Sleep and Rest

UNIT FIFTEEN

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 Objectives
At the end of this session you will be able to:
• Define sleep and rest
• Describe the stages of sleep
• List factors affecting sleep and rest
• Describe the most common sleep alterations
• Discuss nursing interventions that promote
normal sleep and rest.

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 Sleep and Rest
• Sleep and rest are fundamental components of
wellbeing.
• Their need varies with age, developmental level,
health status, & activity level.
• Pain and impaired sleep are closely related in
most people.
• Sleep deprivation can decrease pain tolerance
and, thus, may exacerbate pain (especially
headaches).
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 Con’t...
Sleep
• It’s a reversible and naturally occurring state
of altered consciousness in which an
individual experiences:-
• Minimal physical activity &
• General slowing of the body’s physiological
processes.
• Occurs in a periodic cycle & lasts for several hours
at a time
• It’s necessary for physiological and psychological
healing to occur.
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 Con’t…

Rest
• A state of relaxation and calmness, both mentally
and physically.
• It can range from lying down to reading a book to
taking a quiet walk.
• Nurses should try to understand what activities and
environments the client defines as restful.

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 Physiology Sleep
• The cycles of wakefulness and sleep are controlled by
centers in the brain
• Are also influenced by routines and environmental
factors.
• An individual’s biological clock also helps determine
the specific cycles followed for wakefulness and sleep.
• The two systems in the brain stem are:-
– The reticular activation system &
– The bulbar synchronizing region
• Both work together to control the cyclic nature of
sleep 6
 Con’t …
• Also various neurotransmitters are involved in
the sleep process:-
– Norepinephrine , acetylcholine, dopamine,
serotonin and histamine ( for excitation)
– Gama amino butyric acid ( inhibition)

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 Stages 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:
– Non-rapid eye movement (NREM) and
– Rapid eye movement (REM) sleep
NREM Sleep
• With the onset of sleep, the heart rate and
respiratory rate slow slightly and remain regular.
• It’s the first phase of sleep
• It consists of four different stages.
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 NREM Sleep Con’t …
Stage 1
• As the client enters stage 1 sleep, there is:-
- A general slowing of EEG frequency but an
appearance of wave spikes;
- The eyes tend to roll slowly from side to side, and
- Muscle tension remains absent except in the
facial and neck muscles.
• In adults with normal sleep patterns, it usually lasts only
10 minutes
• It’s of a very light quality i.e (during this stage a sleeper
can be easily awakened)
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 NREM Sleep Con’t …
Stage 2
• It’s still fairly light sleep, with a further slowing
of EEG patterns and loss of slow rolling eye
movements.
• Fifty percent of normal adult sleep may be
spent in stage 2.
• After an initial 20 minutes or so of stage 2
sleep, a deep form of sleep called stage 3 to 4 is
entered.
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 NREM Sleep Con’t …

Stage 3 and stage 4 sleep

• Are frequently discussed together because of
the difficulty of identifying and separating the
two.
• Stage 3 refers to medium-depth sleep
• Stage 4 signals the deepest sleep
• During these stages, all cortical brain cells
appear to be firing at the same time, resulting
in large slow waves on the EEG

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 NREM Sleep Con’t …

• When roused from these stage, an adult can

take 15 seconds or so to become fully awake
and in children it’s even more pronounced .
• It’s where most sleepwalking, sleep talking,
enuresis, and night terrors occur.
• It’s felt to have restorative value, necessary for
physical recovery.

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 NREM Sleep Con’t …
• The majority of growth hormone is secreted at
night, peaking during stage 3 to 4 sleep near the
beginning of a sleep period.
• Growth hormone is required not only for growth but
also for normal tissue repair in clients of all ages.
• It accounts for approximately 25% of sleep in
children, declines slightly in young adulthood, then
gradually declines in middle age and may be absent
in elderly clients.
• Are most abundant during the early portion of a
sleep period
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 Rapid eye movement / REM/ Sleep
• After the initial 90 minutes or so of NREM sleep in
adults, the client enters rapid eye movement, or
REM, sleep.
• The EEG pattern resembles that of the awake
state;
• There are rapid conjugate eye movements;
• Heart rate and respiratory rate are irregular and
often higher than when awake;
• Muscles, including those of the face and neck, are
flaccid, leaving the body immobilized.
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 REM Sleep Con’t …
• Dreams occur 80% of the time clients are in REM
sleep.
• It become longer as the night progresses and the
individual becomes more rested.
• An adult typically has four to six REM sleep periods
through the night, accounting for 20% to 25% of
sleep.
• It makes up 50% of sleep in the newborn, then
gradually declines to 20% to 25% of sleep by early
childhood and remains fairly constant throughout
the remainder of the life span.
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 Sleep Cycle

A sleep cycle is the sequence of sleep that :

• Begins with the four stages

of NREM sleep in order, then

• Return to stage 3, then 2 then

• Passage into the REM stage.

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 Con’t …
• The duration of a sleep cycle is between 70
and 90 minutes
• A typical sleeper will pass through four to six
sleep cycles during an average sleep period of
7 to 8 hours.
• The 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.
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 Con’t….
• 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 intense.
• If the sleep cycle is broken at any point, a new
sleep cycle will start, beginning again at stage 1
of NREM sleep and progressing through all the
stages to REM sleep.

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 Biological Clock
• The biological clock
– An endogenous mechanism that measures time
– Controls the daily fluctuations in hundreds of
physiological processes including:-
• Body temperature, respiratory rate, performance, alertness,
and hormone levels.
• The most widely studied are the circadian
rhythms, or those that cycle on a daily basis.

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 Con’t
• When external time cues such as day-night,
sleep-wake, and mealtimes are inconsistent, a
desynchronization, (mismatching of the
circadian biological rhythms) occurs.
• This disrupts the timing of physiological and
behavioral activity,
– which in turn causes chronic fatigue, disrupts
sleep patterns, and causes decreased performance
and coping abilities
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 Factors Affecting Sleep and Rest
• Several factors can influence the quality and
quantity of both sleep and rest.
Degree of Comfort
• Comfort is a highly subjective experience.
• The nurse must assess the degree to which the
client’s physical and psychological needs have
been met.
• Unmet basic needs discomfort physiological-
tension resultant anxiety potential
impairments in
sleep/rest.
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 Con’t….
Anxiety
• A restless body and mind interfere with the ability
to sleep.
Example
– Unpleasant thoughts
– Work pressures, family demands, and other stressors
• Anxiety often results in difficulty falling or staying
asleep.

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 Con’t...
Environment
• It can either enhance or impair sleep.
• Different environment from the client’s usual
norm
– Lighting, temperature, odors, ventilation, and noise
level can all interrupt the sleep process

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 Con’t….
Lifestyle
• A fast-paced life filled with multiple stressors
results inability to relax easily or to fall asleep
quickly.
– Relaxation precedes healthy sleep.
• Having a work schedule that does not coincide
with an individual’s biological clock (e.g., working
at times other than the day shift).
– Individuals who frequently change work shifts have a
real challenge in trying to stabilize biological rhythms
and rest comfortably. 24
 Con’t.….
Diet
• Foods high in caffeine, such as:-
– Coffee, colas, and chocolate, serve as stimulants and often
disrupt the normal sleep cycle.
• Consuming a large, heavy, or spicy meal just before
bedtime
– May cause indigestion, which will likely interfere with sleep.
• Going to bed when hungry can also result in sleep
problems because
– The individual may be preoccupied with food and hunger
pangs instead of concentrating on sleep.
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 Con’t...
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 may interfere with REM sleep, causing
very restless and non-refreshing sleep.
• Nicotine (a stimulant)
– Impair the sleep cycle by stimulating the body, resulting in
difficulty falling and staying asleep.
• Many medications cause fatigue, sleepiness,
restlessness, agitation, or insomnia.
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 Life Span Considerations
• A person’s need for sleep changes with age in a
fairly predictable pattern.
The neonate (birth to 1 month)
• Sleeps in 3- to 4-hour intervals for a total of about
16 to 20 hrs per day.
• Is very passive, with little activity during sleep, and
typically sleeps very soundly.
• For the first few days or weeks of life, a baby’s
biological clock is not adjusted to regular day-night
patterns
– So there is often no difference in sleep patterns
between day and night.
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 Con’t…

The infant (one month to one year)

• About 12 to 16 hours of sleep per day
• As the infant ages, the amount of sleep needed
decreases.
• At approximately 2 months of age,
– Begins to sleep through the night and will typically
nap two or three times during the day.

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 Con’t…
Toddlerhood (1yr – 3yr)
• The daily average amount of sleep is 12 to 14
hours, which is 10 to 12 hours at night with one or
two daytime naps.
• During this stage, bedtime rituals often develop
and assume great importance in providing
nighttime security.
• Repeated and predictable nighttime routines such
as baths, brushing teeth, and reading books are
helpful in establishing expectations and comfort.
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 Con’t…
The preschool child (3yr – 6yr)
• Sleeps approximately 10 to 12 hours per day.
• Daytime napping decreases or ceases.
• Night sleep is often filled with vivid dreams and
nightmares, which often awaken children
several times during the night.

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 Con’t...
A school-age child (6yr – 12yr)
• Sleeps averagely about 10 to 12 hours daily.
• Resistance to bedtime and struggles for independence are
hallmarks of the school-age child.
• During this time, the child may develop fear of the dark
and will need reassurance and methods to handle this
fear.
Adolescents ( 12yr – 18yr)
• Sleep about 8 to 10 hours per day and often decide
themselves their bedtime routines and hours.
• High activity levels often interfere with regular sleep
patterns and irregular sleeping habits often become the31
 Con’t…
The young adult ( 18yr – 35yr)
• Sleeps averagely about 8 hours day.
• During this stage, sleep is often interrupted by
young children in the home or work responsibilities.
• Lifestyle patterns cause many young adults to
experience difficulties falling or staying asleep.
The middle-aged adult ( 36yr – 55yr)
• Sleeps about 6 to 8 hours a day.
• Daily stressors may continue to result in insomnia,
and use of sleep-inducing medications is common.
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 Cont...
The older adult (55yr and above)
• The sleep requirements decrease to 5 to 7 hours
per day, and often include a daytime nap.
• The quality of sleep often diminishes due to
frequent waking, physical pain, and shortened
REM sleep.
• Many elderly people misinterpret this decreased
need for sleep as insomnia and are thus overly
concerned about not getting “enough” sleep.

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 Illness or Hospitalization
• The stress imposed by illness usually disrupts sleep.
• Sleep is especially disrupted when a person is
hospitalized.
• Some factors associated with hospitalization that
lead to sleep impairment include:
– Physical or emotional pain
– Loss of familiar surroundings
– Fear of the unknown
– Timing of procedures and treatments
– Noise level (especially unfamiliar noises)
– Loss of privacy 34
 Alteration in Sleep Patterns
• Sleep pattern disturbance is defined as:
- The state in which an individual experiences or is
at risk of experiencing a change in the quantity or
quality of his or her rest pattern as related to the
person’s biological and emotional needs.
• The most common sleep alterations include
insomnia, hypersomnia, narcolepsy, sleep
apnea, sleep deprivation, and parasomnias.

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 Con’t...
Listed below are problems associated with sleep
disturbances:
• Decreased work productivity (more missed days of
work)
• Increased utilization of health care services
• Greater risk of accidents
• Decreased in concentration
• Increased irritability
• Cognitive and motor performance impairments

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 Con’t...
Insomnia
• Insomnia refers to the chronic inability to sleep or
inadequate quality of sleep due to sleep prematurely
ended or interrupted by periods of wakefulness.
• Insomnia is not a disease, but it may be a manifestation
of many illnesses.
• The person experiencing insomnia often gets caught up
in a vicious cycle of
– Not being able to sleep, trying harder to fall asleep, increasing
anxiety about not sleeping, which in turn increases the inability
to fall asleep.

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 Con’t…
• Perception of sleep quantity can also be
important; many insomniacs actually sleep
significantly more than they think they do.

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 Con’t...
Hypersomnia
• It’s an alteration in sleep pattern characterized
by excessive sleep, especially in the daytime.
• The person often feels that he can’t get enough
sleep at night, and therefore sleeps very late
into the morning and nap several times
throughout the day.
• Causes can be physical or psychological;
treatment depends on addressing the
underlying cause.
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 Con’t…
Narcolepsy
• Manifests as sudden uncontrollable urges to fall
asleep during the daytime.
• These individuals often achieve adequate sleep at
night but are overwhelmed by sleepiness at
unexpected and unpredictable periods during the
day.
• Effective treatments for narcolepsy include:-
– Avoiding substances or activities that cause sleepiness,
taking short daytime naps, or taking prescribed stimulant
medications.
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 Con’t...
Sleep Apnea
• Refers to periods of sleep during which airflow stops
for 10 seconds or more.
• It gives rise to complications as a result of oxygen
desaturation and carbon dioxide retention.
• Short-term consequences may include:-
– Cognitive impairment (including memory changes),
personality changes, and impotence.
• A major problem is daytime sleepiness, which may
interfere with functional abilities such as driving and
working.
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 Con’t...
• If untreated, sleep apnea can result in the following:
– Hypertension
– Cardiac arrhythmias
– Cognitive dysfunction
– Death
• The first line of defense against apnea is treating its
cause (emotional, cardiac, or respiratory alteration).
• With some individuals, surgical intervention is required
to correct the cause of the apnea.

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 Con’t...
Sleep Deprivation
• A prolonged inadequate quality and quantity of sleep,
either of the REM or the NREM type.
• It can result from age, prolonged hospitalization,
drug and substance use, illness, and frequent changes
in lifestyle patterns.
• It can cause symptoms ranging from irritability,
hypersensitivity, and confusion to apathy, sleepiness,
and diminished reflexes.
• Treating or minimizing the factors that cause the
sleep deprivation is the most effective resolution.
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 Con’t...
Parasomnia
• Refers to sleep alterations resulting from “an activation of
physiological systems at inappropriate times during the
sleep-wake cycle”.
• Somnambulism (sleepwalking), sleep talking, bed wetting,
and bruxism (teeth grinding) are the most common
parasomnias.
• It’s treatment varies, and care should be focused on helping
the client and family understand the disorder and its
potential safety risks.

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 Nursing Process
Assessment
• The client is a reliable source for this information,
but a spouse or partner who shares sleeping
arrangements may be able to add valuable to the
client’s report.
• Any client acknowledging a sleep disturbance
should be thoroughly
• Some of the questions used to assess are listed
here:

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 Con’t.….
• Questions regarding the client’s usual sleep patterns
should include:
– Nature of sleep (restful, uninterrupted)
– Quality of sleep (usual sleep pattern, schedules, hours
of sleep, feeling on waking)
– Sleep environment (description of room, temperature,
noise level)
– Associated factors (bedtime routines, use of sleep
medications or any other sleep inducers)
– Opinion of sleep (adequate, restores energy
adequately, inadequate, problematic)
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 Con’t.….

Questions regarding altered sleep patterns are

intended to discover such information as:
– Nature of the problem (inability to fall asleep,
difficulty remaining asleep, inability to fall asleep after
awakening, restless sleep, daytime sleepiness)
– Quality of the problem
• No. of hrs of sleep Vs No. of hrs spent trying to sleep
• No. of hrs of sleep at night, duration and frequency of naps
or other compensatory measures
• No. of wakings per sleep period

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 Con’t…
- Environmental factors (lighting, bed, noise level,
surrounding stimulation, sleep partner)
- Associated factors (relation to meals eaten, activity
before retiring, life stressors, work stressors, anxiety
level, pain, recent illness or surgery)
- Alleviating factors (mild diet, warm drink before
retiring, reading a book, listening to quiet music, taking a
hot bath, taking sleeping pills)
- Effect of problem (fatigue, irritability, confusion)

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 Nursing Diagnosis

• The primary diagnosis for individuals

experiencing sleep problems is Disturbed Sleep
Pattern.
• According to NANDA, it’s defined as
“A disruption of sleep time [that] causes
discomfort or interferes with desired lifestyle”.

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 Con’t…
• Alterations in sleep can manifest through
– Verbal complaints of the client,
– Physical signs such as yawning or dark circles under
the eyes, or
– Alterations in mood such as apathy or irritability.

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 Implementation

• It ranges from simple (e.g. correct bed making

techniques) to complex (teaching clients about
necessary lifestyle modifications).
• Several interventions that facilitate sleep are
discussed here.

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 Con’t
Establish a Trusting Nurse-Client Relationship
• The quality of the nurse-client relationship can
enhance a client’s ability to rest and sleep.
• Knowing that the nurse is a trustworthy
individual allows the client to relax and feel
secure.

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 Con’t...
Create a Relaxing Environment
• Arranging the immediate surroundings to
promote sleep
• A place to sleep should be inviting
• Determine the type of environment the client
finds relaxing, then provide this environment in
the inpatient setting, or help the client establish
this type of environment in the home setting.

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 Con’t…
Initiate Relaxation Techniques
• The client’s mood before sleep is very important.
• The client who is calm and relaxed is likely to fall
asleep quickly and stay asleep all night.
• Relaxation techniques are useful sleep aids.
• Progressive muscle relaxation is especially
therapeutic for the person who needs to lessen
muscular tension and quiet the mind.

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 Con’t….

Ensure Appropriate Nutrition

• Certain foods can actually enhance sleep.
– Tryptophan, a substance in milk, promotes sleep by
stimulating the brain’s production of the
neurotransmitter serotonin.
• Avoiding large or heavy meals close to bedtime
• Refraining from eating spicy or other foods that
cause gastrointestinal distress
• Avoiding caffeine after noon

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 Con’t…
Initiate Pharmacologic Interventions
If unrelieved pain is a factor in the client’s sleep
disturbance, pain management should be the
focus of initial interventions.
Pharmacologic agents for clients with sleep
disturbances include tricyclic antidepressants,
antihistamines, and short-acting hypnotics.

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 Con’t...
• The tricyclic antidepressants of choice are
amitriptyline or doxepin.
• Amitriptyline improves the client’s ability to fall
asleep and stay asleep by causing sedation when
given 1 to 3 hours before bedtime.
• Antihistamines such as hydroxyzine and
diphenhydramine have mild sedative effects that
could promote sleep if given at bedtime.
• If anxiety throughout the day is of concern, low
doses of these medications at regular intervals
throughout the day may be effective. 57
 Con’t...
• The final group of pharmacologic interventions for
sleep disturbances are the short-acting hypnotics.
• These are not recommended for routine or long-
term use, but they may be effective as a short-
term intervention.
• When they are chosen, it is recommended that
one with a short half-life be used.

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 Con’t…
Provide Client Education
• About sleep-promoting activities
• This helps them
– To gain a sense of control over their sleep
disturbance
– To enhance their confidence that they can
successfully meet their sleep and rest needs.

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