Psychiatric / Mental Health Nursing
Sleep DisordersChapter 20
Sleep DisordersSleep deprivation – discrepancy
between hours of sleep obtained and hours of sleep required for optimal functioning
Implications for ◦Health ◦Safety◦Quality of life
Theories of Sleep Disorders - continued
Studies show those with chronic insomnia have physiological differences.
Studies suggest that gene variations are involved in human circadian activity.
There is predisposition to sleep disorders based on genetic susceptibility and familial pattern.
Theories of Sleep Disorders - continued
Any emotional or cognitive arousal can precipitate or perpetuate insomnia.
Environmental conditions, including associating the sleeping room with lying awake, cause distress and are a powerful perpetuating factor to sleep problems.
Normal Sleep CycleComplex interaction between CNS
andenvironment Non-REM (NREM) sleep
◦ Composed of four stagesREM sleep
◦ Reduction and absence of skeletal muscle tone
◦ Bursts of rapid eye movement◦ Myoclonic twitches of facial and limb
muscles◦ Dreaming ◦ Autonomic nervous system variability
Regulation of SleepComplex interaction between two
processes◦Homeostatic process or sleep drive –
promotes sleep◦Circadian process or circadian drive –
promotes wakefulness Influenced by
Endogenous factors Exogenous factors
Sleep RequirementsVaries from individual to
individualLong sleepers
◦Require more than 10 hours of sleep each night
Short sleepers◦Can function effectively on fewer
than 5 hours of sleep per night
Primary Sleep DisordersDyssomnias
◦Primary insomnia ◦Primary hypersomnia◦Narcolepsy◦Breathing-related sleep disorders◦Circadian rhythm disorders◦Dyssomnias not otherwise specified
Restless legs syndrome (Box 20-1)
Primary InsomniaMost common sleep complaintDifficulty with sleep initiationSleep maintenanceEarly awakeningNon-refreshing, nonrestorative
sleep
Interventions for Primary InsomniaSleep hygiene – conditions and
practices that promote continuous and effective sleep
Behavioral therapies◦ Educational components◦ Behavioral components◦ Cognitive components
Some instances – hypnotic medication (Table 20-1)
ParasomniasUnusual or undesirable behaviors
or eventsOccur during
◦Sleep/wake transitions◦Certain stages of sleep◦Arousal from sleep
Sleep Disorders Related to Other Mental DisordersInsomnia related to another
mental disorderHypersomnia related to another
mental disorder◦Major depressive disorder◦Anxiety disorders◦Schizophrenia
Sleep Patterns in Major Depressive Disorder
Insomnia of maintenance or early wakening type most common
Insomnia is the most commonly reported residual symptom after remission
Sleep pattern disturbance may respond to antidepressant treatment sooner than other symptoms
Sleep Patterns in Schizophrenia
Exacerbation of illness causes significant sleep disruption
Extreme sleep difficulty can accompany severe anxiety
Heightened concern of delusions and hallucinations
Circadian cycle disrupted
Sleep Patterns in Schizophrenia - continued
Reduction in REM sleep Do not experience REM rebound Deficits in slow-wave sleep found in
clients with acute and chronic schizophrenia
Sleep Patterns in Manic Episodes of Bipolar Disorder
Sleep time significantly reduced Clients don’t complain of insomnia and
can go without sleep Reduced slow-wave sleep Reduced REM latency
Other Sleep DisordersSleep disorders due to a general
medical conditionSubstance-induced sleep
disorders◦In both sleep disorders, sleep
disturbance may be Insomnia Hypersomnia Parasomnia Combination
Sleep Patterns in Substance Abuse
Severe sleep disorder during intoxication or withdrawal periods
Persists even after prolonged abstinence of some substances
Sleep Patterns in Substance Abuse - continued
Substance-induced mood disorder characterized by sustained use of stimulants to stay awake or alcohol to induce sleep
Examples of substances
Key Assessments
Assessment◦General assessment – sleep patterns◦Identifying sleep disorders◦Functioning and safety
Key Assessments - continued
Self-defined - say they get enough sleep to feel refreshed, have energy, fall asleep quickly
Key Assessments - continued
Behaviorally defined - observe alertness during sedentary, repetitive activity; note ability to fall asleep and final wakening at habitual rising time; utilize photographic serializing of movement during sleep
Key Assessments - continued
Comprehensive sleep studies are conducted in sleep labs:
- polysomnogram - multiple sleep latency test
Nursing DiagnosisNursing Diagnosis
◦Sleep deprivation related to inadequate quality and quantity of sleep
◦Insomnia related to medical, psychiatric, or sleep disorder, substance use/abuse, or inadequate sleep hygiene
◦Readiness for enhanced sleep◦Risk for injury related to inadequate
sleep
Nursing Outcome IdentificationOutcomes Identification
◦Sleep◦Rest◦Risk control◦Personal well-being◦(Table 20-2)
Planning
ImplementationBasic Level Interventions◦ Counseling◦ Health teaching and health promotion◦ Pharmacological interventionsAdvanced Practice Interventions◦ Cognitive-behavioral therapy
Guidelines for Good Sleep Hygiene
Maintain regular sleep–wake schedule Rise at the same time each day Go to bed when sleepy and relaxed Maintain rituals in preparation for sleep Control for temperature, lighting, noise Avoid stimulants before bed Focus on enjoying sleep that is
achieved
Guidelines for Insomnia
Treatment for sleep disorders is complex
Follow guidelines for good sleep hygiene
Utilize good sleep hygiene before taking sedative hypnotic medications
Instill a sense of hope that insomnia will improve, client can manage it effectively
Guidelines for Insomnia - continued
Facilitate setting realistic goals. Teach normal developmental changes
in sleep patterns. See treatment provider for continued
insomnia. Differentiate between myths and
evidence-based practice.
Evaluation
◦Based on whether or not patient experiences improved sleep quality as evidenced by Decreased sleep latency Fewer nighttime awakenings Shorter time to get back to sleep after
awakening
Pharmacology
Sleep and WakefulnessGoal: Improve quantity and
quality of sleepMay prevent worsening of mood,
anxiety and pain if sleep improves
Many choices: evaluate lifestyleDo not underestimate the POWER
of sleep
Sleep Agents: NTNearly all hypnotics work on at
least one of these neurotransmitters:
◦GABA◦Histamine
Rx Sleep agentsBarbituratesBenzodiazepines
Non-benzosMelatonin Receptors Agonists
Sleep agentsBarbituturates – first used in
1860s named after St Barbara
Nembutal (pentobarbital)Seconal (secobarbital)
Sleep agentsBenzodiazepines
◦Short Acting Halcion (triazolam)
◦Intermediate Restoril (temazepam) Prosom (estazolam)
◦Long Acting Dalmane (flurazepam)
Sleep AgentsNon-Benzos
◦Zolpidem - Ambien (5 - 10 mg/night)◦Ambien CR◦Zaleplon - Sonata (10 mg/night)◦Eszopiclone -Lunesta (1-3 mg/night)◦Cholral Hydrate – Noctec,
Aquachloral Supprettes, Somnote (500 - 2000 mg/d)
◦Diphenhydramine - Benadryl, Sominex, Nytol (25 - 100 mg/d)
Sleep AgentsMelatonin Receptor Agonist
◦Rameltoeon - Rozerem (8mg/d)◦Valdoxan (agomelatine) also works
on 5-HT2c so is antidepressant
Sleep AgentsOver the Counter OTC
◦Benadryl (diphenhydramine)◦Atarax/Vistaril (hydroxyzine
Kava Kava Caution: may cause liver toxicity
Valerian
Side EffectsHangoverAmnesiaHeadache
When Starting on SleepersSleep hygiene first – remember
caffeineCool, quiet, dark room without
dogs and kidsDon’t mix with AlcoholGo straight to bed and lay down
Wake Agents: NTNearly all wake promoting agents
work on at least one of these neurotransmitters:◦Norepinephrine◦Dopamine
Wake AgentsProvigil = NuvigilFDA Indication
◦Excessive sleepiness due to narcolepsy
◦Obstructive sleep apnea◦Shift work sleep disorder
Treat fatigue and sleepiness due to other conditions – depression and MS
Wake AgentsStimulantsProvigil (modafinil)Nuvigil (armodafinil)
When Starting on WakersSleep hygiene first – not a
replacement for sleep
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