Sleep and Rest: Definitions, Physiology, and Disorders

Definition and Scope of Sleep Definitions: ​ Craven (2025):​ Sleep is a readily reversible state of altered consciousness in which awareness and responsiveness to the environment are decreased.​ ​ Giddens (2021):​ Sleep is a natural and necessary process that involve...

Definition and Scope of Sleep Definitions: ​ Craven (2025):​ Sleep is a readily reversible state of altered consciousness in which awareness and responsiveness to the environment are decreased.​ ​ Giddens (2021):​ Sleep is a natural and necessary process that involves a shift in physiologic and neurologic activity, and is intended to be restorative. Rest ​ Definition:​ Rest involves relaxation of the whole body or a specific body part while staying awake and aware of the environment.​ ​ Key Points:​ ○​ Rest can happen during periods of reduced mental and physical activity.​ ○​ A person might also rest a specific body part while remaining mentally and physically active otherwise.​ ○​ It’s possible to spend hours in bed resting without actually gaining the restorative benefits of sleep. Benefits of Sleep ​ Brain health:​ Sleep helps brain synapses grow or shrink properly — essential for memory and learning.​ ​ Alertness:​ Needed to stay focused and awake during the day.​  ​ Hormone balance:​ Helps keep normal levels of:​ ○​ Anabolic hormones (like growth hormone)​ ○​ Inflammatory cytokines​ ○​ Cortisol (the stress hormone)​ ​ Blood sugar regulation:​ Supports healthy glucose metabolism.​ ​ Energy & well-being:​ Boosts energy levels and improves overall quality of life Consequences of Sleep Deficiency ​ Reduced attention and task performance, memory lapses, and altered mood​ ​ Increased blood pressure​ ​ Reduced blood levels of growth hormone and prolactin​ ​ Altered glucose metabolism and appetite regulation​ ​ Higher blood levels of inflammatory cytokines and cortisol during evening hours​ ​ Possible link between development of chronic disease and obesity Sleep Physiology #1 ​ Polysomnography: A test used to measure sleep patterns.​ ​ Non–Rapid Eye Movement (NREM) Sleep:​ ○​ Makes up 80% of total sleep.​ ​ Stages of NREM Sleep:​ ○​ Stage N1: Transition from drowsiness to sleep.​ ○​ Stage N2: Makes up 40% to 50% of total sleep time.​ ○​ Stage N3 (Slow-wave or Delta sleep):​ ​ Dreams, if they happen, feel very realistic.​  ​ Somnambulism (sleepwalking) and enuresis (bedwetting) are most likely to occur during this stage.​ Sleep Physiology #2 ​ Rapid Eye Movement (REM) sleep (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 or absent​ ○​ Thermoregulation is reduced​ ​ Vaginal secretions increase in women​ Erections may occur in men​ ​ Dreams are vivid, very emotional, and often unrealistic​ Normal Sleep and Rest ​ Sleep duration – Total amount of sleep time​ ​ Sleep latency – How long it takes to fall asleep​ ​ Body position – Preferred sleeping posture​ ​ Nocturnal awakenings – How often a person wakes up during the night​ ​ Napping – Short periods of sleep during the day​ ​ Circadian rhythms and sleep regulation – The body’s internal clock that influences sleep-wake cycles​ Life Span and Cultural Considerations Life Span Considerations ​ Newborn and Infant – Sleep patterns are irregular; need the most sleep​ ​ Toddler and Preschooler – Begin to develop regular sleep routines; may resist bedtime​  ​ School-aged Child and Adolescent – Need consistent sleep schedules; adolescents often experience shifts in sleep timing​ ​ Adult and Older Adult – Sleep may become lighter; more frequent awakenings; sleep disorders are more common with age​ Cultural Considerations ​ Cultural beliefs, practices, and environments can influence sleep routines, bedtime rituals, and attitudes toward sleep ​ Factors Affecting Sleep and Rest #1 ​ Need – Varies by age, health status, and individual differences​ ​ Environment – Comfort, safety, and familiarity of the surroundings​ ​ Noise – Can disturb or interrupt sleep cycles​ ​ Light – Bright light can delay sleep; darkness promotes it​ ​ Temperature – Too hot or too cold can disrupt sleep​ ​ Relationships – Stress or comfort from personal relationships can affect sleep​ ​ Shift Work – Alters natural circadian rhythms and sleep schedules​ ​ Nutrition and Metabolism – Caffeine, heavy meals, or low blood sugar can affect sleep quality Factors Affecting Sleep and Rest #2 ​ Elimination patterns – Frequent urination at night (nocturia) can interrupt sleep​ ​ Exercise, passive heating, and thermoregulation – Physical activity and body temperature changes can affect sleep onset and quality​ ​ Vigilance – Being mentally alert or anxious can delay sleep​ ​ Lifestyle and habits – Irregular sleep schedules, screen time, or substance use can interfere with rest​ ​ Illness – Pain, discomfort, or symptoms of illness may disrupt sleep​ ​ Medications – Some drugs can cause drowsiness or insomnia as side effects​ ​ Mood states – Stress, anxiety, or depression can significantly affect sleep patterns​ Altered Sleep and Rest ​ Insomnias – Difficulty falling or staying asleep, or waking too early​ ​ Sleep-disordered breathing – Includes conditions like obstructive sleep apnea, where breathing stops and starts during sleep​ ​ Narcolepsy – Sudden, uncontrollable episodes of sleep during the day​ ​ Restless Legs Syndrome and Periodic Limb Movement Disorder – Uncomfortable leg sensations or repetitive limb movements that disrupt sleep​ ​ Circadian Rhythm Sleep Disorders – Misalignment between a person’s sleep-wake pattern and their environment (e.g., jet lag, shift work disorder)​ ​ Parasomnias – Abnormal behaviors during sleep such as sleepwalking, night terrors, or sleep talking Assessment: Pattern, Risk, & Dysfunction Identification ​ Normal Sleep–Wake Cycle Identification​ Understand the patient’s usual sleep habits and schedule.​ ​ BEARS Approach to Sleep Assessment​ ○​ Bedtime problems​ ○​ Excessive daytime sleepiness​ ○​ Awakenings during the night​ ○​ Regularity and duration of sleep​ ○​ Snoring or breathing issues during sleep​ ​ 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 of a sleep diary to track patterns Physical Assessment ​ Adults:​ Look for signs like:​ ○​ Dark circles under the eyes​ ○​ Yawning or nodding off​ ○​ Slow responses​ ○​ Irritability​ ○​ Trouble concentrating​ ○​ Difficulty finding words​ ​ Children:​ Signs may be similar to adults depending on age, 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 after physical activity​ Diagnostic Tests ​ An overnight sleep study (called a polysomnogram) is done at a sleep center to help diagnose:​ ○​ Obstructive sleep apnea (OSA)​ ○​ Periodic limb movement disorder (PLMD)​ ○​ Narcolepsy Possible Nursing Diagnoses ​ Disturbed sleep pattern: A short-term problem where the person isn’t getting enough or good quality sleep.​ ​ Sleep deprivation: Going a long time without enough sleep. Outcome Identification and Planning ​ The patient will report fewer problems falling or staying asleep.​ ​ The patient will report feeling more rested.​ ​ The patient will demonstrate physical signs of being rested (e.g., improved energy, alertness).​ Implementation: Health Promotion ​ Sleep hygiene recommendations: Teach healthy sleep habits, such as a consistent bedtime, limiting screen time, and avoiding caffeine before bed.​ ​ Environment modification: Make the sleep environment comfortable—dark, quiet, and cool.​ ​ Provision of intimacy and security: Offer emotional support or reassurance to help the patient feel safe and relaxed.​ ​ Use of sleep rituals: Encourage calming activities before bed, such as reading or meditation.​ ​ Managing individual sleep needs: Adapt sleep strategies based on the patient’s unique needs, especially if there are sleep difficulties. Implementation: Disturbances in Sleep ​ Use of consistent routine: Encourage a regular sleep schedule to help regulate sleep patterns.​ ​ Cognitive measures: Use strategies like cognitive behavioral therapy (CBT) to address thoughts or behaviors that interfere with sleep.​ ​ Counseling for hypnotic use:​ ○​ Hypnotic medications should not be relied on to induce normal sleep.​ ○​ They can impair daytime functioning while still active in the body.​ ○​ Hypnotics are typically used for short-term insomnia.​ ○​ Use with caution in older adults or those with compromised pulmonary function.​ Obtaining 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 do you think 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: When did the sleep problem start? How often does it happen?​ ​ How the problem affects everyday living: How does poor sleep affect daily activities (e.g., work, social life, mood)?​ ​ Severity of the problem and how it can be treated: How severe is the problem? Have any treatments been tried, and were they successful?​ ​ How the patient is coping with the problem and success of treatments attempted: How is the patient managing the sleep issue, and how well have past treatments worked? Sleep Assessment Physical Assessment ​ Energy level: Check if the patient feels rested or fatigued after waking up.​ ​ Facial characteristics: Look for signs like dark circles under the eyes or a tired expression.​ ​ Behavioral characteristics: Observe signs of sleepiness, such as yawning, irritability, or difficulty focusing.​ ​ Physical data suggestive of sleep problems: Check for physical indicators like signs of snoring, restless movements, or difficulty staying awake.​ Sleep Characteristics ​ Restlessness: Look for signs of restlessness during sleep, such as tossing and turning.​ ​ Sleep postures: Note if the patient maintains unusual or uncomfortable positions during sleep.​ ​ Sleep activities: Observe any behaviors like sleepwalking, talking in sleep, or other abnormal sleep activities.​ ​ Snoring: Listen for loud or irregular snoring, which could indicate sleep-disordered breathing.​  ​ Leg jerking: Look for leg movements or jerking, often seen with conditions like restless leg syndrome or periodic limb movement disorder. Screening Tools to Assess Sleep Disturbances 1.​ The Epworth Sleepiness Scale (ESS)​ ○​ A questionnaire used to measure daytime sleepiness and assess the likelihood of falling asleep in various situations.​ 2.​ The Pittsburgh Sleep Quality Index (PSQI)​ ○​ A self-rated questionnaire that assesses sleep quality and disturbances over a 1-month time period, providing insight into sleep patterns and related issues.​ 3.​ STOP-Bang Questionnaire​ ○​ A screening tool used to assess the risk of obstructive sleep apnea (OSA) based on factors like snoring, tiredness, observed apneas, blood pressure, BMI, age, neck circumference, and gender.​ Epworth Sleep Scale ​ Scoring: Each question is rated on a scale of 0 to 3:​ ○​ 0 = Would never doze​ ○​ 1 = Slight chance of dozing​ ○​ 2 = Moderate chance of dozing​  ○​ 3 = High chance of dozing​ ​ Total Score: After answering all 8 questions, the scores are added together for a total score that ranges from 0 to 24.​ ​ 0-7: Normal daytime sleepiness; no significant concern for sleep disorders.​ ​ 8-10: Mild daytime sleepiness; may indicate some risk of sleep problems.​ ​ 11-12: Moderate daytime sleepiness; further assessment may be needed.​ ​ 13 or higher: High daytime sleepiness, which may suggest the presence of a sleep disorder like sleep apnea or narcolepsy. STOPBANG Sleep Apnea ​ Score your yes tally ○​ 0 – 2 Low risk ○​ 3 – 4 Intermediate risk ○​ 5 – 8 High risk Sleep Diary A sleep diary tracks key sleep-related details to help identify factors influencing sleep quality: 1.​ Time patient goes to bed.​ 2.​ The patient tries to fall asleep.​ 3.​ Approximate time the patient falls asleep.​ 4.​ Times of night awakenings and resumption of sleep.​ 5.​ Time patient wakes up in the morning.​ 6.​ Stressors affecting sleep.​  7.​ Food, drink, or medication that may affect sleep.​ 8.​ Physical and mental activities during the day.​ 9.​ Activities performed 2-3 hours before bedtime.​ 10.​ Worries or anxieties affecting sleep. Common Etiologies for Sleep Disorders: 1.​ Physical or emotional discomfort or pain​ 2.​ Changes in bedtime rituals or sleep environment​ 3.​ Disruption of circadian rhythm​ 4.​ Exercise and diet before sleep​ 5.​ Drug dependency and withdrawal​ 6.​ Symptoms of physical illness Nursing Interventions to Promote Sleep: 1.​ Prepare a restful environment.​ 2.​ Promote bedtime rituals.​ 3.​ Offer appropriate bedtime snacks and beverages.​ 4.​ Promote relaxation and comfort.​ 5.​ Respect normal sleep–wake patterns.​ 6.​ Schedule nursing care to avoid disturbances.​ 7.​ Use medications to promote sleep.​ 8.​ Teach about rest and sleep. Obstructive Sleep Apnea (OSA) What it is: ​ OSA is a sleep disorder where the airway gets blocked, stopping or reducing airflow during sleep.​ ​ Signs of OSA:​ ○​ 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. Signs and Symptoms: ​ Loud snoring and waking up with difficulty breathing.​ ​ Observed Apnea: Family members may notice you stop breathing during sleep.​ ​ Health problems: If untreated, OSA can lead to problems like high blood pressure, heart disease, and diabetes.​ Treatment for Obstructive Sleep Apnea (OSA) 1.​ 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.​ 2.​ 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.​ 3.​ Surgery:​  ○​ 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). CPAP Pressure Injury A CPAP pressure injury occurs when the 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: 1.​ Adjust the mask fit to avoid tightness.​ 2.​ Use a soft mask liner or gel to reduce friction.​ 3.​ Apply a gentle moisturizer to protect the skin.​ 4.​ Try different mask types if needed.​ 5.​ Take breaks from wearing the mask.​ 6.​ Consult a doctor if the injury persists.