NCM100 12th Sleep and Rest

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Serotonin

Melatonin

Acetylcholine

Norepinephrine

Fundamentals of Nursing

Sleep and Rest

Rest

- Calmness, relaxation without emotional stress and freedom from anxiety

- Meaning of rest vary among individuals

Sleep

- Cyclical psychological process that alternates with longer periods of wakefulness

- Characterized by minimal physical activity variable levels of consciousness, changes in the body’s

physiologic process, and decreased responsiveness to stimuli

Physiology of Sleep

• Circadian Rhythm

o Diurnal, 24-Hour day-night cycle

o Rhythmic biologic clock that synchronize sleep cycles

o Circadian regulation begins by the third week of life and may be inherited

o Circadian rhythm of sleep frequently is synchronized with other body functions

Theories Related to Sleep Theory of active inhibitory process of sleep

� Regulation of sleep depends on the interrelationship of cerebral mechanism

a. Activates higher brain function

� WAKEFULNESS

b. Suppression of higher brain functions

� SLEEP

~Sleep Regulation Theory~

Decreased

visual,

auditory pain,

tactile stimuli

Upper Brain Stem

Emotion and

thought

process

Activation of cerebral cortex

Stimulation ascending

Reticular Activating System

(RAS)

Release Catecholamine

(Norepinephrine)

Maintains alertness & wakefullness

Decreased

stimulation of RAS

sleep

system of pons

& medulla

Bulbar Synchronizing

Region (BSR)

BSR will takeover RAS

Production of serotonin

Person will sleep

Stages of SLEEEEEEEEEEEEEEEP~

1. Non-Rapid Eye Movement (NREM) Sleep

a. Stage I

b. Stage II

c. Stage III

d. Stage IV

2. REM Sleep

NREM Sleep

- Referred to as slow wave sleep (slower α and β waves than awake person)

- Deep, restful sleep

- Decreased physiologic and metabolic processes of the body

- Consists of 4 Stages~


Pre-Sleep Period

- Person is aware of gradually developing sleepiness

- Normally lasts 10 – 15 minutes

- If a person experiences difficulty of sleep, this may take one hour or more☻

NREM Stage I

- Lightest level of sleep

- May last for a few minutes

- The person feels drowsy and relaxed

- Decreased physiological activity begins with gradual fall in vital signs (VS) and metabolism

- Person can be easily aroused

- Awakened, person feels as though daydreaming has occurred

NREM Stage II

- Fairly light sleep

- Period of sound sleep

- Body processes continue to slow down

- Arousal remains relatively easy

- Lasts about 10 – 20 minutes

- Constitutes 40 – 45% of total sleep

- Loss of slow rolling eye movement

NREM Stage III - Involves initial stages of deep sleep

- Body processes slows further due to domination of parasympathetic nervous system

- Vital signs declines but remain regular

- Lasts about 15 – 30 minutes

NREM IV

- Skeletal muscles are very relaxed and sleeper rarely moves

- Sleeper is difficult to arouse and is not disturbed by sensory stimuli

- Snoring may occur

- Lasts 15 – 30 minutes

- Deepest stage of sleep (delta sleep)

- VS drops to 20 – 30% lower than waking hours

- Thought to restore the body physically

- Eyes usually roll, some may occur

NREM - Lasts approximately 15 – 30 minutes

- Accounts for approximately 25% of sleep in children

- Declines slightly in young adulthood

- Gradually decreases in middle age

- May be absent in elderly

REM

- Vivid, full-color dreaming may occur (80%)

- The brain is very active, and brain metabolism increase by 20%

- Also called paradoxical sleep, because sleep can take place simultaneously

- Autonomic response produce rapidly moving eyes. Heart rate, respiratory rate fluctuates and

gastric secretions increases - May be difficult to arouse or may wake spontaneously

- Usually begins 90 minutes after sleep has begun

- Lasts 15 – 30 minutes with each cycle

- Becomes longer as the night progresses, individuals become more rested


Sleep Cycle

� The complete cycle usually last about 90 minutes in adults

� Sleeper may pass to the first 3 NREM Stage in total of 20 – 30 minutes

� NREM Stage 4, sleeper may pass back to Stage 3 and Stage 2 about 20 minutes

� Then the first REM stage occurs for about 10 minutes

� Sleeper may experience 4 – 6 cycles of sleep during an average of 7 – 8 hours

NREM

Stage 1

NREM

Stage 3

NREM

Stage 4

NREM

Stage 3

NREM

Stage 2

REM

Sleep

NREM

Stage 2

SLEEP CYCLE

ZZZZzzz...

Functions of Sleep

Physiologic Effects

- Restores normal levels of brain activity

- Maintains normal balance of neuro activity among parts of the nervous system

- Necessary for CHON synthesis, important for repair process to occur

- Allows the vital organs of the body to rest

- Conserves body energy for cellular processes

- During Stage 4 NREM sleep, the body releases GH (Growth Hormone)

- REM Sleep is associated with increased cerebral blood flow, increased cortical activity,

increased oxygen consumption and epinephrine release which assists in memory storage and

learning

- Maintains normal mental function

- Loss of REM leads to confusion and suspicion


Dream

- Dreams can erase certain fantasies/ non-sensical memories

- To remember a dream, a person must consciously think about it on awakening

- People who can remember usually their dreams awakes just after a period of REM sleep

- Can occur in both (NREM and REM sleep)

- It is more vivid and elaborate during REM

- REM dreams may contain current life events, emotional dreams during childhood or past

significant events

- Personality can influence the quality of dreams

- Objects in dreams hold symbolic significance

Sleep Patterns and Regulation

1. Neonates

a. Newborns (3 months) have average sleep of 16 – 18 hours per day, divided into 7 sleep

periods

b. Sleep cycle is generally 40 – 50 minutes with alternating waking periods after 1 – 2 sleep

cycles

c. Most sleep time is spent in Stage 3 and Stage 4 NREM sleep

d. Approximately 50% of sleep REM

2. Infants

a. Developing nighttime pattern of sleep upon reaching the age of 3 – 4 months

b. Average sleep is 12 – 15 hours per day, an average of 8 – 10 hours spent at nighttime

c. About 30% of sleep is in REM cycle

d. At the end of first year, infant usually takes 1 – 2 naps per day and sleeps about 14 hours

per day

e. Awakes most often early in the morning and in the late afternoon

f. 4 months

i. Sleep occurs mostly during night

ii. Go into 24 hour cycle

g. 5th

and 6th

month

i. Infants sleep-wake pattern is almost similar with adults

ii. During light sleep, infants may exhibit movement, gurgles and coughing

iii. It is uncommon for infants to wake during the night

iv. If awakening frequently occurs during the night, the problem may be with diet.

Hunger frequently awakes the child

3. Toddlers

a. Sleep requirement declines to 10 – 12 hours per day

b. REM sleep: 20 – 30%

c. Normally normal sleep-wake cycle is established by age of 2 or 3

d. May exhibit resistance in going to bed at night

e. Child who wakes during the night may be afraid of the dark or experiences nightmares

f. At the age of 3, child might omit daytime naps

4. Pre-Schooler

a. Usually require 11 – 12 hours of sleep per night

b. REM Sleep: 20%

c. Sleep needs fluctuates in relation to activities and growth spurts

d. Dislikes bedtime

e. By the age of 5, child rarely takes daytime nap except for traditional customs

f. Usually have difficulty relaxing after a long active day

g. Problems arise due to bedtime fears, waking during the night or nightmares

h. If the child becomes irritable and restless when sleep is inadequate

i. Practice bedtime rituals

5. School age

a. Sleeps are individualized due to varying activities

b. 6 year old child: Average of 11 – 12 hours


c. 11 year old child: Average of 9 – 10 hours

d. Child begins to sleep late than the usual as a symbol of dominance and independence

e. May still experience nightmares, but continues to decrease with age

6. Adolescent

a. May need 8 – 10 hours of sleep to prevent fatigue and susceptibility to infections

b. Sleep needs increase time spent, sleeping decreases

c. Parents are no longer involved in setting time for sleep

d. Teen often experiences Excessive Daytime Sleepiness (EDS)

e. Boys begin to experience Nocturnal Emissions (wet dreams)

7. Young Adults

a. Sleeps an average of 6 – 8 hours every night

b. To provide energy for their busy lifestyle

c. Lifestyle patterns cause difficulty falling or staying asleep

d. Long-term medication use can disrupt sleeping pattern and make insomnia worse

e. Prone to daytime sleepiness

8. Middle Adults

a. Sleeps 6 – 8 hours per night

b. The amount of Stage 4 NREM sleep declines together with advancing age resulting in

frequent arousal during sleep

c. Insomnia is particularly common

d. Disturbances in sleep is commonly caused by anxiety, depression or certain ailments

9. Older Adults

a. Complaints of sleeping difficulties increase with age

b. REM Sleep shortens

c. Stage 3 and Stage 4 NREM sleep shorten and sometimes Stage 4 NREM is absent (less in

restorative sleep)

d. Awakens more often during the night and it takes more time for an adult to go back to

sleep

10. Elderly

a. Tendency to nap seems to increase progressively with age

b. Sundowners Syndrome – Confusional state that tends to appear at dusk (may be due to

changes in circadian rhythm and decreased stimulation at the end of day

Developmental Stage Amount of Sleep in Hours

Neonates 16 – 18 Hours Per Day

Infants 12 – 15 Hours Per Day

Toddlers 10 – 12 Hours Per Day

Pre-Schooler 11 – 12 Hours Per Day

School Age 6 Year-old 11 – 12 Hours. 9 Year-old 9 – 10 Hours

Adolescent 8 – 10 Hours Per Day

Young Adult 6 – 8 Hours Per Day

Middle Adult Ewan, baka the same sa Young Adult

Older Adult Depends?

Elderly Ewan? XD

Factors Affecting Sleep Quality of Sleep

- Individuals ability to stay asleep and to get appropriate REM and NREM

Quantity of Sleep

- Total time the individual sleeps


Illness

- Diseases causing pain and physical discomfort

- An ill person usually require more sleep

- Rhythm of sleep and wakefulness is often disturbed

- Increase in REM sleep

- Elevated body temperature reduces Stage 3 and Stage 4 NREM sleep, as well as REM

- Respiratory problems, gastric and duodenal ulcers, hyperthyroidism, hypothyroidisms

Environment

- Absence of usual stimuli or presence of unfamiliar stimuli

- Size, firmness and position of bed

- Volume of environmental sound

- Light levels

- Environments temperature and ventilation

Exercise and Fatigue

- Moderate fatigue promotes restful sleep

- Excess fatigue as a result of exhaustion and stress can make falling asleep more difficult

- Exercise 2 hours or more before sleep - The more tired the person is, the shorter the REM Sleep

Life Style

- Changes in work shifts and schedule

- Several weeks may be needed to adjust circadian rhythm

- Alterations in routines such as unconstitutional heavy work, engaging in late-night social activities

and changing evening mealtime

Stress

- Personal problems and situations

- Emotional stress - Anxiety increase norepinephrine blood levels upon stimulation of sympathetic nervous system

- Less Stage 4 NREM and REM sleep

Stimulants and Alcohol

- Caffeine-containing beverages serves as stimulant, thus interfering with sleep

- Excessive alcohol disrupts REM sleep, making the person compensate for the lost REM –

nightmares

Food and Caloric Intake

- Reduced total sleep time, broken sleep and earlier awakening result to weight loss

- Weight gain increase sleep period with fewer interruptions

- Large, heavy and or spicy foods result in indigestion

- Food allergies can cause insomnia

Medication

- Hypnotics and Antidepressants – interfere with Stage 3 and Stage 4 NREM and suppress REM

Sleep

- Nicotine - results in difficulty in sleeping, easy arousal (light sleepers)

- Antihistamines – have mild sedative effects that could promote sleep if given at bedtime


Nursing Process

~Assessment

Nursing History

- Client is the best source of data describing sleep problem

- Bed pattern

- Partners of the client during sleep

- Parents are good source of sleep pattern assessment for children

Sleep History

A. Description of sleeping problem

� Nature

� Inability to fall asleep

� Inability to fall asleep after awakening

� Daytime sleepiness

� Restful? Or Interruption

� Sign and Symptom

� Snoring

� Headaches when awake

� Difficulty of remaining asleep

� Restless sleep

� Onset

� First time the problem manifested

� Duration

� Periods during which the problem lasted

� Severity

� Number of hours of sleep vs. number of hours spent trying to sleep

� Predisposing factors

� Activity before retiring

� Life and work stressors

� Anxiety levels

� A recent injury/illness

� Effects on client

� Confusion

� Irritability

� Restlessness

� Fatigue

B. Usual Sleep Pattern

� Schedule of sleep

� Number of hours of sleep

� Number of times awaken at night

� Time the client wakes up in the morning

C. Physical and Psychological Illness

� Preexisting health problem

� Psychiatric health problem

� Chronic disease: COPP, painful disorders

� Post-operative client

D. Current life events

� Any changes in lifestyle

� Work related factors

� Social activity, recent travel (meal time schedule)

E. Emotion and mental status

� Anxious, excitable, anger

� Mental preoccupation

� Emotional stress

� Related to illness


� Situational crises: loss of job/loved one

F. Bedtime routines

G. Bedtime environment

H. Behaviors

Sleep Diary

- Written record of client’s sleep pattern and habit

- Should be kept by the client home and should be maintained for one week

- Can be stressful for client and affect sleep

- Assistance of a bed partner may be necessary

Physical Assessment

- Assessment of client’s facial appearance, behavior and energy level

1. Facial Appearance

a. Darkened area around the eye

b. Puffy eyelids

c. Reddened conjunctiva

d. Glazed or dull appearing eyes

e. Limited facial expressions

2. Behavior

a. Irritability

b. Restlessness

c. Inattentiveness

d. Slowed speech

e. Slumped posture

f. Hard tremor

g. Yawning

h. Rubbing of the eyes

i. Confusion

j. Incoordination

3. Energy Levels

a. Weakness

b. Lethargy

c. Fatigue

Diagnostic Studies

- Polysomnography

- Object measurement of sleep disorders, through assessment of the following simultaneously

o EEG (Electroencephalogram)

� Placement of electrodes in the center of the scalp to record brain waves

o EMG (Electromyography)

� Used to record muscle activity

o EOG (Electrooculography)

� On the outer canthus of each eye to record eye movement

- The following may be monitored as well

o Respiratory effort and airflow

o ECG

o Leg movement

o Oxygen saturation

Common Sleep Disorders �

1. Parasomnia - Behavior that may interfere with sleep that occurs during sleep

a. Broxism – Clenching and grinding of teeth that can eventually erode dental crowns and

cause teeth to come loose

b. Nocturnal Erections – Enlargement of the male genital organ with subsequent emission


c. Periodic Limb Movement Disorder – Leg jerk twice or 3 times per minute. The jerking

motion can wake the client and result in poor sleep

d. Somnambulism – Episodes of waking during the night, occurs 1 – 2 hours after falling

asleep. May risk the client to dangers due to unawareness to environmental dangers

e. Sleep talking – Talking during sleep. Rarely presents a problem to the person unless it

becomes troublesome to others

2. Primary Sleep Disorder – Disease wherein the main disorder is the persons sleep problem

a. Insomnia

i. Most common sleep disorder

ii. Inability to obtain adequate quantity or quality of sleep

iii. Client does not feel refreshed after sleep

b. Types

i. Difficulty in falling asleep (Initial)

ii. Difficulty staying asleep due to prolonged waking (Intermittent)

iii. Early morning or pre-mature waking (terminal insomnia)

3. Hypersomnia

a. Excessive sleep, particularly in the daytime

b. Client often sleeps until noon and takes a nap during the day

c. May be caused by medical condition (CNS damage, kidney, liver and metabolic disorder)

d. May be caused as coping mechanism to avoid facing the responsibilities of the day

4. Narcolepsy

a. Sudden wave of overwhelming sleepiness that occurs during the day

b. Also known as “Sleep attack”

c. Idiopathic cause

d. Attacks starts with REM phase

e. Doesn’t affect nighttime sleep pattern

5. Sleep Apnea

a. Periods cessation of breathing during sleep

b. Susceptible persons manifests

i. Loud snoring

ii. Frequent nocturnal awakening

iii. Excessive daytime sleepiness

iv. Morning headaches

v. Irritability

vi. Personality changes

vii. Intellectual deterioration

c. Most frequent in men over 50 and post-menopausal women

d. Period of apnea lasts from 1 – 2 minutes

e. Frequency of episodes ranges from 50 – 60 per night

f. Three Common Types

i. Obstructive Apnea – Structures of the pharynx/oral cavity block the flow of air

ii. Central Apnea – Detect location at the respiratory center of the brain

iii. Mixed – Combination of obstructive and central apnea

6. Sleep Deprivation

a. Syndrome of prolonged disturbance in amount, quality and consistency of sleep

b. Types

i. REM deprivation

ii. NREM deprivation

7. Secondary Sleep Disorder

a. Sleep disturbances caused by other clinical conditions

b. Includes

i. Depression

ii. Alcoholism

iii. Dementia

iv. COPP

v. Parkinsonism


vi. Thyroid function

Diagnosis

- Anxiety

- Ineffective breathing pattern

- Acute confusion

- Compromised family coping

- Ineffective coping

- Fatigue

- Ineffective protection

- Insomnia

- Disturbed sensory perception

- Sleep deprivation

Health Promotion

1. Environmental Control

a. Minimal noise

b. Comfortable room temperature

c. Appropriate ventilation

d. Appropriate lighting

e. Remove environmental distractions

f. Provide mattress with appropriate support and comfortable firmness

2. Promotion of Bedtime Routines

a. Follow usual sleep routine for individual

b. Read books, have bedtime snacks

c. Avoid excessive mental stimulation

d. Relaxing exercises

e. Guided imagery and praying may promote sleep

3. Promoting Comfort

a. Remove of minor irritant

b. Provide warm bath before sleep

c. Wear soft cotton loose fitting clothes

4. Stress Reduction

a. Do not encourage emotionally upset client to force sleep

b. Clients having difficulty of sleep must not stay in bed and pursue instead relaxing

activities

c. Parents can accompany children who have night fears

5. Establish Periods of Rest and Sleep

a. Encourage the client to be physically active during the day

b. Avoid waking client for non-essential task

c. Schedule treatments, procedures

Pharmo…

Consider

- Prolonged use may disrupt normal sleep pattern

- Pregnant women are not advised to take benzodiazipines – may lead to congenital anomalies

“Since NCM ang subject na to, may ret dem din dtto! Siguradong 1 na grade ko!”

- WEH JC XD

NCM100 12th Sleep and Rest

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