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Nursing Management of Sleep Disorders
This page was last updated on September 19, 2013

Outline

INTRODUCTION

Sleep is the state of natural rest observed throughout the animal kingdom, in all mammals and birds, and in many reptiles, amphibians, and fish. In humans, other mammals, and many other animals that have been studied - such as fish, birds, ants, and fruit-flies - regular sleep is necessary for survival. The capability for arousal from sleep is a protective mechanism and also necessary for health and survival.

DEFINITION

Sleep can e defined as a normal state of altered consciousness during which the body rests; it is characterized by decreased responsiveness to the environment, and a person can be aroused from it by external stimuli.

INCIDENCE & CHARACTERISTICS:

Sleep is generally characterized by a reduction in voluntary body movement, temporary blindness, decreased reaction to external stimuli, loss of consciousness, a reduction in audio receptivity, an increased rate of anabolism (the synthesis of cell structures), and a decreased rate of catabolism (the breakdown of cell structures.

Almost a third of the general population has some problems with sleep during any given year. More than half of the 9000 participants in a study of sleep in elderly persons (65 years or older) reported the following as sleep pattern disturbance that they experience most of the time:

  • Trouble falling asleep

  • Frequent awakening

  • Waking too early

  • Needing to nap

  • Not feeling rested

These disturbances may be secondary to situational, environmental or developmental stressors, or they may be associated with illness or with pre-existing disorders. The relationship is often reciprocal, in that the disorder decreases sleep & the decreased sleep affects the disorder.

CHRONOBIOLOGY

Chronobiology refers to the study of biologic changes as they occur in relation to time. The sleep wake cycle is one of the circadian rhythms of the body. Circadian rhythms follow an approximate 24 hour cycle through a complex process linked to light & dark.  The effect of illness & hospitalization may disrupt these rhythms, particularly in older persons. Ultradian cycles are circadian rhythms of less than 24 hours. The recurrent pattern of sleep stages, repeating approximately 90 minutes in adults, is an example. Chronopharmacology refers to the study of how biorhythms affect the absorption, metabolism, & excretion of drugs. E.g.the blood level achieved by a continuous infusion of heparin varies throughout the day.

PHYSIOLOGY OF SLEEP:

The timing of sleep- wake cycle & other circadian rhythms, such as body temperature, is controlled by the suprachiasmatic nucleus in the anterior hypothalamus. Located above the optic chiasm, this area receives input from the retina, which provides information about darkness & light. The suprachiasmatic nucleus controls the production of melatonin, which is believed to be a potent sleep inducer.

Arousal from sleep, wakefulness and the ability to respond to stimuli rely on an intact reticular activating system (RAS). The RAS is located in the brain stem & contains projections to the thalamus & the cortex. The diffuse network of neurons in the RAS is in a strategic position to monitor ascending and descending stimuli through feedback loops.

Although the RAS provides anatomic framework for arousal, it is the neurotransmitters that serve as the chemical messengers. The onset of sleep and of each subsequent sleep stage is an active process involving delicate shifts in the balance of several of these neurotransmitters.

STAGES OF SLEEP

Sleep can be defined behaviorally, functionally and electro physiologically.  Electro physiologic monitoring of sleep is called Polysomnography includes at least 3 parameters L1) brain wave activity, (2) eye movements and (3) muscle tone. Polysomnography shows that sleep can be divided into REM and NREM.  NREM sleep can be further divided into 4 stages. The stages vary in depth, but are characterized by slow rolling eye movements, low level and fragmented cognitive activity, maintenance of moderate muscle tone, and slower, but generally rhythmic respirations and pulse rate.

NREM sleep is characterized as follows:

Stage 1:

  • includes lightest level of sleep

  • stage lasts a few minutes

  • decreased physiological activity begins with gradual fall in vital signs and metabolism

  • sensory stimuli such as noise, easily arouse sleeper

  • if awakened, person feels as though daydreaming has occurred

Stage 2:

  • includes period of sound sleep

  • relaxation progresses

  • arousal is still relatively easy

  • stage lasts 10 – 20 mts

  • body functions continue to slow

  • the brain waves are frequently mixed and low voltage in pattern, with bursts of activity called sleep spindles  and large amplitude waves called K complexes

Stage 3:

  • it involves initial stages of deep sleep

  • sleeper is difficult to arouse and rarely moves

  • oxygen consumption

  • muscles are completely relaxed

  • vital signs decline, but remain regular

  • stage lasts 15 – 30 mts

Stage 4:

  • it is deepest stage of sleep

  •  it is very difficult to arouse sleeper

  • If sleep loss has occurred, sleeper will spend considerable portion  of night in this stage

  • Vital signs are significantly lower than during waking hours

  • Stage lasts approximately 15 – 30 mts

  • Sleep walking and enuresis  sometimes occur

  • Stage 3 and 4 known as slow wave sleep, named for the characteristic high voltage and low – frequency delta waves

REM sleep:

  • Vivid, full- color dreaming occurs

  • Stage usually begins about 90 mts after sleep has begun

  • Stage typified by autonomic responses of rapidly  moving eyes, fluctuating heart and respiratory rates, and increased or fluctuating blood pressure

  • Loss of skeletal muscle tone occurs

  • Gastric secretion increase

  • It is very difficult to arouse sleeper

  • Duration of REM sleep increases with each cycle and averages 20 mts

  • Stage is characterized by low voltage, random fast waves, as in stage 1 NREM

SLEEP CYCLE

Normally an adult’s routine sleep pattern begins with a pre-sleep period during which the person is aware only of a gradually developing sleepiness. This period normally lasts 10 – 30 mts. individuals experiencing difficulty in falling asleep often remain in this stage for an hour or more.

Once asleep, the person passes through 4 – 6 complete sleep cycles; each consists of 4 stages of NREM sleep and a period of REM sleep. The cyclical pattern usually progresses from stage 1 through stage 4 of NREM, followed by a reversal from stage 4 to 3 to 2, ending with a period of REM sleep.

                   

With each successive cycle, stages 3 and 4 of NREM sleep shorten and the period of REM lengthens. REM sleep lasts up to 60 mts during the last sleep cycle. The number of sleep cycle depends on the amount of time that the person spends sleeping, in an average of 90 mts.    

FUNCTIONS OF SLEEP

The purpose of sleep is still unclear. Theories suggest that:

  • It is a time of restoration and preparation for the next period of wakefulness

  • During NREM stage 4 body releases human growth hormone for the repair and renewal of epithelial and specialized cells such as brain cells

  • Protein synthesis and cell division for the renewal of tissues occur during rest and sleep

  • REM sleep appears to be important for cognitive restoration

The benefits of sleep often go unnoticed until a person develops a problem resulting from sleep deprivation. A loss of REM sleep leads to feelings of confusion. Various body functions ( eg. Motor performance, memory and immune function) alter when prolonged sleep loss occurs

NORMAL SLEEP REQUIREMENTS & PATTERNS

Sleep duration and quality vary among persons of all age groups

  • Infants            16 Hours /Day

  • Toddlers          12 Hours /Day

  • Preschoolers     11 Hours /Day

  • Schoolers         9 - 10 hours /day

  • Adolescents      8 – 9  hours /day

  • Adults              6 – 8  hours /day

As people age, their circadian clock advances, causing advanced sleep phase syndrome. The syndrome is common in older adults and often is the reason behind the complaint of waking early in the morning and unable to get back to sleep. They get sleepy early in the evening.

FACTORS AFFECTING SLEEP

A number of factors affect the quality and quantity of of sleep. Often more than one factor combined to cause a sleep problem.

  • Physical illness (eg. Nausea, mood disorders, breathing difficulty, pain)

  • Drugs and substances (eg. Tryptophan)

  • Lifestyle (eg. Daily routines, exercises)

  • Usual sleep patterns and excessive daytime sleepiness

  • Emotional stress

  • Environment ( ventilation)

  • Sound

  • Exercise and fatigue

  • Food and caloric intake

SLEEP DISORDERS

Sleep pattern disturbance is a nursing diagnosis that is defined as a disruption of sleep time that causes discomfort or interferes with a desired life cycle. A sleep pattern disturbance may be related to one of more than 80 sleep disorders identified in the international classification of sleep disorders, a partial list of which is given below:

I, DYSSOMNIAS

The Dyssomnias include sleep disorders characterized by difficulty in initiating or maintaining sleep (insomnia) or by excessive sleepiness. These disorders may arise predominantly from within the body (intrinsic), from external sources (extrinsic), or from disruption of circadian rhythm.

A. Intrinsic sleep disorders

1. Insomnia:

It is the persistent difficulty in initiating or maintaining sleep. The difficulty does not respond readily to improved sleep habits or removal of precipitating factors. Idiopathic insomnia is a rare disorder characterized by a lifelong history of inability to obtain adequate sleep. Its cause is thought to be an abnormality in the neurologic control of sleep. Psycho physiologic insomnia is more common and is characterized by learned sleep – preventing associations and heightened physiologic response to stress. It can be confirmed by polysomnographic recording, which usually shows the same pattern of long sleep latency or fragmentation that the client describes. The total sleep time is often within normal range but is felt to be inadequate. They will fall asleep unintentionally in low stimulus situations, such as watching TV, but feel increased arousal when they go to bed. It is difficult to get sleep in places , other than their usual bedroom.

Management of insomnia is complex. Sleep should be restricted by curtailing time bed to the minimum believed necessary with a consistent rising time. Relaxation exercises can be helpful, but they should initially be practiced at times other than bedtime so that by the time they are introduced at bedtime, they are effective. Referral to a sleep specialist or mental health professional who can work with the client over a period of time should be considered.

2. Narcolepsy

Narcolepsy is one of the disorders characterized by excessive daytime sleepiness. The client also experiences disturbed nocturnal sleep and repeated episodes of almost irresistible daytime drowsiness followed by brief periods of sleep, especially when engaged in monotonous activities. Many Narcoleptic clients also experience cataplexy, a sudden loss of muscle tone at times of unexpected emotion (eg. Fright). Malfunctioning of the mechanism controlling REM sleep leads to sleep paralysis for one to several minutes, and hypnagogic hallucinations i.e. Hallucinatory experiences that occur at sleep onset or awakening.

On polysomnography, the most characteristic finding is sleep onset REM periods.

3, Sleep apnea syndrome:

Sleep apnea is characterized by cessation of breathing for 10 seconds or longer occuring at least 5 times / hour. Sleep apnea can be classified as obstructive and central nervous system apnea. A combination of the two may be seen.

Obstructive Sleep apnea syndrome: In   Obstructive Sleep apnea syndrome, respiratory efforts of the diaphragm and intercostals muscles are apparent but ineffective against a collapsed or obstructed upper airway. Snoring indicates partial obstruction. As hypoxia ensues; the person eventually awakens to breathe. The frequent awakenings impair the normal sleep cycle. Repeated micro arousals lead to daytime sleepiness.

4. Periodic limb movement disorder

It may also contribute to daytime sleepiness and frequent nocturnal wakening. Originally described as nocturnal myoclonus, it is characterized by periodic episodes of repetitive, stereotypic leg movements that occur during sleep, causing partial arousals. It is common in the elderly population. Clonazepam, a benzodiazepine, or baclofen, a skeletal muscle relaxant, may be ordered to diminish the magnitude of the movement and frequency of arousals. For some clients the use of transcutaneous electrical nerve stimulation (TENS) before sleep has been helpful.

5. Restless leg syndrome:

Restless leg syndrome involves anything “crawling”, itching or tingling sensations of the leg while at rest and causes an almost irresistible urge to move. The syndrome is often most severe before sleep onset. Clients always have periodic limb movements during sleep. Treatment is similar to that of Periodic limb movement disorder.

B. Extrinsic sleep disorders

It encompasses a range of factors, from environmentally to chemically induced. Some environmental factors temporarily present during hospitalization.

1. Circadian rhythm sleep disorders

In the general population, the Circadian rhythm sleep disorders, such as time zone change syndrome and shift work sleep disorder are not uncommon. Elderly and chronically ill clients who live alone may be vulnerable to irregular sleep- wake patterns. In this disorder, prolonged ignoring or absence of external cues to time, such as regular meal timings, work periods and daylight leads to erratic periods of sleeping and wakefulness. Internal circadian cues may also be damped as a result of ageing or diffuse brain disease.

II. PARASOMNIAS:

The Parasomnias are disorders that occur during sleep but that usually do not produce insomnia or excessive sleepiness. It may be due to partial arousal or abnormalities in sleep-wake transition.

A. Arousal disorders

Partial arousal occur during slow- wave sleep. Sleepwalking, also known as somnambulism, may include semi purposeful behaviour, such as dressing. However the behaviour may be lacking in coordination and appropriateness, such as voiding in the closet. . The occurrence of sleep walking in adults is associated with anxiety. Sleep terrors are sudden arousals from slow wave sleep accompanied by screaming, tachycardia, tachypnea, diaphoresis, and other manifestations of fear. If awakened, the person is often disoriented and has little recall of the nature of the dream image. Sleep terrors usually occurs in young children.

B. Sleep-wake transition disorders

Sleep-wake transition disorders are common in the general population. Sleep starts refers to the sudden jerking movement of the legs that often occurs as a person is falling asleep. Nocturnal leg cramps also common. The frequency andand intensity may be greater with high caffeine intake, stress, or intense physical activity before going to bed. . Sleep talking also may occur during times of stress.

C. Parasomnias usually associated with  REM sleep

Nightmares are frightening dreams that arise in REM sleep and are often vividly recalled on awakening.  Sleep [paralysis is one of the classic signs of narcolepsy, but can occur in isolation.  This effect may be an extension of the normal state of low muscle tone during REM sleep.

D. Other Parasomnias

Other Parasomnias are not specifically associated with particular sleep stage. Sleep bruxism refers to grinding of the teeth during sleep and may lead to dental damage. Sleep enuresis, or bed wetting, may occur in adult in association with other disorders, such as Obstructive Sleep apnea syndrome. Primary snoring is distinguished from Obstructive Sleep apnea syndrome by its rhythmic nature without episodes of apnea or hypoventilation.

ASSESSMENT AND MANAGEMENT

Diagnostic assessment:

  • Polysomnography

  • Electroencephalogram

  • Multiple sleep latency test (MSLT)

MSLT is performed to assess the impairment of daytime alertness. It is performed a day after a standard polysomnogram. The time required for clients to fall asleep when in a relaxed state is evaluated at 2 hour intervals, with each nap limited to 20 minutes.  The type of sleep also is assessed.

NURSING PROCESS

A. Assessment:  Assess client’s usual sleep habits and recent sleep quality as part of the initial nursing history. If sleep quality is reported to be poor, explore the nature of

disturbances by noting the following:

  • Usual activities in the hour before retrieving

  • Sleep latency

  • Number and perceived cause of awakenings

  • Regularity of sleep pattern

  • Consistency of rising time

  • Frequency and duration of naps

  • Events associated with initial onset of sleep disturbances

  • Ease of falling asleep in places other than the usual bedroom

  • Situations in which client fights sleepiness

  • Daily caffeine intake

  • Use of alcohol, sleeping pills,and other medications

  • Incidence of morning headaches

  • Frequency of snoring, apparent pauses in breathing, and kicking movements

  • Objective data may include visible signs of fatigue and lack of sleep, such as circles under the eyes, lack of coordination, drowsiness and irritability.

B. Nursing diagnosis:

1. Disturbed sleep pattern related to changes in routine due to hospitalization and pain

                                                     Or

Disturbed sleep pattern related to lack of cues for day- night schedule; manifested by erratic sleep schedule, frequent naps and nocturnal wandering

C. Client Outcome criteria:

client increases nocturnal sleep time by 20% over next 2 weeks.

D. Nursing intervention

Rationale

*offer meals at regular times, corresponding to client’s previous pattern

*provide active meaningful activities during daytime hours, including exposure to natural light, and an outdoor environment when possible

*monitor frequency and duration of naps

  *create an individualized  bedtime ritual that includes a quieting activity, a light carbohydrate snack, going to the bathroom  and settling a routine

* Do not waken even if incontinent. Change and assist the client to the bathroom when he or she spontaneously awakens

*if turning or other care is necessary, try to provide for periods up to 2 hours of undisturbed sleep time whenever possible

*mealtimes are important social cues, that reinforce circadian rhythms, which tend to weaken with advancing age

*light exposure is communicated through  the retina to the suprachiasmatic nucleus, helping to set the circadian clock

*napping is not contraindicated but is best at the time of day opposite to the midpoint of the nocturnal sleep period. Short naps are preferable to avoid deep sleep

*reduced stimulation and rituals associated with sleep enhance  sleep onset

*older adults who can turn themselves generally do better to have their sleep undisturbed and tend to waken spontaneously if wet when their sleep cycle lightens

* Sleep cycles average 90 mts. A sleep latency of 20- 30 mts mean it would take about 2 hours to experience a full sleep cycle.

SUMMARY

The adequacy of sleep is important factor in caring for clients with acute and chronic illness.

Some sleep disturbances are temporary and related to the stress of hospitalization. It is possible that temporary stress problems will be corrected only after the client’s return home. Clients with sleep disturbances may need follow –up care with repeated assessments to determine whether the problem was corrected. Clients with long term sleep disorders may need ongoing support to maintain the effectiveness of treatment. The nurse can play a pivotal role in environmental modification and client teaching to minimize the impact of sleep.

REFERENCES

  1. Black JM, Hawks JH. Medical Surgical Nursing clinical management for positive outcomes. Vol 1.7th edition. Saunders; India 2005 Pp 461-500.

  2. Potter PA, Perry AG. Basic nursing- essentials for practice. 6th edition. Missouri: Mosby publishers; 2007

  3. Brunner. Medical surgical nursing. 6th edition. London: Mosby publishers; 2005.

  4. Lewis SM, Heitkemper MM, Dirksen SR.  Medical surgical nursing. 6th edition. Philadelphia: Mosby publishers; 2004.

  5. Tylor C, Lillis C, Le Mone P. fundamentals of nursing- the art and science of nursing care. 5th edition. London: Lippincott Williams & Wilkins publishers; 2006

  6. Lewis, Heitkemper, Dirksen. Medical Surgical nursing.6th edition. Mosby. Page no 131-157

   
 
     
     

 
 
 
 
 
           
 

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