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Course: Fundamentals of Nursing�Topic: Sleep and Rest

The Nurses International Community

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Module Goals

Learners will be able to:

Describe the physiological processes regulating sleep.
Differentiate between normal sleeping patterns across the lifespan.
Discuss common sleep disorders.
Discuss nursing interventions that promote sleep and rest in the primary, secondary, and tertiary care settings.

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Introductions

Ernstmeyer, & Christman, 2021

Maslow’s hierarchy of needs indicates sleep as one of our physiological requirements
Quality sleep at the right times according to our circadian rhythms can protect:

Mental and physical health
Safety
Quality of life

Chronic sleep deficiency increases the risk of:

Heart disease
Kidney disease
High blood pressure
Diabetes
stroke

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Physiological Process of Sleep

Ernstmeyer, & Christman, 2021.

There are two internal biological mechanisms that work together to regulate wakefulness and sleep:

Circadian rhythms
Sleep-wake homeostasis

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Circadian Rhythm

Ernstmeyer, & Christman, 2021

Direct a wide variety of body functions including:

Wakefulness
Core temperature
Metabolism
The release of hormones

Causing a person to feel sleepy at night and creating a tendency to wake in the morning without an alarm.
Based roughly on a 24-hour clock and use environmental cues, such as light and temperature to determine the time of day.

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Anatomy of Sleep

Several structures within the brain are involved with sleep:

The hypothalamus, Within the hypothalamus is the suprachiasmatic nucleus (SCN:

Receive information about light exposure directly from the eyes and control sleep and arousal.

The brain stem:

Produce GABA, which acts to reduce the activity of arousal centers
Also plays a special role in REM sleep, it sends signals to relax muscles essential for body posture and limb movements, so that we don’t act out our dreams.

National institute of

Neurological Disorders and Stroke, 2019

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Anatomy of Sleep Conti...

The thalamus:

Acts as a relay for information from the senses to the cerebral cortex.
During most stages of sleep, the thalamus becomes quiet, letting you tune out the external world.

The pineal gland:

Receives signals from the SCN and increases production of the hormone melatonin, which helps put you to sleep once the lights go down.

The basal forebrain:

Release of adenosine supports the sleep drive.

National institute of

Neurological Disorders and Stroke, 2019

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Sleep Wake Homeostasis

Keeps track of a person’s need for sleep.
Adenosine is linked to this drive for sleep.
While awake, the level of adenosine in the brain continues to rise, with increased levels signaling a shift toward sleep and while sleeping, the body breaks down adenosine.
In the dark, the hormone melatonin is released and signals the body that it’s time to prepare for sleep and creates a feeling of drowsiness.
The hormone cortisol, is released in the early morning hours and naturally prepares the body to wake up.

Ernstmeyer, & Christman, 2021

Contact info: info@nursesinternational.org

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Sleep Wake Homeostasis Conti..

Factors that influence sleep and wakefulness

Medical conditions
Medications
Stress
Sleep environment, and foods and fluids consumed. However, the greatest influence is exposure to light

Specialized cells in the retina process light and provide messages to the brain to align the body clock with periods of day or night
Exposure to bright artificial light in the late evening can disrupt this process, making it hard to fall asleep (example include the light from a TV screen, computer, or smartphone).

Ernstmeyer, & Christman, 2021

Contact info: info@nursesinternational.org

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Sleep Phases and Stages

When sleeping, individuals cycle through two phases of sleep and five stages:

Rapid Eye Movement (REM) and
Non-REM sleep

A full sleep cycle takes 80 to 100 minutes to complete.
Most people typically cycle through four to six cycles per night and is common to wake up briefly between cycles.
Restoration takes place mostly during slow-wave non-REM sleep, during which the body’s temperature, heart rate, and brain oxygen consumption decrease.

Ernstmeyer, & Christman, 2021

Contact info: info@nursesinternational.org

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Sleep Phases and Stages

Non-REM sleep has these three stages:

Stage 1: The transition between wakefulness and sleep.

Lightest stage of sleep.
Muscle tone present in this stage.

Stage 2: The initiation of the sleep phase.

The sleeper is less able to be awakened.

Stage 3 and 4 : The deep sleep.

Also called ‘Slow Wave Sleep’ (SWS), or delta sleep.
A sleeper in SWS is often difficult to awaken.

Ernstmeyer, & Christman, 2021
American Sleep Association, 2021

Contact info: info@nursesinternational.org

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Sleep Phases and Stages

REM (5th Stage of sleep)

First occurs about 90 minutes after falling asleep.
A person’s heart rate and respiratory rate increase blood pressure increases.
Eyes twitch as they rapidly move back and forth and the brain is active.
The skeletal muscles are atonic, or without movement.
Dreaming occurs during REM sleep.
People typically experience more REM sleep as the night progresses.

Ernstmeyer, & Christman, 2021
American Sleep Association, 2021

Contact info: info@nursesinternational.org

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Stages of Sleep

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Critical Thinking Question

In which stage does deep sleep occur?

stage 1
stage 2
Stage 3 and 4
Stage 1 and 2

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Normal Sleeping Patterns

The patterns and types of sleep change as people mature.
For example:

Newborns spend more time in REM sleep.
The amount of slow-wave sleep peaks in early childhood and then drops sharply in the teenage years.
Slow-wave sleep continues to decrease through adulthood, and older people may not have any slow-wave sleep at all.
Older people wake up more often because they spend less time deep sleep and dreamless sleep.

Ernstmeyer, & Christman, 2021

Contact info: info@nursesinternational.org

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Sleep Time Duration

Hirshkowitz et al., 2015

According to National Sleep Foundation for healthy individuals the appropriate sleep duration recommendation are:

Newborns: Between 14 and 17 hours,
Infants: Between 12 and 15 hours,
Toddlers: Between 11 and 14 hours,
Preschoolers: Between 10 and 13 hours, and
School-aged children: Between 9 and 11 hours
For teenagers: 8 to 10 hours
Young adult and Adults: 7 to 9 hours
Older Adults: 7 to 8 hours

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Importance of Sleep

Ernstmeyer, & Christman, 2021

Healthy Brain Functions and Emotional Well Being:

Helps the brain work properly.
A good night’s sleep improves learning and problem-solving skills.
Helps a person pay attention, make decisions, and be creative.
Sleep deficiency alters activity in some parts of the brain, causing difficulty in making decisions, solving problems, controlling emotions and behavior.
Sleep deficiency has also been linked to depression, suicide, and risk-taking behavior.

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Importance of Sleep

Ernstmeyer, & Christman, 2021

Physical Health:

Supports healthy growth and development.
Sleep is involved in healing and repairing the heart and blood vessels.
Sleep deficiency is linked to an increased risk of:

Heart disease
Kidney disease
High blood pressure
Diabetes
Stroke

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Importance of Sleep

Ernstmeyer, & Christman, 2021

Day Time Performance:

Getting enough quality sleep at the right times also enhances functioning throughout the day.
People who are sleep deficient are less productive at work and school.
Lack of sleep can lead to microsleep.
Microsleep refers to brief moments of sleep that occur when one is normally awake.

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Sleep Disorders

Ernstmeyer, & Christman, 2021

There are several sleep disorders that can cause sleep deficiency, such as:

Insomnia,
Sleep apnea, and
Narcolepsy

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Critical Thinking Question

Discussion:

Describe the conditions that have a negative effect on sleep

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Insomnia

Ernstmeyer, & Christman, 2021

A common sleep disorder that causes trouble falling asleep, staying asleep, or getting good quality sleep.
Caused by stress or changes in one’s schedule or environment.
Chronic insomnia occurs three or more nights a week, lasts more than three months, and cannot be fully explained by another health problem or a medication.
Chronic insomnia raises the risk of:

High blood pressure
Coronary heart disease
Diabetes
Cancer

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Insomnia

Ernstmeyer, & Christman, 2021

Symptoms of insomnia include the following:

Lying awake for a long time before falling asleep.
Sleeping for only short periods due to waking up often during the night or being awake for most of the night.
Waking up too early in the morning and not being able to get back to sleep.
Having poor-quality of sleep that causes one to wake up feeling unrested.
Insomnia can also cause irritability, anxiousness, and depression.

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Sleep Apnea

A common sleep condition that occurs when the upper airway becomes repeatedly blocked during sleep, reducing or completely stopping airflow.
If the brain does not send the signals needed to breathe, the condition may be called central sleep apnea.
Caused by a person’s physical structure or other medical conditions
Risk factors include:

Obesity, large tonsils, thyroid disorders, neuromuscular disorders, heart or kidney failure, genetic syndromes (such as cleft lip or Down’s syndrome), and premature birth.

Ernstmeyer, & Christman, 2021

Contact info: info@nursesinternational.org

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Sleep Apnea

Common signs and symptoms of sleep apnea include:

Reduce/absent breathing, known as apnea events
Frequent loud snoring
Gasping for air during sleep
Excessive daytime sleepiness and fatigue
Decreases in attention, vigilance, concentration, motor skills, and verbal and visuospatial memory
Dry mouth or headaches when waking
Sexual dysfunction or decreased libido
Waking up often during the night to urinate

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Sleep Apnea

Treatment: CPAP(Continuous Positive Airway Pressure)

CPAP machine, is the most commonly recommended treatment for clients with sleep apnea.
It uses mild air pressure to keep the airways open.

A mouth pieces in the mild sleep apnea or occurs only when lying on their back.

Mandibular repositioning mouthpieces and Tongue Retaining devices prevents upper airway blocking.

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Narcolepsy

Ernstmeyer, & Christman, 2021

Uncommon sleep disorder that causes periods of extreme daytime sleepiness and sudden, brief episodes of deep sleep during the day.
Signs and symptoms of narcolepsy include:

Extreme daytime sleepiness;
Falling asleep without warning
(called sleep attacks)
Difficulty focusing or staying awake; and
Waking frequently at night

May experience hallucinations while falling asleep or waking up or sleep paralysis, a feeling of being awake but being unable to move for several minutes.

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Nursing Interventions to Promote Sleep

Ernstmeyer, & Christman, 2021

Adjust the environment (e.g., light, noise, temperature, mattress, and bed) to promote sleep.
Encourage the client to establish a bedtime routine to facilitate wakefulness to sleep.
Facilitate maintenance of the client’s usual bedtime routines during inclientcare.
Encourage elimination of stressful situations before bedtime.
Instruct the client to avoid bedtime foods and beverages that interfere with sleep.

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Nursing Interventions to Promote Sleep

Ernstmeyer, & Christman, 2021

Encourage the client to limit daytime sleep and participate in activity, as appropriate.
Bundle care activities to minimize the number of awakenings by staff to allow for sleep cycles of at least 90 minutes.
Consider sleep apnea as a possible cause and notify the provider for a possible referral for a sleep study when daytime drowsiness occurs despite adequate periods of undisturbed night sleep.
Educate the client regarding sleep-enhancing techniques.

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Tips for Getting a Good Night's Sleep

Set a schedule:

Go to bed and wake up at the same time each day.

Relax before retiring to bed

Try a warm bath, reading, or another relaxing routine.

Exercise 20 to 30 minutes a day but no later than a few hours before going to bed.
Avoid caffeine and nicotine late in the day and alcoholic drinks before bed.

National institute of

Neurological Disorders and Stroke, 2019

Contact info: info@nursesinternational.org

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Tips for Getting a Good Night's Sleep

Create a room for sleep:

Avoid bright lights and loud sounds,
Keep the room at a comfortable temperature, and
Don’t watch TV or have a computer in your bedroom

Don’t lie in bed awake:

If you can’t get to sleep, do something else, like reading or listening to music, until you feel tired

See a doctor if you have a problem sleeping or if you feel unusually tired during the day

National institute of

Neurological Disorders and Stroke, 2019

Contact info: info@nursesinternational.org

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What would the nurse do?

A nurse is caring for a client who has been hospitalized after undergoing hip-replacement surgery. The client complains of not sleeping well and feels very drowsy during the day

What are the interventions the nurse can implement to enhance sleep for this client?

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References:

American Sleep Association, (2021). Stages of Sleep: The Sleep Cycle. https://www.sleepassociation.org/about-sleep/stages-of-sleep/

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentals by Chippewa Valley Technical College is licensed under CC BY 4.0

Hirshkowitz et al., (2015). National Sleep Foundation’s sleep time duration recommendations: methodology and results summary.Sleep Health: Journal of the National Sleep Foundation.

https://www.sleephealthjournal.org/action/showPdf?pii=S2352-7218%2815%2900015-7

National institute of Neurological Disorders and Stroke, (2019).Brain Basics: Understanding Sleep. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Understanding-Sleep#1

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