What is Rest?
Condition in which the body is in a decreased state of activity, with the consequent feeling of being
refreshed; state of relaxation
What is sleep?
State of rest accompanied by altered consciousness and relative inactivity
Period of inactivity and restoration of mental and physical function; the mind restores itself
What is wakefulness?
Time of mental activity and energy expenditure
Circadian Rhythm
Predictable cycle that happens every 24 hours
Ex: cortisol levels, appetite levels changing throughout the day, sleep-wake patterns (regulated by
hypothalamus)
Stages of Sleep
Non-rapid eye movement (NREM)
o Consists of four stages
Stages I and II: light sleep, easy to arouse
Stages III and IV—deep-sleep states (delta sleep), more difficult to arouse; stage 4 is the
deepest
Rapid eye movement (REM)
o 20% to 25% of a person’s nightly sleep time
o Phase when cognitive restoration occurs; if the person doesn’t make it to REM then they do not
get a good night’s rest
o Varying vital signs (sometimes vitals increase with dreams)
o Skeletal muscle tone and deep tendon reflexes are depressed (kind of like being paralyzed)
o Dreaming occurs during REM
o Average length of REM is 20 minutes, longer with each sleep cycle
The person passes consecutively through four stages of NREM sleep
The pattern is then reversed
o Return from stage IV to III to II
o Enter REM sleep instead of re-entering stage I; you never go back into stage I unless you wake up
The person re-enters NREM sleep at stage II and moves on to III and IV; you typically wake up around a
stage II
Effects of Insufficient Sleep
May affect normal growth and development in children due to lack of cognitive restoration
Increases risk for heart attack, diabetes, stroke, depression, obesity
Lowers leptin levels and elevates ghrelin levels
o Leptin: hormone that tells the brain to stop eating
o Ghrelin: promotes continued eating; becomes elevated when tired
Developmental Patterns of Sleep
The younger the person, the more sleep they require; sleep requirements decrease over time. Harder for
geriatric patients to get into deep sleep due to smaller bladder, obesity and pain
Older adults- lighter sleep
Factors Affecting Rest and Sleep
Developmental considerations
Motivation
Culture
Lifestyle and habits
Environmental factors (temperature, light, noise level)
Psychological stress
Illness
Medications (some cause hyperactivity)
Exercise promotes sleep if completed 3hr before bedtime
Lifestyle and Habits
Activity and exercise increase fatigue and can promote relaxation followed by sleep; increases both REM
and NREM sleep; contributes to a more restful sleep
Dietary habits:
o Amino acid L-tryptophan promotes sleep
o Small protein snack combined with a healthy complex carbohydrate(slowly raise blood sugar)
before bed improves sleep
o Large quantities of alcohol limit REM and delta sleep
o Caffeine blocks the ability of adenosine to cause drowsiness
Smoking and nicotine are associated with poorer sleep
Sleep Hygiene: promoting good sleep habits
Establish and follow a bedtime routine.
Limit waking clients during the night.
Promote a quiet hospital environment.
Help with personal hygiene needs or a back rub prior to sleep to increase comfort.
Consider continuous positive airway pressure (CPAP) devices for clients who have sleep apnea.
Consult the provider about trying sleep-promoting over-the-counter products (melatonin, valerian,
chamomile).
As a last resort, suggest that the provider prescribe a pharmacological agent.
Adjust inpatient routines when possible, to conform with clients’ home routines (bathing, bedtime).
Psychological Stress
Can be caused by illness or life situations
Disturbs sleep
o Difficult to obtain the amount of sleep needed
o REM sleep decreases, leading to anxiety and stress
Illnesses Associated that disturb sleep
Gastroesophageal reflux (avoid laying patient flat)
Coronary artery diseases
Epilepsy seizures
Liver failure and encephalitis
Hypothyroidism (patient is very tired all the time)
End-stage renal disease
Medications that Interrupt Sleep (think about the timing you administer medication)
Amphetamines
Antidepressants
Diuretics
Antihypertensives
Steroids
Decongestants
Caffeine
Insomnia
Characterized by difficulty falling asleep, intermittent sleep or difficulty maintaining sleep
People with a history of depression are more likely to experience insomnia
May be acute or chronic in nature
Women and older adults are at greater risk
Sleep-Related Breathing Disorder: Obstructive Sleep Apnea (OSA)
Defined by more than five breathing cessations lasting longer than 10 seconds per hour during sleep,
resulting in decreased arterial oxygen saturation levels.
Sleep apnea can be a single disorder or a mixture of the following.
o Central: Central nervous system dysfunction in the respiratory control center of the brain that fails
to trigger breathing during sleep.
o Obstructive: Structures in the mouth and throat relax during sleep and occlude the upper airway.
Diagnosed through a sleep study test
Narcolepsy
Characterized by excessive daytime sleepiness and frequent overwhelming urges to sleep or inadvertent
daytime lapses into sleep; usually lasts about 2 minutes; uncontrollable
Most people with narcolepsy also experience cataplexy, the sudden, involuntary loss of skeletal muscle
tone lasting from seconds to one or two minutes
Hypersomnolence Disorder
Excessive daytime sleepiness lasting at least 3 months
Impairs social and vocational activities
Increased risk for accident or injury related to sleepiness
Parasomnias- unusual events that occur during sleep
Somnambulism
o Sleep walking, unaware of environment; safety concern
REM sleep behavior disorder (RBD)
o Exaggerated movements during sleep
Sleep terrors (Important to know the difference between sleep terrors and nightmares)
o Patient doesn’t remember it happening
o Unresponsive to comforting behavior, occurs during deep sleep stages
Nightmare disorder
o Frightening dreams; occurs during lighter stages of sleep so you remember it the next morning
Sleep enuresis (bed wetting)
Sleep-related eating disorder
o Eating in your sleep without knowing; safety concern
Sleep-Related Movement Disorders/Restless Legs Syndrome (RLS)
AKA Willis–Ekbom disease (WED), is common among middle-aged and older adults
People with RLS cannot lie still and report unpleasant creeping, crawling, or tingling sensations in the legs
No diagnosis and no known cure
Nonpharmacologic treatments- massage, walking, stretching
Obtaining a Sleep History
Ask all the detailed questions:
o Nature of problem
o Cause of problem
o Related signs and symptoms
o When the problem began and how often it occurs
o How the problem affects everyday living
o Severity of the problem and how it can be treated
o How the patient is coping with the problem and success of treatments attempted (ex: have you
taken melatonin or other sleep aids?)
Information Recorded in a Sleep Diary: have the pt. write down everything about their sleep life
Time patient retires
Time patient tries to fall asleep
Approximate time patient falls asleep
Time of any awakening during the night and resumption of sleep
Time of awakening in morning
Presence of any stressors affecting sleep
Record of food, drink, or medication affecting sleep
Record of physical and mental activities
Record of activities performed 2 to 3 hours before bedtime
Presence of worries or anxieties affecting sleep
Sleep Characteristics to Assess
Restlessness
Sleep postures**
Sleep activities
Snoring***
Leg jerking
Key Findings of Physical Assessment
Energy level (means you’re getting good adequate sleep)
Facial characteristics (red eyes, droopy eyes)
Behavioral characteristics