SLEEP REST PATTERN

SLEEP REST PATTERN
Afroz Lakhani, R.N., BScN

 What is sleep?
 SOMNOLOGY: Study of sleep
 Basic human need
 We spend about 8 hours/day, 56 hours/week, 224 hours/month and 2,688 hours/year sleeping (1/3 of our lives)
 We need sleep
 To cope with daily stress
 To prevent fatigue
 To conserve energy
 To restore mind and body
 Healing of damaged tissue is greatest during sleep

Physiology of sleep

 Altered state of consciousness. (perception and reaction to the environment is decreased)
 Minimal physical activity
 Changes in physiologic processes
 Decreased responsiveness to (some) external stimuli
 The cyclic nature of sleep is controlled by neurons located within the reticular formation.


Reticular Formation

 A diffuse network of nerve fibers and cells in parts of the brainstem, important in regulating consciousness or wakefulness.
 Stimulation induces arousal
 Destruction induces sleep
 Neurotransmitters located within neurons affect sleep-wake cycles.
 Acetylcholine (Ach antagonist and Ach agonist)
 Serotonin (lessen to sensory response)
 Histamine (keeps us awake)


Sleep is sensitive to darkness

 Decreases stimulation of RF
 Pineal gland secretes melatonin, and the person feels less alert,
 GH released, cortisol inhibited
 Beginning of daylight, melatonin is at its lowest level and stimulating cortisol at its highest, also Ach , dopamine and nonadrenaline.

 Types of Sleep
 Two types
 NREM
 REM

NREM: 75% to 80% of sleep during a night
Divided into 4 stages
 Stage 1: very light sleep, few mins, drowsy, relaxed, can easily awakened
 Stage 2: light sleep, 44% to 55%, 10 to 15 mins, requires stimuli to be awake
 Stage 3 & 4: deepest, difficult to arouse, not disturbed by sensory stimuli, reflex diminished, snoring.

REM: (paradoxical sleep)
occurs every 90 mins, lasts 5 to 30 mins, dreams, Brain highly active, Ach, dopamine at highest, eye movements, voluntary muscle tone decreased, sleeper difficult to arouse or wakes up spontaneously.
 Initially lasts 5-10 minutes, gradually lengthens until final REM period lasts 50minutes.
 Very important stage of sleep.


Sleep Cycles

 NREM and REM
 Lasting about 90 to 110 mins in adults
 In first sleep cycle: passes thru all 3 NREM stages in 20 to 30 mins,
 then stage 4 NREM for about 30 mins
 Sleep passes back through stage 3 and 2 for 20 mins
 Thereafter, the first REM occurs, lasting 10 mins
 This completes first sleep cycle.
 Healthy adult experiences 4 to 6 cycles in 7 to 8 hrs

Functions of sleep

 Restores normal levels of activity and balance among parts of nervous system
 Important of protein synthesis (repair )
 important psychological well-being ( emotionally irritable, poor concentration, difficulty making decisions)

Normal Sleep Patterns

 NEWBORNS: 16 to 18 hrs/day, enters REM immediately, sleep cycle about 50 mins, tuck in when sleepy.
 INFANTS: 14 to 15 hrs, awakens 3 to 4 hrs, eat and back to sleep. By 6 months sleeps entire night, nap patterns. Put them to bed when drowsy.
 TODDLERS: 12 to 14 hrs, afternoon nap, resistance going to bed and awakens during night. Nightmares common.
 SCHOOL-AGE CHILDREN: (5-12 yrs) needs 10 to 11 hrs, but they sleep less, avoid caffeinated drinks and late TV, have bedtime routine.
 ADOLESCENTS: (12-18 yrs), needs 9 to 10 hrs, few sleeps that long and sleepy at school results in lower grades, negative moods.
 ADULTS: needs 7 to 9 hrs but some can function well with 6 hrs as well.
 ELDERS: earlier bedtime and wake times, disturbed sleep impacts quality of life, mood and alertness.

Factors Affecting Sleep

 Sleep quality: subjective, person wakes up energetic or not.
 Sleep quantity: total time of sleep

 ILLNESS: pain, physical distress (arthritis, SOB, ulcers, low estrogen__hot flashes, elevated body temperature, urge to urinate)
 ENVIRONMENT: noise, unfamiliar, hospital, temperature, lack of ventilation, lights, snoring partner.
 LIFESTYLE: irregular am and pm schedule, late exercise, inability to relax before bedtime.
 EMOTIONAL STRESS: #1 cx of sleep disturbance, Anxiety increases norepinephrine.
 STIMULANTS AND ALCOHOL: coffee, caffeine stimulates CNS, excessive alcohol disrupts REM but hasten the onset.
 DIET: weight gain cx broken sleep and early awakening, weight loss in total sleep time and less broken sleep. Warm milk can help.
 SMOKING: Nicotine
 MOTIVATION: can increase alertness.
 MEDICATIONS: Hypnotics interfere deep sleep and suppress REM sleep. Beta blockers cx insomia, Narcotics suppress REM cx drowsiness, awakenings.

Common Sleep Disorders

 INSOMNIA: inability to fall asleep or remain sleep,
stimulus control, Cognitive therapy (positive sleep thoughts and beliefs), Sleep restriction, antihistamine.
 HYPERSOMNIA: sufficient sleep at night but still sleepy, cx CNS damage, metabolic disorder.
 NARCOLEPSY: sleep attacks or EDS, Ritalin
 SLEEP APNEA: frequent short breathing pauses during sleep. More than 5 episodes or longer than 10 seconds/hr is abnormal, loud snoring, frequent awakenings, morning headaches, EDS.

Nursing Management

History:
 Generally rested and ready for daily activities after sleep?
 Sleep onset problems
 Aids
 Dreams, nightmares
 Early awakening
 Rest_ relaxation period
 Nursing Diagnosis:
 Sleep Deprivation (prolong time without sleep)
 Sleep Pattern, Disturbance
 Insomnia (delayed onset of sleep)
Related to:
 Over stimulation prior to bedtime
 Pain
 Discomfort
 Anxiety
 Alcohol
 Fatigue r/t insufficient sleep
 Risk for impaired gas exchange r/t sleep apnea
 Activity intolerance r/t sleep deprivation or EDS

Goal:
 To maintain or develop sleep pattern that provides sufficient energy for daily activities.
 Improving quality and quantity of sleep.
 Keep the etiology in mind

Implementing: Largely non pharmacologic measures like health teachings about sleep habits, bedtime rituals, provision of restful environment, avoid heavy meals before bedtime.
 For hospitalized clients activities should be scheduled, less stimulus environment, support for anxious patients, safe use of sleep medications.

Evaluating:
 Goals and outcomes achieved?
 Observation about client’s sleep pattern
 How the client feels on awakening?
 Client’s level of alertness during the day
If desired outcomes not met then identify following:
 Etiologic factors were correct?
 Any change in medication therapy?
 Client’s compliance
 Were the measures effective?

References:

Carpenito, J.L. (2002). Nursing diagnosis: Application to clinical practice (9th edition) Philadelphia: Lippincott.
Kozier & Erb. (2008). Fundamentals of Nursing (8th edition) New Jersy: Pearson.
Ross and Wilson. (2006). Anatomy and physiology (10th edition) Churchill Livingstone