Sleep disorder
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.
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 L
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 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
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
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
Types
I]Dyssomnias
Intrinsic sleep disorders
Psycho physiologic insomnia
Narcolepsy
Obstructive sleep apnea syndrome
Central sleep apnea syndrome
Periodic limb movement disorder
Restless leg syndrome
Extrinsic sleep disorders
Inadequate sleep hygiene
Environmental sleep disorder
Circadian rhythm sleep disorder
II] Parasomnias
Arousal disorders
Sleep walking
Sleep terrors
Sleep – wake transition disorders
Parasomnias usually associated with REM sleep
Nightmares
Sleep paralysis
Other Parasomnias
Sleep bruxism
Sleep enuresis
Primary snoring
III ]Sleep disorders associated with medical or
psychiatric disorders
A. Neurotransmitter imbalances
B. Head injury
C. Hormonal imbalances
D. Respiratory disorders
E. Cardiovascular disorders
F. Gastrointestinal disorders
G, Other disorders
Associated with mental disorders
Associated with neurologic disorders
Associated with medical disorders
Proposed sleep disorders
TYPES A)STAGE 4 SLEEP DISORDERS
These are disorders occuring during deep sleep.
The common stage 4 parasomnias are:
1)sleep-walking(somnambulism)
2)sleep-terrors or night terrors(pavor nocturnus)
3)sleep-related enuresis
4)bruxism
5)sleep-talking(somniloquy)
1)SLEEP-WALKING(SOMNAMBULISM)
The patient carries out autonomic motor activities that
range from simple to complex.
He may leave the bed,walk about or leave the house.
Arousal is difficult and accidents may occur during sleep-
walking
2)SLEEP-TERRORS OR NIGHT TERRORS(PAVOR
NOCTURNUS)
The patient suddenly gets up screaming,with autonomic
arousal(tachycardia,sweating,and hyperventilation).
He may be difficult to arouse and rarely recalls the episode
on awakening.
In contrast,nightmares(which occur during REM sleep) are
clearly remembered in the morning.
3)SLEEP-RELATED(BED WETTING)
4)BRUXISM
The patient has involuntary,and forceful grinding of
teeth during sleep.
It causes the destruction of the tooth enamel.
The patient remains completely unaware of the episode.
5)SLEEP-TALKING(SOMNILOQUY)
The patient talks during the stage 3 and 4 of sleep but
doesnot remember anything about it in the morning on
awakening.
TREATMENT Since benzodiazepines suppress stage 4 of
NREM sleep,a single dose at bedtime usually provides
relief from stage 4 parasomnias.
B)OTHER SLEEP DISORDERS
Nocturnal angina
Nocturnal asthma
Nocturnal seizures
Sleep paralysis
SLEEP HYGIENE
Avoid naps except for a brief 10-15 min nap 8 hrs after rising but check with
the physician first because in some sleep disorders naps can be beneficial.
Get regular exercise at least 40 min each day that causes sweating
Take a warm bath or warm shower about 2 hrs before bedtime. Don’t use
bright light even you have to remain awake for long during nighttime
Expose to half an hour of sunlight during 30 min of rising should be useful to
prevent drowsiness in the morning
Take regular time out of bed for 7 days a week
Don’t smoke to get sleep
Give up smoking entirely or don’t smoke after 7 p.m.
Avoid caffeine entirely or limit no more than 3 cups per day and not after 10
a.m.
Too much time in bed is not good Remember that quality of sleep is
important.
Keep the clock face turned away. Don’t see what time of night you are
awake.
Don’t eat heavily or drink 3 hrs before bedtime. A light bedtime
snacks is o.k.
Incase of problem of regurgitation, elevate the head of bed and
prevent spicy as well as oily meal before bedtime
Keep your room well ventilated, dark and quiet during nighttime.
Reading non-professional materials may be useful. Perform bedtime
rituals.
Use stress management technique in daytime.
Make sure that mattress isn’t too firm or too soft. Ensure that the
pillow is of appropriate height and firmness.
An occasional sleeping pill is alright but use only after consultation
with doctor.
Use bedroom only for sleep. Avoid activities that lead to prolonged
arousal.
FOR PATIENT WITH SLEEP
DISORDER
Assessment
To promote the restful sleep for clients, nurse can
assess the sleep pattern.
Usually patients are the best resources for describing
their sleep problem. Some time we can take history
from the partner.
In case of children, older children or mother can best
describe the pattern of sleep and its problem.
The tools for sleep assessments are:
Sleep history including -Description of client’s sleep
problem; nature, sign/symptoms, onset, duration,
predisposing factors, severity, effects on client. -Usual sleep
pattern prior to sleep problem -Recent changes in sleep
pattern -Physical illness -Bedtime routine and sleeping
environment -Use of any medication
Pattern of dietary intake or any substance -symptoms
experienced during waking hours -recent life event -
Current emotional and mental status
Sleep diary including -times when patient tries to fall
asleep -approximate time that patient fall asleep -time of
awakening during night -record of food, physical activity,
worries, mental activity
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.
NURSING DIAGNOSIS
Sleep Pattern Disturbance Related To:
1. Impaired oxygen transport
2. Impaired elimination
3. Immobility
4. Medication
5. Hospitalization
6. Lack of exercise
7. Anxiety response
8. Life-style disruptions
As evidenced by: Major: (Must be present ) Difficulty
falling or remaining asleep Minor: (May be present) Fatigue
on awakening or during the day Dozing during the day
Agitation Mood alterations
NURSING DIAGNOSIS
Sleep pattern disturbance related to decreased physical
activity, fear, anxiety, inability to assume usual sleep
position, frequent assessments or treatments, unfamiliar
environment, and discomfort resulting from current
illness/injury.
EXPECTED OUTCOME
The client will attain optimal amounts of sleep as
evidenced by:
statements of feeling well rested
usual mental status
absence of frequent yawning and dark circles under
eyes
INTERVENTION
Assess for signs and symptoms of a sleep pattern
disturbance. (e.g. statements of difficulty falling asleep,
not feeling well rested, or interrupted sleep; irritability;
disorientation; lethargy; frequent yawning; dark circles
under eyes).
Determine the client's usual sleep habits.
Implement measures to promote sleep:
perform actions to reduce fear and anxiety.
Discourage long periods of sleep during the day
unless signs and symptoms of sleep deprivation exist or
daytime sleep is usual for client
Perform actions to relieve discomfort if present (e.g.
reposition client; administer prescribed analgesics,
antiemetics, or muscle relaxants
discourage intake of foods and fluids high in caffeine
(e.g. chocolate, coffee, tea, colas) in the evening.
offer client an evening snack that includes milk or
cheese unless contraindicated (the L-tryptophan in milk
and cheese helps induce and maintain sleep)
allow client to continue usual sleep practices (e.g.
position; time; presleep routines such as reading,
watching television, listening to music, and meditating)
whenever possible.
satisfy basic needs such as comfort and warmth
before sleep.
encourage client to urinate just before bedtime.
reduce environmental distractions
ensure good room ventilation
encourage client to avoid drinking alcohol in the evening (alcohol
interferes with REM sleep)
if possible, administer medications that can interfere with sleep (e.g.
steroids, diuretics) early in the day rather than late afternoon or evening
administer prescribed sedative-hypnotics if indicated.
perform actions to reduce interruptions during sleep (80 - 100 minutes
of uninterrupted sleep is usually needed to complete one sleep cycle)
restrict visitors
group care (e.g. medications, treatments, physical care, assessments)
whenever possible.
Consult appropriate health care provider if signs and symptoms of
sleep deprivation persist or worsen.
Evaluation
Reassessment
