2. Physiology of Sleep
• Sleep is altered state of consciousness where
perception of and reaction to environment
decreased.
• The cyclic nature of sleep is thought to be
controlled by the lower part of brain.
• The upper part of the reticular formation consists of
a network of ascending nerve called RETICULAR
ACTIVATING SYSTEM (RAS)– which is involved
with the sleep/wake cycle.
• The intact cerebral cortex and reticular formation
are necessary for the regulation of sleep and
waking states.
3. Physiology of Sleep
• Neurotransmitters, located within neurons in the brain, affect the
sleep/wake cycles.
• 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.
• Pineal gland in the brain begins to actively secrete the natural
hormone melatonin, and the person feels less alert.
• During sleep, the growth hormone is secreted, and cortisol is
inhibited.
• With the beginning of daylight, melatonin is at its lowest level in the
body and the stimulating hormone, cortisol, is at its highest.
• High levels of acetylcholine, dopamine, and noradrenaline is
associated with wakefulness.
4. Circadian Rhythm
It is a sort of 24-hour internal biologic clock.
are physical, mental and behavioral changes that follow
a roughly 24-hour cycle, responding primarily to light
and darkness in an organism's environment.
–Person awakes when body temp highest and asleep
when body temp lowest
• Circadian regularity begins to develop by the sixth week
of life, and By 3-6 months of age an individual already
have a regular sleep-wake cycle.
5. Sleep Architecture
SLEEP ARCHITECTURE - Refers to basic
organization of sleep.
Two types of sleep:
1. Non-Rapid-Eye-Movement (NREM)
2. Rapid-Eye-Movement (REM)
6. NREM Sleep
• Occurs when activity in RAS (reticular activating
system) is inhibited.
• About 75% - 80% of sleep during a night is NREM
sleep
• NREM sleep was previously divided into four stages.
It is now divided into three stages.
7. STAGES of Non-rapid eye movement
(NREM) Sleep
• Stage I
– Very light sleep and lasts only a few minutes
– The person feels drowsy and relaxed
– The eyes roll from side to side
– The heart rate and respiratory rate drop
slightly
– The person can be readily awakened and may
deny that he/she is sleeping.
8. STAGES of Non-rapid eye movement
(NREM) Sleep
• Stage II
– Light sleep lasts only about 10 to 15 minutes
– Body processes continue to slow down
– Eyes are generally still
– The heart rate and respiratory rate decreases
slightly
– Body temperature falls
– 44% to 55% of total sleep
– Requires more intense stimuli to awaken such
as touching and shaking
9. STAGES of Non-rapid eye movement
(NREM) Sleep
• Stage III
– Deepest stages of sleep (delta sleep or deep sleep)
– The persons heart rate and respiratory rate drop 20%
to 30% below waking hours
– The sleeper or the person is difficult to arouse
– The person is not disturbed by sensory stimuli
– The skeletal muscles is very relaxed, and reflexes are
diminished
– Snoring is most likely to occur
– Swallowing and Saliva production are reduced.
– These stages are essential for restoring energy and
releasing important growth hormone.
11. Characteristics of Rapid Eye
Movement (REM) Sleep
• Usually occurs every 90 minute and lasts for 5 to 30 minutes
• Most dreams take place during REM Sleep
• Brain is highly active and brain metabolism increases as
much as 20%
• Distinctive eye movements occur
• Voluntary muscle tone is dramatically decreased and deep
tendon reflex are absent.
• In this phase, the sleeper may be difficult to arouse.
• Gastric secretion increases
• The heart rate and respiratory rate often are irregular.
• The regions of the brain that are used in learning, thinking
and organizing information are stimulated during REM sleep.
12. Functions of Sleep
• Restores normal levels of activity
• Restores normal balance among parts of
the nervous system
• Necessary for protein synthesis.
• Allows repair processes to occur.
• Enhances psychological well-being.
13. Sleep Patterns: Newborns
• Sleep 12 to 18 hours a day
• Periods of 1 to 3 hours spent awake
• Enter REM sleep immediately
• Newborns spend nearly 50% NREM and
50% REM
• Sleep cycle is about 50 minutes.
14. Sleep Patterns:
Infants (a child in the first year of life)
• Infants awaken every 3 to 4 hours, eat, and
then go back to sleep.
• Periods of wakefulness gradually increase
during the 1st month.
• By 6 months, most infants sleep through
the night and begin to establish a pattern of
daytime naps.
• At the end of the 1st year, an infant usually
takes 2 naps per day and get about 9-12
hours of sleep in 24 hours.
15. Sleep Patterns:
Toddlers (a child between the ages of one and three)
• Between 12 to 14 hours are
recommended.
• Most still need an afternoon nap.
• Nighttime fears and nightmares are also
common.
16. Sleep Patterns:
Preschool and School-age
• Preschool child (3-5 years)
– requires 11 to 13 hours of sleep.
– Sleep needs fluctuate in relation to activity and
growth spurts.
• School-age child (aged 5 to 12)
– needs 10-11 hours of sleep but most receive
less.
– They may also spend more time on computer
and watching television.
17. Sleep Patterns: Adolescents
(12 – 18 years of age)
• Require 9-10 hours of sleep each night
however, few actually get that much sleep
• Circadian rhythms tend to shift thus,
tendency to stay up late at night and wake
up later in the morning.
18. Sleep Patterns: Adults and Older Adults
• Adults
– Most healthy adults need 7-8 hours of sleep per night
– There is individual variations—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 old)
– Tendency toward earlier bedtime and wake times
– May show an increase in disturbed sleep which may create a
negative impact in their quality of life, mood and alertness.
– They may awaken an average of six times during the night.
19. Factors the Affect Sleep
• Illness- that cause pain or physical distress can result to sleep
problems.
• Environment- can either promote or hinder sleep.
(Noise, too hot/too cold, light preferences, snores/ sleep habits)
• Lifestyle – irregular morning and nighttime schedule can affect
sleep e.g. (Night shift workers, Wearing dark wrap-around
sunglasses during the drive)
• moderate exercise in the morning or early afternoon usually is
conducive to sleep, but exercise late in the day can delay sleep.
• Emotional stress- Stress is considered number one of causes sleep
difficulties. Anxiety increases the norepinephrine blood levels
through stimulation of the sympathetic nervous system.
• Stimulants and alcohol -Drinking beverages containing caffeine
in the afternoon or in the evening may interfere with sleep.
20. Factors the Affect Sleep (cont'd)
• Diet
– weight gain -is associated with reduced total sleep
time as broken sleep and earlier awakening.
– Weight loss – seems to be associated with an
increase in the total sleep time and less broken
sleep.
• Smoking – nicotine has stimulating effect on the body and
smokers often have difficulty falling asleep.
• Motivation- can increase alertness in some situation (a
tired person can stay alert attending a concert or while surfing
the web late at night.)
• Medications – some medications affect the quality of
sleep.
22. Insomnia
❑is described as the inability to fall asleep or
remain asleep.
Clinical Manifestations of Insomnia:
– 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
24. Excessive Daytime Sleepiness
Clients may experience excessive daytime sleepiness as a
result of hypersomnia, narcolepsy, sleep apnea, and
insufficient sleep.
✔Hypersomnia
✔Narcolepsy
✔Sleep apnea
✔Insufficient sleep
25. Hypersomnia
❑Refers to conditions where the affected
individual obtains sufficient sleep at night
but still cannot stay awake during the
day.
o Caused by medial or psychological disorders
26. Narcolepsy
❑is a disorder of excessive daytime
sleepiness.
✔caused by the lack of the chemical
hypocretinin the area of the Central Nervous
System (CNS) the regulates sleep.
✔Clients have sleep attacks
✔Sleep at night usually begins with sleep-onset
REM period
27. Sleep Apnea
❑is characterized by frequent short
breathing pauses during sleep.
o Breathing pauses can last from a few seconds
to minutes.
o Frequent short breathing pauses during night
o More than 5 apneic episodes or 5 breathing pauses
longer than 10 sec/hr is considered abnormal.
o Symptoms suggestive of sleep apnea
✔ Snoring
✔ frequent nocturnal awakenings
✔ Excessive daytime sleepiness
✔ Difficulty falling asleep at night
✔ Morning headaches
✔ Memory and cognitive problems and irritability
28. Parasomnia
❑ a behavior that may interfere with sleep
and may even occur during sleep.
oArousal disorders (example: Sleepwalking,
sleep terrors)
oSleep-wake transition disorders (example:
Sleep talking)
oAssociated with REM sleep (example:
Nightmares)
o Others- Bruxism (involuntary or habitual grinding of
the teeth, typically during sleep.)
29. Parasomnias
Sleepwalking -Also called SOMNAMBULISM.
-Occurs during stage III and IV of NREM
sleep.
-Sleep walkers tend NOT to notice
dangers.
- they often need to be protected from
injury.
Sleeptalking -talking during sleep.
- Occurs during NREM sleep
Bruxism -Clenching and grinding of the teeth.
- Usually occurs during Stage ii of NREM
sleep.
Enuresis -Bed-wetting during sleep can occur in ٢٩
30. Assessment
• Sleep history
• Health history
• Physical exam
• If warranted, a sleep diary and diagnostic
studies
31. Sleep History
• When does client usually go to sleep?
• Bedtime rituals?
• Does client have any problem in her/his
sleep?
• Taking any prescribed or OTC medications?
• Is there anything else I need to know about
your sleep?
32. Health History
• Obtain information about medical or
psychiatric problems that may influence
sleep. (e.g., depression, Parkinson’s disease,
Alzheimer’s disease, or arthritis)
• Medication history should be obtained (all
of the prescribed and nonprescribed and
herbal remedies)
33. Physical Examination
• Rarely are sleep abnormalities noted
during the physical examination unless the
client has obstructive sleep apnea.
Common findings among clients with sleep
apnea includes:
– Enlarged and reddened uvula and soft palate
– Enlarged adenoids and tonsils (children)
– Obesity (adults)
– Neck circumference greater than 17.5 inches (men)
– Deviated septum (occasionally)
34. Sleep Diary
• Client may be asked to keep track of:
– Time of going to bed.
– Activities performed 2 to 3 hours before bedtime (type,
duration and time).
– Consumption of caffeinated beverages and alcohol
and amounts of those beverages.
– Any prescribed medications.
– Bedtime rituals before sleep.
– Any difficulties remaining awake during day and times
when difficulties occurred.
– Any worries or fears of the client that may affect sleep.
– Factors that client believes have a positive or negative
effect on sleep.
35. Diagnostic Studies
• Polysomnography - also called a sleep study, is
a test used to diagnose sleep disorders.
- records the brain waves, the oxygen level in
your blood, heart rate and breathing, as well as eye and
leg movements during the study.
✔EEG (Electroencephalogram) - a test that detects
electrical activity in your brain using small, flat metal discs
(electrodes) attached to your scalp.
✔EMG (Electromyography) - an electrodiagnostic
medicine technique for evaluating and recording the electrical
activity produced by skeletal muscles.
✔EOG (Electrooculography) - a technique for
measuring the corneo-retinal standing potential that exists
between the front and the back of the human eye.
36. NANDA Nursing Diagnoses
• Insomnia “difficulty falling asleep” or “diffi- culty
staying asleep”
• 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 related to misinformation
• Anxiety related to sleep apnea.
• Activity intolerance related to sleep deprivation or
excessive daytime sleepiness.
37. Planning
• Maintain (or develop) a sleeping pattern
that provides sufficient energy for daily
activities.
• Enhance client’s feeling of well being.
• Improve the quality and quantity of the
client’s sleep.
38. Implementation: Sleep Hygiene
Sleep Hygiene – refers to interventions used to
promote sleep.
These are used to promote sleep:
– Client education – healthy individuals need to learn the
importance of sleep in maintaining active and productive
lifestyles.
– Supporting bedtime rituals- this includes: listening to
music, reading, taking a soothing bath, and praying.
– Creating a restful environment- an environment with
minimal noise, comfortable temp., appropriate lighting.
– Promoting comfort and relaxation – comfort
measures help client fall asleep.
– Sleep medications, if appropriate- sleep
medications are often prescribed in PRN basis.
39. Client Teaching
• Explain the importance of sleep.
• Encourage conditions that promote sleep.
• Prevent conditions that interfere with sleep.
• Safe use of sleep medications
• Inform the effects of the prescribed
medications on sleep.
• Explain the effects of disease states on
sleep.
40. Bedtime Rituals
• Discourage routines that can affect sleep.
• To encourage sleep among adults:
– Listening to music
– Reading
– Soothing bath
– Praying
41. Bedtime Rituals (cont'd)
• Children
– Need to be socialized into a pre-sleep routine such
as a bedtime story, holding onto a favorite toy or
blanket, and kissing everyone goodnight.
– Usually preceded by hygienic ritual (Washing
the face, hands or bathing, and brushing the
teeth and voiding.
42. Creating a Restful Environment
• Minimize noise
• Provide a comfortable room temperature
• Provide an appropriate ventilation
• Appropriate lighting
43. Promoting Comfort and Relaxation
• A Concerned, caring attitude along with the following interventions:
• 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.
• Offer to provide a back massage before sleep.
• Position dependent clients appropriately to aid muscle relaxation, and
provide supportive devices to protect pressure areas.
• Schedule medications, especially diuretics, to prevent nocturnal
awakenings.
• For clients who have pain, administer analgesics 30 minutes before
sleep.
• Listen to the client’s concerns and deal with problems as they arise.
44. Medications
• Sedative-hypnotics (induce sleep)
• Anti-anxiety or tranquilizers
• Be aware of actions, effects, risks of specific medications.
• Clients need to be cautioned about such effects and about
driving or handling machinery.
• Sleep medications affect REM sleep more than NREM sleep.
• Initial doses of medications should be low, and increases
added gradually.
• Regular use of any sleep medication can lead to tolerance
over time.
•
45. 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.
46. Evaluating
• 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.
• If the desired outcomes are not achieved, the
nurse and client should explore the reasons.
