Unit 5 Promoting Sleep.pdf

Sri Rahaya Nafitri Abdul Razak U6240037 UNIT 4. PROMOTING SLEEP Learning Outcomes After completing this topic students will be able to: 1. Explain the physiology and the functions of sleep. 2. Identify the characteristics of the NREM and REM sleep states. 3. Describe variations...

Sri Rahaya Nafitri Abdul Razak U6240037 UNIT 4. PROMOTING SLEEP Learning Outcomes After completing this topic students will be able to: 1. Explain the physiology and the functions of sleep. 2. Identify the characteristics of the NREM and REM sleep states. 3. Describe variations in sleep patterns throughout the life span. 4. Identify factors that affect sleep. 5. Describe common sleep disorders. 6. Identify the components of a sleep pattern assessment. 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems. 8. Describe interventions that promote sleep. 1. PHYSIOLOGY OF SLEEP  Sleep is a cyclical physiological process that alternates with longer periods of wakefulness.  The sleep-wake cycle influences & regulates physiological function and behavioural responses.  RAS (Reticular Activating System) – located at anterior brainstem, the central neurological regulatory centre for the sleep-wake   cycle, act as regulating cortical alertness, wakefulness, attention  1.1. CIRCADIAN RHYTHMS  Biologic rhythms exist in plants, animals, and humans / internal biologic clock. In humans, these are controlled from within the body and synchronized with environmental factors: light and darkness  Circadian rhythm – it’s sort 24 hour internal biologic rhythm  Sleep and walking cycle are best known as circadian rhythms, body temp, BP, and many other physiological functions follow circadian pattern  Night, melatonin production increase and induce sleepiness along with a drop body temp  Morning, exposure light halts melatonin production and raise body temp to promote wakefulness  Aligning circadian rhythms with natural light-dark cycles enhances the quality of sleep 1.2. TYPES OF SLEEP Sleep architecture – basic organization of normal sleep i. NREM (non-rapid-eye-movement) sleep  Occur when activity in the ARS inhibited  Mostly occur during night  Three stages:  Stage 1: - light sleep, a few mins, the person feels drowsy and relaxed - the eyes roll from side to side , heart and repiratory drop slightly - the sleeper can be readily awakened and may deny she/he was sleeping - low voltage brain wave  Stage 2:  Sleep during which body processes continue to slow down  Eyes generally still, heart and respiratory rates decrease slightly, body temp falls  Requires more intense stimuli than stage 1: touching/shaking  Stage 3:  Deepest stage of sleep  Differing only in the percentage of delta waves recorded during 30 sec period  Deep sleep/delta sleep, sleeper’s heart and RR drop 20%-30%  Sleeper is difficult to arouse  Sleeper not disturbed by sensory stimuli, skeletal muscle very relaxed, reflexes are diminished, snoring occur  Essential for restore energy & release important growth hormone   Physiological changes during NREM Sleep  Arterial blood pressure falls  Pulse rate decreases  Peripheral blood vessels dilate  Cardiac output decreases  Skeletal muscles relax  Basal metabolic rate decreases 10% to 30%  Growth hormone levels peak  Intracranial pressure decrease ii. REM SLEEP (rapid eye movement)  Recur @ every 90 min & lasts 5 to 30 min.  Dreams take place – but not remembered  Brain – highly active @ 20%  Paradoxical sleep (EEG) – electroencephalogram activity resembles – wakefulness  Distinctive eye movements occur, voluntary muscle tone – dramatically decreased, deep tendon reflexes – absent.  Difficult – arouse / wake spontaneously, gastric secretions increase, heart &respiratory rates often – irregular  Region of brain –used in learning, thinking, & organizing information –stimulated   - SLEEP CYCLES  Pass through NREM and REM sleep  Complete cycle – lasting @ 90 to 110 min – adults.  Sleeper usually passes through the first two stage of NREM sleep about 20-30 mins  Stage 3: 50-60 mins  After stage 3, the sleep passes back through stage 2 and 1 about 20 mins  Then, first REM occur, about 10 mins, completing first cycle of sleep  Adult usually sleep 4-6 cycle during 7-8 hour  Sleeper who is awakened during any stage must begin a new at stage 1NREM sleep and proceed through all stages to REM sleep  Early part of night, deep sleep periods are longer, while night progress; sleeper spends less time in stage 3 of NREM sleep  REM sleep increase & dreams tend to lengthen  Before sleep ends, period 0f near wakefulness occur and stage 1 and 2 NREM and REM sleep dominate 2. Functions of Sleep  Boosting your immune system  Strengthening your emotional processing  Improving your mood and decreasing stress  Improving memory function  Improving cellular growth  Repairing tissue and muscle recovery  Increasing productivity  Improving exercise performance 3. Normal Sleep Patterns & Requirements Newborns  12-18 hrs a day, irregular schedule with period of 1-3 hrs spent awake  Enter REM sleep (called active sleep during newborn) immediately, can observed REM through close eyelids, body movement & irregular respirations  NREM sleep (called quiet sleep during newborn period), regular respirations, closed eyes, the absence of body and eye movement  Spend their time 50% in sleep only, sleep cycle 50 mins Infants  awaken every 3-4 hrs, eat, then back to sleep  wakefulness gradually increases during first month,  end of first year, takes 2 naps per day and 9-12 hrs of sleep  sleep time is spent in light sleep, exhibit some activities; movement, gurgles, coughing  putting infants to bed when they are drowsy but not asleep helps them to become “self-soothers”, it means they fall asleep independently & if they do awake at night, they can put themselves back to sleep  infant that used to parental assistance at bedtime may become ‘signalers’ and cry for their parents to help them return to sleep Toddlers  1-3 y/o, need 12-14hres sleep  still need afternoon nap, but mid-morning naps gradually decrease  usually often to resistance to going bed & may awaken during night,  nighttime & nightmares are common , blanked/stuffed animals will help  parents need to maintain their daily sleep schedule for good sleep habits Preschooler  3-5 y/o requires 11-13 hrs per night  Usually resist bedtime cause of; story, game, television program, they can be restless & irritable if sleep requirements not met  Parents can help children who resist bedtime by maintaining a regular and consistent sleep schedule  They frequently wake up at night, may be afraid of the dark/experience night terrors/nightmares, often limiting/eliminate TV will reduce nightmares School-age  5-12 y/o needs 10-11hrs per sleep children  Mostly they had less sleep due to homework, sports, social activities, spending more time at computers/TV, drink caffein Adolescents  12-18 y/o, need 9-10hrs  Teens usually sleepy when they’re at times & places where they should be fully awake; school, home, on the road   Leads to -ve moods; unhappy, sad, tense, increase potential of accident  Circadian rhythms tend to shift; later sleep and wake pattern is desire for greater independent  Use of the internet, watching TV, cell phone usage disrupt ability to fall sleep due to blue-spectrum light exposure  Boys begin to experience ‘nocturnal emissions’/wet dreams (orgasm n emission of semen during sleep), they need to know that it was normal Adult  Need sleep 7-8hrs, but some of them can function well without sleepiness/drowsiness.  Sign not getting enough of sleep: falling asleep/becoming drowsy during task, not being able to concentrate/remember information, being unreasonably irritable  Contributes to short term memory loss & in adequate performance  Certain adults vulnerable to not getting enough sleep; students, shift worker, travelers suffering from acute stress, depression, chronic pain Older adult  65-75 y/o usually awaken 1.3hrs earlier  Go bed approximately 1hr earlier than younger adults(20-30 y/o)  Impact their quality of life, mood, alertness  Awaken 6 times during night, even the ability to sleep become difficult, the need to sleep does not decrease the age  during sleep, flattened-circadian rhythm, morning arousal(advanced sleep phase syndrome)  difficult to sleep back after awakening & diminished REM sleep  napping daytime lead to reduce nocturnal sleep  medical conditions & pain factors of disturbing  client with dementia experience (sundown syndrome)  agitation, anxiety, aggression, delusion that occur in late afternoon can goes to night and lead to sleep disruption Clinical Manifestations – (what are sleep deprivation and sleep problems in teen) Has difficulty waking in the morning for school Falls asleep in class or during quiet times of the day Increases the use of caffeinated beverages like coffee, soda, energy drinks Feels tired, making it difficult to initiate/persist in projects such as a school, assignment Is irritable, anxious, angers easily on days when he/she gets less sleep Is involved in many extracurricular activities, has a job, stays up too late doing homework every night, cutting into sleep time Sleeps extra long periods of time on the weekend 4. Factors Affecting Sleep 1. Illness:  Pain/physical distress (arthritis, back pain), require more sleep than normal, normal rhythm of sleep & wakefulness disturbed  Respiratory conditions; SOB, nasal congestion, sinus drainage  Gastric/duodenal ulcers  Endocrine disturbances; hyperthyroidism lengthens presleep time, so client difficult to fall asleep. Decrease stage 3 sleep. Women with low levels of estrogen often report excessive fatigue, felt discomfort, hot flashes/night sweats 2. Environment  Noise, absence usual stimuli, unfamiliar stimuli  Discomfort temp, lack of ventilation, light level   Comfort and size bed  Partner sleep that has sleep habits, snores 3. Lifestyle  Irregular morning and nighttime schedule  Exercise in morning/late afternoon good for sleep but exercise late in the day is bad for sleep  Ability to relax before retiring, e.g. doing homework /office work before/after getting into bed  Night shift workers 4. Emotional Stress  Constant exposure to stress will increase activation of hypothalamic-pituitary-adrenal (HPA)  Preoccupied person/personal problems  Anxiety 5. Stimulants and Alcohol  Caffeine-containing beverages  Alcoholic person 6. Diet  Weight gain : broken sleep n earlier awakening  Weight loss : increase sleep  Cheese, milk induce sleep 7. Smoking  Nicotine has a stimulating effect on body, easily aroused, describe themselves as light sleeper 8. Motivation  Increase alertness in some situations, e.g. tired person can probably stay alert while attending interesting concert/ surfing the web night  Not sufficient to overcome the normal circadian drive to sleep during night. Nor is motivation sufficient to overcome sleepiness due to insufficient sleep 9. Medications  Hypnotic meds can breaks deep sleep and suppress REM sleep  Beta-blockers cause insomnia & nightmares  Narcotic (e.g. morphine), suppress REM & cause frequent awakening and drowsiness 5. Common Sleep Disorders 1. Insomnia – inability to fall asleep/remain asleep I. Cause of insomnia  Lifestyle factors  Pregnancy and childbirth  Mental health menopause  Urinary issue  Chronic pain/meds conditions  Certain meds II. Clinical manifestation  Difficulty falling asleep  Waking up frequently during the night  Difficulty returning to sleep  Waking up too early in the morning  Unrefreshing sleep  Daytime sleepiness  Difficulty concentrating  Irritability 2. Excessive daytime sleepiness  Hypersomnia  Person had sufficient sleep at night but still cannot stay awake at day  Cause by meds conditions: (e.g. CNS damage and certain kidney, liver), metabolic disorders: (e.g. diabetic acidosis, hypothyroidism)  Narcolepsy  a chronic neurological disorder that affects the brain’s ability to control sleep- wake cycles.  Caused by: - Lack of the brain chemical hypocretin (orexin): Narcolepsy is often caused by a deficiency in hypocretin, a brain chemical that regulates wakefulness. This lack of hypocretin can result from the immune system mistakenly attacking the cells that produce it or the receptors that allow it to function.  Autoimmune response: In some cases, narcolepsy can be triggered by an autoimmune response where antibodies target healthy cells and tissues, leading to a lack of hypocretin production. Research has shown that antibodies against a protein called trib 2, produced by the same brain area as hypocretin, may contribute to this autoimmune reaction.  Possible triggers: Various factors such as hormonal changes during puberty or menopause, major psychological stress, infections like swine flu or streptococcal infections, and even certain vaccines like Pandemrix used during the swine flu epidemic have been suggested as potential triggers for narcolepsy. However, not all cases are fully explained by these triggers.  Sleep apnea  a condition where breathing stops and restarts multiple times during sleep, leading to oxygen deprivation in the body.  Cause by: - Obstructive Sleep Apnea (OSA): Occurs when the upper airway becomes blocked during sleep due to factors like obesity or large tonsils. - Central Sleep Apnea (CSA): Results from the brain failing to send signals for breathing. - Mixed/complex Sleep Apnea: Combine features of both obstructive and central sleep apnea  Insufficient sleep  a condition characterized by inadequate or insufficient sleep sustained over a period of time.  Caused by:  Mood Changes: Lack of sleep can result in mood swings, irritability, increased anxiety, and symptoms of depression. It can also impact decision-making abilities and lead to impulsive behavior.  Microsleeps and Tiredness: Sleep deprivation can cause episodes of microsleep during the day, where individuals unintentionally fall asleep for short periods. This can lead to increased tiredness, decreased productivity, and pose risks in situations like driving or operating machinery.  Physical Health Risks: Insufficient sleep is linked to various health problems such as weight gain, weakened immune system, increased risk of chronic conditions like diabetes mellitus and heart disease, respiratory issues like obstructive sleep apnea, digestive problems affecting weight management,  and cardiovascular diseases.  Hormonal Imbalance: Sleep deprivation disrupts hormone production, affecting hormones like leptin and ghrelin that regulate hunger levels. It can also impact growth hormone production crucial for muscle growth and repair.  Immune System Suppression: Lack of sleep hampers the immune system’s ability to produce infection-fighting substances like antibodies and cytokines. This weakens the body’s defense against illnesses and delays recovery from infections. 3. Parasomnias (refer Box 45-4; pg-1101)  Bruxism: usually occurring during stage 2NREM sleep, this clenching and grinding of the teeth can eventually erode dental crowns, causes teeth to come loose, lead to deterioration of the temporomandibular(TMJ) joint, called TMJ syndrome  Enuresis: bed-wetting during sleep can occur in children over 3 y/o. more males than females are affected. It often occurs 1 -2 hrs after falling asleep, when rousing from NREM stage 3  Periodic Limb Movement Disorder (PLMD): the legs jerk twice/three times per mins during sleep. Its common among older adults. This kicking motion ca wake the client and results in poor sleep. PLMD differs from restless leg syndrome (RLS), which occurs whenever the person is at rest, not just at night when sleeping. RLS may occur during pregnancy/be due to other medical problems that can be treated. Many clients with PLMD/RLS respond well to meds; levodopa, pramipexole, ropinirole, gabapentin  Sleeptalking: talking during sleep occurs during NREM sleep before REM sleep. It rarely presents a problem to the person unless it becomes troublesome to others  Sleepwalking: sleepwalking(somnambulism) occurs during stage 3 of NREM sleep. Its episodic and usually occurs 1-2hrs after falling asleep. Tend not to notice dangers and often need to be protected from injury 6. NURSING MANAGEMENT 1. Assessing I. Sleep history  When do you usually go to sleep? And when do you wake up? Do you nap? If so, when? If the client is a child, its also important to ask about bedtime rituals. This information provides the nurse with information about client’s usual sleep duration and preferred sleep times, allows for the incorporation of the client’s preferences in the plan of care  Do you have any problems with your sleep? Has anyone ever told you that you snore loudly/thrash around a lot at night? Are you able to stay awake at work, when driving, engaging in you usual activities? This question elicit information about sleep complaints including the possibility of excessive daytime sleepiness. Loud snoring suggests the possibility of obstructive sleep apnea, and any client replying yes to this question should be referred to a specialist. Referrals should also be made if clients indicate they have difficulty staying awake during the day/ that their movements disturb the sleep of their bed partners.  Do you take any prescribed meds, over-the-counter(OTC) meds, or herbal remedies to help you sleep? Or to stay awake? This information alerts the nurse to the use of prescription hypnotics & stimulant as well as the use of OTC sleep aids and herbal remedies.  Is there anything else I need to know about your sleep? To voice any concerns /bring up topics that nurse may not have ask about. II. Health history  To rule out medical & psychiatric causes of client (depression, parkinsons disease, alzheimer’s disease, arthritis, obstructive sleep apnea)  Prescribed / nonprescription meds, herbal remedies  Cause meds can frequently cause or exacerbate sleep disturbances  III. Physical examination  E.g client with sleep apnea; enlarged & reddened uvula and soft palate , enlarged tonsils and adenoids (in children), obesity(in adults), male client with neck size greater than 1.75 inch IV. Sleep diary – ask clients sleep diary or log for 1-2 weeks  Time of going to bed, time of trying to fall asleep, approximate time falling asleep, time of any instances of waking up and duration of this periods, time of waking up in the morning, time of any naps and their duration  Activities performed 2-3 hrs before bedtime (type, duration, time)  Consumption of any caffeinated beverages and alcohol and amounts of those beverages  Any prescribed meds, OTC meds, and herbal remedies taken during the day  Bedtime rituals before sleep  Any difficulties remaining awake during the day and time when difficulties occurred  Any worries that client believes may affect sleep  Factors that the client believes have a positive/negative effect on sleep V. Diagnostic studies – sleep measure by polysomnography : EEG; EMG; EOG  Electrodes are placed on the scalp to record brain waves : electroencephalogram (EEG)  Electrodes placed on the outer canthus of each eye to record eye movement : electro- oculogram (EOG)  Electrodes placed on the chin muscles to record structural : electromyogram (EMG) 2. Diagnosing Insomnia – difficulty falling asleep/difficulty staying asleep, delayed onset of sleep Physical discomfort or pain; anxiety about actual/anticipated loss of a loved one , loss of job, loss of life due to serious disease process, worry about family members behaviour/ illness Frequent changes in sleep due to shift work/overtime Changes sleep environment/bedtime rituals; noisy, alcohol/drug dependency, drug withdrawal, misuse of sedative prescribed for insomnia Meds effect; steroids and stimulants Risk for injury related to somnambulism (sleep walking) Ineffective coping related to insufficient quality and quantity of sleep Fatigue related to insufficient sleep Impaired gas exchange related to sleep apnea Deficient knowledge (nonprescription remedies for sleep) related to misinformation Anxiety related to sleep apnea and/or the diagnosis of a sleep disorder Activity tolerance related to sleep deprivation or excessive daytime sleepiness 3. Planning  The major goal for patients with sleep disturbances is to maintain a sleeping pattern that provides sufficient energy for daily activities and to enhance the patient’s feeling of well being/improving the quality and quantity of sleep.  Nurses interventions; reduce environmental distraction, promoting bedtime rituals, providing comfort measures, scheduling nursing care to provide for uninterrupted sleep period, teaching stress reduction, relaxation technique, good sleep hygiene. 4. Implementing i. Sleep hygiene – is intervention to promote sleep; teaching about sleep habits, support of bedtime rituals, the provision of a restful environment, specific measures to promote comfort & relax, appropriate use of hypnotic meds ii. Client teaching a. Sleep pattern if you have difficulty falling asleep or staying asleep, its important to establish  a regular bedtime and wake up time for all days of the week to enhance your biologic rhythm. A short daytime nap (e.g. 15-30 mins), particularly among older adults, can be restorative and not interfere with nighttime sleep. A younger person with insomnia should not nap. Establish a regular, relaxing bedtime routine before sleep such as reading, listening to soft music, taking a warm bath, doing some other quiet activities you enjoy. Get adequate exercise during the day to reduces stress, but avoid excessive physical exertion at least 3hrs before bedtime Use the bed for sleep or sexual activity, so that you associate it with sleep. Take work material, computers, TV out of the bedroom. Lying awake, tossing, turning, will strengthen the association between wakefulness and lying in bed (many people with insomnia report falling asleep in a chair or in front the TV but having trouble sleep in bed). When you are unable to sleep, get out of bed, go into another room, pursue some relaxing activity until you feel drowsy Avoid dealing with office work or family problems before bedtime b. Environment create a sleep conductive environment; dark, quiet, comfortable, cool keep noise to minimum, block out extraneous noise as necessary with white noise from a fan, air conditioner, white noise machine. Music is not recommended because studies have shown that music will promote wakefulness sleep on comfortable mattress and pillows c. Diet Avoid heavy meals 2-3 hrs before bedtime Avoid alcohol and caffeine If bedtime snacks necessary, consume only light carbohydrates and milk. Not heavy and spicy food cause it can gastrointestinal upset d. Medications Use sleeping meds on as last resort. Use OTC meds sparingly because contain many antihistamines that cause drowsy during daytime Take analgesic before bedtime to relieve aches and pains Consult with health care provider to adjust other meds for insomnia iii. Supporting Bedtime Rituals  Adults: listening to music, reading, taking a soothing bath, praying  Children: bedtime story, holding onto favorite toy/blanket, kissing everyone goodnight  Hygienic routines: washing face and hands/ bathing, brushing teeth, voiding  Nurse can assist: hand and face wash, provide massage, hot drink, plumping pillow, provide extra blankets  Conversation about accomplishments of the day/ enjoyable events lead to peace of mind iv. Creating A Restful Environment  Minimize noise  Comfort room temp  Appropriate ventilation and lighting  At hosp: placing beds in low position, use night light, placing call bells with easy reach v. Promoting Comfort And Relaxation  provide loose fitting nightwear  assist clients with hygienic routines  close window curtains if street lights shine through  close curtains between clients in semiprivate and large rooms  reduce/eliminate overhead lighting; provide a night light at bedside/bathroom  use a flashlight to check drainage  ensure a clear pathway around the bed to avoid bumping the bed and jarring the client during sleeping hours  close the client’s room door   adhere to agency policy about times to turn off communal television and radios  lower the ring tone of nearby telephones  discontinue use of the paging system after a certain hour/reduce its volume  keep required staff conversation at low levels; nursing reports/discussions in a separate area  wear rubber sole shoes  perform only essential noisy activities during sleeping hrs  make sure bed linen is smooth,clean,dry  assist or encourage the client to void before bedtime  offer to provide a back massage before sleep  position dependent clients appropriately to aid muscle relaxation, provide supportive devices to protect pressure area  schedule meds  warm bed with prewarmed bath blankets  use 100% cotton flannel sheets vi. Enhancing Sleep With Meds  sedative hypnotic meds produce general CNS depression and unnatural sleep ; zolpidem(ambien)  antianxiety meds decrease levels of arousal, it contraindicate in pregnant women because risk of congenital anomalies and excreted in breast milk  sleep meds vary in their onset and duration of action and will impair waking function  sleep meds affect REM sleep more than NREM sleep  initial doses of meds should be low and increases added gradually depends on the client’s response  regular use of any sleep meds can lead to tolerance over time and rebound insomnia  abrupt cessation of barbiturate sedative hypnotics can create withdrawal symptoms; restlessness, tremors, weakness, insomnia, increased heart rate, seizures, convulsions, death 5. Evaluating  the nurse judges whether pt. goals & outcomes have been achieved  if outcomes not achieve, ask this;  were etiologic factors correctly identified?  Has the client’s physical condition or medication therapy changed?  Did the client comply with instructions about establishing a regular sleep/wake pattern?  Did the client participate in stimulating daytime activities to avoid excessive daytime naps?  Were all possible measures taken to provide a restful environment for the client?  Were the comfort and relaxation measures effective?