The Science of Sleep and Rest

• Sleep is a readily reversible state of altered consciousness with decreased awareness and responsiveness.
• Sleep is a natural, restorative process involving shifts in physiologic and neurologic activity.
• Rest involves relaxation while staying awake and aware.
• Rest reduces mental and physical activity, or involves resting a specific body part while staying mentally/physically active.
• Spending time in bed doesn't always provide sleep's restorative benefits.
• Sleep helps brain synapses grow/shrink, important for memory and learning.
• Alertness is maintained when you are focused and awake during the day.
• Hormone balance occurs during sleep.
• Normal hormone levels are maintained during sleep.
• Anabolic hormones such as growth hormone are kept at normal levels during sleep.
• Inflammatory cytokines are kept at normal levels during sleep.
• Cortisol, the stress hormone, is kept at normal levels during sleep.
• Blood sugar regulation occurs during sleep.
• Healthy glucose metabolism is supported when you get enough sleep.
• Energy and well-being improves the overall quality of life.
• Sleep deficiency can reduce attention, task performance, and alter mood.
• Increased blood pressure is a consequence of sleep deficiency.
• Reduced blood levels of growth hormone and prolactin result from sleep deficiency.
• Altered glucose metabolism and appetite regulation can occur from sleep deficiency.
• Higher blood levels of inflammatory cytokines and cortisol can occur during evening hours because of sleep deficiency.
• Chronic disease and obesity is possibly linked to sleep deficiency.
• Polysomnography measures sleep patterns.
• Non-Rapid Eye Movement (NREM) sleep makes up 80% of total sleep.

Stages of NREM Sleep:

• Stage N1 is a transition from drowsiness to sleep.
• Stage N2 makes up 40% to 50% of total sleep time.
• Stage N3 (Slow-wave or Delta sleep) is when dreams feel realistic.
• Somnambulism (sleepwalking) and enuresis (bedwetting) occur during stage N3.
• Rapid Eye Movement (REM) sleep is also called Stage R.
• Makes up 20% of total sleep.
• EEG pattern looks similar to when a person is awake.
• Vital signs vary widely, muscle tone is low/absent, and thermoregulation is reduced during REM sleep.
• Vaginal secretions increase (women) and erections may occur (men).
• Dreams are vivid, emotional, and often unrealistic.
• Sleep duration is the total amount of sleep time.
• Sleep latency is how long it takes to fall asleep.
• Body position matters, it is about preferred sleeping posture.
• Nocturnal awakenings are how often a person wakes up during the night.
• Napping means short periods of sleep during the day.
• Circadian rhythms and sleep regulation is the body's internal clock.
• Newborn/infant sleep patterns are irregular and they need the most sleep.
• Toddlers/preschoolers start developing sleep routines but may resist bedtime.
• School-aged children/adolescents need consistent sleep schedules; adolescents often experience shifts in sleep timing.
• Adults and older adults may have lighter sleep, more awakenings, and more sleep disorders.
• Cultural beliefs, practices, and environments influence sleep routines, bedtime rituals, and attitudes about sleep.
• Sleep need varies by age, health status, and individual differences.
• A comfortable, safe, and familiar environment impacts sleep.
• Noise can disturb or interrupt sleep cycles.
• Light: Bright light delays sleep, darkness promotes it.
• Temperature impacts sleep, too hot or too cold disrupts sleep.
• Relationships: Stress or comfort from relationships affects sleep.
• Shift work alters natural circadian rhythms and sleep schedules.
• Nutrition/metabolism: Caffeine, heavy meals, or low blood sugar affect sleep quality.
• Frequent urination at night (nocturia) disrupts sleep.
• Exercise, passive heating, and thermoregulation affect sleep onset and quality.
• Vigilance: Being mentally alert or anxious delays sleep.
• Lifestyle/habits: Irregular sleep schedules, screen time, or substance use interfere with rest.
• Illness, pain, discomfort, or symptoms disrupt sleep.
• Medications can cause drowsiness or insomnia.
• Mood states (stress, anxiety, or depression) affect sleep patterns.
• Insomnias: Difficulty falling/staying asleep or waking too early.
• Sleep-disordered breathing includes conditions like obstructive sleep apnea (breathing stops/starts).
• Narcolepsy causes sudden, uncontrollable episodes of sleep during the day.
• Restless Legs Syndrome/Periodic Limb Movement Disorder: Uncomfortable leg sensations or repetitive limb movements disrupt sleep.
• Circadian Rhythm Sleep Disorders: Misalignment between sleep-wake pattern and environment (e.g., jet lag, shift work disorder).
• Parasomnias: Abnormal behaviors during sleep (sleepwalking, night terrors, or sleep talking).
• Identify the normal sleep-wake cycle.
• Understand the patient's usual sleep habits and schedule.

BEARS approach to sleep assessment:

• Bedtime problems should be assessed.
• Excessive daytime sleepiness should be assessed.
• Awakenings during the night should be assessed.
• Regularity and duration of sleep should be assessed.
• Snoring or breathing issues during sleep should be assessed.
• Risk identification: Family history of sleep problems.
• Developmental or situational changes.
• Use of caffeine, nicotine, or alcohol.
• Shift work involvement.
• Dysfunction/Sleep Problem Identification: Is the issue chronic or situational?
• What helps improve sleep?
• What makes it worse?
• Use a sleep diary to track patterns.
• Look for signs in adults such as dark circles under the eyes,.
• Yawning or nodding off, slow responses.
• Note if there is irritability, trouble concentrating, or difficulty finding words.
• Signs in children may be similar to adults but instead of looking sleepy, they might act hyperactive.
• Adequacy of Rest After Activity: Check if heart rate and other body functions return to normal.
• Diagnostic Tests: Overnight sleep study (polysomnogram) to diagnose obstructive sleep apnea (OSA), periodic limb movement disorder (PLMD), or narcolepsy.
• Nursing diagnoses: disturbed sleep pattern is a short-term problem.
• Sleep deprivation: Going a long time without enough sleep.
• Outcome Identification and Planning: fewer problems falling or staying asleep.
• Feeling more rested.
• Physical signs of being rested (e.g., improved energy, alertness).
• Implementation: Health promotion - Teach healthy sleep habits (consistent bedtime, limit screen time, avoid caffeine).
• Environment modification: Make the sleep environment comfortable—dark, quiet, and cool.
• Provision of intimacy and security: Offer emotional support/reassurance.
• Use of sleep rituals: Encourage calming activities before bed (reading or meditation).
• Managing individual sleep needs: Adapt sleep strategies based on the patient's unique needs.
• Implementation: Disturbances in Sleep
• Use a consistent routine to encourage a regular sleep schedule.
• Cognitive measures: strategies like CBT to address thoughts/behaviors interfering with sleep.

Counseling for hypnotic use:

• Rely on hypnotic medications to induce normal sleep.
• Hypnotics can impair daytime functioning.
• They are for short-term insomnia.
• Use with caution in older adults or those with compromised pulmonary function.
• Obtain a sleep history.
• Nature of the problem: What exactly is the sleep issue? (e.g., trouble falling asleep, staying asleep, or waking up too early).
• Cause of the problem: What is causing the sleep issue? (e.g., stress, medication, illness).
• Related signs and symptoms: Are there any other symptoms linked to sleep problems? (e.g., snoring, daytime fatigue).
• When the problem began and how often it occurs.
• How the problem affects everyday living.
• Severity of the problem and how it can be treated.
• How the patient is coping with the problem and success of treatments attempted.
• Physical assessment: Check if the patient feels rested or fatigued after waking up, facial characteristics, behavioral characteristics, physical data suggestive of sleep problems
• Sleep characteristics: restlessness, sleep postures, sleep activities, snoring

Screening Tools to Assess Sleep Disturbances

• The Epworth Sleepiness Scale (ESS) is a questionnaire to measure daytime sleepiness.
• The Pittsburgh Sleep Quality Index (PSQI) is a self-rated questionnaire that assesses sleep quality and disturbances.
• The STOP-Bang Questionnaire is a tool to assess OSA risk based on snoring, tiredness, observed apneas, blood pressure, BMI, age, neck circumference, and gender.
• A sleep diary tracks key sleep-related details to identify factors influencing sleep quality.
• Time patient goes to bed.
• The patient tries to fall asleep.
• Approximate time the patient falls asleep.
• Times of night awakenings and resumption of sleep.
• Time patient wakes up in the morning.
• Stressors affecting sleep.
• Food, drink, or medication affecting sleep.
• Physical and mental activities during the day.
• Activities performed 2-3 hours before bedtime.
• Worries or anxieties affecting sleep.
• Common Etiologies for Sleep Disorders:
• Physical or emotional discomfort or pain.
• Changes in bedtime rituals or sleep environment.
• Disruption of circadian rhythm.
• Exercise and diet before sleep.
• Drug dependency and withdrawal.
• Symptoms of physical illness.

Nursing Interventions to Promote Sleep:

• Prepare a restful environment.
• Promote bedtime rituals.
• Offer appropriate bedtime snacks and beverages.
• Promote relaxation and comfort.
• Respect normal sleep-wake patterns.
• Schedule nursing care to avoid disturbances.
• Use medications to promote sleep.
• Teach about rest and sleep.
• OSA is a sleep disorder where the airway gets blocked, stopping or reducing airflow during sleep.

Signs of OSA could include:

• Apnea: Breathing stops completely for at least 10 seconds.
• Hypopnea: Breathing becomes shallow or weak.
• People may wake up often during the night because they can't breathe properly, leading to poor-quality sleep.
• Symptoms: Feeling tired during the day, loud snoring, and sometimes stopping breathing during sleep.
• Loud snoring and waking up with difficulty breathing.
• Observed Apnea: Family members may notice you stop breathing during sleep.
• Health problems: Untreated OSA can lead to high blood pressure, heart disease, and diabetes.

Treatment for Obstructive Sleep Apnea (OSA):

• CPAP (Continuous Positive Airway Pressure) Machine
• Most common treatment for moderate to severe OSA.
• The CPAP machine has a mask connected to a pump that blows air into the nose to keep the airway open.
• It's worn while sleeping and is very effective at improving sleep quality and reducing tiredness during the day.

Oral Appliances:

• For mild cases of OSA, doctors may recommend a special mouthpiece.
• This device moves the jaw or tongue to keep the airway open while sleeping. Surgery may be needed if other treatments don't work.
• The surgery usually involves removing extra tissue in the throat to open up the airway, like tonsils or the uvula (part of the soft tissue in the back of the throat).
• A CPAP pressure injury occurs when a CPAP mask causes skin damage from pressure or friction.
• It's common on the nose, face, and chin, especially with a poor fit or high pressure settings.
• Causes: Poor mask fit or tightness.
• High CPAP pressure.
• Prolonged use without breaks.

Symptoms:

• Redness, irritation, or sores on the skin.
• Pain or tenderness in affected areas.
• Blisters or swelling.

Prevention/Management:

• Adjust the mask fit to avoid tightness.
• Use a soft mask liner or gel to reduce friction.
• Apply a gentle moisturizer to protect the skin.
• Try different mask types if needed.
• Take breaks from wearing the mask.
• Consult a doctor if the injury persists.