Comfort, Rest, and Sleep

Kozier C 45
 Objectives
 Identify the characteristics of NREM
and REM sleep
 Identify the four stages of NREM sleep
 Describe variations in sleep patterns
throughout the life span
 Identify factors that affect normal sleep
 Describe common sleep disorders
 Objectives
 Identify the components of a sleep
pattern assessment
 Develop nursing diagnosis, outcomes,
and nursing interventions related to
sleep problems
 Describe interventions that promote
normal sleep
 Question 1
A client has a history of sleep apnea. The nurse
should ask which of the following most
appropriate questions?
1. Do you have a history of cardiac irregularities?
2. Do you have a history of any kind of nasal
obstruction?
3. Have you had chest pain with or without
activity?
4. Do you have difficulty with daytime sleepiness?
 Rationales 1
1. Although cardiac arrhythmias may occur, they are
usually only detectable during a sleep study, and thus the
client would not be aware of them.
2. Nasal obstruction is rarely the cause of sleep apnea or a
complaint of clients with sleep apnea.
3. There are many causes of chest pain, and this is unlikely
to be something reported by clients with sleep apnea
unless they have underlying cardiac disease.
4. Correct. Most clients with sleep apnea report excessive
daytime sleepiness. If they don’t volunteer this, clients
should be asked if they fall asleep or struggle to stay
awake at work.
 Physiology of Sleep
 Darkness & preparing for sleep cause
decrese in stimulation of the RAS
 Pineal gland secretes melatonin
 This results in person feeling sleepy
 Growth hormone is secreted & cortisol
inhibited.
 Biorhythms
Circadian Rhythms = “about a day”
Circadian Synchronization = awake when
physiologic and psychological rhythms
are most active and asleep when lest
active.
 Cicadian regularity
 Begins by 3rd week of
life
 May be inherited

 By 5th or 6th month

more like parents

sleep-wake pattern.
 Question 2
Because of significant concerns about financial
problems a middle-aged client complains of
difficulty sleeping. Which of the following would
be an appropriate outcome for the nursing care
plan? “By day 5, the client will:
1. Sleep 8 to 10 hours per day.”
2. Report falling asleep within 20 to 30 minutes.”
3. Have a plan to pay all the bills.”
4. Decrease worrying about financial problems and
will keep busy until bedtime.”
 Rationales 2
1. Most adults do not need to sleep 8 to 10 hours
per day.
2. Correct. Falling asleep within 20 to 30 minutes is
normal for adults and would represent
substantial improvement in the client’s
difficulties.
3. Although it would be ideal to remove the source
of the client’s stress, he is unlikely to have a plan
to pay all his bills within 5 days.
4. Distraction or keeping busy until bedtime will
not prevent the client from worrying about his
bills at bedtime.
 Types of Sleep
 Two types of sleep
 NREM-
 REM
 Stages of Sleep: NREM
 Stage I- very light sleep (drowsy-
relaxed) lasts a few mins.
 Stage II- light sleep,
 body process continue to slow
 Eyes still
 T, HR & RR decrease slightly
 Lasts about 10 – 15 min
 Makes up 44 – 55% of total sleep.
 Stages of Sleep: NREM
 Stage III-heart and
respiratory rate are slower
 Stages of Sleep: NREM
 Stage VI-signals deep, restful sleep /w slower
brain waves.
 Thought to restore the body physically.
 Some dreaming occurs.
 Skeletal muscles relaxed
 Reflexes diminished
 Snoring most likely to occur
Physiologic changes during NREM sleep
 Arterial BP falls
 Pulse increases
 Peripheral blood vessels dilate
 Cardiac output decreases
 Skeletal muscles relax
 Basal metabolic rate decreases 10 – 30%
 Growth hormone levels peak
 Intracranial pressure decreases
 REM-Rapid eye Movement-
 Occurs about every 90 min & lasts 5-30
min
 Not restful

 Most dreams take place here

 Brain metabolism increases 20%

 Sleep Cycles
 Pass the four stages in 90 – 110 mins
 Sleeper passes through the 1st 3 NREM

stages in about 20-30 min.

 After stage IV NREM sleeper passes thru

Stages III and II in about 20mins

 Than the 1st REM occurs (lasts 10 mins)
 Sleep Cycles
 Healthy adult passes thru 4 – 6 cycles of
sleep in 7 – 8 hrs
 Functions of Sleep
 Restores normal levels of activity
 Lack of sleep results in poor concentration,

irritability, difficult decision making.

 It use to be thought that a regular sleep pattern was

more important than actual hours slept but sleep

deprivation is associated
with cognitive & health problems.
Normal Sleep Patterns and Requirements
 Newborns- sleep 16 to 18 hours a day, usually
seven sleep periods & enter REM sleep
immediately.
 Infants at end of yr sleep 14 -15 hours a day
 Toddlers- 12-14 hours a day.
 Preschoolers- 11-13 hours of sleep per night
 School Aged children (5 – 12 yrs) need 10- 11
hours at night.
 Normal Sleep Patterns and Requirements
 Adolescents- 9-10 hours of sleep
 Young adults- 7-9 hours may require less
 Older Adults- 7-9 hours
 Sundowner’s syndrome
 Question 3
A client reports to the nurse that she has been
taking barbiturate sleeping pills every night for
several months and now wishes to stop taking
them. The nurse advises the client to:
1. Take the last pill on a Friday night so disrupted
sleep can be compensated on the weekend.
2. Continue to take the pills since sleeping without
them after such a long time will be difficult and
perhaps impossible.
3. Discontinue taking the pills.
4. Continue taking the pills and discuss tapering the
dose with the primary care provider.
 Rationales 3
1. Suddenly stopping barbiturate sleeping pills can
precipitate a dangerous withdrawal.
2. Stopping requires a plan but can be done.
3. Suddenly stopping barbiturate sleeping pills can
precipitate a dangerous withdrawal.
4. Correct. Doses should be tapered gradually and
the tapering process supervised by the client’s
primary care provider.
 Sleep and the Elderly Video

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 Factors Affecting Sleep
 Age- One of the most important factors
affecting persons sleep and rest periods.
 Illness- causing pain or physical distress can
result in sleep problems.
 Environment-Noise level
 Fatigue- more tired the shorter the first (REM)
sleep
 Lifestyle-Shift work
 Factors Affecting Sleep
 Emotional Stress
 Alcohol and Stimulants

 Diet

 Smoking

 Motivation

 Medications
 Drugs That Affect Sleep
 Alcohol Antidepressants
 Beta-blockers Caffeine
 Bronchial dilators Steroids
 Decongestants Narcotics
 Amphetamines
 Common Sleep Disorders
 Insomnia- most common sleep disorder, inability to
obtain an adequate amount or quality of sleep.
 Hypersomnia- Opposite of insomnia, excessive
sleep, especially daytime.
 Narcolepsy- Sudden wave of overwhelming
sleepiness that occurs during the day. Referred to
as “sleep attack”.
 Primary Sleep Disorders
 Sleep Apnea- periodic cessation of breathing
during sleep.
 Obstructive apnea
 Central apnea

 Mixed

 >5 apneic episodes or 5 breathing pauses

longer than 10 seconds/hour.
 Primary Sleep Disorders
 Sleep Apnea-
 Load snoring
 Nocturnal awakenings

 Excessive daytime sleepiness

 Difficulties falling asleep

 Morning headaches

 Memory/cognitive problems

 Irritability.
Sleep Disorders
 Parasomnias- Behavior that may interfere with
sleep. (somnambulism, sleep talking,
Nocturnal enuresis, nocturnal erections,
bruxism).
 Insufficient Sleep - prolonged disturbance
resulting in decreases amount, quality,
consistency of sleep.
Box 43-3 Parasomnias
 Assessment of Sleep
 Assessment of a client’s sleep includes:
 a sleep history,
 sleep diary,

 physical examination,

 a review of diagnostic studies.

 Sleep History
 When does client usually go to sleep?
 Bedtime rituals?
 Does client snore?
 Can client stay away during day?
 Taking any prescribed or OTC
medications?
 Sleep History
 What is the usual sleeping pattern,
specifically:
 sleeping and waking times
 hours of undisturbed sleep, etc.

 Bedtime rituals
 Use of sleep medications
 Sleep environment
 Changes in sleep pattern
 Sleep Diary
 Written record to be much more precise
 Total number of sleep hours a day
 Activities performed 2-3 hours before sleep

 Bedtime rituals

 Any worries that may affect client’s sleep

 Factors that client believes to be positive or

negative towards sleep

 Physical Examination
 Observation of clients facial appearance,
behavior, and energy level.
 Darkened areas around the eyes, puffy
eyelids, reddened conjunctiva, glazed or dull
appearing eyes.
 Irritability, yawning, slumped posture, hand
tremor, rubbing of eyes, confusion, fatigued,
lethargic, etc.
 Physical Examination
 Rarely yields information unless client has
obstructive sleep apnea
 Enlarged and reddened uvula and soft palate

 Enlarged adenoids and tonsils (children)

 Obesity (adults)

 Neck circumference > 17.5 inches (men)

 Deviated septum (occasionally)

Diagnostic studies
 Polysomnography – (EEG,
electromyogram & electro-
oculogram are recorded
simultaneously).
 May also include respiratory effort

& airflow, ECG, leg movement &

O2 sat.
 NANDA Nursing Diagnoses
 Disturbed Sleep Pattern
 With specific descriptions such as “difficulty
falling asleep” or “difficulty staying asleep”
 Various etiologies may be involved and
specified
 NANDA Nursing Diagnoses
 Sleep pattern disturbances as etiology of
other diagnoses:
 Risk for injury
 Ineffective coping
 Fatigue
 Risk for impaired gas exchange
 Deficient knowledge
 Anxiety
 Activity intolerance
 Outcomes for Clients
With Sleep Disturbances
 Maintain (or develop) a sleeping pattern
that provides sufficient energy for daily
activities
 Enhance feeling of well being
 Improve the quality and quantity of the
client’s sleep
 Implementation
 Nursing interventions are used to enhance the
quantity and quality of sleep & involve largely
non-pharmacologic measures. Interventions
include-
 guided imagery
 therapeutic message
 progressive muscle relaxation
 uninterrupted sleep periods.
 Implementation
 Client teaching
 Individuals need to learn the importance of rest
and sleep in maintaining active and productive
lifestyles.
 Supporting bedtime rituals
 Many are accustomed to rituals or pre-sleep
routines and if altered can affect sleep.
 Creating Restful Environment
 Bedtime Rituals
 Altering or eliminating routines can affect sleep
 Adults
 Listening to music
 Reading
 Soothing bath
 Praying
 Children
 Need to be socialized into presleep routine
 Usually preceded by hygienic ritual
 Implementation
 Promoting Comfort and Relaxation
 Assist client with hygienic routines
 Offer back message

 Administer analgesics 30 min before sleep

 Enhancing Sleep with Medications

 Nurse responsible for making decisions with the
client about when to administer sedative or
hypnotics.
Figure 43.2 One suggested pattern for a back massage.

Effeurage massage consists of long, slow, gliding strokes.

 Question 4
During a yearly physical, a 52-year-old male client
mentions that his wife frequently complains about his
snoring. During the physical exam, the nurse notes that
his neck size is 18 inches, his soft palate and uvula are
reddened and swollen, and he is overweight. The most
appropriate nursing intervention for this client is to:
1. Recommend that he and his wife sleep in separate
bedrooms so that his snoring does not disturb his wife.
2. Refer him to a dietician for a weight loss program.
3. Caution him not to drink or take sleeping pills since they
may make his snoring worse.
4. Refer him to a sleep disorders center for evaluation and
treatment of his symptoms.
 Rationales 4
1. This does not address the client’s problem.
2. It would not be wrong to refer him to a dietician
for weight loss counseling, but being evaluated
by a sleep disorders specialist is more critical.
3. Drinking alcohol or taking sleeping pills is not
advised in clients with sleep apnea because they
reduce the client’s ability to get around.
4. Correct. The client’s symptoms, combined with
his weight, suggest that he has obstructive sleep
apnea and should be referred to a sleep
disorders specialist for further evaluation.
 Sedative-Hynoptic Meds
 Medication Half-Life
 Chloral hydrate 7-10 hrs
 Placidyl 10-20 hrs
 Dalmane 47-100 hrs
 Doriden 1-12 hrs
 Ativan 10-20 hrs
 Lunesta 6 hrs
 Sedative-Hynoptic Meds
 Medication Half-Life
 Melatonin 1 hr
 Restoril 9-15 hrs
 Halcion 1.5-5.5 hrs
 Sonata 1 hr
 Ambien 2.6 hrs
 Reducing Environmental
Distractions in Hospitals
 Close window curtains if street lights
shine through
 Close curtains between clients in
semiprivate and larger rooms
 Reduce or eliminate overhead lighting:
provide night light at the bedside or in
the bathroom
 Close the door of the client’s room
 Reducing Environmental
Distractions in Hospitals
 Perform only essential noisy activities
during sleeping hours
 Ensure that all carts wheels are well
oiled
 Wear rubber soled shoes
 Keep required staff conversations at
low levels: conduct nursing reports or
other discussions in a separate area
away from clients rooms
Teaching to promote rest & sleep
 Establish regular betime & wake up
 Eliminate lengthy naps
 Exercise just not 2 hrs before bedtime
 Est regular bedtime routine – listen to
music, warm bath,
 Avoid heavy meals 3 hrs before bedtime
Teaching to promote rest & sleep
 Avoid alcohol & caffeine at least 4 hrs
before bedtime
 Decrease fluid intake 2-4 hrs before bed
 Use sleeping meds as last resort
 Take analgesics before bedtime if needed
 Question 5
A new nursing graduate’s first job requires 12-hour
night shifts. Which of the following strategies will make
it easier for the graduate to sleep during the day and
remain awake at night?

1. Wear dark wrap-around sunglasses when driving home

in the morning, and sleep in a darkened bedroom.
2. Exercise on the way home to avoid having to stand
around as long waiting for equipment at the gym.
3. Drink several cups of strong coffee or 16 oz of
caffeinated soda when beginning the shift.
4. Try to stay in a brightly lit area when working at night.
 Rationales 5
1. Correct. Reducing exposure to bright light in the
morning, driving home, and when going to sleep will
make it easier to fall asleep after work.
2. Exercising before going to bed will increase arousal.
3. Caffeine consumed at the beginning of a 12-hour shift
will not assist the nurse in remaining awake during the
later part of the shift.
4. Although working in a brightly lit area will reduce
drowsiness, this strategy is rarely available to nurses
working the night shift; lights are often dimmed in
hospital corridors and client rooms.