Kozier Ch 44 Sleep

• •Problem in US is lack of sleep:
• –Causes decreased concentration, sleepiness, fatigue,
• distractibility

• •Chronic lack of sleep puts person at risk:
• –Hypertension
• –Diabetes
• –Heart attack
• –Stroke
• –Accidents, especially car

•Sleep is altered state of consciousness where perception of and reaction to environment decreased

• •Person is unaware of the environment & will respond
• selectively to external stimuli
• –Meaningful stimuli: Alarm clock, smoke alarm
• –Non-meaningful stimuli: Everyday noises, soft light
• 

• •Melatonin- decreased
• •Cortisol- the “stimulating hormone” is increased
• •Neurotransmitters associated with wakefulness are high:
• –Acetylcholine
• –Dopamine - helps connections of brain for parkinsons
• –Noradrenaline

• •Neurotransmitters
• –Serotonin- lessens response to sensory stimuli
• –GABA- shuts off RAS
• •Darkness & preparing for sleep
• –decreases stimulation of RAS
• •Hormones
• –Melatonin- secreted, person feels less alert
• –Growth hormone (GH)- secreted
• –Cortisol- the “stimulating hormone” is inhibited
• - - higer risk for diabeties

• •Humans have many biological rhythms
• •Circadian rhythm is one type
• •Circadian-means “about day” & involves the sleep-wake cycle
• •Circadian synchronization
• –Person awake when body temp highest and asleep when body temp lowest
• *why hospital feels colder at night

• •Refers to basic organization of sleep
• •Two types that alternate in cycles during sleep
• –NREM: non-rapid-eye movement
• –REM: rapid eye movement

• •Occurs when activity in RAS inhibited
• •Constitutes 75% - 80% of sleep
• •Consists of 4 stages
• –As progress through the stages:
• •body systems slow down (BP, P, HR, CO, RR, metabolic rate, temp)
• •Harder to awaken
• •Skeletal muscles relax
• •Intracranial pressure decreases

• •Stage 1: lasts few minutes, light sleep, easily awakened
• •Stage 2: lasts only 10-15 minutes, more difficult to
• awaken
• •Stage 3 & 4: deeper sleep, involves delta waves,
• very difficult to awaken, snoring. Essential for restoring energy and releasing important growth hormones

• •Occurs every 90 minute
• •Lasts 5 to 30 minutes
• •Acetylcholine and dopamine increase
• •Most dreams take place
• •Brain is highly active
• •Brain metabolism increases as much as 20%
• •Distinctive eye movements occur
• •Voluntary muscle tone decreased
• •Deep tendon reflexes absent
• •Gastric secretions increase
• •HR and RR often are irregular
• •Regions of brain associated with learning, thinking, organizing information stimulated
• –Lack of REM: apathy, depression, irritability, confusion, impaired memory

• •Cycle through NREM and REM
• •Complete cycle lasting 90-110 minutes
• •Length of time for each stages varies with each cycle
• •Adult sleeper has 4-6 cycles per 7-8 hours
• •If awakened during a stage- must start at stage 1 NREM
• 

• •Infant:
• –Awaken every 3 to 4 hours
• –Periods of wakefulness gradually increase
• –By 6 months, most infants sleep through the night
• and establish a pattern
• –Establish a pattern of daytime naps

• •Toddler (1-3 years):
• –Require 12 to 14 hours
• –Most still need an afternoon nap
• –Nighttime fears and nightmares are also common

• •Preschool child (3-5 years)
• –Require 11 to 13 hours of sleep
• –Sleep needs fluctuate in relation to activity and
• growth spurts

• •School-age child (aged 5 to 12)
• –Require 10-11 hours of sleep
• –Most receive less

• •Require 9-10 hours of sleep each night
• •Few actually get that much sleep
• •Circadian rhythms tend to shift
• –Tendency to stay up later and wake later

• •Adults
• –Most healthy adults need 7-9 hours of sleep
• –Individual variations

• •Elders
• –Tendency toward earlier bedtime and wake times
• –May show an increase in disturbed sleep
• –Need to sleep does not decrease with age

• •Illness
• –Pain
• –Endocrine disorders- thyroid, low estrogen, increased body temp, frequent urination
• •Environment- hospital
• •Lifestyle
• –Jobs
• –kids
• •Emotional stress-
• –anxiety stimulates sympathetic NS
• •Stimulants
• –Caffeine
• –Alcohol (disturbs REM)
• –Smoking
• •Diet
• –Some food promote sleep
• –Weight gain & loss
• •Motivation- forcing self to stay awake or interest in activity
• •Medications- page 1172, Box 45-2

• Alcohol
• Amphetamines
• Antidepressants
• Beta-Blockers
• Broncodialators
• Caffeine
• Decongestants
• Narcotics
• Steroids

• •Difficulty falling asleep or remaining asleep
• •Waking up frequently
• •Daytime sleepiness
• •Difficulty concentrating
• •Irritability
• •Risk factors
• –Older age due to medical conditions
• –Female- hormone fluctuations

• •Insufficient sleep
• •Hypersomnia
• –Has sufficient sleep at night but cannot stay awake
• during day
• –Medical cause (hypothyroidism)

• •Narcolepsy
• –Cause: lack of hypocretin in CNS that regulates sleep
• –Have excessive daytime sleepiness & have sleep
• attacks
• –Sleep at night usually begins with sleep-onset REM

• •Frequent short breathing pauses during night
• •More than 5 apneic episodes > 10 sec/hr considered abnormal
• •Symptoms include snoring, frequent awakenings, difficulty falling asleep, morning headaches, memory and cognitive problems, irritability
• •Types include obstructive (mouth), central (resp center of brain), mixed

• •Behavior that may interfere with or occur during sleep
• •Arousal disorders
• –Sleepwalking, sleep terrors
• •Sleep-wake transition disorders
• –Sleep talking
• •Associated with REM sleep
• –Nightmares
• •Others
• –Bruxism- teeth grinding, jaw clenching

• •Sleep history
• •When does client usually go to sleep?•Bedtime rituals?•Does client snore?•Can client stay awake during day?•Taking any prescribed or OTC medications?
• •Health history
• •Obtain information about medical or psychiatric problems that may influence sleep
• •Medication history
• •Physical exam
• •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)

• •Sleep diary
• •Client may be asked to keep track of
• –Time factors associated with sleep
• –Activities performed 2-3 hours prior to sleep
• –Consumption of caffeine, alcohol
• –Medications
• –Bedtime rituals
• –Difficulty remaining awake during day
• –Any worries or fears that may be contributing

• •Diagnostic studies
• •Polysomnography done in lab. These done together with electrodes to measure muscle movement and
• brain waves:
• –EEG (electroencephalogram)
• –EMG (electromyogram)
• –EOG (electro-oculogram)
• •Other
• –Measure ECG, resp, O2, leg movement

• •Sleep deprivation
• •Insomnia

• •Other ND from sleep pattern disturbances:
• –Risk for injury
• –Ineffective coping
• –Fatigue
• –Risk for impaired gas exchange
• –Anxiety
• –Activity intolerance

• •Reducing environmental distractions
• •Promoting bedtime rituals
• •Providing comfort measures
• •Scheduling nursing care to promote uninterrupted sleep
• •Teaching stress reduction, relaxation techniques or good sleep hygiene

• •Reducing environmental distractions
• •Promoting bedtime rituals
• •Providing comfort measures
• •Scheduling nursing care to promote uninterrupted sleep
• •Teaching stress reduction, relaxation techniques or good sleep hygiene

• •The importance of sleep
• •Conditions that promote or interfer with sleep
• •Safe use of sleep medications
• •Effects of prescribed medications on sleep
• •Effects of disease states on sleep

• •Routines promote sleep. Usually first nursing intervention to try. If interfered with, can affect one’s sleep
• •Adults
• –Listening to music
• –Reading
• –Soothing bath
• –Praying
• •Children- need to be socialized into rituals
• –Bedtime stories, holding favorite toy

• •Prescribed as PRN
• •Sedative-hypnotics (induce sleep)-
• –General CNS depression
• –Unnatural sleep- NREM & REM is altered
• –May cause daytime sleepiness & hangover
• –Rebound insomnia
• –Table 45-1 (Ambien- not alter REM)
• –Barbituates (alter REM) cannot be stopped abruptly
• •Anti-anxiety or tranquilizers-
• –Suppress CNS response to stimuli
• •Using medications:
• –Be aware of actions, effects, risks of specific medications
• –Use smallest does possible
• –Regular use can cause tolerance & rebound insomnia

• Chloral hydrate (Noctec) - Half-life 7-10 hours
• Eszopilone (Lunesta) - 6 hours
• Ethchlorvynol (Placidyl) - 10-20 hours
• Flurazepam (Dalmane) 47-100 hours
• Glutethimide (Doriden) 1-12 hours
• Lorazepam (Ativan) 10-20 hours
• Melatonin - 1 hour
• Temazepan (