UNIT VII: Concept of rest and sleep

Presented By: Acknowledge By:

Asad Ullah Sir, Hanif Ullah
BSN* MTI MCN (BKMC), MARDAN Nursing lecturer MCN (BKMC), MARDAN

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 Objectives
At the end of this unit, learners will be able to:

• Define rest and sleep pattern

• Define terms related to rest and sleep.

• Compare the characteristics of sleep and rest.

• Discuss the characteristics of two kinds of sleep.

• Enumerate the functions of sleep.

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 Cont..
• Discuss factors affecting sleep.

• Identify common sleep disorders.

• Detect conditions necessary to promote sleep.

• Discuss nursing process for a patient to promote sleep.

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 Rest and sleep
 Rest and sleep are fundamental components of well-being. All
individuals require certain periods of calm / lesser activity. So,
their bodies can regain energy and rebuild stamina.

Rest:
 A condition in which the body is in a
decreased state of activity without altered
level of consciousness.
 State of relaxation and calmness, both
mental and physical
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 Sleep
 A state of altered consciousness during which an individual
experiences minimal physical activity and a general slowing of the
body’s physiological processes.

 The need for rest and sleep varies with age, developmental level,
health status, activity level, and cultural norms.

Sleep generally occurs in a periodic cycle and

usually lasts for several hours at a time;
disruptions in the usual sleep routine can be
distressing to clients.

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 Physiology Sleep
The cycles of wakefulness and sleep are controlled by centers in the
brain and influenced by routines and environmental factors.
An individual’s biological clock also helps determine the specific
cycles that will be followed for wakefulness and sleep.

Neurotransmitters, located within neurons in the brain, affect

the sleep-wake cycles, for example:
• Serotonin reduce the response to sensory stimulation
• Gamma amino butyric acid (GABA) inhibit the wake promoting
center (reticular activating system RAS) cerebral cortex.
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 Cont..
Another key factor to sleep is exposure to darkness
• Pineal gland in the brain activate the natural hormone melatonin, and the
person feels less alert. During sleep, the growth hormone is secreted and
Cortisol stimulating hormone is inhibited.
• Decrease in stimulation of the RAS at sleep beginning and as sleep hour
increase then cortisol hormone also increased and peak level in morning.
Initiation of sleep process, wakefulness is also associated with
• Acetylcholine is released in the reticular formation
• Dopamine in the midbrain
• Noradrenaline in the pons.
These neurotransmitters are localized within the reticular formation and
influence cerebral cortical arousal.
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 CIRCADIAN RHYTHMS
• The term circadian is Latin ward circa dies, meaning "about a day."
• Controlled by two factors, body (hormones) and environmental factors,
such as light and darkness.

• Body temperature, blood pressure, and many other physiologic functions

also follow a circadian pattern.
• When a person's biological clock coincides with the sleep-wake cycles,
the person is said to be in circadian synchronization; that is, the person is
awake when the body temperature is highest, and a sleep when the body
temperature is lowest.
• In the age of 3 to 6 months most infants have a regular sleep-wake cycle.
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 High body low body
temperature temperature
High blood
pressure
low body blood pressure

Melatonin secretion
stop

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 Types of Sleep

Electroencephalograph (EEG) patterns, eye

movements, and muscle activity are used to
identify stages of sleep. The stages of sleep are
classified in two categories:

NREM SLEEP REM SLEEP

(Rapid-eye-
(Non-rapid-eye
movement) sleep.
movement) sleep.

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 NREM SLEEP
• The first phase of sleep
• About 75% to 80% of sleep during a night is NREM sleep
• NREM sleep consists of four different stages

Stage 1 Sleep:
• Very light sleep and lasts only a few minutes
• General slowing of EEG frequency but an appearance of wave spikes
• The person feels drowsy and relaxed, eyes tend to roll slowly from side to
side, and the heart and respiratory rates drop slightly and readily awareness.
• Muscle tension remains absent except in the facial and neck muscles.
• Typically, this stage represents only about 5% of the total sleep time.
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 Cont..
Stage II:
• Still fairly light sleep, with a further slowing of EEG patterns
• Loss of slow rolling eye movements, the heart and
respiratory rates decrease slightly, and body temperature
falls.
• Stage II lasts only about 10 to 15 minutes but constitutes 44%
to 55% of total sleep.
• An individual in stage II requires more intense stimuli than in
stage I to awaken.
• Fifty percent of normal adult sleep may be spent in stage 2.
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 Stages III and IV
• Stage 3 & 4 sleep are frequently discussed together because of resemblance.
Just we can say 3 refers to medium-depth sleep, and stage 4 signals the
deepest sleep & represent with delta waves.

• During deep sleep or delta sleep, the sleeper's heart and respiratory rates drop
20% to 30%.

• Difficult to arouse, not disturbed by sensory stimuli, the skeletal muscles are
very relaxed, reflexes are diminished, and snoring is most likely to occur.
Even swallowing and saliva production are reduced during delta sleep

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 Cont..
• These stages are essential for restoring energy and releasing important
growth hormones.

• Stage 3 to 4 sleep is where most sleepwalking, sleep talking, enuresis,

and night terrors occur.

• The majority of growth hormone is secreted at night, peaking during

stage 3 to 4 sleep near the beginning of a sleep period.

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 REM Sleep
• REM sleep usually recurs about every 90 minutes and lasts 5 to 30 minutes
and periods become longer as the night progresses.

• Most dreams take place during REM sleep but usually will not be
remembered unless the person arouses briefly at the end of the REM
period.

• During REM sleep, the brain is highly active, and brain metabolism may
increase as much as 20%.

• Also called paradoxical sleep because electroencephalogram (EEG)

activity resembles that of wakefulness.
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 Cont..
• Distinguishing eye movements occur, voluntary muscle tone
is dramatically decreased, and Absence of muscle tone and
skeletal muscle activity is known as atonia.

• Difficult to arouse or may wake spontaneously, gastric

secretions increase, and heart and respiratory rates often are
irregular.

• Regions of the brain that are used in learning, thinking, and

organizing information are stimulated during REM sleep.
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 Brain Waves represented by EEG
• After the invention of the EEG, the stages of sleep were determined in
1936 by Harvey and Loomis, the first descriptions of delta and theta
waves were made by Walter and Dovey, and REM sleep was
discovered in 1953.

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 Sleep Cycles
• The duration of a sleep cycle is
generally between 90 and 110
minutes, and the typical sleeper will
pass through four to six sleep cycles
during an average sleep period of 7 to
8 hours

• length of the NREM and REM periods

of sleep will change as the overall
sleep period progresses and the person
becomes more relaxed and re-
energized. 18
 Sleep Cycle
• There is less need for stage 3 to 4 sleep and more need for REM
sleep as the sleep period progresses

• Dreams during the REM phases of later sleep may become more
vivid and strong.

• If the sleep cycle is broken at any point, a new sleep cycle will
start, if sleep cycle continue again at stage 2 of NREM sleep and
progressing through all the stages to REM sleep.
 Sleep Across the Life Span

12-18 19 -65 years

YEARS
5-12 years 65 + years
1-5 years

0-1 year

16-18 hours/24hour 11 -13 10-11H, 9H 7-8 hours need 7-8 H

 Developmental Patterns of Sleep
• All aspects of sleep behavior across the lifespan demonstrate
a large degree of variability among individuals and across
cultures.

• Sleep patterns are shaped by intrinsic biological processes

and psycho-social factors such as cultural norms, family
values, school and work.

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 NEWBORN AND INFANT SLEEP
• Newborn sleep has 2 stages;
50% “quiet or non-rapid eye movement (NREM) sleep” and
50% “active or rapid eye movement (REM) sleep”.

• Total sleep time = 16 to 18 hours / 24 hour period with

frequent awakenings for feeding and nurturing.

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 Children Ages 1-5 Years
• The preschool child (3 to 5 years of age) requires 11 to 13 hours of sleep
per night.
• Many children of this age dislike bedtime and resist by requesting
another story, game, or television program, so parents can help through
maintaining a regular and consistent sleep schedule.
• Become restless and irritable if sleep requirements are not met.
• Preschool children wake up frequently at night, and they may be afraid
of the dark or experience night terrors or nightmares.
• Naps during the day as needed
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 Sleep in Middle Childhood (5-12 years)
• Needs 10 to 11 hours of sleep, but receive less because of increasing
demands (e.g., homework, sports, social activities). Some may be
drinking caffeinated beverages.

• All of these activities can lead to May experience parasomnias

(sleep problems) such as enuresis (bedwetting), nightmares, and sleep
walking.

• Nurses can teach parents and school-age children about healthy sleep
habits. A regular and consistent sleep schedule and bedtime routine
need to be continued.

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SLEEP IN ADOLESCENTS (12-18 YEARS):
• Need - 9 hours of nightly sleep for optimal health, emotional well being, and
cognitive functioning

• Often experience delayed sleep phase syndrome …. can’t go to sleep until late at
night and prefer to sleep later in the morning

• Frequently do not get sufficient sleep

SLEEP IN ADULTS:
• Generally need 7 to 8 hours of nightly sleep, some adults may function well with 6
hours of sleep & some need 10 hours to function optimally.

• Increasing frequency of problems sleeping; including common sleep disorders such

as obstructive apnea, insomnia, and restless leg syndrome. 25
 Sleep in Aging Adults (65+ years)
• Still need -7 to 8 hours of total sleep time, may decrease to as little as 6 hours
a night with naps.
• The elder may have a major sleep disorder that is complication of other
conditions.
• Increased number of night time awakenings
• Frequently awaken very early in the morning
• Sleep may be impacted by illness and medications
• Important for nurse to teach about the connection between sleep, health, and
aging.
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 Factors Affecting Sleep
• Illness: pain or physical distress, respiratory problem, need to urinate etc.
• Environment: Environmental factors can either enhance or impair sleep.
Lighting, temperature, odors, ventilation, and noise level can all interrupt the
sleep process when they differ from the norms of the client’s usual sleep
environment.

• Lifestyle: A problematic life filled with multiple stressors can result in the
person’s inability to relax easily or to fall asleep quickly. Relaxation precedes
healthy sleep.

• Emotional Stress: To most sleep experts the number one cause of short-term
sleeping difficulties. Anxiety increase the norepinephrine blood levels through
stimulation of the sympathetic nervous system, results in less deep sleep and
changes to awakening. 28
 Cont..
Cultural Norms: Some people perceive sleep as a extra when some one too busy
with “important” activities. Others view sleep as an absolute necessity.
Life Span Considerations: A person’s need for sleep changes with age in a
fairly predictable patter
Diet: The type of food consumed has an impact on the quality and quantity of
sleep. Foods high in caffeine, such as coffee, and chocolate, serve as stimulants
and often disrupt the normal sleep cycle. Also, consuming a large, heavy, or
spicy meal just before bedtime may cause indigestion, which will likely interfere
with sleep.
Dietary (L-tryptophan) milk—may induce sleep.
Drugs and Other Substances: Alcohol and nicotine use can impair sleep. Small
amounts of alcohol may help some people fall asleep; however, in others alcohol
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may interfere with REM sleep, causing very restless and no refreshing sleep.
 Alteration in Sleep Patterns
• Dyssomnias: Group of sleep disorders which cause you an inability to sleep
or complications with your sleeping.
• Dyssomnias is categorized to hyper-somnolence (daytime sleepiness or
prolonged night sleep) or insomnia (an inability to sleep).
• Hypersomnolence types:
• Hypersomnia (excessive sleep): Conditions where the affected individual
obtains sufficient sleep at night but still cannot stay awake during the day.
Mostly caused by medical conditions such as central nervous system
damage and hypothyroidism.
• Narcolepsy: is a disorder of excessive daytime sleepiness caused by the
lack of the chemical hypocretin in the area of the central nervous system
that regulates sleep.
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 Cont..
Insomnia:

• Is described as the inability to fall asleep or remain asleep. Persons with

insomnia awaken not feeling rested.

• May be due to stress, anxiety, hormonal changes, lifestyle, environmental

factors, or psychiatric illness.

• Acute insomnia lasts one to several nights and is often caused by personal
stressors and/or worry. If the insomnia persists for longer than a month, it is
considered chronic insomnia.
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 Type of Insomnia
Restless leg syndrome:  Sleep Apnea:
• Neurological disorder characterized • Frequent short breathing pauses during
by unpleasant sensations in the legs sleep. Five or more apneic episodes
and an uncontrollable urge to move longer than 10 seconds/hour is
when resting as an attempt to relief considered abnormal.
• Oxygen levels in blood drop, normal
feelings.
breathing starts again with a loud snort.
• Causes difficulty falling asleep
• Often associated with overweight
• Cause unknown difficult to treat
/obesity/congested nose
 Sleep deprivation:
• Symptoms: Loud snoring, frequent
• Prolonged disturbance in amount,
nocturnal awakenings, excessive
quality. daytime sleepiness, morning headaches,
memory and cognitive problems 32
Alteration in Sleep Patterns due to Parasomnias
• Parasomnias (disruptive sleep-related disorders): Patterns of waking
behavior that appear during sleep
• Parasomnias types:
 Nightmares: disturbing dream associated with negative feelings
 Sleep terrors/night terrors
 Sleepwalking (somnambulism)
 Sleep paralysis
 Sleep enuresis
 Bruxism: Grinding of teeth during sleeping
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Nursing Care Plan
 Assessment
Data [Link] of sleep (restful, uninterrupted)
• Sleep routines [Link] of sleep (usual sleep pattern, schedules,

• Sleep alterations hours of sleep, feeling on waking)

• Type of [Link] environment (description of room,

temperature, noise level)
disturbances
[Link] factors (bedtime routines, use of sleep
• Impact of sleep
medications or any other sleep inducers)
problems
[Link] of sleep (adequate, restores energy,
adequately, inadequate, problematic etc)
 Nursing Diagnosis
• Activity Intolerance related to lack of sleep as evidenced by verbal complaint,
extreme fatigue, disorientation, confusion, and lack of energy.

• Risk for Injury related to somnambulism

• Ineffective Coping related to insufficient quality and quantity of sleep

• Fatigue related to insufficient sleep

• Risk for Impaired gas exchange related to sleep apnea

• Deficient Knowledge (Nonprescription remedies for sleep ) related to misinformation

• Anxiety related to sleep apnea

 Outcome Identification and Planning

• For clients with sleep disturbances is to maintain (or develop ) a sleeping

pattern that provides sufficient energy for daily activities.

• Enhancing the client's feeling of well-being

• Improving the quality and quantity of the client's sleep .

 Implementation
• Establish a Trusting Nurse-Client • Provide privacy
Relationship • Schedule nursing care to avoid
• Create a Relaxing Environment disturbances

• Ensure Appropriate Nutrition • Use medications to produce sleep

• Provide Client Education • Encourage patient to void (activity)

• Promoting Comfort and Relaxation before sleep

• Offer appropriate bedtime snacks and • Remove any irritants against patients
beverages skin such as moist or wrinkled sheets
 Evaluation
Observations of the duration of the client's sleep,
• Questions about how the client feels on awakening.
• Observations of the client's level of alertness during the day.

 If the desired outcomes are not achieved, the nurse and client should
explore the reasons, which may include answers to the following
questions:
• Were etiologic factors correctly identified?
• Has the client's physical condition or medication therapy changed?
• Did the client comply with instructions about establishing a regular
sleep-wake pattern?
• Did the client avoid ingesting caffeine?
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References

• Erb’s and KOZIER Fundamentals of Nursing: Concept of rest & sleep

(8th edition) page number (1164-1183).