NURS 230: Rest and Sleep Stages

• Rest and Sleep are being discussed in NURS 230.

CDC Guidelines for Sleep Duration

• Newborns (0-3 months) need 14-17 hours of sleep, according to the National Sleep Foundation; the American Academy of Sleep Medicine has no recommendation.
• Infants (4-12 months) need 12-16 hours of sleep, including naps, per 24 hours.
• Toddlers (1-2 years) need 11-14 hours of sleep, including naps, per 24 hours.
• Preschoolers (3-5 years) need 10-13 hours of sleep, including naps, per 24 hours.
• School-age children (6-12 years) need 9-12 hours of sleep per 24 hours.
• Teens (13-18 years) need 8-10 hours of sleep per 24 hours.
• Adults (18-60 years) need 7 or more hours of sleep per night.
• Adults (61-64 years) need 7-9 hours of sleep.
• Adults (65 years and older) need 7-8 hours of sleep.

Non-Rapid Eye Movement (NREM) Sleep Stages

• NREM Stage I involves the transition between wakefulness and sleep.
• Individuals in NREM Stage I are relaxed, easily aroused, and this stage lasts only minutes, accounting for 5% of total sleep.
• NREM Stage II is when one falls into a deeper stage of sleep but can still be aroused with relative ease, making up 50% of sleep.
• NREM Stage III is characterized by an increased depth of sleep.
• Arousing someone in NREM Stage III is difficult, and they may be confused, with vital signs decreasing.
• Skeletal muscles are very relaxed during NREM Stage III, snoring may occur, and this stage accounts for 20-25% of sleep.

Rapid Eye Movement (REM) Sleep

• Eyes dart quickly back and forth during REM sleep.
• Small muscle twitching and large muscle immobilization are typical in REM.
• Vital signs increase, as do gastric secretions and metabolism.
• Dreaming occurs during REM sleep, which constitutes 25% of total sleep.
• More spontaneous awakenings may occur during REM.
• Loss of REM sleep impairs memory and learning.
• REM rebound occurs after sleep deprivation, leading to increased time in REM on successive nights to keep total REM constant over time.
• individuals Reenter NREM at Stage II, repeats the cycle 4-6 times per night.

Sleep Patterns in Young Adults

• Young adults typically require 8 hours of sleep.
• Factors affecting sleep in young adults include physical health, occupation (shift work, work demands, travel), exercise, and lifestyle demands.
• Nursing interventions include reinforcing good sleep habits, exploring lifestyle demands and stressors, and teaching relaxation and stress reduction techniques.
• Medications can decrease REM sleep, may be habit-forming, and lose effectiveness over time, can result to medication.

Sleep Patterns in Middle-Aged Adults

• Middle-aged adults experience a decrease in total sleep time, including stage IV sleep
• They also experience an increase in awake time.
• Middle-aged adults are more aware of sleep disturbances.
• Menopausal women experience fluctuations in sleeping patterns.
• Nursing interventions include exploring pathological causes and anxiety or depression, and encouraging avoidance of sleep-inducing medications on regular basis.

Sleep Patterns in Older Adults

• Older adults average 7-9 hours of sleep
• have a tendency to sleep less soundly, including absent or shortened Stage IV sleep, and shorter periods of REM.
• Older adults may experience more difficulty falling asleep.
• They may have a decline in physical health, psychosocial/environmental factors, and drug therapy issues that affect sleep.
• Nursing interventions include comprehensive assessment and provision of a safe environment.
• Common medications affecting sleep are diuretics, sedatives, and pain medications.

Factors Affecting Sleep

• Motivation: Being interested and engaged promotes wakefulness, while being disinterested and bored promotes sleep.
• Culture: Beliefs and practices, such as co-sleeping arrangements ("family bed"), herbal remedies, and considerations for privacy, impact sleep.
• Lifestyle and Habits: Shift work, melatonin production at night, and screen time affect sleep patterns.
• Physical Activity and Exercise: Exercise increases REM and NREM sleep, but there is a 2-hour rule to avoid exercise too close to bedtime, and exhaustion decreases sleep quality.
• Environmental: Factors like city vs. country living, home vs. away atmosphere, noise levels, and light vs. dark exposure influence sleep.
• Dietary Habits: Consuming carbohydrates and protein may improve sleep.
• Alcohol: Large amounts can limit REM and delta sleep; cessation 6 hours before sleep can improve sleep quality.
• Caffeine: It binds to adenosine receptors and prevents drowsiness.
• Smoking: Nicotine is a stimulant, and refraining from smoking after dinner can improve the ability to fall asleep.
• Psychological: Anxiety or depression and general psychological health affect amount of sleep.
• Illness: Conditions like GERD, CAD, and ESRD, as well as pain and respiratory issues, can disrupt sleep.
• Medications: Hypnotics promote sleep but can decrease sleep quality.
• Opioids: suppress REM sleep and cause frequent awakenings.

Insomnia

• Insomnia is the most common sleep disorder.
• It is characterized by symptoms that occur at least 3 nights per week and persist for at least 3 months or longer.
• Characteristics include difficulty falling asleep, intermittent sleep, and early awakening.
• It is more common in individuals over 60 years of age.
• Women experiencing menopause and individuals on shift work or experiencing jet lag, may experience this disorder more often.
• Non-pharmacologic interventions include cognitive behavioral therapy (CBT) + biofeedback and relation and avoiding napping during the day.
• It can also include getting up at the same time, or going to bed when feeling sleepy.
• Pharmacologic interventions include sedatives and hypnotics for short-term use.
• OTC medications are generally not effective.

Restless Leg Syndrome (RLS)

• RLS is characterized by the inability to lie still, with creeping, crawling, tingling sensations in the legs (ankle to thigh).
• There is an "irresistible urge" to move legs as a result of RLS.
• RLS is associated with medical conditions such as ESRD, diabetes, iron deficiency, peripheral neuropathy, and pregnancy.
• There is no specific diagnostic test for restless leg syndrome.
• Treatment involves walking, massage, and knee bends.
• Eliminating caffeine, alcohol, and tobacco can improve symptoms.
• Mild analgesics at HS (hour of sleep).
• TENS and biofeedback for relaxation techniques can improve the impact of RLS.
• Medications such as Requip, Mirapex, Horizant ER, and Neupro transdermal can be used for treatment.

Sleep Deprivation

• Sleep deprivation is defined in NANDA nursing diagnosis as a decrease in the amount, consistency, or quality of sleep affecting REM or NREM.
• Experiencing more than 30 hours of wakefulness may be an indicator.
• Safety risks increase with sleep deprivation with impaired level of concentration, information processing, and performance.
• Hospital environment issues, such as unfamiliar surroundings, noise, and “ICU psychosis” contribute.
• Causal relationships exist between sleep deprivation and other conditions such as cancer, obesity, diabetes, and cardiovascular disease (CAD).

Hypersomnia

• Hypersomnia is a condition characterized by excessive sleep, especially during the day.
• Individuals experiencing it may fall asleep at work or in the middle of conversations or while eating.
• Naps do not relieve the symptoms.
• When awake, individuals are typically disoriented, irritated, restless, and have slowed speech and thinking processes.
• The cause is often unknown but it can be a caused by other sleep disorder, such as sleep apnea or narcolepsy.
• It can attributed to substance abuse, a head injury, or trauma, or a variety of conditions, such as kidney, liver, metabolic conditions, DKA, or hypothyroidism.
• Hypersomnia can be a symptom of depression.
• Treatment is symptomatic which can include the use of stimulants, antidepressants, dietary changes, and avoidance of shift work or late nights.

Obstructive Sleep Apnea

• Obstructive sleep apnea is characterized by sleep-disordered breathing and apnea (cessation of breathing) during snoring intervals.
• This causes Hypopharynx collapses.
• These collapses last 10 to 20 seconds, up to 2 minutes.
• Causes Fight or Flight → startle awake.
• This causes excessive daytime sleepiness.
• Indicators are being overweight with short, thick neck and enlarged tonsils, adenoids, deviated septum, or enlarged thyroid.
• Diagnosis: sleep study.
• Treatment: CPAP (Compliance issues).
• It can also be treated with MAD (mandibular advancement device) or surgical removal of soft tissue at the back of the mouth.
• Treatment includes Weight loss and smoking or alcohol cessation.

Narcolepsy

• Narcolepsy is characterized by an uncontrollable desire to sleep.
• Sufferers quickly fall asleep, have difficulty to wake up, have less & restless sleep.
• It typically onsets around adolescence, or early adulthood.
• There is no cure.
• It can diagnosis with a sleep study.
• Treatment: includes No driving.
• The use of medications, and lifestyle changes.

Parasomnias

• Parasomnias are waking behavior patterns that appear during REM or NREM sleep.
• Common in children.
• They include: Sleepwalking, REM Sleep Behavior Disorder, Night terrors, Nightmares, Bruxism, Enuresis, and Sleep-related eating disorder.
• It may be important to focus SAFETY & INJURY PREVENTION.

Nursing Assessment

• Look at Usual sleep/wake pattern, any recent changes?, the number of hours undisturbed sleep, the quality of sleep, naps, the ability to perform ADLs, and sleep diary.
• Consider sleep aids either pharmacologic & non-pharmacologic, and observe sleep disturbances & contributing factors.

Physical Assessment

• Evaluate level of consciousness LOC, how is the Focus, is the Ability to answer questions is hindered, Speech.
• Examine Posture, and Body mass index BMI and note the presence of Deviated septum, and Enlarged tonsils/adenoids.
• Information from a partner may identify Restlessness and Snoring with sudden stop/snort.
• Nurses should observe Nursing observation during sleep behaviors of Restlessness, Snoring with sleep apnea, posture while sleeping, and observable sleep activity.

Nursing Diagnoses

• Potential diagnosis for a disturbed sleeping pattern include Difficulty Falling Asleep, Difficulty Remaining Asleep, and Altered Sleep-Wake Patterns.
• Recognize the Risk for injury such as Narcolepsy , Sleep walking.
• Be aware to look for Alteration in Nutrition r/t sleep depravation.
• The are potential concerns of role conflict should look to Fatigue r/t prolonged.

Nursing Interventions

• Identify sleep stressors in the patient.
• Adjust sleep environment to promote rest.
• Assess current medications for impact on sleeping patterns.
• Provide comfort measures utilizing massage or repositioning.
• Educate patient family on creating a Positive sleep environment with no caffeine, alcohol, or smoking.
• Decrease screen time, increase physical activity and evaluate medication use with patients.

Effects of Insufficient Sleep

• Short Sleepers who get less than 6 hours of sleep might have Increasing! and potential link to sleep to Sleep-weight.
• Shift Work which can can lead to Increased risk of Type 2 diabetes, Breast/colorectal cancer, Cardiovascular disease, and Substance abuse.
• Performance of person awake 17 hours that of alcohol intoxication !

Healthcare Worker Fatigue

• Cause: Rotating shifts, Mandatory overtime, and 12-hour shifts.
• Consequences: Medication errors, Adverse Medical Events, Patient Safety compromised, Ability to competently perform tasks compromised and Decision-making compromised.

Healthcare Worker Fatigue - Impact

• Poor concentration
• Increased errors & injuries
• Impaired judgement & decision making
• Decreased reaction time
• Altered communication
• Reduced motivation, apathy

Insufficient Sleep & Medical Errors

• TJC Sentinel Alert 48 (2011)
• Assess schedules & staffing to get Staff input encouraged
• Review handoff procedures
• Have a Fatigue Management Plan
• Encourage Education: sleep/fatigue effect on patient safety
• Respond to Fatigue issue in Adverse events
• Teamwork to support shift workers

Factors caused by Sleep Deprivation

• Med Errors cause Significant issues after 8 hours or with being Higher > 12.5 hours
• Employee Accidents tend to Increases after 9 hours and Doubles after 12 hours
• General function can cause Lapses in attention, Diminished reaction time, as well as Decision Regret.

Healthcare Worker Fatigue - Strategies

• Know your tolerance when working rotating shifts, or 12-hour shifts or Overtime hours
• Try to Get up and move around.
• Engage in conversation
• Take frequent breaks if possible
• Use caffeine wisely