Chapter 43 Sleep PDF

Chapter 43 Sleep Copyright © 2021, Elsevier Inc. All Rights Reserved. Potter & Perry (2021), page1038-1039  Intended Student Learning  Explain the effects that the 24-hour sleep-wake cycle has on biological function.  Discuss mechanisms that regulate sleep.  Explain the st...

Chapter 43 Sleep Copyright © 2021, Elsevier Inc. All Rights Reserved. Potter & Perry (2021), page1038-1039  Intended Student Learning  Explain the effects that the 24-hour sleep-wake cycle has on biological function.  Discuss mechanisms that regulate sleep.  Explain the stages of a normal sleep cycle.  Explain the functions of sleep.  Compare & contrast the sleep requirements of different age-groups.  Identify factors that normally promote & disrupt sleep.  Discuss characteristics of common sleep disorders.  Conduct a sleep history for a patient.  Identify nursing interventions designed to promote normal sleep cycles for patients of all ages.  Explain ways to evaluate the effects of sleep therapies. Copyright © 2021, Elsevier Inc. All Rights Reserved.  The Importance of Sleep Sleep is a biological need for life and health, similar to the need for food. Sleep affects your mental and physical performance and long-term health. Proper rest & sleep are as important to health as good nutrition & adequate exercise. Sleep provides healing & restoration, promotes health & recovery from illness. Lack of sleep  poor concentration, judgment, ↓participation in ADLs, ↑irritability Physiologic changes during sleep: ↓HR, ↓RR, ↓BP, ↓blood sugar, and ↓response to external stimuli (Yeager, 2015). Sleep is an active, multiphase, complex brain process that provides restorative functions and promotes memory consolidation. (McCance & Heuther, 2014)  Dangers of Sleepiness and Fatigue o When the brain is deprived of adequate sleep, at some point it will go to sleep no matter what the situation. o The brain moves rapidly from wakefulness to sleep, like an on/off switch  leads to dangerous situations while performing critical tasks such as driving. o Waning signs when the brain is close to falling asleep: difficulty focusing, frequent blinking, heavy eyelids, eye- rubbing, daydreaming or disconnected thoughts, repeated yawning, difficulty keeping head up, feeling restless and irritable. o Impaired Performance from lack of sleep mimics alcohol intoxication o Being awake for 17 hours is similar to having a blood alcohol concentration (BAC) OF 0.05% (the level some countries use for drunk driving violations). o Being awake for 24h is similar to having a BAC of 0.10% (above the US drunk driving level of 0.08. Copyright © 2021, Elsevier Inc. All Rights Reserved. Potter & Perry (2021), page1038-1039  Circadian Rhythm Circadian rhythm are internally driven cycles that rise & fall during the 24h day-night cycle ~ diurnal Helps you fall asleep @ night & wakes you up in AM. The suprachiasmatic nucleus (SCN) nerve cells in the hypothalamus controls the rhythm of the sleep-wake cycle. The predictable changing of body temp, HR, BP, hormone secretion, sensory acuity, & mood depend on the maintenance of the 24h circadian cycle.1 All people have biological clocks that synchronize their sleep cycles  variations for going to bed The internal body clock sets the timing for many circadian rhythms which regulate processes such as sleep/wake cycles, body temp rhythm, hormonal activity, eating & digesting Reversals in the sleep-wake cycle sometimes indicate a serious illness. Copyright © 2021, Elsevier Inc. All Rights Reserved. Potter & Perry (2021), page1038-1039  Sleep Regulation o 2 Processes r/t sleep/wake cycles o Homeostatic process (Process S) regulates the length & depth of sleep o Circadian rhythms (Process C: “biological time clocks”) influence the internal organization of sleep & the timing & duration of sleep-wake cycles o The hypothalamus is the major sleep center o It secretes hypocretins (orexins) that promote wakefulness & REM sleep. o Prostaglandin D2, L-tryptophan, & growth factors control sleep. o Reticular Activating System (RAS) contains special cells that maintain alertness & wakefulness. o Visual, auditory, pain, tactile sensory stimuli, emotions, & thought processes stimulate the RAS. Copyright © 2021, Elsevier Inc. All Rights Reserved. BOX 43.1 Stages of the Sleep Cycle BOX 43.1 Stages of the Sleep Cycle NREM (75% of Night) REM (25% of Night) N1 (Formerly Stage 1) REM Sleep Stage of lightest level of sleep, lasting a few minutes. Vivid, full-color dreaming occurs. ↓ physiological activity begins with gradual fall in VS & Stage usually begins about 90 minutes after sleep has metabolism. begun. Sensory stimuli such as noise easily arouse sleeper. Stage is typified by autonomic response of rapidly If awakened, person feels as though daydreaming has moving eyes, fluctuating heart & respiratory rates, & occurred. increased or fluctuating BP. GI ↑secretions N2 (Formerly Stage 2) MS Loss of skeletal muscle tone occurs. Stage of sound sleep during which relaxation Difficult to arouse progresses. Duration of REM sleep increases with each cycle & Arousal is still relatively easy. averages 20 minutes. Brain & muscle activity continue to slow. D REM sleep  anxiety, difficulty concentrating, or N3 (Formerly Stages 3 & 4) irritability the next day Called slow-wave sleep. Deepest stage of sleep. Sleeper is difficult to arouse & rarely moves. Brain & muscle activity are significantly decreased. VS are lower than during waking hours. Copyright © 2021, Elsevier Inc. All Rights Reserved.  Sleep Cycle Presleep period: 1st 10-30 min Once asleep, a person passes through 4-6 complete sleep cycles Sleep cycles range from 70-120 minutes, with 4-6 complete sleep cycles occurring @ night People progress through 4 stages during a typical 90-min sleep cycle. A complete sleep cycle = 3 stages of NREM + a period of REM sleep: 90-110 min Sleep cycles range from 70-120 minutes With each successive cycle, stage N3 of NREM sleep shortens, & REM sleep lengthens. REM sleep lasts up to 60 min during the last sleep cycle. The number of sleep cycles depends on the total amount of time that the person spends sleeping. Copyright © 2021, Elsevier Inc. All Rights Reserved.  Functions of Sleep A time for restoration, memory consolidation, & prep for the next period of wakefulness. Biological functions slow during NREM sleep AEB ↓VS. NREM Sleep: The body human growth hormone for the repair & renewal of epithelial & specialized cells such as brain cells. Protein synthesis & cell division for the renewal of tissues occur during rest & sleep. The basal metabolic rate lowers during sleep, which conserves the energy supply of the body. REM Sleep Important for early brain development, cognition & memory. Researchers associate REM sleep w/ changes in the brain including cerebral blood flow & ↑ cortical activity. There is increased ↑O2 consumption & epinephrine release. These changes are associated with memory storage & learning. Copyright © 2021, Elsevier Inc. All Rights Reserved.  Vital Body Processes Occur During Sleep During sleep, your body is busy Repairing tissues Fighting off infections Forming memories of experiences that occurred during the day If you do not get adequate sleep, you could experience health effects such as Impaired mental functioning Disruption of insulin/blood glucose system, promoting insulin resistance Increased appetite, resulting in overeating and weight gain Sleep loss can also weaken the immune system by Reducing the proper function of cells that attack cancer cells and viruses Increasing the inflammatory response, which increases the risk for cardiovascular and metabolic disorders such as diabetes Reducing production of antibodies, thereby increasing the risk for infection  Physical Illness Any illness that causes pain, physical discomfort, or mood problems such as anxiety or depression  develop sleep problems. Restless leg syndrome (RLS) Heart disease (HTN) Respiratory disease (asthma, bronchitis, COPD, allergic rhinitis) GI diseases Nocturia Patients who are ill often require more sleep Sleep problems leads to more chronic illness such as HTN, obesity, DM Copyright © 2021, Elsevier Inc. All Rights Reserved. Potter & Perry (2021), page 1040  Sleep Disorders  Insomnia chronic difficulty falling sleep  Sleep apnea patient is unable to breathe & sleep at the same time.  Narcolepsy: Excessive daytime sleepiness, during the day this person falls asleep; REM sleep occurs within 15 min after falling asleep; vivid dreams as person falls asleep; sleep paralysis, feeling of being unable to move or talk just before waking or falling asleep is another symptom  Narcolepsy Type 1 Cataplexy Sudden muscle weakness during intense emotions, e.g., anger, sadness, or laughter that occurs @ any time during the day; lasts a few seconds; if severe, pt falls to the floor  Narcolepsy Type 2 (previously known as narcolepsy without cataplexy) excessive daytime sleepiness but usually do not have muscle weakness triggered by emotions.  Sleep deprivation: Patient experiences sleep deprivation due to sleep disorders. Acute or chronic, results from insufficient or disrupted sleep.  Parasomnias: Sleep problems that are more common in children & occur during non-REM or REM sleep. Hypothesis that sudden infant death syndrome (SIDS) related to apnea, hypoxia, & cardiac arrhythmias caused by abnormalities in the autonomic nervous system. The American Academy of Pediatrics (AAP) recommends positioning infants in supine position to reduce SIDS. Copyright © 2021, Elsevier Inc. All Rights Reserved. Potter & Perry (2021), page 1040 Normal Sleep Requirements & Patterns Neonates: 16 hours of sleep Infants: 15 hours total with naps Toddlers: 12 hours total with a nap Preschoolers; 12 hours per night School-age: varies; 9-12 hours Adolescents: 8-10 hours recommended Young adults: 6-8.5 hours per night UCLA students: sleep-deprived Middle adults: 7-9 hours per night Older adults: varies; many have sleep problems Copyright © 2021, Elsevier Inc. All Rights Reserved. Potter & Perry (2021), page 1043  Factors Affecting Sleep Drugs & substances Lifestyle Usual Sleep Patterns Emotional Stress Environment Exercise & fatigue Food & caloric intake Copyright © 2021, Elsevier Inc. All Rights Reserved.  Factors Affecting Sleep BOX 43.4 Drugs & Their Effects on Sleep Alcohol Anticonvulsants Antidepressants & Stimulants Speeds onset of sleep ↓ REM sleep time Suppresses REM sleep Reduces REM sleep Cause daytime drowsiness ↓ total sleep time Awakens person during night & causes difficulty returning to sleep Benzodiazepines Beta-Adrenergic Blockers Caffeine Alter REM sleep Cause nightmares Prevents person from falling asleep ↑ sleep time Cause insomnia Causes person to awaken during night ↑ daytime sleepiness Cause awakening from sleep Interferes with REM sleep Diuretics Hypnotics Nicotine Nighttime awakenings caused by Interfere with reaching deeper sleep ↓ total sleep time nocturia stages ↓ REM sleep time Provide only temporary (1 week) ↑ in Causes awakening from sleep quantity of sleep Causes difficulty staying asleep Opiates Eventually cause “hangover” during Suppresses REM sleep day; excess drowsiness, confusion, ↓ Cause ↑ daytime drowsiness energy Copyright © 2021, Elsevier Inc. All Rights Reserved. Potter & Perry (2021), page 1044  Assessment: Epworth Sleepiness Scale  Contains 8 questions about likeliness of a pt being sleepy during certain activities, i.e., watching tv, reading, sitting & talking with someone) on a scale 0-3  0 = would never dose or sleep  3 = high chance of dozing or sleeping Score Description 0-5 Lower normal daytime sleepiness 6-10 Higher than normal daytime sleepiness 11-12 Mild excessive daytime sleepiness 13-15 Moderate excessive daytime sleepiness 16-24 Severe excessive daytime sleepiness  Tools for sleep assessment Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Visual Analog Scale, Numeric Scale 0-10 sleep rating (0 = worse sleep; 10 = best sleep) BOX 43.5 Nursing Assessment Questions Nature of the Problem Describe the type of sleep problem you’re having Why do you think you’re not getting enough sleep? Describe a recent night’s sleep. How is this sleep different from your usual sleep? Signs & Symptoms (Cues) Do you have difficulty falling asleep, staying asleep, or waking up? Have you been told that you snore loudly? Do you have headaches when awakening? Signs & Symptoms: Onset & Duration When did you notice the problem? What do you do to relieve the symptom? How long has this problem lasted? Severity How long does it take you to fall asleep? How often during the week do you have trouble falling asleep? On average, how many hours of sleep a night did you get this week? How does this compare to your usual amount of sleep? What do you do when you awaken during the night or too early in the AM? Copyright © 2021, Elsevier Inc. All Rights Reserved. BOX 43.5 Nursing Assessment Questions Predisposing Factors What do you do just before going to bed? Have you recently had any changes at work or at home? How is your mood? Have you noticed any changes recently? Which meds or recreational drugs do you take on a regular basis? Are you taking any new prescriptions or over-the-counter meds? Do you eat food (spicy or greasy foods) or drink substances (alcohol or caffeinated beverages) that affect your sleep? Do you have a physical illness that affects your sleep? Does anyone in your family have a history of sleep problems? Effect on Pt How has the loss of sleep affected you? Do you feel excessively sleep or irritable or have trouble concentrating during waking hours? Do you have trouble staying awake? Have you fallen asleep at the wrong times (e.g., while driving, sitting quietly in a meeting?) Copyright © 2021, Elsevier Inc. All Rights Reserved. BOX 43.6 Questions to Ask for Specific Sleep Disorders Impaired Sleep How easily do you fall asleep? Do you fall asleep & have difficulty staying asleep? What time do you awaken in the AM? What causes you to awaken early? What do you do to prepare for sleep? To improve your sleep? What do you think about as you try to fall asleep? How often do you have trouble sleeping? Sleep Apnea Do you snore loudly? Does anyone else in your family snore loudly? Has anyone ever told you that you often stop breathing for short periods during sleep? (Spouse or bed partner/roommate may report this.) Do you experience headaches after awakening? Do you have difficulty staying awake during the day? Narcolepsy Do you fall asleep @ the wrong times? (Friends/family may report this) Do you have episodes of losing muscle control or falling to the floor? Have you ever had the feeling of being unable to walk or talk just before waking or falling asleep? Copyright © 2021, Elsevier Inc. All Rights Reserved. Do you have vivid, lifelike dreams when going to sleep or awakening? BOX 50.2 The STOP-BANG Questionnaire Height_______cm/inches Weight_______lbs/kg Age_______ Male/Female_______ BMI _______ Collar size of shirt: S, M, L, XL, or _______ cm/inches Snoring Do you snore loudly (louder than talking or loud enough to be heard through closed doors? Y/N Tired Do you often feel tired, fatigued, or sleep during daytime? Y/N Observed Has anyone observed you stop breathing during your sleep? Y/N Blood Pressure Do you have or are you being treated for high blood pressure? Y/N BMI BMI > 35 kg/m2? Y/N Age Age over 50 years old? Y/N Neck circumference (measure with approved measuring tape)a Neck circumference >40 cm? Y/N Gender Gender male? Y/N Score of 4 – High sensitivity of 88% for identifying severe obstructive sleep apnea (OSA) Score of 5 or more – High risk of OSA Score of 6 is more specific a Neck circumference is measured by staff Copyright © 2021, Elsevier Inc. All Rights Reserved.  Sleep History  Description of Sleeping Problem  Usual sleep pattern Have pts describe their usual sleep pattern to ID changes; mimic sleeping conditions while in the hospital.  Physical & psychological illness Ask pt about preexisting health problems, e.g., COPD, arthritis, bipolar disorder, depression, caffeine intake, meds (prescribed & over- the-counter).  Current life events Ask about changes in lifestyle that disrupt sleep, e.g., occupation (changes in job responsibilities, rotating shifts, long hours); social activities, recent travel, mealtime schedule  Emotional & mental status Anxiety, emotional stress rt illness, situational crisis rt loss of loved one, job loss. Treat primary problem. Pts with mental illness may need sedation for adequate rest.  Bedtime routines Ex: glass of milk, sleeping pill, eating snack, watching tv. Ask about child’s bedtime rituals, e.g., bedtime story, rocking child to sleep, engaging in quiet play; special blanket or stuffed animal  Bedtime environment Ask about preferred environmental conditions, e.g., lighting, music, tv, door open or closed, presence of electronic devices  Behaviors of sleep deprivation Observe for behaviors indicating sleep deprivation, e.g., irritability, disorientation (~drunken state), frequent yawning, slurred speech;  Nursing Dx Planning  Adequate Sleep  Fatigue  Impaired Sleep  Goals & Outcomes  Reduced Fatigue  Follow professional standards  Sleep Deprivation  Create a concept map  Collaborate  Setting priorities  Frequently, sleep disturbances are the result of other health problems  Teamwork & collaboration  Partner closely with the patient & sleep partner  Implementation  Health Promotion  Acute care  Environmental controls  Environmental controls  Promoting comfort  Promoting bedtime routines  Establishing periods of rest &  Promoting safety sleep  Promoting comfort  Promoting safety  Promoting activity  Stress reduction  Stress reduction  Restorative or continuing care  Bedtime snacks  Promoting comfort  Controlling physiological  Pharmacological disturbances approaches  Pharmacological approaches  Evaluation  Through the patient’s eyes  Patient outcomes  Determine whether expected outcomes have been met.  Are you able to fall asleep within 20 minutes of getting into bed?  Describe how well you sleep when you exercise.  Does the use of quiet music at bedtime help you to relax?  Do you feel rested when you wake up? Copyright © 2021, Elsevier Inc. All Rights Reserved.  Age-Related Changes in Sleep  ↑ sleep latency, ↓ sleep efficiency, nocturnal awakenings, ↑ early morning awakenings, & ↑ daytime sleepiness  Older adults awaken four or more times a night  Daytime napping is common  Daytime sleepiness may suggest underlying disease  Other sleep changes are associated with chronic disease and other health problems  When cognitive dysfunction is present, daytime sleepiness is a predictor of mortality & cardiovascular disease. Copyright © 2021, Elsevier Inc. All Rights Reserved.