SLEEP - is a basic human need; it is a universal biologic process common to all people.

Humans spend
about one third of their lives asleep.

- enhances daytime functioning, and is vital for cognitive, physiological, and psychosocial function
(Gruber, 2013).

IMPORTANCE: We require sleep for many reasons: to cope with daily stresses, to prevent fatigue, to
conserve energy, to restore the mind and body, and to enjoy life more fully.

Physiology of Sleep: Sleep was considered a state of unconsciousness. More recently, sleep has come to
be considered an altered state of consciousness in which the individual’s perception of and reaction to the
environment are decreased.

NEUROTRANSMITTERS:
Affect sleep-wake cycle
Serotonin - Thought to lessen response to sensory stimulation
GABA (gamma aminobutyric acid) - Thought to shut off activity in neurons of RAS
High levels of Acetylcholine, dopamine, noradrenalin associated with cerebral cortical arousal-
associated with wakefulness
EXPOSURE TO DARKNESS:
Darkness and preparing for sleep cause decrease in stimulation of RAS (reticular activating system)
Pineal gland begins to secrete melatonin and person feels less alert
During sleep Growth Hormone secreted and cortisol inhibited
Biologic rhythms exist in plants, animals, and humans.
- In humans, these are controlled from within the body and synchronized with environmental
factors, such as light and darkness.
circadian rhythm - the most familiar biologic rhythm. It is a sort of 24-hour internal biologic clock. The
term circadian is from the Latin CIRCA DIES, meaning “about a day.”

Sleep architecture - refers to the basic organization of normal sleep.

The two types of sleep are:
A. NREM (NON–rapid-eye-movement) sleep
B. REM (RAPID-eye-movement) sleep.
During sleep, NREM and REM sleep alternate in cycles. CHANGES in the architecture of one’s sleep can be
linked to physiological or psychosocial changes.
1. NREM - About 75% to 80% of sleep during a night is NREM sleep.
• NREM sleep was previously divided into four stages.
• It is now divided into three stages.
Stage 1 is the stage of very light sleep and lasts only a few minutes.
- the person feels drowsy and relaxed, the eyes roll from side to side, and the heart and respiratory
rates drop slightly.
Stage 2 is the stage of sleep during which body processes continue to slow down.
- The eyes are generally still, the heart and respiratory rates decrease slightly, and body temperature
falls.
 Stage 3 is the deepest stage of sleep, differing only in the percentage of delta waves recorded during
a 30-second period. – During deep sleep or delta sleep, the respiratory rates drop 20% to 30% below
those exhibited during waking hours.

Physiologic Changes in NREM Sleep

• BP falls, Pulse rate decreases, Peripheral blood vessels dilate, CO decreases, Skeletal muscles relax,
BMR decreases 10% - 30%, GH levels peak, Intracranial pressure decreases.
What happens to the sleep deprived client?
• Slows tissue repair,
• lowers pain tolerance,
• triggers fatique
• Increases susceptibility of infection
2. REM SLEEP

• REM sleep usually recurs about every 90 minutes and lasts 5 to 30 minutes. 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.
• In this phase, the sleeper may be difficult to arouse or may wake spontaneously, gastric secretions
increase, and heart and respiratory rates often are irregular.
• Acetylcholine and dopamine increase
• Brain is highly active
• Brain metabolism increases as much as 20%
• Distinctive eye movements occur
• Voluntary muscle tone dramatically decreased
• Deep tendon reflexes absent
• May be difficult to arouse or may wake spontaneously
• Gastric secretions increase
• HR and RR often are irregular
• Regions of brain associated with learning, thinking, organizing information stimulated
FUNCTIONS OF SLEEP: The effects of sleep on the body are not completely understood.
• Sleep exerts physiological effects on both the nervous system and other body structures.
• The role of sleep in psychological well-being is best noticed by the deterioration in mental
functioning related to sleep loss.
• Individuals with inadequate amounts of sleep tend to become emotionally irritable, have poor
concentration, and experience difficulty making decisions.

NORMAL SLEEP PATTERNS

Newborns
• Newborns sleep 12 to 18 hours a day, on an irregular schedule with periods of 1 to 3 hours spent
awake newborns enter REM sleep (called active sleep during the newborn period) immediately.
Infants
• At first, infants awaken every 3 or 4 hours, eat, and then go back to sleep. Periods of wakefulness
gradually increase during the first months. By 6 months most infants sleep through the night (from
midnight to 5 am) and begin to establish a pattern of daytime naps.
Toddlers
• Between 12 and 14 hours of sleep are recommended for children 1 to 3 years of age.
• Most still need an afternoon nap, but the need for midmorning naps gradually decreases.
Preschoolers
• The preschool-age child (3 to 5 years of age) requires 11 to 13 hours of sleep per night, particularly
if the child is in preschool.
• The 4- to 5-year-old may become restless and irritable if sleep requirements are not met.
School-Age Children
• The school-age child (5 to 12 years of age) needs 10 to 11 hours of sleep per night, but most
receive less because of increasing demands (e.g., homework, sports, social activities).
Adolescents
• Adolescents (12 to 18 years of age) require 9 to 10 hours of sleep each night; however, few actually
get that much sleep.
• Teens are sleepy at times and places where they should be fully awake—at school, at home, and
on the road.
Adults
• Most healthy adults get 7 to 8 hours of sleep per night (National Sleep Foundation, n.d.d).
However, individual needs do vary—some adults may be able to function well (e.g., without
sleepiness or drowsiness) with 6 hours of sleep, and others may need 10 hours to function
optimally.
▪ Older adults (65 to 75 years) usually awaken 1.3 hours earlier and go to bed approximately 1 hour
earlier than younger adults (ages 20 to 30).
▪ Older adults may show an increase in disturbed sleep that can create a negative impact on their
quality of life, mood, and alertness.

SLEEP DEPRivATiON AND SLEEP PRObLEMS

The teens:
• Has difficulty waking in the morning for school.
• Falls asleep in class or during quiet times of the day.
• Increases the use of caffeinated beverages like coffee, soda, or energy drinks.
• Feels tired, making it difficult to initiate or persist in projects such as a school assignment.
• Is irritable, anxious, and angers easily on days when he or she gets less sleep.
• Is involved in many extracurricular activities, has a job, and stays up late doing homework every
night, cutting into sleep time.
• Sleeps extra long periods of time on the weekend.

• Sleep quality is a subjective characteristic and is often determined by whether a person wakes up
feeling energetic or not.
• Quantity of sleep is the total time the individual sleeps.
 FACTORS AFFECTiNG SLEEP

A. Illness
• Illness that causes pain or physical distress (e.g., arthritis, back pain) can result in sleep problems.
B. Environment
▪ Noise in the environment—can inhibit sleep.
▪ Discomfort from environmental temperature (e.g., too hot or cold) and lack of ventilation can
affect sleep.
▪ Light levels can be another factor.
▪ Following an irregular morning and nighttime schedule can affect sleep.
▪ Moderate exercise in the morning or early afternoon usually is conducive to sleep, but exercise
late in the day can delay sleep.
▪ Night shift workers frequently obtain less sleep than other workers and have difficulty falling
asleep after getting off work
D. Emotional Stress
▪ Stress is considered by most sleep experts to be the one of the greatest causes of difficulties in
falling asleep or staying asleep.
▪ Hellhammer and Schubert (2013) have identified that a constant exposure to stress will increase
the activation of the hypothalamic–pituitary–adrenal (HPA) axis leading to sleep disorders.
E. Stimulants and Alcohol
• Caffeine-containing beverages act as stimulants of the central nervous system (CNS).
• Drinking beverages containing caffeine in the afternoon or evening may interfere with sleep.
F. Diet
• Weight gain has been associated with reduced total sleep time as well as broken sleep and earlier
awakening.
• Weight loss, on the other hand, seems to be associated with an increase in total sleep time and
less broken sleep.
G. Smoking
• Nicotine has a stimulating effect on the body, and smokers often have more difficulty falling asleep
than nonsmokers.
• Smokers are usually easily aroused and often describe themselves as light sleepers.
H. Motivation
• Motivation can increase alertness in some situations (e.g., a tired person can probably stay alert
while attending an interesting concert or surfing the web late at night).
I. Medications
• Some medications affect the quality of sleep.
• Most hypnotics can interfere with deep sleep and suppress REM sleep. Beta-blockers have been
known to cause insomnia and nightmares.
• Narcotics, such as morphine, are known to suppress REM sleep and to cause frequent awakenings
and drowsiness. Tranquilizers interfere with REM sleep.
COMMON SLEEP DiSORDERS
a. Insomnia
• Insomnia is described as the inability to fall asleep or remain asleep.
• Individuals with insomnia do not awaken feeling rested. Insomnia is the most common sleep
complaint in America.
B. Excessive Daytime Sleepiness
• Clients may experience excessive daytime sleepiness as a result of hypersomnia, narcolepsy, sleep
apnea, and insufficient sleep.

EXCESSIVE DAYTIME SLEEPINESS:

B.1.HYPERSOMNIA
• Hypersomnia refers to conditions where the affected individual obtains sufficient sleep at night
but still cannot stay awake during the day.
• Hypersomnia can be caused by medical conditions, for example, CNS damage and certain kidney,
liver, or metabolic disorders, such as diabetic acidosis and hypothyroidism.
B.2. NARCOLEPSY
• Narcolepsy is a disorder of excessive daytime sleepiness caused by the lack of the chemical
hypocretin in the area of the CNS that regulates sleep.
B.3. SLEEP APNEA
• Sleep apnea is characterized by frequent short breathing pauses during sleep.
• More than five apneic episodes or five breathing pauses longer than 10 seconds per hour is
considered abnormal and should be evaluated by a sleep medicine specialist.
• Symptoms suggestive of sleep apnea include loud snoring, frequent nocturnal awakenings,
excessive daytime sleepiness, difficulties falling asleep at night, morning headaches, memory and
cognitive problems, and irritability.
B.4. INSUFFICIENT SLEEP
• Healthy individuals who obtain less sleep than they need will experience sleepiness and fatigue
during the daytime hours.
• Depending on the severity and chronicity of this voluntary, albeit unintentional sleep deprivation,
individuals may develop attention and concentration deficits, reduced vigilance, distractibility,
reduced motivation, fatigue, malaise, and occasionally diplopia and dry mouth.
C. Parasomnias
• A parasomnia is behavior that may interfere with sleep and may even occur during sleep.
• It is characterized by physical events such as movements or experiences that are displayed as
emotions, perceptions, or dreams.
Other Parasomnias
• Bruxism. Usually occurring during stage 2 NREM sleep, this clenching and grinding of the teeth
can eventually erode dental crowns, cause teeth to come loose, and lead to deterioration of the
temporomandibular (TMJ) joint, called TMJ syndrome.
• Enuresis. Bed-wetting during sleep can occur in children over 3 years old. More males than females
are affected. It often occurs 1 to 2 hours after falling asleep, when rousing from NREM stage 3.

• Periodic limb movement disorder (PLMD). In this condition, the legs jerk twice or three times per
minute during sleep. It is most common among older adults. This kicking motion can wake the
 client and result in poor sleep. PLMD differs from restless leg syndrome (RLS), which occurs
whenever the person is at rest, not just at night when sleeping.

• Sleeptalking. Talking during sleep occurs during NREM sleep before REM sleep. Sleepwalking
(somnambulism) occurs during stage 3 of NREM sleep. It is episodic and usually occurs 1 to 2 hours
after falling asleep.

THE NURSiNG PROCESS FOR SLEEP DiSTURbANCE

ASSESSING
• A complete assessment of a client’s sleep difficulty includes a sleep history, health history,
physical exam, and, if warranted, a sleep diary and diagnostic studies. All nurses, however, can
take a brief sleep history and educate their clients about normal sleep.
Sleep History
• A brief sleep history, which is usually part of the comprehensive nursing history, should be
obtained for all clients entering a health care facility. It should, however, be deferred or omitted if
the client is critically ill.
Health History
• A health history is obtained to rule out medical or psychiatric causes of the client’s difficulty
sleeping. It is important to note that the presence of a medical or psychiatric illness.
Physical Examination
• Rarely are sleep abnormalities noted during the physical examination unless the client has
obstructive sleep apnea or some other health problem.
• Common findings among clients with sleep apnea include an enlarged and reddened uvula and
soft palate, enlarged tonsils and adenoids (in children), obesity (in adults), and in male clients a
neck size greater than 17.5 inches.
Sleep Diary
• A sleep specialist may ask clients to keep a sleep diary or log for 1 to 2 weeks in order to get a
more complete picture of their sleep complaints.
Diagnostic Studies
• Sleep is measured objectively in a sleep disorder laboratory by polysomnography in which an
electroencephalogram (EEG), electromyogram (EMG), and electro-oculogram (EOG) are recorded
simultaneously.

DIAGNOSING
Risk for Injury related to somnambulism
• Ineffective Coping related to insufficient quality and quantity of sleep
• Fatigue related to insufficient sleep
• Impaired Gas Exchange related to sleep apnea
• Deficient Knowledge (nonprescription remedies for sleep) related to misinformation
• Anxiety related to sleep apnea and/or the diagnosis of a sleep disorder
• Activity Intolerance related to sleep deprivation or excessive daytime sleepiness.

PLANNING
• The major goal for clients with sleep disturbances is to maintain (or develop) a sleeping pattern
that provides sufficient energy for daily activities.
• Other goals may relate to enhancing the client’s feeling of well-being or improving the quality and
quantity of the client’s sleep.
These interventions may include:
-reducing environmental distractions,
-promoting bed time rituals,
-providing comfort measures,
-scheduling nursing care to provide for uninterrupted sleep periods, and
-teaching stress reduction, relaxation techniques, or good sleep hygiene.
IMPLEMENTING
• The term sleep hygiene refers to interventions used to promote sleep.
• Nursing interventions to enhance the quantity and quality of clients’ sleep involve largely non-
pharmacologic measures. These involve:
1. health teaching about sleep habits
2. support of bedtime rituals
3. provision of a restful environment
4. measures to promote comfort and relaxation, and
5. appropriate use of hypnotic medications.
A. Client Teaching
They need to learn :
(a) the conditions that promote sleep and those that interfere with sleep,
(b) safe use of sleep medications,
(c) effects of other prescribedmedications on sleep,
(d) effects of their disease states on sleep, and
(e) importance of long periods of uninterrupted sleep.
B. Supporting Bedtime Rituals
Common pre bedtime activities of adults include:
a. listening to music
b. reading
c. taking a soothing bath, and
d. praying.
• Sleep is also usually preceded by hygienic routines, such as:
a. washing the face and hands (or bathing),
b. brushing the teeth, and voiding.
C. Creating a Restful Environment
All people need a sleeping environment with minimal noise, a comfortable room temperature
 To create a restful environment, the nurse needs to reduce environmental distractions, reduce sleep
interruptions, ensure a safe environment, and provide a room temperature that is satisfactory to the
client.
D. Promoting Comfort and Relaxation
Provide loose-fitting nightwear.
Assist clients with hygienic routines.
Make sure the bed linen is smooth, clean, and dry
Assist or encourage the client to void before bedtime.
For clients who have pain, administer analgesics 30 minutes before sleep.
Listen to the client’s concerns and deal with problems as they arise.
E. Enhancing Sleep with Medications
• Sleep medications often prescribed on a prn (as-needed) basis for clients include the sedative-
hypnotics, which induce sleep, and antianxiety drugs or tranquilizers, which decrease anxiety and
tension.
EVALUATING
• Using data collected during care and the desired outcomes developed during the planning stage
as a guide, the nurse judges whether client goals and outcomes have been achieved.
• Data collection may include
(a) observations of the duration of the client’s sleep,
(b) questions about how the client feels on awakening, or
(c) observations of the client’s level of alertness during the
day.