SLEEP AND ITS

DISTURBANCES
SUBMITTED TO
Ms. Ranganayaki L
( Professor )

SUBMITTED BY:-
Kamalpreet Kaur
[Link]. ( Nsg.) Ist yr
Roll no. 301605
 INTRODUCTION
Proper rest and sleep are as important to
good health as good nutrition and adequate
exercises. Individuals need different amounts
of sleep and rest. Physical and emotional
health depends on the ability to fulfill these
basic human needs . Without proper amount
of rest and sleep , the ability to concentrate ,
make judgements and participate in daily
activities decreases and irritability increases.
 Contd….

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 of Sleep
Sleep can be 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.
 CONTD…
Sleep is distinguished from wakefulness
by a decreased ability to react to stimuli. It
is to be distinguished from coma , which is
unconsciousness from which the person
cannot be aroused.
Sleep is observed in all mammals, all birds
and many reptiles , amphibians and fish
etc.
 Characteristics of Sleep:-
Sleep is generally characterized by a:-
Reduction involuntary 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)
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
 Conti……
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. eg.
the blood level achieved by a continuous infusion of heparin
varies throughout the day.
CIRCADIAN RHYTHM
 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.
 Physiology of sleep
Physiology of sleep can be discussed
simply by considering the three basic
research approaches:
ELECTROPHYSIOLOGIC
HORMONAL
NEURAL
 ELECTROPHYSIOLOGIC
The electrophysiological approach centers
on the pylograph recordings of electrical
changes in the brain waves(EEG), eye
movements (EOG) and muscle
activity(EMG).
This approach characterize sleep as Non
Rapid Eye movement(NREM) and the
Rapid Eye Movement Sleep( REM).
 NEURAL
The neural approach views sleep as an
active process involving the RAS and the
interactions of neurotransmitter.
The RAS is a network of neurons in the
medulla , pons and midbrain with
projections to the spinal cord,
hypothalamus, cerebellum and cerebrum
 CONTD…
SEROTONIN is said to be the major
neurotransmiter associated with sleep,
produced in the median raphe nuclei of
brainstem.
Serotonin decreases the activity of the
RAS including sleep. REM sleep appears
to be due to the influence of norepinephrine.
 HORMONAL
The hormonal approach views sleep as a
pattern affected by hormones.
MELATONIN from the pineal gland in the
brain is secreted in enormous quantities
during sleep.
Its activities is influenced by the
relationship of darkness and light.
 CONTD…..
ACTH is also high during the elderly
period of sleep and CORTISOL rises
toward the end of the night time sleep
period.
GROWTH hormone and PROLACTIN
also increase during sleep.
 STAGES OF SLEEP
Sleep can be defined behaviorally, functionally and
electrophysiologically Electrophysiologic monitoring
of sleep is called Polysomnography includes at
least 3 parameters 1) 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
1. Slow rolling eye movements,
2. low level and fragmented cognitive activity,
3. Maintenance of moderate muscle tone, and
4. Slower, but generally rhythmic respirations and pulse rate.
 NREM sleep
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
Different types of brain waves in
EEG
Stage 2:
includes period of sound sleep
relaxation progresses
arousal is still relatively easy
stage lasts 10 – 20 minutes
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 minutes
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
 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.
STAGES OF THE ADULT
SLEEP CYCLE
 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
 NORMAL SLEEP REQUIREMENTS
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
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
DRUGS AND THEIR EFFECT
ON SLEEP
Hypnotics: Interfere with reaching deeper
sleep stages . Provide only temporary (1
week) increase in quantity of sleep
eventually cause “Hangover” during day
excess drowsiness , confusion ,
decreased energy. Sometimes worsens
sleep apnea in older adults.
Antidepressants and Stimulants:
Suppress REM sleep, Decrease total
sleep time.
 CONTD…
Alcohol:- Speeds onset of sleep .
Reduces REM sleep . Awakens person
during night and causes difficulty returning
to sleep.
Caffeine:- Presents person from falling
asleep. Causes person to awaken during
night. Interferes with REM sleep.
Diuretics:- Nightime awakening caused
by nocturia .
 CONTD…
Benzodiazepens:- Alter REM sleep .
Increase sleep time. Increase daytime
sleepiness.
Narcotics:- Suppress REM sleep. Cause
increased daytime drowsiness.
Anticonvulsants:-Decrease REM sleep
time. Causes daytime drowsiness.
 INTERNATIONAL
CLASSIFICATION OF SLEEP
DISORDERS:
 International classification of sleep disorders
Dyssomnias
Intrinsic sleep disorders: 1. Psycho physiologic
insomnia 2. Narcolepsy 3. Obstructive sleep apnea
syndrome 4. Central sleep apnea syndrome 5.
Periodic limb movement disorder 6. Restless leg
syndrome
Extrinsic sleep disorders: 1. Inadequate sleep
hygiene 2. Environmental sleep disorder
Circadian rhythm sleep disorders
Parasomnias
Arousal disoders: r1. Sleep walking 2. Sleep terrors
Sleep – wake transition disorders
 Parasomnias usually associated
with REM sleep:
1. Nightmares
2. Sleep paralysis
Other Parasomnias :
1. Sleep bruxism
2. Sleep enuresis
3Sleep disorders associated with medical,
mental or neurological disorders
4Proposed sleep disorders
 DYSSOMNIAS
Dyssomnias:- Sleep disorders that are
charachterized by disturbances in the
amount ,quality or timing of sleep .These
disorders may arise predominantly from
within the body ( Intrinsic) ,from external
sources( extrinsic) or from ds dissruptions
of circardian rhythm.
PSYCHOLOGICAL INSOMNIA
 INSOMNIA CONTD…
Insomnia also known as DIMS (Disorder
of Initiation and Maintenance of Sleep). It
means-
Difficulty in initiating sleep (going off to
sleep)
Difficulty in maintaining sleep (remaining
asleep).
Non-restorative sleep i.e. despite
adequate duration of sleep, feeling of not
having rested present (poor quality sleep).
 CAUSES OF INSOMNIA
Medical illness: PMS (Periodic
Movements in Sleep).
Alcohol and drug use:
Current medication: fluoxetine, steroids,
propranolol
Psychiatric disorders: mania, major
depression, dysrthymia, anxiety disorder,
stress.
Idiopathic insomnia
 ASSESSMENT &
DIAGNOSTIC FINDINGS:
A thorough medical and psychiatric
assessment.
Polysomnography
EEG(Electroencephalographic)
EOG( Electrooculography)
EMG( Electromyography)
TREATMENT OF INSOMNIA
Underlying physical and psychiatric
disorder must be treated, if present.
Withdrawal of current medications, if any
Relaxation techniques before sleep time and
education regarding sleep hygiene
Psychotherapy
Benzodiazepines may be used, either
alone or with the treatment of underlying
physical or psychiatric disorders. The use
of benzodiazepines should only be for
short-term periods, not more than 4-6
weeks at one time.
 NARCOLEPSY:
Narcolepsy is a dysfunction of mechanism
that regulate the sleep and wake states.
Excessive daytime sleepiness is the most
common complaint associated with this
disorder. Cataplexy or sudden muscle
weakness during intense emotion,such as
anger ,sadness or laughter occurs at any
time during the [Link] the catalaptic attack
is severe, the client losses voluntary
muscle control and falls to the floor.
OBSTRUCTIVE SLEEP APNEA
SYNDROME
OSAS one of the most common cause of
disturbed sleep at night, obstructive sleep
apnea syndrome. Snoring is an essential
indicator of sleep apnea and occurs
because the narrowed opening of the
airway causes the soft palate to vibrate
loudly during respiration with each
obstructive event, the low oxygen
saturation level arouse the CNS and
stimulate to breathing to resume. A variety
of therapies are offered CPAP.
 CENTRAL SLEEP APNEA
SYNDROME
It is charcterized by apneic periods during
which no apparent respiratory effort
[Link] may be seen in stroke and brain
stem involvement, but it is most commonly
mixed with obstructive sleep apnea
[Link] stroke respiration are
common and CPAP is the usual treatment.
MYOCLONUS OR RESTLESS
LEG SYNDROME
Periodic leg movement is during the night
can also result in frequent and brief
arousal from sleep and excessive
sleepiness.
TREATMENT: Clonzepam ,
Benzodiazepene a skeletal muscle
relaxant may be ordered to dimnish the
magnitude of the movement and
frequency of arousals
 GASTROESOPHAGEAL
REFLUX
Nocturnal gastroesophageal reflux a
condition in which a person complaints of
heart burn or a tightness in the chest or
awakening, can result from the low
pressure at the esophageal sphincter
while sleping in a relieved posture.
 Extrinsic sleep disorder in
Dyssomnia
CIRCADIAN rhythm sleep disorder:-In the
general population, the circadian rhythm
sleep disorders, such as time zone change
syndrome and shift work sleep disorder
are not uncommon .
MANAGEMENT:Includes maintenance of
regular schedule and exposure to natural
sunlight. Light therapy is being used to
facilitate adjustment in circadian rhythm.
 2 PARASOMNIAS
The parassomnias are disorders that
occur during sleep but those usually do
not produce insomnia or excessive
sleepiness. It may be due to partial
arousal or abnormalities in sleep wake
transition.
 Arousal Disorder
Partial arousal occurs during slow –wave
sleep. SLEEPWALKING also known as
SOMNAMBULISM may include semi
purposeful behavior such as dressing .The
occurrence of sleep walking in adults is
associated with anxiety.
 Sleep Terrors
These are sudden arousals from slow –
wave sleep accompanied by screaming,
tachycardia , diphoresis and other
manifestation of fear. Sleep tremors
usually occur in young children.
 Sleep wake Transaction
disorders
Sleep wake transaction disorders are
common in the general population . Sleep
starts refer to the sudden jerking
movement of the legs that often occurs as
and when a person is falling asleep.
Nocturnal leg cramps are also common.
The frequency and intensity may be
greater with high caffeine intake, stress or
intense physical activity before going to
bed.
Parasomnias usually associated
with REM sleep
Nightmares are frieghtening dreams that
arise in REM sleep are often vivdly
recalled on awakening.
Sleep Paralysis is one of the classic signs
of narcolepsy, but can occur in isolation .
The effect may be an extension of the
normal state of low muscle tone during
REM sleep.
 OTHER PARASOMNIAS
Sleep Bruxism refers to grinding of the teeth
during sleep and may lead to dental damage.
Sleep Enuresis bed wetting may occuring 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.
Primary Snoring
Sleep disorders associated with
medical or psychiatric disorders.
Associated with mental disorders:-
Psychosis, Mood disorders , Anxiety,
Panic disorders and alcoholism.
Associated with neurological disorders:-
Cerebral degenrative
disorder,dementia,Parkinsonism,Fatal
familal insomnia ,Sleep related epilepsy,
Sleep related headaches.
 CONTD…
Associated with other mental disorders:-
Sleeping, Sickness, Nocturnal cardiac
ischemia , chronic obstructive pulmonary
disease, peptic ulcer disease.
HOSPITAL ACQUIRED SLEEP
DISTURBANCES
Sleep Onset Difficulty:-Sleep onset
difficulty is a common problem in hospital
because of the strange environment and
the anxities associated with illness and
hospitalization.
Sleep Maintenance Disturbances:-
These are may be associated with
sustained use or withdrawl from a variety
of medications and related substances.
 CONTD..
Internal stimuli:- such as pain ,dyscomfort
and urge to void are frequent causes of
disturbed sleep. External stimuli :- Include
environmental factors such as light ,noise
, and temperature as well as disruption by
others.
Early Morning Awakening:-Early
morning awakening occurs frequently
among older clients. Sleep is grossly
distributed with
 CONTD…
Frightening dreams, disorientation and
restless.
Sleep Deprivation:- Sleep deprivation is of
particular concern for clients in critical care
units . Multiple factors contribute to sleep
deprivation including noise level, 24 hour
lighting and frequency of caregiver
interruptions.
 CONTD….
REM Rebound:- REM sleep occurs later in
the sleep cycle and therefore can be
missed when sleep time is reduced or
interrupted.
 NURSING PROCESS
Assessment: Assess client usual sleep
habits and recent sleep quality . If sleep
quality is reported 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.
 CONTD…
Regularity of sleep pattern
Consistency of rising time
Frequency and duration of naps
Events associated with initial onset of
sleep disturbances
Situations in which client fights sleepiness
Daily caffeine intake
Use of alcohol , sleeping pills and other
medications.
 Contd…

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.
 NURSING MANAGEMENT
Nursing Diagnosis

[Link] pattern disturbances related to

(specific medical condition); use of , or
withdrawal from, substances; anxiety or
depression; circadian rhythm disruption;
familial patterns; evidenced by insomnia,
hypersomnia , nightmares, sleep terrors,
or sleepwalking
 OUTCOME CRITERIA

Client will be able to achieve adequate,

uninterrupted sleep

Client will report feeling rested and

demonstrate a sensation of wellbeing.
NURSING INTERVENTIONS
To promote sleep
 Encourage activities that prepare one for sleep: soft

music, relaxation exercise, warm bath

 Discourage strenuous exercise within 1 hr of bedtime

 Control intake of caffeine-containing substances

within 4 hr of bedtime.
 Provide a high-carbohydrate snack before bedtime

 Keep the temp of the room between 68°F and 72°F

 Instruct the client not to use alcoholic beverages

 Discourage smoking and daytime napping

 NURSING DIAGNOSIS 2
Risk for injury related excessive
sleepiness, sleep tremors, or
sleepwalking.

Outcome criteria
Client will not experience injury
NURSING INTERVENTIONS
Ensure that side rails are up on the bed.
Keep the bed in a low position
Equip the bed with a bell that is activated
when the bed is exited
Keep a night light on and arrange the
furniture in the bedroom in a manner that
promotes safety.
Administer drug therapy as ordered
 ROLE OF NURSE
Preparing a restful environment
Promoting bedtime rituals
Offering appropriate bedtime snacks and
beverages
Promoting relaxation
Promoting comfort
 CONTD…

Respecting normal sleep patterns

Scheduling nursing care to avoid

unnecessary disturbances

Using medication to produce sleep

Teaching about rest and sleep

 RESEARCH ABSTRACT
Association of physical activity and human sleep
disorders. (Archives of Internal Medicine (1998,
September 28), 158, 1894-1898)

This was the study of 319 men and 403 women who
were taking part in the Tucson epidemiological study
of obstructive airways disease. Part of the study
included completing health questionnaires related to
physical exercises and sleep disorders.

Results: A program of regular exercise may be a useful

 SUMMARIZATION
Introduction
Definition of Sleep
Terminologies
Physiology of sleep
Sleep Cycle
Disturbed sleep Pattern
Factors Affecting Sleep
Sleep Pattern in Hospital Settings
Nursing Process and Role of Nurse
Research Abstract
 BIBLIOGRAPHY
Perry Potter. Fundamental of nursing:7th
[Link]:Elseiver;2009,p.1029-1050.
Basheer. P. Shabeer, Khan Yaseen S.A
concise textbook of : Advanced nursing
practice . Banglore : Hedge S.
Manjunath;2012.p264-272.
 Contd…
Lindeman [Link],Mcathie
[Link] of contemporary
nursing [Link] States of
America:Saunders W.B.;1999.p.723-742.
Brar Kaur Navdeep,Rawat HC.A textbook
of advanced nursing [Link]
Delhi:Jaypee Brothers
Medical;2015.p.466-474.
 ASSIGNMENT
Apply theory on disturbed sleep pattern
I Can’t
Sleep Stop thinking
about your
research protocol
submission!!