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1. REST AND SLEEP
PREPARED BY
MS REKHA KUMARI
ASSISTANT PROFESSOR
SHARDA UNIVERSITY

2. SLEEP AND REST

3. 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

4. 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.

5. CONT…
• 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 neurons
results in intensifying sleep process.

6. CONT……
• 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.

7. CONT………
• 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.

8. 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.

9. 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

10. 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

11. 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.

12. 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

13. 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

14. 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

15. 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.

16. SLEEP CYCLE AND ITS STAGES

18. 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

19. 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

20. 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

21. CONT………..
• 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

22. CONT……………
• 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.

23. CONT…………..
• 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.

24. CONT………………
• 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.

25. CONT………………..
• 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.

26. CONT……..
• 7. Diet
• Certain foods induces sleep
• Ex: the L- tryptophan present in the milk
induces sleep

27. • 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

28. CONT……..
• 9. Motivation
• Motivation can increase alertness in some
situations
• Ex: During the time of examination
Browsing internet in the late night

29. CONT………..
• 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

30. SLEEP DISORDERS
• Sleep disorders are mainly classified into 3
categories
SLEEP
DISORDERS
DYSOMNIAS PARASOMNIAS
DISORDERS DUE
TO OTHER
MEDICAL
CONDITIONS

31. 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.

32. DYSOMNIAS
• Common Dysomnias are:
• Insomnia
• Hypersomnia
• Narcolepsy
• Sleep Apnea
• Insufficient Sleep/ Sleep Deprivation

33. 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.
• 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

34. ……..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.

35. 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

36. Insomnia
• Treatment is development of new behavioral
patterns that induces sleep
• Create a sleeping environment that induces
sleep
• Create positive sleep thoughts

37. 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.

38. Hypersomnia
• Treatment of hypersomnias include treating
the underlying disease conditions

39. 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).

40. Narcolepsy
• 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.

41. 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.

42. …….Sleep Apnea
• 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

43. …….Sleep Apnea
• 1. OBSTRUCTIVE APNOEA:
• 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.

44. …….Sleep Apnea
• 2. CENTRALAPNEA:
• Due to defect in the respiratory centre of the
brain.
• Clients who have brainstem injuries and often
have central sleep apnea.
• 3.MIXED APNOEA
• Mixed apnoea is combination of obstructive
and central apnea

45. 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.

46. Insufficient Sleep/ Sleep
Deprivation
Individuals may develop:
• Attention and concentration deficits
• Reduced vigilance
• Distractibility
• Reduced motivation
• Fatigue
• Diplopia and dry mouth.

47. 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

48. …….PARASOMNIAS
■ 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 (TMJ) joint, called
TMJ syndrome

49. …….PARASOMNIAS
■ 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.

50. …….PARASOMNIAS
• 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, and
gabapentin

51. …….PARASOMNIAS
• 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

52. …….PARASOMNIAS
• 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

53. MANAGEMENT OF SLEEP DISORDERS
1. Primary insomnia:
- Relaxation therapy
- Pharmacotherapy
2. Primary hypersomnia/ Nacrolepsy:
- Pharmacotherapy
3. Parasomnias:
4. Sleep wake schedule disturbances:
-Behaviour modifications.
- Phototherapy.

54. APPLICATION OF NURSING PROCESS TO SLEEP
DISORDERS
1. Disturbed sleep pattern related to use of or
withdrawal from substances, anxiety or
depression ,circadian rhythm disturbance,
familial pattern, or specific medical condition
, evidenced by insomnia , hypersomnia,
nightmare , sleep terror ,
sleepwalking.

55. Nursing process to sleep disorders
2.Risk for injury related to excessive sleepiness,
sleep terror, or sleepwalking .

56. 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.

57. …..Nursing Interventions To
Promote Sleep
• 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.

58. …….Nursing Interventions To
Promote Sleep
• 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

59. ……..Nursing Interventions To
Promote Sleep
• 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

60. ……Nursing Interventions
• 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.

61. BIBLIOGRAPHY
1. Townsend c. Mary. Psychiatric mental health nursing. Jaypee
brothers medical publishers pvt. ltd; 2010; 5th ed.p.583-591.
2. Nancy, Principles and practice of nursing, Senior Nursing
Procedures, Fourth Edition, Indore: N. R. Brothers,2005.
.p.115-116
3. Kozier, Barbara & Erb, Glenora. (1991). “Fundamentals of
Nursing.” 4th edition. California; A division of the
Benjamin/Cummings Publishing Company. Pp – 1114 - 111
4.Jacob.A. Rekha.R, Tarachand.J.S, Clinical Nursing Procedures:
The art of Nursing Practice, First edition, New Delhi: Jaypee,
2007.Pg 278-287

62. REFERANCES
1. http://onlinelibrary.wiley.com/doi/10.1111/j.14
69-8749.1994.tb11818.x/abstract
2. http://www.ahrq.gov/clinic/epcsums/melatsu
m.htm
3. http://www.uphs.upenn.edu/news/News_Rele
ases/2011/10/natural_sleep/