Rest and Sleep

Physiology of Sleep
 Darkness & preparing for sleep cause decrease in stimulation of the RAS
 Pineal gland secretes melatonin
 This results in person feeling sleepy
 Growth hormone is secreted & cortisol inhibited.
Biorhythms

 Circadian Rhythms =
 “about a day”
 Circadian Synchronization =
 awake when physiologic and psychological rhythms are most active
and asleep when lest active.
Circadian regularity

 Begins by 3rd week of life

 May be inherited
 By 5th or 6th month more like parents sleep-wake pattern.
Types of Sleep

Two types of sleep

NREM-
REM
Stages of Sleep: NREM
 Stage I- very light sleep (drowsy-relaxed) lasts a few mins.
 Stage II- light sleep
 body process continue to slow
 HR & RR decrease slightly
 Lasts about 10 – 15 min
 Makes up 44 – 55% of total sleep.
 Stage III- heart and respiratory rate are slower
Stages of Sleep: NREM

 Stage VI - signals deep, restful sleep /w slower brain waves.

 Thought to restore the body physically.
 Some dreaming occurs.
 Skeletal muscles relaxed
 Reflexes diminished
 Snoring most likely to occur
Physiologic changes during NREM
sleep
 Arterial BP falls
 Pulse increases
 Peripheral blood vessels dilate
 Cardiac output decreases
 Skeletal muscles relax
 Basal metabolic rate decreases 10 – 30%
 Growth hormone levels peak
 Intracranial pressure decreases
REM-Rapid eye Movement-
 Occurs about every 90 min & lasts 5-30 min
 Not restful
 Most dreams take place here
 Brain metabolism increases 20%
Sleep Cycle
Sleep Cycles
 Pass the four stages in 90 – 110 mins
 Sleeper passes through the 1st 3 NREM stages in about 20-30 min.
 After stage IV NREM sleeper passes thru Stages III and II in about
20mins
 Than the 1st REM occurs (lasts 10 mins)
Functions of Sleep
 Restores normal levels of activity
 Lack of sleep results in poor concentration, irritability, difficult decision
making.
 It use to be thought that a regular sleep pattern was more important than
actual hours slept but sleep deprivation is associated with cognitive & health
problems.
Normal Sleep Patterns and Requirements

 Newborns- sleep 16 to 18 hours a day, usually seven sleep periods

& enter REM sleep immediately.
 Infants at end of yr sleep 14 -15 hours a day
 Toddlers- 12-14 hours a day.
 Preschoolers- 11-13 hours of sleep per night
 School Aged children (5 – 12 yrs) need 10- 11 hours at night.
 Normal Sleep Patterns and Requirements

 Adolescents- 9-10 hours of sleep

 Young adults- 7-9 hours may require less
 Older Adults- 7-9 hours
Factors Affecting Sleep
 Age- One of the most important factors affecting persons sleep and rest
periods.
 Illness- causing pain or physical distress can result in sleep problems.
 Environment - Noise level
 Fatigue- more tired the shorter the first (REM) sleep
 Lifestyle- Shift work
Factors Affecting Sleep
 Emotional Stress
 Alcohol and Stimulants
 Diet
 Smoking
 Motivation
 Medications
Common Sleep Disorders
 Insomnia- most common sleep disorder, inability to obtain an adequate
amount or quality of sleep.
 Hypersomnia- Opposite of insomnia, excessive sleep, especially daytime.
 Narcolepsy- Sudden wave of overwhelming sleepiness that occurs during
the day. Referred to as “sleep attack”.
Primary Sleep Disorders
 Sleep Apnea- periodic cessation of breathing during sleep.

 Obstructive apnea : caused by occlusion of the

airway during sleep.
 Central apnea : Dysfunction in central respiratory
control
 Mixed : combination of Obstructive and Central
Sleep Apneas
 >5 apneic episodes or 5 breathing pauses longer than 10
seconds/hour.
Primary Sleep Disorders
 Sleep Apnea-
 Load snoring
 Nocturnal awakenings
 Excessive daytime sleepiness
 Difficulties falling asleep
 Morning headaches
 Memory/cognitive problems
 Irritability.
Sleep Disorders
 Parasomnias- Behavior that may interfere with sleep. (somnambulism,
sleep talking, Nocturnal enuresis, nocturnal erections, bruxism).
 Insufficient Sleep - prolonged disturbance resulting in decreases
amount, quality, consistency of sleep.
Assessment of Sleep
 Assessment of a client’s sleep includes:

a sleep history,
 sleep diary,
 physical examination,
a review of diagnostic studies.
Sleep History

 When does client usually go to sleep?

 Bedtime rituals?
 Does client snore?
 Can client stay away during day?
 Medication ?
Sleep History
 What is the usual sleeping pattern, specifically:
 sleeping and waking times
 hours of undisturbed sleep, etc.
 Bedtime rituals
 Use of sleep medications
 Sleep environment
 Changes in sleep pattern
Sleep Diary
 Written record to be much more precise

 Total number of sleep hours a day

 Activities performed 2-3 hours before sleep
 Bedtime rituals
 Any worries that may affect client’s sleep
 Factors that client believes to be positive or
negative towards sleep
Physical Examination
 Observation of clients facial appearance, behavior, and energy level.
 Darkened areas around the eyes, puffy eyelids, reddened
conjunctiva, glazed or dull appearing eyes.
 Irritability, yawning, slumped posture, hand tremor, rubbing of eyes,
confusion, fatigued, lethargic, etc.
Physical Examination

 Rarely yields information unless client has obstructive sleep apnea

 Enlarged and reddened uvula and soft palate

 Enlarged adenoids and tonsils (children)
 Obesity (adults)
 Neck circumference > 17.5 inches (men)
 Deviated septum (occasionally)
Diagnostic studies
 Polysomnography – (EEG, electromyogram & electro-oculogram are
recorded simultaneously).
 May also include respiratory effort & airflow, ECG, leg movement &
O2 sat.
NANDA Nursing Diagnoses

 Disturbed Sleep Pattern

 With specific descriptions such as “difficulty falling

asleep” or “difficulty staying asleep”
 Various etiologies may be involved and specified
NANDA Nursing Diagnoses

 Sleep pattern disturbances as etiology of other diagnoses:

 Risk for injury
 Ineffective coping
 Fatigue
 Risk for impaired gas exchange
 Deficient knowledge
 Anxiety
 Activity intolerance
Outcomes for Clients
With Sleep Disturbances
 Maintain (or develop) a sleeping pattern that provides sufficient
energy for daily activities
 Enhance feeling of well being
 Improve the quality and quantity of the client’s sleep
Implementation
 Nursing interventions are used to enhance the quantity and
quality of sleep & involve largely non-pharmacologic measures.
Interventions include-

 guided imagery
 therapeutic message
 progressive muscle relaxation
 uninterrupted sleep periods.
Implementation
 Client teaching
 Individuals need to learn the importance of rest
and sleep in maintaining active and productive
lifestyles.
 Supporting bedtime rituals
 Many are accustomed to rituals or pre-sleep
routines and if altered can affect sleep.
 Creating Restful Environment
Bedtime Rituals

 Altering or eliminating routines can affect sleep

 Adults
 Listening to music
 Reading
 Soothing bath
 Praying
 Children
 Need to be socialized into presleep routine
 Usually preceded by hygienic ritual
Implementation
 Promoting Comfort and Relaxation
 Assist client with hygienic routines
 Offer back message
 Administer analgesics 30 min before sleep
 Enhancing Sleep with Medications
 Nurse responsible for making decisions with the
client about when to administer sedative or
hypnotics.
Reducing Environmental Distractions
in Hospitals
 Close window curtains if street lights shine through
 Close curtains between clients in semiprivate and larger rooms
 Reduce or eliminate overhead lighting: provide night light at the bedside or in the
bathroom
 Close the door of the client’s room
Reducing Environmental Distractions in
Hospitals
 Perform only essential noisy activities during sleeping hours
 Ensure that all carts wheels are well oiled
 Wear rubber soled shoes
 Keep required staff conversations at low levels: conduct nursing reports or other
discussions in a separate area away from clients rooms
Teaching to promote rest & sleep

 Establish regular betime & wake up

 Eliminate lengthy naps
 Exercise just not 2 hrs before bedtime
 Est regular bedtime routine – listen to music, warm bath,
 Avoid heavy meals 3 hrs before bedtime
Teaching to promote rest & sleep

 Avoid alcohol & caffeine at least 4 hrs before bedtime

 Decrease fluid intake 2-4 hrs before bed
 Use sleeping meds as last resort
 Take analgesics before bedtime if needed
Nutrition Impact on Sleep

 No large fatty meals before sleep

 L-tryptophan increases sleep (milk & cheese)
 Protein – increases alertness (not a good before bed snack)
 Carbohydrates promote sleep

 crackers, bread, cereal

Comfort/Pain

 True
or False?
The nurse is the best judge of a
patient’s pain
TRUE OR FALSE?

 Youshould wait until pain has

reached the maximum amount
bearable before medicating.
True or False?

True pain always produces

observable signs/symptoms such
as grimacing or moaning
True or False?

 Ifthe patient doesn’t look like he’s in

pain, it’s ok to withhold medications
or decrease the dose.
True or False?

 Clients
taking pain medications will
become addicted.
So….What IS Pain?

A sensation that HURTS

 A SUBJECTIVE experience
 An interference : a multi-dimensional
experience and impact
 Protective
Types or Origins of Pain

 Cutaneous - superficial
 Somatic - ligaments, joints, muscles
 Visceral – internal organs/body cavities
 Neuropathic – nerve pain
 Radiating – Starts at origin, but extends to
other locations
 Referred – Pain felt distant to origin
 Phantom
Phantom
Duration of Pain

 Acute Pain - Sudden onset/short

duration (up to 6 months)
 Chronic Pain –Has lasted 6 months or
longer
 Intractable Pain – Chronic and very
resistant to relief
 http://www.youtube.com/watch?v=Hskb
fhiVJro
Quality of Pain

 What does it feel like?

 Sharp?
 Dull?
 Aching?
 Stabbing?
 Burning?
 Crushing?
 Tingling?
Intensity or Severity of Pain

How much does it hurt?????

Pain Rating Scales imperative –
Allows assessment of level of pain
and effectiveness of interventions
0-10 scale
Faces Pain Rating Scale
Poker Chips - “pieces” of pain
Faces
Numeric
.
Assessment of Pain: The Who,
What, When, Where, and How
Who?
The patient self-report is the most
reliable indicator of pain
What if it’s a child? The
parent/caregiver knows the child
best
What?

 What the patient says AND

 Your observations which may include:
 Physiological responses: Acute pain - Increased blood pressure, pulse
and respirations; dilated pupils, rapid speech
 Behavioral responses: Moaning, facial grimacing, crying, agitation,
guarding, withdrawing from painful stimuli
 Psychological responses: Anxiety, depression, anger, fear, exhaustion,
irritability
When?

 On admission
 Before
and after procedures or
treatments
 With each assessment/vital signs
 When the patient is resting as well as
during activity
 Before you give pain meds and 30 minutes
after
Where?

 Where ever the patient is and whatever is

going on?
Resting in bed
Ambulating
Before, during, after procedures whether
in the patient’s room or in another
location
How?

 Begin with a pain history

Do you have pain now?
When did the pain begin? (Onset)
Where is the pain located? (Location)
How do you rate your pain? (use a pain
scale) (Intensity)
How would you describe your pain?
(Quality)
How? (Pain History)

 How often do you have pain? (Frequency)

 What makes the pain better? (Alleviating
Factors)
 What makes it worse? (Aggravating Factors)
 Do you have any other symptoms when you
are experiencing pain, i.e. nausea/vomiting?
(Associated Factors)
How? (Pain History)

 Have you experienced this type of pain in the

past? If so, how did you manage/cope with
it? (History of Previous Pain Experience)
 Have you used any medications to treat the
pain? If so, what have you used and was it
effective?
 What, if any, alternative treatments have you
used for pain?
Review: Assessing Pain
How do we assess?
 Onset of symptoms  Alleviating Factors
 Location  Aggravating
 Intensity Factors
 Quality  Associated Factors
 Frequency  History
of Previous
Pain Experience
How?

 Combine your pain history with your

observations of:
Physiological responses
Behavioral responses
Psychological responses
Factors That May Affect Perception
of Pain
 Age
Child – may not recognize sensation of
pain or may have paradoxical reaction
Adolescent – may be expressed as
“attitude,” anger, aggression
Older adult – may have trouble
verbalizing because of perception that
pain is “normal” part of aging
Factors that may Affect Pain

 Culture
May impact level of pain one is willing to
endure
Need to use assessment tools that are
culturally sensitive
 Perception
of pain is impacted by
age and culture.
Analgesics Used for Pain

3 common groups of drugs used for

pain management
Opioids
Nonopioids
Adjuvants
 Pain Medications: Opioid
Analgesics
 Work on pain by blocking receptors in the Central Nervous System
Opioid Analgesics

 morphine sulfate
 methadone
 meperidine HCl (Demerol)
 hydromorphone (Dilaudid)
 Fentanyl
 oxycodone (Percocet)
 hydrocodone (Vicodin)
Opioid Analgesics

 Indications/Uses: More effective for

visceral pain
 Side/Adverse Effects: Respiratory
depression N/V, constipation,
drowsiness, pruritis (itching), dry
mouth, difficulty urinating,
tachy/bradycardias, hypotension
Opioid Analgesics

 Nursing Considerations:
Assess respiratory status frequently. If
respiratory depression occurs, administer
Narcan to reverse effects. Monitor blood
pressure.
Monitor for constipation and make
appropriate interventions (pg 741)
Treat other symptoms as indicated
Nonopioid Analgesics

 Used to relieve mild to moderate pain, acute or chronic (also may

relieve inflammation and fever)
 Acetaminophen (Tylenol) (minimal anti-inflammatory effect)
 NSAIDS (nonsteroidal anti-inflammatory drugs)
 aspirin
 ibuprofen (Motrin, Advil)
 naproxen (Aleve)
 Prescription NSAIDS: Celebrex, Voltaren, Indocin and others
Side/Adverse Effects of Nonopioids

 Acetaminophen – Can cause liver toxicity especially in patients

who consume alcohol or who have liver disease. Current
recommendation: maximum of 3000 mg (3g) per day as of July,
2011
 Aspirin – regular use can cause prolonged clotting time (bruise easily
and bleed more)
 Other NSAIDS – gastric irritation and bleeding, use with caution in
patients with impaired clotting and renal disease
Nursing considerations for
Nonopioids
 Tylenol– teaching regarding maximum
daily dose. Importance of reporting
overdose (liver damage occurs rapidly)
 NSAIDS – importance of taking with food.
Use of enteric-coated pills if gastric
irritation occurs. Monitor for gi bleeding.
Be aware of the possibility for drug
interactions.
Adjuvant Medications

Enhance the analgesic effect

of opioids
Anticonvulsants
Antidepressants
Sedatives
Steroids
Non-pharmacological Interventions for
Pain Management(see pgs. 736-738)
 Relaxation
 Guided imagery
 Distraction
 Therapeutic Touch
 Hypnosis
 Cutaneous Stimulation: TENS units, PENS units, Spinal Cord
stimulator, Acupuncture, Acupressure, Massage, Heat/Cold
Application, Contralateral stimulation