing menopausal symptoms may have insomnia.
Older adults
The total amount of sleep does not change as age increases. However,
quality of sleep deteriorates and REM sleep shortens. There an older adult
has almost no stage 4 sleep. An older adult awakens more often during the
night and total wake time increases. It may also take more time for an older
adult to fall asleep. The changes in an older person’s sleep pattern are due
changes in CNS that affect the regulation of sleep. Sensory impairment,
common with aging, may reduce sensitivity to time cues that maintain
circadian rhythm. An older adult’s chronic illness may also impair the quality of
sleep.

Factors affecting sleep and rest

 Both the quality and the quantity of sleep are affected by a number of
factors. Quality of sleep means the individuals ability to stay asleep and to get
appropriate amount of REM and NREM sleep. Factors are: -
a) Age
Age is probably one of the most important factors affecting a person’s
sleep and rest needs. We already discussed the amount of sleep
requirements at different age levels.
b) Illness
Illness of all types can result in sleep problems. Physiological and
physical illness can cause distractions in the sleep wake cycle. Certain
illnesses of respiratory disease like Asma, bronchitis may interrupt with normal
breathing pattern and disrupt sleep. MI occurs more often during REM sleep.
Epilepsy most likely to occur during NREM sleep. Gastric secretion increases
during REM sleep. People with peptic ulcer awaken at night. Also, clients with
chronic medical illness may experience pain that can interfere rest and sleep.
c) Environment
Environment can promote or hinder sleep. Any change can alter their
sleep like: -
 Noise level in the environment
 Absence of usual stimuli
 Presence of unfamiliar stimuli
 Ventilation and environmental temperature
 Light levels: - A person accustomed to darkness, while sleeping may
find it difficult to sleep and a light.
d) Activity and Exercises
Activity and exercise increases fatigue and 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
excessive exercise increases tiredness. The more tired person is the shorter
the period of REM.
e) Life style and habits
Smoking: - Nicotine has a stimulating effect on the body and smokers
often have more difficulty falling asleep than non-smokers.
Alcoholism: -when used in moderation can induce sleep in some people,
but who drink an excessive amount find their sleep disturbed. Excessive
alcohol disrupts REM sleep.
Caffeine: - caffeine is a CNS stimulant, can interfere with the ability to fall
asleep.
Working on the night shift distracts the natural process of sleep and can
result in loss of sleep. Following an irregular morning and night time schedule
can affect sleep. Example watching TV late night participating outside
activities during night.

f) Stress
Anxiety and depression frequently disturb sleep. The person
experiencing stress may find it difficult to obtain the amount of sleep he or she
needs. A person preoccupied with the personal problems may be unable to
relax sufficiently to get sleep.
g) Diet
Certain food induces sleep. Eg: - the amino acid L-tryptophan is thought
to induce sleep which is present in the milk. Protein intake may increase
alertness and concentration, whereas carbohydrate appear to affect the brain
serotonin levels and promote calmness and relaxation.
h) Caloric intake
Weight loss or gain influences sleep pattern. When a person gains
weight sleep periods becomes longer with fewer interruptions. Weight loss can
cause short and fragmented sleep. Certain sleep disorders maybe the result
of semistarvation diets population in a weight conscious society.
i) Medication
Sleep quality also influenced by certain drugs. Drugs that decrease
REM sleep includes barbiturates, amphetamines, antidepressants, diuretics,
antihypertensives, steroids, decongestants, narcotics, etc. Hypnotics and
sedatives can interfere stage 3 and 4 of NREM sleep and suppress REM
sleep.
j) Motivation
Motivation can increase alertness in some situations. Eg: - during
browsing internet and a late night. And also, when there is minimal motivation
to be awake sleep generally follows. Eg: - a student who is bored and not
interested in a lecture or class may sleep during the lecture.

Common sleep disorders

The common sleep disorders are:-
1. Dyssomnias
2. Parasomnias
3. Sleep disorders associated with medical and psychological
problems.

A. DYSSOMNIAS
 Dyssomnias include sleep disorder characterised by difficult initiating or
maintaining sleep (insomnia) or by excessive sleepiness. The client sleeps too
little or too much or at the wrong time. So the problem is with the amount or
quantity or with its timing and sometimes with quality of sleep. The disorders
may arise predominantly from within the body (intrinsic), from external sources
(extrinsic) or disruption of circadian rhythm.

 Intrinsic sleep disorders

 Insomnia
 Hypersomnia
 Narcolepsy
 Sleep apnea syndrome
 Periodic limb movement disorder
 Restless leg syndrome

a) Insomnia
Insomnia is defined as difficulty with initiating or maintaining sleep, that
is the inability to fall asleep or remain asleep. It is the most common sleep
disorder. People with insomnia do not feel refreshed on a rising. Insomnia, the
most common sleep disorder.

Types of insomnia are:-

1. Initial insomnia :- Difficulty in falling asleep
2.Intermittent or maintenance insomnia:- Difficulty in staying asleep because
of frequent or prolonged waking
3. Terminal insomnia:- Early morning or premature waking
4. Transient insomnia:- Insomnia lasts for few days
5. Acute or short term insomnia:- Insomnia lasts less than three months with
an unspecified frequency
6. Chronic insomnia:- Is defined to occur at least three nights per week for at
least 3 months. It may lasts for years and even decades.
7. Primary insomnia:- Insomnia that is present with no other co-existing
disease.
8. Co-morbid insomnia:- When insomnia exists in conjunction with another
medical or psychiatric condition.
Causes
 Physical discomfort
 Mental tension or anxiety
 Depression
 Habitual to any drug
  Alcoholism
Clinical features
 Difficulty in falling asleep
 Waking up frequently during night
 Difficulty to return to sleep
 Waking too early in the morning
 Daytime sleepiness
 Irritability
 Trouble concentrating
 Fatigue
Treatment
Behavioural therapy:- Identifying and stopping of habits like alcoholism,
caffeine intake, etc.
Stimulus control:- A stimulus is anything that causes a response. The goal of
this method is for you to have a positive response when you get into bed at
night. This method teaches you to use the bed only for sleep. You are not
supposed to read, watch or do anything else in bed. You are also taught to go
to bed only when you feel very sleepy. The time in bed should not be
decreased to less than 5 hours per night.
Sleep restriction: -Based on the theory of limiting the time in bed to actual
sleep time. It is thought that excessive time in bed may result in fragmented
sleep. Brief midday naps are permitted with this type of therapy.
Sleep hygiene: - refers to the practices that may influence the length and
quality of sleep.
Cognitive therapy: - It involves meeting with a therapist and working through
maladaptive sleep beliefs. This includes discussing what is normal and
abnormal. Cognitive therapy also does not work well by itself but when used in
conjunction with another complementary therapy is very successful.
Relaxation therapy: - involves any type of relaxation, such as progressive
muscle relaxation, imagery training, or medication. Not all relaxation methods
are beneficial for all patients.
Medications: - pharmacology therapies may include use of sedatives and a
hypnotics. However, only short-term use, at the lowest dose is recommended.

b) Hypersomnia
 Hypersomnia is a condition characterised by excessive sleep, particularly
in the daytime.
 The affected person may fall asleep for intervals during work, while eating
or even during conversation.
 These naps do not usually relieve their symptoms. When they awake they
are often disoriented, irritated, restless, and have slower speech and
thinking process.
 Hypersomnia can be caused by medical conditions like central nervous
system damage, depression and certain kidney, liver, or metabolic
disorders, such as diabetic acidosis and hypothyroidism.
 It can have some serious consequences such as motor vehicle accidents,
because of drowsiness or falling asleep while driving.
 Treatment includes antidepressants, attention to diet like controlling coffee
intake, avoidance of work and social activities later in the evening.

c) Narcolepsy
Narcolepsy is one of the disorders characterised by excessive
daytime sleepiness. It is a sudden wave of overwhelming sleepiness that
occurs during the day; thus, it is referred to as a sleep attack. It is believed to
be a genetic defect of the CNS in which REM sleep cannot be controlled.
Sleep starts with REM sleep.
Common features of narcolepsy include the following: -
Sleep attacks: irresistible urge to sleep, regardless of the type of activity in
which the patient is engaged
Cataplexy: sudden loss of motor tone that may cause the person to fall
asleep; usually experienced during a period of strong emotion
Hypnagogic hallucinations: nightmares or vivid hallucinations Sleep-onset
REM periods: during a sleep attack, the person moves directly into REM sleep
Sleep paralysis: skeletal paralysis that occurs during the transition from
wakefulness to sleep.
Treatment includes A central nervous system stimulant (eg, methylphenidate
[Ritalin]) that causes wakefulness may be used to control narcolepsy. Newer
medications such as modafinil (Provigil), a wakefulness-promoting compound,
and gamma-hydroxybutyric acid (GHB), a sedative used for treat- ing
disturbed nocturnal sleep, have proved effective in treating.

d) Sleep Apnea syndrome

Sleep apnoea is the periodic cessation of breathing during sleep. Most
frequent in men over 50 years and post-menopausal women. The period of
apnoea, which lost from 10 seconds to 2 minutes occurs during REM or
NREM sleep. Frequency of episodes ranges from 50 to 600 per night. The
apneic episodes drain the energy of patient and lead to excessive daytime
sleepiness. Prolonged sleep apnea can cause sharp increase in BP and may
also lead to cardiac arrest, also cause cardiac arrhythmias, pulmonary
hypertension and subsequent left-sided heart failure.

Common types of sleep apneas are

• Obstructive sleep apnea syndrome: -
In this case, respiratory efforts of the diaphragm and intercostal muscles
are apparent, but ineffective against a collapsed or obstructed upper airway.
Occurs when the structures of pharynx and oral cavity block the flow of air.
Enlarged tonsils, a deviated nasal septum, and nasal polyps are predisposing
factors. An episode of sleep apnoea begins with snoring, which indicates
partial obstruction. Escalating snoring followed by a silent pause that end with
a gasp probably indicates complete airway obstruction. Towards the end of
each apnoeic episode increased carbon dioxide level in blood causes the
client to wake up. Frequent awakening impairs the normal sleep cycle.
Management includes the application of Continuous positive airways
pressure (CPAP) by means of a face mask covering the nose is the treatment
of choice.
• Central apnea syndrome: -
It is characterised by apneic periods during which no apparent
respiratory effort occurs. Is thought to involve a defect in the respiratory centre
of the brain. All actions involved in breathing, such as a chest movement and
airflow ceases. Client who has brain stem injuries and muscular dystrophy
often have central sleep apnea. Cheyne strokes respiration is common with
this disorder (alternating periods shallow and deep respiration) The oxygen
saturation of blood falls slightly.
Management is the application of CPAP. In severe cases, the use of
diaphragmatic pacemaker or mechanical ventilator may be required.

• Mixed apnea:
combination of obstructive and central apnea. Treatment directed
towards the treatment of the cause of apnea. Eg:- enlarged tonsils can be
removed. The use of nasal CPAP device at night is often effective.

e) Periodic limb movement disorders

Periodic limb movement disorder may also contribute to daytime
sleepiness and frequent nocturnal awakenings. It is characterised by period
ice episode of repetitive, stereotypic leg or arm movements during sleep
causing partial arousal. It is more common in elderly population.
Management: Clonazepam, a benzo diazepam or baclofen, skeletal
muscle relaxant may be given to diminish the magnitude of the movement and
the frequency of arousal. The ant parkinsonism drug carbidopa levodopa also
can be given.

f) Restless leg syndrome

People with restless leg syndrome cannot lie still and report
unpleasant creeping, crawling, or tingling sensations in the legs. Usually,
these sensations are in the calf, but they may occur anywhere from the ankle
to the thigh. Patients describe an irresistible urge to move the legs when these
sensations occur. Massaging the legs, walking, doing knee bends, and
moving the legs sometimes bring relief. Although restless leg syndrome is a
common sleep disorder that affects millions, many healthcare workers are
unaware of its existence. Research continues to additional treatment options
but the following may improve the condition: -
 Eliminate the use of tobacco, alcohol and caffeine
 Take a mild analgesic at bedtime
 Apply heat or cold to extremity
 Use relaxation techniques
 Treatment similar to periodic limb movement.

 Extrinsic sleep disorder

The extrinsic sleep disorders encompass a range of factors from
environmentally to chemically induced disorders such as :
 Inadequate sleep hygiene
 Environmental sleep disorder
Management: Extrinsic sleep disorder can be managed by maintaining a
consistent and a regular bedtime routine, avoiding stimulants such as
caffeine and adequate sleep.

 Circadian rhythm sleep disorder

In the general population, the circadian rhythm sleep disorder,
such as time zone change syndrome, shift work sleep disorders are not
uncommon. In taking a nursing history, be alert to a history of long-time
shift work because these people may have developed altered sleep
schedules. Older and clinically ill clients who live alone may be vulnerable
to irregular sleep wake pattern. In this disorder, prolonged ignoring or
 absence of external cues to time such as regular mealtime, work periods,
and daylight leads to erratic periods of sleeping and wakefulness. Internal
circadian cues may also be damped as a result of aging or diffused brain
disease.

 Hospital acquired sleep disturbances

Clients in the hospital may report difficulty getting to sleep, awakening
frequently with difficulty getting back to sleep or early morning awakening.
1. Sleep onset difficulty
It is a common problem in hospital because of strange
environment, noise, and anxieties associated with illness and
hospitalization.
Management incudes environmental controls such as reduction of
noise and interruptions and conservative relaxation measures, such as
back rub. The rapid acting hypnotics are most effective with this type of
insomnia.
2. Sleep maintenance disturbance
• Sleep maintenance disturbance may be associated with sustained use
or withdrawal from a variety of medication and related to substance.
• Alcohol hastens sleep onset, but leads to awakening later in the night.
• In acute intoxication, REM sleep is suppressed.
• Abrupt withdrawal, as occurs with hospitalization, may trigger massive
REM rebound.
• Sustained use of or withdrawal from antidepressants, monoamine
oxidase inhibitors, propranolol and phenytoin can also contribute to
insomnia.
• Other factors include stimuli tend to awaken people in the middle of the
night. Internal stimuli such as pain, discomfort, urge to void and sleep
disorders or external stimuli includes environmental factors such as light,
noise, temperature, etc
3. Early morning awakening
• It occurs frequently among older clients. Sensitivity to environmental
disturbances increases toward morning in people of all ages, but even
more so in older adults. Sleepiness and agitation may be associated
with an acute confusional state i.e, delirium. Sleep is grossly disturbed
with frightening dreams, disorientation, and restlessness. Clients who
are disturbed by early morning awakening should be screened for
indications of depression.
4. Sleep deprivation
 A prolonged disturbance results in decreases in amount,
quality, and consistency of sleep and can lead to a syndrome referred to as
sleep deprivation. This is not a sleep disorder in itself but a result of sleep
disturbances. It produces a variety of physiologic and behavioural
symptoms, the severity of which depends on the degree of the symptom of
sleep deprivation. Two major types of sleep deprivation are REM
deprivation and NREM deprivation.
A combination of the two increases the severity of symptoms.
Symptoms includes
o Excitability, restlessness, irritability
o Confusion and suspicious
o Withdrawal, apathy, hypo responsiveness
o Lack of facial expression
o Speech deterioration
o Excessive sleepiness
o Decreased reasoning ability
o Inattentiveness
o Fatigue
 Chronic fatigue syndrome
Chronic fatigue syndrome (CFS) also referred to as myalgic
encephalomyelitis, which is characterised by 6 months or more of severe,
debilitating fatigue, often accompanied by myalgia, headache, pharyngitis,
low grade fever, cognitive complaints, gastro intestinal symptoms, and
tender lymph nodes. The fatigue worsens with physical or mental activity,
but doesn’t improve with rest. The exact cause is unknown. Viral infection
(Epstein Barr virus), immune system problems, hormonal imbalance,
physical or emotional trauma can trigger to CFS. There is no cure for
chronic fatigue. Treatment focuses on symptom relief.
B. PARASOMNIAS
The parasomnias are disorders that occur during sleep but usually do
not produce insomnia or excessive sleepiness. The underlying pathologic
mechanism may involve partial arousal or abnormalities in sleep wake
transition.
Somnambulism: Somnambulism (sleepwalking) occurs during Stages III
and IV of NREM sleep. It is episodic and usually occurs 1 to 2 hours after
falling asleep. Sleepwalkers tend not to notice dangers (eg, stairs) and
often need to be protected from injury.
Sleep terrors: Are sudden arousal from slow wave sleep accompanied by
screaming, tachycardia, tachypnoea, diaphoresis, and other manifestations
of intense fear. If awakened, the person is often disoriented and has little
recall of the nature of the dream image. It occurs during slow wave sleep.
Nightmares: Are frightening dreams that arise in REM sleep and are often
vividly recalled on awakening.
Sleep talking: Talking during sleep occurs during NREM sleep before REM
sleep. It rarely presents a problem to the person unless it becomes trouble-
some to others.
Sleep paralysis: is one of the classic of the classic manifestations of
narcolepsy but can occur in isolation. At sleep onset or on awakening,
people experience episodes of one to several minutes during which they
are unable to move. This effect may be an extension of the normal state of
low muscle tone during REM sleep.
Nocturnal enuresis: Bed-wetting during sleep usually occurs in children
over 3 years old. More males than females are affected. It often occurs 1 to
2 hours after falling asleep, when rousing from NREM Stages III to IV.
Nocturnal erections. Nocturnal erections and emissions occur during REM
sleep. They begin during adolescence and do not present a sleep problem.
Bruxism. Usually occurring during Stage II NREM sleep, this clenching and
grinding of the teeth can eventually erode dental crowns and cause teeth to
come loose.
C. SLEEP DISORDERS DUE TO OTHER MEDICAL CONDITIONS
These disorders are associated with medical and psychiatric or
other illness
• Neurotransmitter imbalances
• Brain injury
• Hormonal imbalances
• Depression
• Alcoholism
• Thyroid dysfunction
• Gastro intestinal disorders like Peptic ulcer
• Respiratory disorders like COPD
• Cardiovascular disorders
Effects of sleep disorders
 Cognitive impairment
 Impaired moral judgment
 Sever yawning
 Hallucinations
 Impaired immune system
 Symptoms similar to ADHD
  impaired immune system
 Increased heart rate
 Risk of heart disease
 Risk for type 2 DM
 Tremors
 Aches
 Risk of obesity
 Temperature

Diagnostic assessment
The primary diagnostic test for sleep disorder is polysomnography.
 Polysomnography
Is a comprehensive recording of the biophysiological changes that
occurs during sleep. It is usually performed at night, when most people sleep,
though some laboratories can accommodate, shifts workers and people with
circadian rhythm sleep disorders. The PSG monitors many body functions
including brain (EEG), eye movement (electro oculatory EOG) and muscle
activity electromyography (EMG)

 A multiple sleep latency test (MSLT)

It may also be performed to assess impairment of daytime alertness.
The MSLT is performed the day after a standard overnight polysomnogram.
The time required for client to fall asleep when in a relaxed state is evaluated
at 2-hour interval with each nap limited to 20 minutes. The type of sleep is
also assessed making the test particularly useful in diagnosing narcolepsy.
 Actigraphy
It is based on the fact, in general, considerably fewer limb movements
occur during sleep than during wakefulness. It consists of a movement
detector and considerable memory storage.

Nursing management
Assessment
 To promote the restful sleep for clients, nurse can assess the sleep
pattern.
 Usually, patients are the best resources for describing their sleep problem.
Some time we can take history from the partner.
 In case of children, older children or mother can best describe the pattern
of sleep and its problem.
The tools for sleep assessments are:
 Sleep history including -Description of client's sleep problem; nature,
sign/symptoms, onset, duration, predisposing factors,
 severity, effects on client. -Usual sleep pattern prior to sleep problem
 Recent changes in sleep pattern
 Physical illness
 Bedtime routine and sleeping environment
 Pattern of dietary intake or any substance
 Use of any medication
 Current emotional and mental status
 Sleep diary including
- times when patient tries to fall asleep
- approximate time that patient fall asleep
- time of awakening during night -record of food, physical activity, worries,
mental
Nursing diagnosis
 Disturbed sleep pattern
 Insomnia
 Sleep deprivation
 Impaired comfort
 Fatigue
 Disturbed energy field
 Risk for injury
 Anxiety

Interventions….
The nurse can implement all the measures to improve the quality of sleep
which collectively called sleep hygiene which includes the following: -
Sleep hygiene
 Sleep hygiene refers to healthy habits, behaviours and environmental
factors that can be adjusted to help you have a good night’s sleep.
 Some sleeping problems are often caused by bad sleep habits reinforced
over years or even decades.
 Improved sleep will not happen as soon as changes are made. But if
good sleep habits are maintained, sleep will certainly get better.
 Paying attention to sleep hygiene is one of the most straightforward ways
that you can set yourself up for better sleep.
 Strong sleep hygiene means having both a bedroom environment and
daily routines that promote consistent, uninterrupted sleep. Keeping a
stable sleep schedule, making your bedroom comfortable and free of
disruptions, following a relaxing pre-bed routine, and building healthy
habits during the day can all contribute to ideal sleep hygiene
Why Is Sleep Hygiene Important?
Obtaining healthy sleep is important for both physical and mental
health, improving productivity and overall quality of life. Everyone, from
children to older adults, can benefit from better sleep, and sleep hygiene can
play a key part in achieving that goal. Forming good habits is a central part of
health. Crafting sustainable and beneficial routines makes healthy
behaviours feel almost automatic, creating an ongoing process of positive
reinforcement. On the flip side, bad habits can become engrained even as
they cause negative consequences. Sleep hygiene encompasses both
environment and habits, and it can pave the way for higher-quality sleep and
better overall health. Improving sleep hygiene has little cost and virtually no
risk, making it an important part of a public health strategy to counteract the
serious problems of insufficient sleep and insomnia

What Are Signs of Poor Sleep Hygiene?

Having a hard time falling asleep, experiencing frequent sleep
disturbances, and suffering daytime sleepiness are the most telling signs of
poor sleep hygiene. An overall lack of consistency in sleep quantity or quality
can also be a symptom of poor sleep hygiene.

How Do You Practice Good Sleep Hygiene?

Good sleep hygiene is all about putting yourself in the best
position to sleep well each and every night. Optimizing your sleep schedule,
pre-bed routine, and daily routines is part of harnessing habits to make
quality sleep feel more automatic. At the same time, creating a pleasant
bedroom environment can be an invitation to relax and doze off. A handful of
tips can help in each of these areas, they aren’t rigid requirements. You can
adapt them to fit your circumstances and create your own sleep hygiene
checklist to help get the best sleep possible.

Set Your Sleep Schedule

  Having a set schedule normalizes sleep as an essential part of your day
and gets your brain and body accustomed to getting the full amount of
sleep that you need.
 Have a Fixed Wake-Up Time: Regardless of whether it’s a weekday or
weekend, try to wake up at the same time since a fluctuating schedule
keeps you from getting into a rhythm of consistent sleep.
Prioritize Sleep
 It might be tempting to skip sleep in order to work, study, socialize, or
exercise, but it’s vital to treat sleep as a priority. Calculate a target bedtime
based on your fixed wake-up time and do your best to be ready for bed
around that time each night.
Make Gradual Adjustments
 If you want to shift your sleep times, don’t try to do it all in one fell swoop
because that can throw your schedule out of whack. Instead, make small,
step-by-step adjustments of up to an hour or two so that you can get
adjusted and settle into a new schedule.
 Don’t Overdo It with Naps: Naps can be a handy way to regain energy
during the day, but they can throw off sleep at night. To avoid this, try to
keep naps relatively short and limited to the early afternoon.
Follow a Nightly Routine
 How you prepare for bed can determine how easily you’ll be able to fall
asleep. A pre-sleep playbook including some of these tips can put you at
ease and make it easier to get to fall asleep when you want to.
Keep Your Routine Consistent:
 Following the same steps each night, including things like putting on your
pyjamas and brushing your teeth, can reinforce in your mind that it’s
bedtime.
Budget 30 Minutes for Winding Down:
 Take advantage of whatever puts you in a state of calm such as soft music,
light stretching, reading, and/or relaxation exercises.
Dim Your Lights:
 Try to keep away from bright lights because they can hinder the production
of melatonin, a hormone that the body creates to facilitate sleep.
Unplug From Electronics:
 Build in a 30–60-minute pre-bed buffer time that is device-free. Cell phones,
tablets, and laptops cause mental stimulation that is hard to shut off and
also generate blue light that may decrease melatonin production.
Test Methods of Relaxation:
 Instead of making falling asleep your goal, it’s often easier to focus on
relaxation. Meditation, mindfulness, paced breathing, and other relaxation
techniques can put you in the right mindset for bed.
Don’t Toss and Turn:
 It helps to have a healthy mental connection between being in bed and
actually being asleep. For that reason, if after 20 minutes you haven’t
gotten to sleep, get up and stretch, read, or do something else calming in
low light before trying to fall asleep again.
Cultivate Healthy Daily Habits
 It’s not just bedtime habits that play a part in getting good sleep.
Incorporating positive routines during the day can support your circadian
rhythm and limit sleep disruptions.
Get Daylight Exposure:
 Light, especially sunlight, is one of the key drivers of circadian rhythms
that can encourage quality sleep.
Be Physically Active:
 Regular exercise can make it easier to sleep at night and also delivers a
host of other health benefits.

Don’t Smoke:
 Nicotine stimulates the body in ways that disrupt sleep, which helps
explain why smoking is correlated with numerous sleeping problems.
Reduce Alcohol Consumption:
 Alcohol may make it easier to fall asleep, but the effect wears off,
disrupting sleep later in the night. As a result, it’s best to moderate alcohol
consumption and avoid it later in the evening.
Cut Down on Caffeine in the Afternoon and Evening:
 Because it’s a stimulant, caffeine can keep you wired even when you
want to rest, so try to avoid it later in the day. Also be aware if you’re
consuming lots of caffeine to try to make up for lack of sleep.
Don’t Dine Late:
 Eating dinner late, especially if it’s a big, heavy, or spicy meal, can mean
you’re still digesting when it’s time for bed. In general, any food or snacks
before bed should be on the lighter side.
Restrict In-Bed Activity:
 To build a link in your mind between sleep and being in bed, it’s best to
only use your bed for sleep with sex being the one exception.
Optimize Your Bedroom
  A central component of sleep hygiene beyond just habits is your sleep
environment. To fall asleep more easily, you want your bedroom to
emanate tranquillity.
 While what makes a bedroom inviting can vary from one person to the
next, these tips may help make it calm and free of disruptions:
Have a Comfortable Mattress and Pillow:
 Your sleeping surface is critical to comfort and pain-free sleep, so
choose the best mattress and best pillow for your needs wisely.
Use Excellent Bedding:
 The sheets and blankets are the first thing you touch when you get into
bed, so it’s beneficial to make sure they match your needs and
preferences.
Set a Cool Yet Comfortable Temperature:
 Fine-tune your bedroom temperature to suit your preferences, but err on
the cooler side (around 65 degrees Fahrenheit).
Block Out Light:
 Use heavy curtains or an eye mask to prevent light from interrupting your
sleep.

Drown Out Noise:

 Ear plugs can stop noise from keeping you awake, and if you don’t find
them comfortable, you can try a white noise machine or even a fan to
drown out bothersome sounds.
Try Calming Scents:
 Light smells, such as lavender, may induce a calmer state of mind and
help cultivate a positive space for sleep.

Review of literature
Abstract
Objectives
Pain can have a negative impact on sleep and emotional well-being.
This study investigated whether this may be partly explained by
maladaptive sleep-related cognitive and behavioural responses to pain,
including heightened anxiety about sleep and suboptimal sleep hygiene.
Methods
This cross-sectional study used data from an online survey that
collected information about pain (Brief Pain Inventory), sleep (Pittsburgh
 Sleep Quality Index; Sleep Hygiene Index; Anxiety and Preoccupation
about Sleep Questionnaire) and emotional distress (PROMIS
measures; Perceived Stress Scale). Structural equation modelling
examined the tenability of a framework linking these factors.
Results
Of 468 survey respondents (mean age 39 years, 60% female), 29%
reported pain, most commonly in the spine or low back (28%). Pain
severity correlated with poor sleep quality, poor sleep hygiene, anxiety
about sleep and emotional distress. In the first structural equation
model, indirect effects were identified between pain severity and sleep
quality through anxiety about sleep and sleep hygiene. In the second
model, an indirect effect was identified between pain severity and
emotional distress through sleep quality. Combining these models,
indirect effects were identified between pain severity and emotional
distress through anxiety about sleep, sleep hygiene and sleep quality.

Conclusion
A good night’s sleep and decreased stress level are the best for many
illness. Moreover, if we want to be in good mood the whole day we need to
sleep well and long enough. The adequacy of sleep and rest is important to
consider in caring for clients with acute or chronic illness. The nurse can play
a pivotal role in environmental modifications and client teaching to minimize
the impact of sleep, fatigue and sensory disturbances.

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