SLEEP & REST

Allah Rakhi
Nursing Istructor
Postgraduate College of Nursing, Punjab,
Lahore.
 Definition
• Rest is a condition in which the body is in
a decreased state of activity without
physical emotional stress and freedom from
anxiety.

• Sleep is a state of rest accompanied by

altered level of consciousness and relative
inactivity, and perception to environment are
decreased
 Physiology of Sleep
• The cyclic nature of sleep is thought to be
controlled by Centers located in the brain and
by Circadian Rhythms.

• Reticular activating system (RAS)

located at the brain stem and Cerebral Cortex
plays an important role in sleep wake cycle.
 Physiology of Sleep
• Sleep begins with the activation
of the pre optic area of the
anterior hypothalamus.
• Sleep promoting neurons act
over wake promoting neurons
by releasing
Gamma Amino Butyric Acid
(GABA).
• The inhibition of wake promoting
 Conti…
• Another key factor to sleep is exposure to
darkness.
• Darkness and preparing for sleep (e.g., lying
down, decreasing noise) cause a decrease in
stimulation of the RAS.
• During this time, the Pineal gland in the brain
begins to actively secrete the natural hormone
Melatonin, and the person feels less alert.
 Conti…
• With the beginning of daylight, Melatonin is
at its lowest level in the body and the
stimulating hormone, Cortisol , is at its
highest causing wakefulness.
 Circadian Rhythms
• It is a sort of 24-hour internal biological
clock. The term circadian is from the Latin
“circa dies”, meaning “about a day.”
• Biological 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.
 Types/ Stages/ Phases of Sleep
• Electroencephalogram (EEG) patterns, eye
movements and muscle activity are used to identify
stages of sleep. The stages of sleep are classified into
two stages:
• Non Rapid Eye Movement (NREM) Sleep
o Stage 1
o Stage 2
o Stage 3
o Stage 4
• Rapid Eye Movement Stage(rem) Sleep.
During sleep, NREM and REM sleep alternate in cycles
EEG
 Non Rapid Eye Movement
(NREM) Sleep
• First stage of sleep is known as NREM
sleep.
• About 75% to 80% of sleep during a night
is NREM sleep.
• It consists of four stages:
o Stage 1
o Stage 2
o Stage 3
o Stage 4
 NREM Sleep
• Stage 1: NREM
• Stage lasts a few minutes.
• It includes lightest level of sleep.
• Gradual fall in vital signs and metabolism.
• General slowing of EEG frequency
• Eyes tend to roll slowly from side to side
• Sensory stimuli such as noise easily arouses
person.
• Sleeper may deny he is sleeping.
 NREM Sleep
• Stage 2: NREM
• Stage lasts 10 to 20 minutes.
• It is a period of sound sleep.
• Relaxation progresses.
• Further slowing of EEG
• Absent eye ball movements
• Body functions continue to slow.
• Arousal remains relatively easy
 NREM Sleep
• Stage 3: NREM
• Stage lasts 15 to 30 minutes.
• It involves initial stages of deep sleep.
• Muscles are completely relaxed.
• Large slow waves in EEG
• Vital signs decline but remain regular.
• Sleeper is difficult to arouse and rarely moves
 NREM Sleep
• Stage 4: NREM
• Stage lasts approximately 15 to 30 minutes.
• It is the deepest stage of sleep.
• If sleep loss has occurred, sleeper spends
considerable portion of night in this stage.
• Vital signs are significantly lower than
during waking hours.
• Further slowing of EEG
• Sleepwalking and enuresis (bed-wetting)
sometimes occur.
• It is very difficult to arouse sleeper
 REM Sleep
• Stage usually begins about 90 minutes after
sleep has begun.
• Dreaming occurs in this stage
• Stage is typified by rapidly moving eyes,
fluctuating heart and respiratory rates,
increased or fluctuating blood pressure, loss
of skeletal muscle tone, and increase of gastric
secretions.
• EEG pattern resembles that of awake state.
• It is very difficult to arouse sleeper.
Sleep Cycle
 Functions of Sleep
• Conservation of energy
• Restoration of tissues and growth
• Thermoregulation
• Regulation of emotions- sleep deprivation
causes emotional disorders like irritability,
anxiety, depression etc.
• Neural maturation
• Memory and learning- there will be
information transfer between cerebral cortex
and hippocampus during sleep
 Normal Sleep Requirements
• Newborn: 16-18 hours /day
• Infants: 12-14 hours
• Toddlers: 10-12 hours
• Preschool: 11-12 hours
• School-Age: 8- 12 hours
• Adolescents: 8-10 hours
• Adult: 6-8 hours
• Elders: 6 hours
 Factors Affecting Sleep
• Both the quality and the quantity of sleep are affected
by a number of factors.
• Sleep quality is a subjective characteristic
• Quantity of sleep is the total time the individual sleeps.
• 1. Age
• 2. Illness
• Illness that causes pain or physical distress (e.g., arthritis,
backpain) can result in sleep problems
Examples:
• Respiratory conditions
• Pain
• Need to urinate during the night
 Conti…
• 3. Environment
• Environment can promote or hinder sleep
• Any change—for example, noise in the
environment—can inhibit sleep.
• The absence of usual stimuli or the presence of
unfamiliar stimuli can prevent people from sleeping
• Discomfort from environmental temperature (e.g., too
hot or cold) and lack of ventilation can affect sleep
• Light levels can be another factor
• Another influence includes the comfort and size of the
bed.
• A person’s partner who has different sleep habits, snores,
or has other sleep difficulties may become a problem for
the person also.
 Conti…
• 4. Lifestyle
• Following an irregular morning and night time
schedule can affect sleep.
• Night shift workers frequently obtain less sleep than
other workers and have difficulty falling asleep.
• 5. Emotional Stress
• Stress is considered to be the major cause of short-
term sleeping difficulties .
• A person preoccupied with personal problems (e.g.,
school- or job-related pressures, family or marriage
problems) may be unable to relax sufficiently to get to
sleep.
 Conti…
• 6. 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.
• Even though alcohol induces sleep, it disturbs REM
sleep causing irritability.
• 7. Diet
• Certain foods induces sleep
• Ex: the L- tryptophan present in the milk induces sleep
 Conti…
• 8. Smoking
• Nicotine has a stimulating effect on the body,
and smokers often have more difficulty falling
asleep than non smokers.
• Smokers can be easily aroused
• 9. Motivation
• Motivation can increase alertness in some
situations
• Ex: During the time of examination
Browsing internet in the late night
 Conti…
• 10. Medications:
• Beta-blockers have been known to cause
insomnia.
• Narcotics, such as morphine, are known to
suppress REM sleep and to cause frequent
awakenings and drowsiness.
• Most Hypnotics suppresses REM sleep
 Sleep Disorders
• Sleep disorders are mainly classified into
3 categories

SLEEP
DISORDERS

DISORDERS DUE
TO OTHER
DYSOMNIAS PARASOMNIAS
MEDICAL
CONDITIONS
 Dysomnias
• The sleep itself is pretty normal.
• But the client sleeps too little, too much, or
at the wrong time.
• So, the problem is with the amount (quantity),
or with its timing, and sometimes with the
quality of sleep.
 Dysomnias
• Common Dysomnias are:
• Insomnia
• Hypersomnia
• Narcolepsy
• Sleep Apnea
• Insufficient Sleep/ Sleep
Deprivation
 Insomnia
• Insomnia is described as the inability to fall
asleep or remain asleep.
• Persons with insomnia awaken not feeling
rested.
• Insomnia is the most common sleep
complaint.
 Conti…
• Acute insomnia lasts one to several nights and is
often caused by personal stressors or worry.
• If the insomnia persists for longer than a
month, it is considered Chronic insomnia
• Insomnia can result from physicl discomfort
and more often from mental tension or anxiety.
• People who are habituated to drugs or who takes
large amounts of alcohol are at high risk for
insomnia.
 Insomnia
Clinical manifestations:
• Difficulty falling asleep
• Waking up frequently during the night
• Difficulty returning to sleep
• Waking up too early in the morning
• Unrefreshing sleep
• Daytime sleepiness
• Difficulty concentrating
• Irritability
 Conti…
Management:
• Treatment is development of new behavioral
patterns that induces sleep
• Create a sleeping environment that induces
sleep
• Create positive sleep thoughts
 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.
• Treatment of hypersomnia include treating the
underlying disease conditions
 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.
• Clients with narcolepsy have sleep attacks or
excessive daytime sleepiness, and their sleep at
night usually begins with a sleep-onset REM
period (dreaming sleep occurs within the first 15
minutes of falling asleep).
 Conti…
• People sleeps several times a day even when
they are conversing with people or while
driving.
• CNS stimulants and Antidepressants are the
drugs used to treat narcolepsy.
 Sleep apnea
• Sleep Apnea is characterized by frequent short
breathing pauses during sleep.
• Although all individuals have occasional
periods of apnea during sleep, more than five
apneic episodes longer than 10 seconds in
an hour is considered abnormal and should
be evaluated by a sleep medicine specialist.
 Conti…
• Sleep Apnea is most frequently diagnosed
in men and postmenopausal women, it may
occur during childhood.
• Three types of apnoea based on the cause
• 1. Obstructive Apnoea
• 2. Central Apnea
• 3. Mixed Apnea
 Types of Sleep Apnea:
1. Obstructive Apnea:
• Obstructive apnea occurs when the structures of
the pharynx or oral cavity block the flow of air.
• Enlarged tonsils and adenoids, a deviated nasal
septum, nasal polyps, and obesity predispose the
client to obstructive apnea
Treatment
• Includes surgical removal of tonsills,
• Correcting nasal septum,
• Weight loss may be helpful.
 Conti…
2. Central Apnea:
• Due to defect in the respiratory centre of the
brain.
• Clients who have brainstem injuries and often
have central sleep apnea.
3.Mixed Apnea:
• Mixed apnoea is combination of obstructive
and central apnea
Insufficient Sleep/ Sleep Deprivation
• A prolonged disturbance in quality and
quantity of sleep can lead to a syndrome
called as Sleep deprivation.
• It is not a sleep disorder but result of
prolonged sleep disturbance.
• It produces various physiological and
behavioural symptoms based on the severity
of deprivation.
 Conti…
Individuals may develop:
• Attention and concentration deficits
• Reduced vigilance
• Distractibility
• Reduced motivation
• Fatigue
• Diplopia
• dry mouth.
 Parasomnias
• Something abnormal occurs during sleep itself, or
during the times when the client is falling asleep
or waking up
• The quality, quantity, and timing of the sleep are
essentially normal.
Most common DISORDERS are:
• Bruxism
• Enuresis
• Periodic limb movement disorder
• Sleep talking
• Sleep walking
 Parasomnias disorders:
■Bruxism.
Usually occurring during stage II NREM sleep,
 Characterized by clenching and grinding of the
teeth.
 This clenching and grinding of the teeth can
eventually erode dental crowns, cause teeth to
come loose, and lead to deterioration of the
temporomandibular joint (TMJ), called TMJ
syndrome
 Conti…
■Enuresis:
Bed-wetting during sleep occuring in
children over 3 years old.
• More males than females are affected.
• It often occurs 1 to 2 hours after falling asleep.
 Conti…
• 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.
• Respond well to medications such as
• Levodopa,
• Pramipexole ,
• Ropinirole,
• Gabapentin
 Conti…
• Sleeptalking. Talking during sleep occurs
during NREM sleep before REM sleep.
• It rarely presents a problem to the person
unless it becomes troublesome to others
• Sleepwalking. Sleepwalking (somnambulism)
occurs during stages III and IV of NREM
sleep. It is episodic and usually occurs 1 to 2
hours after falling asleep.
• Sleepwalkers tend not to notice dangers (e.g.,
stairs) and often need to be protected from
injury
Disorders due to other medical
conditions
• These disorders are associated with
medical or psychiatric or other illness
• Usually the disorders that cause sleep
disturbance includes:
• Depression
• Alcoholism
• Thyroid dysfunction
• Peptic ulcer
• COPD- chronic obstructive pulmonary
disease
 Nursing interventions to promote
sleep:
• 1. Sleep-Wake Pattern
• Maintain a regular bedtime and wake-up
schedule
• Eliminate day time naps. If naps are taken,
limit to 20 minutes or less twice a day
• Instruct the client to go to bed when sleepy.
• Use warm bath and relaxation techniques
• If unable to sleep in 15 to 30 minutes, get out of
bed and persue some relaxation activity.
 Conti…
• Establish a regular, relaxing bedtime routine
before sleep such as reading, listening to soft
music, taking a warm bath, or doing some
other quiet activity.
• Avoid dealing with office work or
family problems before bedtime
• Get adequate exercise during the day to
reduce stress, but avoid excessive physical
exertion at least 3 hours before bedtime.
 Conti…
• 2. Environment:
• Create a sleep-conducive environment that is
dark, quiet, comfortable, and cool.
• Keep noise to a minimum; block out
extraneous noise as necessary with white
noise from a fan, air conditioner.
• Sleep on a comfortable mattress and
pillows.
• Listen to relaxing music
• Increase exposure to bright light during the
day
 Conti…
• 3. Diet:
• Limit alcohol, caffeine, and nicotine in
late afternoon and evening
• Consume carbohydrates or milk as a light snack
before bedtime.
• Avoid heavy and spicy foods. Heavy or spicy
foods can cause gastrointestinal upsets that disturb
sleep
• Decrease fluids 2 to 4 hours before sleep
 Conti…
• 4.Medications:
• Use sleeping medications only as a last resort
• Minimize the usage of medicines as much as
possible because many contain antihistamines
that cause daytime drowsiness.
• Take analgesics 30 mins before bedtime to
relieve aches and pains.
• Consult the health care provider about
adjusting other medications that may cause
insomnia.
THANKS.