UNIT-1

SLEEP AND REST

Rest and sleep are fundamental components of
wellbeing.
One- third of human life is spent sleeping.
Periods of rest may account for another major portion
of the life span.
The need for rest and sleep varies with age,
developmental level, health status, activity level, and
cultural norms.

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 SLEEP AND REST
Sleep refers to a natural state of altered consciousness
during which an individual experiences minimal
physical activity and a general slowing of the body’s
physiological processes as well as decreased
awareness & responsiveness to stimuli.
Sleep generally occurs in a periodic cycle and usually
lasts for several hours at a time;
Disruptions in the usual sleep routine can be
distressing to clients and will most likely impair sleep
further.
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 SLEEP
• Sleep is a state of unconsciousness from which the
person can be aroused by sensory stimuli.
• A normal adult person sleeps 7-8 hrs/day.
• A newly-born infant sleeps much longer time (16-18
hrs/day), whilst an old person sleeps less (5-6 hrs/day).
WAKING / SLEEPING RHYTHM
• Waking and sleeping periods follow each other in a
circadian rhythm (i.e. 24 hr. rhythm) which is
synchronized with the daily light-dark cycle.
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 SLEEP…
• This synchronization is the function of the
suprachiasmatic nucleus of the hypothalamus
which receives collateral from the visual
pathway.
• Physical and psychological factors affect the
onset and duration of sleep.
– E.g. cold and fear prevent the onset of sleep,

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whilst fatigue and bored facilitate its onset. 4
 Cont…
Sleep
Sleep is defined as unconsciousness from which the person
can be aroused by sensory or other stimuli. It is to be
distinguished from coma, which is unconsciousness from
which the person cannot be aroused. There are multiple
stages of sleep, from very light sleep to very deep sleep .

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 SLEEP AND REST
Rest refers to a state of relaxation and calmness, both
mental and physical.
In rest awareness of the environment is maintained
but motor or cognitive response is decreased and
may involve the total body system or only a part.
Activity during rest periods can range from lying
down to reading a book to taking a quiet walk.
When discussing a client’s rest patterns, the nurse
should try to understand what activities and
environments the client defines as restful.
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 Normal Sleep/ Rest Function
Sleep and rest have the following functions:-
1. Restorative, (having the ability to restore health, strength or feeling of
well-being)
2. Protective
3. . Conservation of metabolic energy
4. Neural maturation,
5. Facilitation of learning or memory,
6. Cognition, (Mental action or process of acquiring knowledge through
thought,
experience, & senses)
7. The principal value of sleep is to restore natural balances among the
neuronal
centers (E.g.. Suicide, depression)
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 Tryptophan

Following hydroxylation of tryptophan to 5-

hydroxytryptophan by liver tyrosine hydroxylase,
subsequent decarboxylation forms serotonin (5-
hydroxytryptamine), a potent vasoconstrictor and
stimulator of smooth muscle contraction.
Catabolism of serotonin is initiated by monoamine
oxidase-catalyzed oxidative deamination to 5-
hydroxyindole-3-acetate
N -Acetylation of serotonin followed by its O -
methylation in the pineal body forms melatonin.

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 Cont…
Circulating melatonin is taken up by all tissues,
including brain, but is rapidly metabolized by
hydroxylation followed by conjugation with sulfate
or with glucuronic acid. Kidney tissue, liver tissue,
and fecal bacteria all convert tryptophan to
tryptamine, then to indole 3-acetate.
The principal normal urinary catabolites of
tryptophan are 5-hydroxyindoleacetate and indole
3-acetate.

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 Normal Physiology of Sleep

Sleep is an active process involving the reticular

activating system (RAS) and a dynamic interaction of
neurotransmitters.
The RAS consists of a network of interconnecting
neurons in the medulla, pons, and midbrain with
projections to the spinal cord, hypothalamus,
cerebellum, and cerebral cortex

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 Normal Physiology of Sleep

Serotonin is a major neurotransmitter associated with

sleep.
It is produced in the Raphe nuclei of the brain stem.
Serotonin is thought to decrease the activity of the RAS
(Reticular Activation System), there by inducing and
sustaining sleep.
Sleep-wake patterns appear to be affected by and to affect
certain hormone levels.
Melatonin from the pineal gland is secreted in enormous
quantities during sleep.
Secretion of growth hormone, Adreno-corticotropic
hormone and prolactin increases early in the sleep period.
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Neuronal Centers, Neurohumoral
Substances, and Mechanisms
That Can Cause Sleep—A
Possible Specific Role for
Serotonin
1. The most conspicuous stimulation area for
causing
almost natural sleep is the raphe nuclei in the lower
half
of the pons and in the medulla. These nuclei
comprise
a thin sheet of special neurons located in the
midline.
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 Cont…
Nerve fibers from these nuclei spread locally in the
brain stem reticular formation and also upward into
the thalamus, hypothalamus, most areas of the limbic
system, and even the neocortex of the cerebrum.
In addition, fibers extend downward into the spinal
cord, terminating in the posterior horns, where they
can inhibit incoming sensory signals, including pain.

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 Cont…
Many nerve endings of fibers from these raphe
neurons secrete serotonin.
When a drug that blocks the formation of serotonin is
administered
to an animal, the animal often cannot sleep for
the next several days. Therefore, it has been assumed
that serotonin is a transmitter substance associated
with production of sleep

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 Cont…
2. Stimulation of some areas in the nucleus of the tractus
solitarius can also cause sleep. This nucleus is the termination
in the medulla and pons for visceral sensory signals entering by
way of the vagus and glossopharyngeal nerves.
3. Sleep can be promoted by stimulation of several
regions in the diencephalon, including (1) the rostral (front end)
part of the hypothalamus, mainly in the suprachiasmal
area, and (2) an occasional area in the diffuse nuclei of
the thalamus.

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Lesions in Sleep-Promoting Centers
Can Cause
Intense Wakefulness
Discrete (individually separate) lesions in the raphe nuclei lead
to a high state of wakefulness. This is also true of bilateral
lesions in the medial rostral suprachiasmal area in the anterior
hypothalamus.
In both instances, the excitatory reticular nuclei of the
mesencephalon and upper pons seem to become released from
inhibition, thus causing
the intense wakefulness.
Indeed, sometimes lesions of the anterior hypothalamus can
cause such intense wakefulness that the individual actually dies
of exhaustion.

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 Stages of Sleep

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 Stages of Sleep
Stage 1: is the transitional stage between drowsiness
and sleep.
During this stage, muscles relaxed, respiration and
pulse decreases.
This stage usually lasts only a few minutes, and if
awakened, the person may say he or she was not asleep.
Stage 2: is still a relative light sleep from which the
person is easily wakened.
Rolling eye movements continue and snoring may
occur.
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 Stages of Sleep

Stage 3 and 4: constitute “deep sleep”, sometimes

termed as slow- wave sleep or delta sleep after
characteristics waves seen on EEG.
During these stages the muscles are relaxed, but
tone is maintained, respiration is even, and blood
pressure, pulse, and temperature decreases as do
formation of urine and oxygen consumption of
muscles.
Snoring, sleepwalking (somnambulism), and bed
wetting (enuresis) are most likely to occur.
Strong stimuli are required to awaken people and
dream contents tend to be realistic.
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 Stages of Sleep
Polygraph recordings of electrophysiologic changes in
brain waves
(electroencephalogram; ECG),
Eye movement (electrooculogram; EOG), and
Muscle (electromyogram; EMG) show five sleep
stages.
Two main types of sleep are:
◦ NREM (non-rapid eye movement), quite sleep and
◦ REM (rapid eye movement) sleep

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 (1)- Slow-wave sleep (NREM)
In which the brain waves are strong and of low frequency,
This sleep is exceedingly restful and is associated
with decreases in both peripheral vascular tone and many
other vegetative functions of the body. For instance, there
are 10 to 30 percent decreases in blood pressure,
respiratory
rate, and basal metabolic rate.

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 Cont…
Although slow-wave sleep is frequently called
“dreamless sleep,” dreams and sometimes even nightmares
do occur during slow-wave sleep. The difference
between the dreams that occur in slow-wave sleep and
those that occur in REM sleep is that those of REM sleep
are associated with more bodily muscle activity. Also,
the dreams of slow-wave sleep are usually not remembered
because consolidation of the dreams in memory does not
occur.

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 REM Sleep (Paradoxical Sleep, Desynchronized
Sleep)
REM sleep: closely resembles wakefulness except for
very low muscle tone.
Respiration is irregular and oxygen consumption
increases, vaginal secretion increases in females, and
erection may occur in male.
Dreams occurring during REM sleep tend to be vivid
and implausible, often including a sense of being
unable to move.

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 Cont…
In a normal night of sleep, bouts of REM sleep lasting 5
to
30 minutes usually appear on the average every 90
minutes.
When the person is extremely sleepy, each bout of
REM sleep is short and may even be absent. Conversely,
as the person becomes more rested through the night, the
durations of the REM bouts increase

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REM sleep has several
important characteristics
1. It is an active form of sleep usually associated with
dreaming and active bodily muscle movements.
2. The person is even more difficult to arouse by sensory
stimuli than during deep slow-wave sleep, and yet people
usually awaken spontaneously in the morning during
an episode of REM sleep.

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 Cont…
3. Muscle tone throughout the body is
exceedingly
depressed, indicating strong inhibition of the
spinal
muscle control areas.
4. Heart rate and respiratory rate usually become
irregular,
which is characteristic of the dream state

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 Cont…
5. Despite the extreme inhibition of the
peripheral muscles, irregular muscle
movements do occur. These are in addition
to the rapid movements of the eyes.
6. The brain is highly active in REM sleep,
and overall
brain metabolism may be increased as much
as 20 percent.

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 Cont…
The electroencephalogram (EEG) shows a pattern
of brain waves similar to those that occur during
wakefulness. This type of sleep is also called
paradoxical
sleep because it is a paradox that a person can still
be a sleep despite marked activity in the brain.

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 Cont…
In summary, REM sleep is a type of sleep in which
the
brain is quite active. However, the brain activity is
not
channeled in the proper direction for the person to be
fully aware of his or her surroundings, and therefore
the
person is truly asleep.

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 Sleep Rhythm
There is 90 minutes cycle during which people
progress in sequence through the sleep stages.
The usual pattern is rapid progression through stages
1 to 4 and then back through stages 3 and 2, from
which REM is then entered.
During the early part of the night, periods of slow
wave sleep (stage 3 and 4) are longer.

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 Sleep Rhythm
In contrast, the time spent in rapid eye movement
during the first cycle may be only 3 to 4 minutes;
Whereas towards morning it may be as much as 45
minutes balanced with shorter periods of slow-
wave sleep in which stage 4 may not be present.
If awakening occurs, the cycle begins again with
stage 1but if the awakening was brief; the
tendency is to reenter the type of cycle from which
the person was aroused.
Most people require 10 to 30 minutes to fall
asleep; this period of time required is called sleep
latency.
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 Sleep Rhythm
A regular sleep latency of less than 5 minutes suggests
excessive sleepiness;
Sleep latency longer than 30 minutes may be
accompanied by some sense of frustration with the
time taken to get to sleep.
Short sleepers, that is those who sleep for less than 6
hours in 24H, tend to be efficient, hardworking
people;
Long sleepers, that is those who sleep for more than 9
hours in 24H, have a higher percentage of REM sleep
and they are more creative.

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 Altered Sleep/ Rest Function
Potential for Altered Sleep
Distraction
A. Noise: people chronically exposed to high noise
levels have less slow-wave and REM sleep with more
stage1 and awakenings than their counterparts who
quieter neighborhoods.
B. Temperature: excessive warmth or cold increases
restlessness.
C. Environment: in new environment sleep latency is
increased and total sleep time and proportion of REM
are decreased.
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 Altered Sleep/ Rest Function
Potential for Altered Sleep
Illness: during acute and chronic illness, clients
are particularly vulnerable to loss of stage 3 sleep.
The pain and discomfort of angina or dyspnea
occurring during the night can disturb sleep.
Mood states: Anxiety frequently delays sleep
onset; Depression usually results in disturbed
sleep.
Both the depression and sleep pattern disturbance
may be linked to neurotransmitter imbalance.
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 Altered Sleep/ Rest Function
Potential for Altered Sleep
Medication and chemicals: sleep patterns are
vulnerable to disturbance from medications taken to
facilitate sleep, alcohol, medications used to treat
other conditions, and other chemicals.
Morphine, for example, increases the time spent
awake during the sleep period and shortens total sleep
time by decreasing both REM and stages 3 and 4.

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 Altered Sleep/ Rest Function
Potential for Altered Sleep
Lifestyle: A fast-paced life filled with multiple
stressors can result in the person’s inability to relax
easily or to fall asleep quickly.
Diet: Foods high in caffeine, such as coffee, colas,
and chocolate, serve as stimulants and often disrupt
the normal sleep cycle.
Also, consuming a large, heavy, or spicy meal just
before bedtime may cause indigestion, which will
likely interfere with sleep.

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 Manifestation of Altered Sleep Function
Signs and symptoms associated with sleep
deprivation are:
◦ Fatigue,
◦ Headache,
◦ Nausea,
◦ Increased sensitivity to pain,
◦ Decreased neuromuscular coordination,
◦ General irritability and
◦ Inability to concentrate.

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 Manifestation of Altered Sleep
Function
Insomnia: is a perceived difficulty in sleeping.
Patterns of insomnia can be classified as onset
insomnia (prolonged sleep latency), maintenance
insomnia (multiple awakening) and early awakening
insomnia.
Narcolepsy: is a disorder of excessive daytime
sleepiness characterized by short, almost irresistible
day time sleep attacks.

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 Manifestation of Altered Sleep
Function
Sleep apnea: refers to recurrent periods of absence of
breathing for ten seconds or longer, occurring at least
5 times per hour.
Parasomnias: are activities that are normal during
activities but abnormal during sleep, such as
sleepwalking (somnambulism), talking, and bed
wetting (enuresis)

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PARASOMNIAS
NIGHTMARE DISORDER
Long frightening dreams from which persons
awaken scared.
Almost always occur during REM sleep and late in
the night.
It is sometimes associated with periods of stress
and illness.
PARASOMNIAS
SLEEP TERROR DISORDER
Usually seen in children.
More common in boys than girls and tends
to run in families.
Minor abnormality in the temporal lobe.
Closely related to sleep walking.
PARASOMNIAS
SLEEP WALKING DISORDER
Peak age 12; boys; family history.
A sequence of complex behaviors occurring in the
first third of the night during stages 3 &4.
The person is expressionless and is unresponsive to
others.
There is amnesia for the event.
Obstruction During Sleep
Obstructive sleep apnea (OSA) is a disorder
characterized by recurrent episodes of upper airway
obstruction and a reduction in ventilation. It is
defined as cessation of breathing (apnea) during
sleep usually caused by repetitive upper airway
obstruction. OSA interferes with people’s ability to
obtain adequate rest, thus affecting memory,
learning, and decision making.
Risk factors for OAS include obesity, male gender,
postmenopausal status, and advanced age.

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 SLEEP APNEA
(breathing related sleep disorder)
Apnea: a complete cessation of respiration for more
than 10sec.
Hypopnea: a minimum of one-third reduction in air
flow.
Sleep apnea: more than five episodes of apnea or
hypopnea per hour of sleep.
Reduces the quality of nocturnal sleep by causing
frequent arousals.
SLEEP APNEA
(breathing related sleep disorder)
Central: no effort is made by the person.
Obstructive: cessation of respiration despite
efforts leads to loud snorts and snores.
◦ Patients may complain of morning headache,
mental dullness and irritability.
Mixed type: the most common type of sleep
apnea.
 Cont…
The major risk factor is obesity; a larger neck
circumference and increased amounts of
peripharyngeal fat narrow and compress the upper
airway. OSA affects 4% of males and 2% of females.
Other associated factors include alterations in the
upper airway, such as structural changes (e.g.
tonsillar hypertrophy, abnormal posterior positioning
of one or both jaws, and variations in craniofacial
structures) that contribute to the collapsibility of the
upper airway.

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 Cont…
OSA is characterized by frequent and loud
snoring with
breathing cessation for 10 seconds or longer, for
at least five episodes per hour, followed by
awakening abruptly with a loud snort as the blood
oxygen level drops.
Patients with sleep apnea may have anywhere
from five apneic episodes per hour to several
hundred per night.

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 Cont…
Classic signs and symptoms of obstructive
sleep apnea
include snorting, gasping, choking, and
witnessed
apneic episodes commonly reported by the
bed partner. Symptoms typically progress
with increases in weight, aging, and during
the transition to menopause.

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 Cont…
Patients are typically unaware of nocturnal upper airway
obstruction during sleep. They frequently complain of
insomnia including difficulty in going to sleep,
nighttime awakenings, and early morning awakenings
with an inability to go back to sleep, as well as chronic
fatigue and hypersomnolence (daytime sleepiness).
When obtaining the health history, the nurse asks the
patient about sleeping during normal activities such as
eating or talking. Patients with this symptom are
considered to have pathologic hypersomnolence.

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Be alert for the following signs and
symptoms

• Excessive daytime sleepiness Personality changes, irritability

• Frequent nocturnal awakening • Impotence
• Insomnia • Systemic hypertension
• Loud snoring • Dysrhythmias
• Morning headaches • Pulmonary hypertension, cor
pulmonale
• Intellectual deterioration
• Enuresis
• Polycythemia

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 Application of Nursing Process
Assessment
Subjective data: the single most important
criterion for adequacy of sleep and rest is the
client’s statement.
Functional pattern identification
Determine the person’s usual sleep and rest
pattern through questions such as:
◦ How many hours of sleep do you usually get?
◦ What time do you usually go to bed? Get up?
◦ What helps you get to sleep?
◦ What makes it hard for you to sleep?
◦ How do you feel when you awaken?
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 Application of Nursing Process
Assessment
Risk identification
◦ Assess caffeine, nicotine, and alcohol intake, and
involvement in shift work.
Objective data
Physical assessment
Observe for circles under the eyes, yawning, nodding,
slowness of response, irritability, impaired
concentration and word finding difficulties.

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 Application of Nursing Process
Nursing Diagnosis
Sleep pattern disturbance
Defining characteristics
◦ Verbal compliant of difficulty falling asleep
◦ Awakening earlier or later than desired
◦ Interrupted sleep
◦ Verbal complaints of not feeling well rested
◦ Changes in behavior and performance – irritability,
restlessness
◦ Physical signs (slight hand tremor, frequent
yawning)

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 Application of Nursing Process
Planning
Specific client goals are:
◦ Client will report fewer problems with falling asleep
◦ Client will report feeling more rested
◦ Client will demonstrate physical signs of being
rested

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 Application of Nursing Process
Planning
Nursing intervention to promote health and
sleep/rest function
Environmental modifications, provision of
intimacy and security, and sleep rituals are among
the nursing interventions to promote health and
sleep.
Nursing intervention for altered function
Rest: remains one of the most common
symptomatic treatments for wide variety of sleep
disorder.
Hypnotics may be useful as a short term
intervention during situationally induced sleep
pattern disturbance
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 Application of Nursing Process
Evaluation
The nurse evaluates the degree to which sleep pattern
disturbance or inadequate rest has been resolved
according to the client goals initially established.
Goal: Client will report fewer problems with falling
asleep.
Possible outcome criteria
◦ Within 7 days, client reports decrease in sleep
latency to 10 to 15 minutes.
◦ Within two days, client reports less anxiety
regarding falling asleep.
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THANK YOU!!!