Rest and Sleep Rest- a state of calmness, relaxation without emotional stress and freedom from anxiety Sleep-

an altered state of consciousness in which the individuals perception and reaction to the environment are decreased Sleep Physiology ELECTROPHYSIOLOGIC This approach centers on the polygraph recordings of electrical changes in the brain waves (EEG), eye movement (EOG) and muscle activity (EMG) Characterizes sleep as Non- Rapid Eye Movement Sleep (NREM) and Rapid Eye Movement Sleep (REM) NEURAL Views sleep as an active process involving the Reticular Activating System (RAS) and the interaction of neurotransmitters RAS network of neurons in the medulla, pons and mid brain with projections to the spinal cord, hypothalamus, cerebellum and cerebrum Serotonin is said to be the major neurotransmitter associated with sleep- decrease the activity of RAS inducing sleep HORMONAL Views sleep as a pattern affected by hormones. Melatonin from the pineal gland in the brain is excreted in enormous quantity during sleep ACTH is also high during the early stage of sleep and cortisol rises towards the end of the nighttime sleep period Growth hormone and prolactin also increases during deep sleep Functions of sleep 1. Restores normal levels of activity and normal balance among parts of the nervous sytem 2. Necessary for protein synthesis Types of sleep Q&A: The following are characteristics of NREM stage of sleep EXCEPT: a. Vital functions are decreased b. Parasympathetic nervous system dominates c. Sympathetic nervous system dominates d. Restores body Answer B. NREM sleep is not dominated by SNS, but by PNS. NREM Non Rapid Eye Movement slow wave sleep- brain waves are slower than those in awake or alert person Deep, restful sleep 4 stages 1. Stage 1- very light sleep - Readily be awakened - eyes tend to roll slowly from side to side and muscle tension remains absent 2. Stage 2- light sleep - body processes slows down -last for 10-15 minutes 3. Stage 3 medium-depth sleep - domination of PNS thus vital signs and metabolic processes slows further - difficult to arouse

4. Stage 4- deepest or delta sleep - RR and HR drop to 20-30% below - some dreaming may occur - maybe absent in elderly REM- Rapid Eye Movement paradoxical sleep Occurs about every 90 min & lasts 5-30 min EEG resembles that of awake Not as restful as NREM Most dreams takes place and they are usually remembered or consolidated to memory Rapid conjugate eye movement, muscle tone depresses but gastric secretions increased, HR and RR are increased and irregular NREM REM Slow eye movement Rapid eye movement Restful sleep Not restful Decreased metabolism Increased metabolism Vital signs low Vital signs irregular Muscle tone maintained Muscle tone depressed No vivid dreams Dreams occur Sleep Variations Neonates sleep for 16 18 hours divided into 7 sleep periods two sleep states: o quiet sleep (NREM)- closed eyes, regular respirations and absence of eye/body movement o Active sleep- eye movements observable through the closed eyelids, with body movements and irregular respirations Infants average sleep is 10-13 hours - sleep cycle is shorter - REM sleep is 20-30% (decreases as they grow and stabilizes at 20% until late adulthood) - 50% is spent during light sleep Toddlers- 12-14 hours a day - normal sleep wake pattern is established at age 2 to 3 - establishe a bed time routine Preschool- 11-12 hours of sleep per night -difficulty falling asleep and waking up during the night are common -commonly experience nighttime fears and nightmares School age 10-11 hours of sleep -not getting enough sleep is common in this age group Adolescents- 8-10 hours of sleep a day - Naps at this age tend to be from not getting enough sleep at night. Q&A: A nurse is planning a care for a 76 year old client who is experiencing difficulty sleeping. In developing the care plan, the nurse takes into account the understanding that elderly individual a. Are deeper sleepers and are more difficult to arouse than younger people b. Have a decline in stage 4 NREM sleep c. Takes less time to fall asleep than younger people d. Required more sleep than middle aged adult

Answer B. stage 4 sleep is a stage of deep sleep, and aging produces a decline in the amount of stage 3 and 4. Q&A: Which intervention is appropriate to include on a care plan for improving sleep in the older adult? a. Decrease fluids 2 to 4 hours before sleep b. Increase fluids 2 to 4 hours before sleep c. Let the client take as much naps as they want d. Let the client exercise a bit before going to bed Answer A. By decreasing fluids 2 to 4 hours before sleep, it is less likely that the client will awaken because of a need to urinate. Limiting naps during the day will help improve nighttime sleep. The client should sleep until the same time each morning. Exercising in the evening can make falling asleep more difficult. Adults 7-8 hours a day - As we age, it gets more difficult to get a good nights sleep -taking longer to fall asleep -Sleep is less deep -Waking up three or four times a night -Frequent nighttime bathroom trips -Sleep is not as restful or satisfying -Tendency to fall asleep in the early evening and wake up in the early morning Common sleep disorders Parasomnias Behavior that may interfere with sleep or a behavior that occurs normally during waking hours but abnormally during asleep. BRUXISM- night teeth grinding - clenching and grinding of teeth during sleep. May erode and diminish the height of dental crowns and may cause the teeth to become loose. - occurring during stage 2 sleep Nocturnal enuresis- bedwetting - occurring in children over 3 years old - occurs 1 to 2 hours after falling asleep and when rousing from NREM stages 3 to 4 Nocturnal erection/ emissions- wet dreams - usually experienced by adolescents males Soliloquy- sleep talking Q&A: The nurse finds a client sleepwalking down the unit hallway. An appropriate intervention the nurse implement is: a. Ask the patient what he/she is doing b. Call someone for assistance c. Lightly tap the client on the shoulder and leading him or her back to bed. d. Block the walkway Answer C. The nurse should not startle the client but should gently awaken the client and lead him or her back to bed. Sleepwalkers are unaware of their surroundings. Asking them what they are doing is not helpful. The nurse may or may not need assistance. Startling the client may result in injury. Blocking the walkway with chairs may result in injury. Somnambulism- sleep walking - occurs during stage 3 to 4 of NREM Periodic limb movements disorder- legs jerk twice or three times per minute during sleep - most common among elders

Insomnia- difficulty in falling asleep Usually a result of physical discomfort, mental overstimulation due to anxiety o Initial insomnia- difficulty in falling asleep o Intermittent insomnia- difficulty in staying asleep because of frequent or prolonged waking o Terminal insomnia- early morning or premature waking Hypersomnia- excessive sleep particularly in daytime Causes can be medical conditions like CNS damage, kidney, liver or metabolic disorder like DM and hypothyroidism Q&A: The nurse is developing a plan of care for a client experiencing narcolepsy. Which intervention is appropriate to include on the plan? a. Encourage client to take one or two 20-minute naps during the day b. Increase Carbohydrates in the diet c. Limit fluid intake d. Preserve energy Answer A. Brief daytime naps of no longer than 20 minutes help reduce subjective feelings of sleepiness. Carbohydrates can increase sleepiness. Limiting fluids will not help the client with narcolepsy, nor will energy preservation. Narcolepsy- sleep attack Overwhelming sleepiness that suddenly occurs during the day Uncontrolled REM Q&A: A client has a history of sleep apnea. The nurse should ask which of the following most appropriate questions? a. Do you have a history of cardiac irregularities? b. Do you have a history of any kind of nasal obstruction? c. Have you had chest pain with or without activity? d. Do you have difficulty with daytime sleepiness? Answer D. Most clients with sleep apnea report excessive daytime sleepiness. If they dont volunteer this, clients should be asked if they fall asleep or struggle to stay awake at work. Although cardiac arrhythmias may occur, they are usually only detectable during a sleep study, and thus the client would not be aware of them. There are many causes of chest pain, and this is unlikely to be something reported by clients with sleep apnea unless they have underlying cardiac disease. Sleep apnea- periodic cessation of breathing during sleep Excessive daytime sleepiness Usually last for 10 seconds to 2 minutes occurring at least 5 times per hour Characterized by snoring Q&A: To assist an adult client to sleep better, the nurse recommends which of the following? a. Mild exercise before sleeping b. Consuming a small glass of warm milk at bedtime c. Eat a large evening meal d. Take alcohol before sleeping Answer B. A small glass of milk relaxes the body and promotes sleep. It contains tryptophan, a substance inducing sleep. Alcohol, large meals, and exercising all within 1 to 2 hours of bedtime have insomniaproducing effects and may, in fact, stimulate wakefulness. Large meals could also produce indigestion. Factors Affecting Sleep Age- One of the most important factors affecting persons sleep and rest periods. Illness- causing pain or physical distress can result in sleep problems.

 Environment-Noise level Fatigue- more tired the shorter the first (REM) sleep Lifestyle-Shift work Emotional Stress, Alcohol and Stimulants, Diet, Smoking, Motivation, Medications Drugs That Affect Sleep Alcohol Antidepressants Beta-blockers Caffeine Bronchial dilators Steroids Decongestants Narcotics Amphetamines Nursing Interventions to Promote sleep 1. Promote comfort and relaxation. E.g. provide loose-fitting night ware, hygiene routines, clean dry linens, offering back massage, place client in comfortable position. 2. Create restful environment. E.g. darkened or dim-lit room, noise should be reduced to minimum, environmental distractions should be eliminated. 3. Attend to bedtime rituals like an evening stroll, music, TV, bath and prayer. Children should promote pre-sleep routines like bedtime stories, holding favorite toys, drinking warm milk. 4. Adequate exercise. Exercise at least 2 hour before sleep to enhance NREM, not immediately before sleep 5. High protein food. Contains tryptophan, depressant 6. Observe habits of sleep periodicity and wake up time 7. Avoid caffeine and alcohol in the evening 8. Go to bed when sleepy 9. Use the bed mainly for sleep Sleep pattern of infant Nursing intervention Teach patient to position infant on the back to decrease risk of sudden infant death syndrome. Encourage parents to have infant sleep in separate crib not their bed Caution parents about placing pillows, quilts, stuff animals in the crib which may pose suffocation hazards Establish a regular bed time routine Encourage attention to safety of the child Advise parents the value of routine sleeping pattern with minimal variation Encourage parents to continue bedtime routine Advice parents that waking from nightmares and terrors are common. Waking the child and comforting them generally helps Discuss the facts that the stress from beginning school may interrupt normal sleep Advised that a relaxed, bedtime routine is most helpful Advised parents that complaints of fatigue or inability to do well in school maybe related to not enough sleep. Excessive daytime sleepiness may make them more vulnerable to accidents and behavioral problems Suggest use of relaxation techniques and stress reduction

toddler

Preschooler

School-aged adolescents

Adults