m.sc nursing first year, advance nursing practice

1. PRESENTATION
ON
SLEEP PATTERN AND
ITS DISTURBANCE
Presented By-
Mrs. Chandu Rana
M.Sc. Nursing 1st year

2. DEFINITION-
Sleep is a naturally occurring altered state
of consciousness characterized by decreases in
awareness and responsiveness to stimuli.

3. PHYSIOLOGY OF SLEEP-
 Reticular activating system (RAS)and the bulbar
synchronizing region controls cyclic nature of sleep.
 During sleep RAS experiences few stimuli from the
cerebral cortex and the periphery of the body.
 Wakefulness occurs when this system is activated
with stimuli from the cerebral cortex and from
periphery sensory organs and cells.
 Norepinephrine and acetylcholine, in addition to
dopamine ,serotonin and histamine are involved with
excitation.
 Gamma – aminobutyric acid(GABA) appears to be
necessary for inhibition.

4. STAGES OF SLEEP-
1. Non-Rapid Eye Movement (NREM)sleep
2. Rapid Eye Movement (REM) sleep

5. 1. NREM SLEEP-
 NREM sleep (comprising about75% of total sleep)
consists of 4 stages.
 Stage 1 and stage 2 is consuming about 5% and 50%
of a person’s sleep time, respectively, are light sleep.
 Stage 3 and 4, each representing about 10% of total
sleep time, are deep sleep stages, termed delta sleep
or slow -wave sleep.

6. Characteristics
stage 1 stage 2
 Transitional stage between Person falls into a stage of
wakefulness and sleep. sleep.
 A relaxed state. Can be aroused with
 Involuntary muscle jerking. relative case.
 Stage normally lasts only Constitutes 50% to 55 %
minute. of sleep.
 Can be aroused easily.
 Constitutes only about 5%
Of total sleep.

7. Stage 3 stage 4
 Depth of sleep increase Reaches the
and arousal becomes greatest depth of
increasingly difficult. sleep.
 Compose about 10% of Arousal from sleep
Sleep. is difficult.
Physiologic changes
in the body.

8. 2. REM SLEEP-
 It is more difficult to arouse a person during REM
sleep than during NREM sleep.
 In normal adults, the REM state consumes 20% to
25% of a person’s nightly sleep time.
 People who are awakened during the REM state
almost always report that they have been dreaming.
 A person who is deprived of REM sleep for several
nights generally then spend more time in REM sleep
on successive nights. This phenomenon, termed REM
rebound, allows the total amount of REM sleep to
remain fairly constant over time.

9. CHARACTERISTICS-
 Eyes dart back and forth quickly.
 Small muscle twitching, such as on the face.
 Large muscle immobility, resembling paralysis.
 Respirations irregular; sometimes interspersed with
apnea.
 Rapid or irregular pulse.
 Blood pressure increases of fluctuates.

10.  Increase in gastric secretions.
 Metabolism increases; body temperature increases.
 Encephalogram tracings active.
 REM sleep enters from stage II of NREM sleep and
reenters NREM sleep at stage II; arousal from sleep
difficult.
 Constitutes of about 20% to 25% of sleep.

11. SLEEP REQUIRMENTS AND PATTERN-
 8 hours of sleep at night has been the accepted
standard for adults.
 On the average, infants require 14 to 20 hours each
day.
 Growing children require from 10 to 14 hours of
sleep.
 for adults is 7 to 9 hours.
 Sleep pattern for older adults vary.
 Patterns of sleep periodicity appear to be learned.

12. FACTORS AFFECTING SLEEP-
 Developmental considerations
 Motivation
 Culture
 Lifestyle habits
 Environmental factors
 Psychological stress

13. SLEEP CYCLE-

14. LIFE SPAN CONSIDERATIONS-
 Newborns and infants-
 Sleeps an average of 16 hours/24 hours
 Usually by 8 to 16 weeks of age, an infant sleeps
through the night.
 REM sleep constitutes much of the sleep cycle of a
young infant.

15.  Toddlers-
 May initially sleep 12 hours at night with two
naps during the day and end this stage
sleeping 8 to 10 a night and napping once
during the day.
 Begin to resist naps and going to bed at night.

16.  Preschoolers-
 Sleep 9to16 hours at night, with 12 hours being the
average.
 The rem sleep pattern is similar to that of an adult.
 Daytime napping decreases
 This age group may continue to resist going to bed
at night.

17.  School-aged Children-
 10-12 hours of sleep.
 Sleep needs usually increase when physical
growth peaks.

18.  Adolescents-
 The growth spurt that normally occurs at this
stage may necessitate the need for more sleep.
 Many adolescents do not get enough sleep.

19.  Young Adults-
 Average amount of sleep required is 8 hours
 Sleep is affected by many factors; physical
health, type of occupation, lifestyle etc.
 Rem sleep averages about 20% of sleep.

20.  Middle-Aged adults-
 Total sleep time decreases during these years with
a decrease in stage IV sleep.
 The percentage of time spend awake in bed begins
to increase.
 Individuals become more aware of sleep
disturbances during this period.

21.  Older Adults-
 Average of 5 to 7 hours of sleep
 Sleep is less sound and stage IV sleep is absent or
considerably decreased. Periods of REM sleep
shorten.
 Elderly people frequently have great difficulty falling
asleep and have more complaints of problems
sleeping.

22. SLEEP DISORDERS-
 A nurse who interviews a patient to obtain a sleep
history needs to understand common sleep
disturbances to recognize significant data.
The more common sleep disorders are the
Dyssomnias and parasomnias.
A. Dyssomnias: they are sleep disorders
characterized by insomnias or excessive
sleepiness.
B. Parasomnias: they are patterns of waking
behavior that appear during sleep

23. 1. INSOMNIA-
 Insomnia is difficulty falling asleep or staying asleep,
even when a person has the chance to do so.
Based on its duration it is classified as:
• Acute insomnia- it is brief and often happens
because of life circumstances.
• Chronic insomnia- is disrupted sleep that occurs at
least three nights per week and lasts at least three
months.

24. Causes:
 Insomnia can be caused by psychiatric and
medical conditions, unhealthy sleep habits,
specific substances, and/or certain biological
factors.
 Nasal/sinus allergies
 Gastrointestinal problems such as reflux
 Endocrine problems such as hyperthyroidism
 Arthritis
 Asthma
 Neurological conditions such as Parkinson's
disease
 Chronic pain
 Low back pain

25. HOW INSOMNIA IS RELATED?
 Insomnia & Depression - by psychiatric conditions
such as depression.
 Insomnia & Anxiety - Most adults have had some
trouble sleeping because they feel worried.
 Insomnia & Lifestyle - Unhealthy lifestyles and sleep
habits can create insomnia.
 Insomnia & Food- Alcohol , Caffeine, Nicotine,
Heavy meals, etc.
 Insomnia & The Brain- may be caused by certain
neurotransmitters in the brain that are known to be
involved with sleep and wakefulness.

26. Symptoms-
 Difficulty falling asleep
 Difficulty staying asleep (waking up during the night and
having trouble returning to sleep)
 Waking up too early in the morning
 Unrefreshing sleep (also called "non-restorative sleep")
 Fatigue or low energy
 Cognitive impairment, such as difficulty concentrating
 Mood disturbance, such as irritability
 Behavior problems, such as feeling impulsive or
aggression
 Difficulty at work or school
 Difficulty in personal relationships, including family, friends
and caregivers

27. DIAGNOSTIC TEST-
 Sleep log
 Blood tests
 Sleep study

28. Treatment-
 Non-Medical (Cognitive & Behavioral) Treatments
for Insomnia
 There are psychological and behavioral techniques that
can be helpful for treating insomnia.
 Relaxation training, or progressive muscle relaxation,
teaches the person to systematically tense and relax
muscles in different areas of the body.
 Stimulus control helps to build an association between
the bedroom and sleep by limiting the type of activities
allowed in the bedroom.
 Cognitive behavioral therapy (CBT) includes
behavioral changes
 Major classes of prescription insomnia medications
include benzodiazepine hypnotics, non-benzodiazepine
hypnotics, and melatonin receptor agonists.

29. 2. Hypersomnia-
 It is a sleep related disorder that causes excessive
daytime sleepiness in people, often regardless of the
presence of other sleeping disorders, or poor sleep
hygiene.
 People with hypersomnia will often sleep in excess of
10 hours
 Hypersomnia is a relatively rare sleeping disorder,
affecting under 1% of the population. It is slightly
more common in females than in males, and typically
starts in early adulthood. It is very rarely found in
children.

30. DIAGNOSIS
 Polysomnogram and multiple sleep latency tests are
both good tools in detecting hypersomnia and other
sleeping disorders.
 The multiple sleep latency test measures the speed
at which a person enters deep sleep over numerous
2 hour intervals.
 People with hypersomnia and other related disorders
like narcolepsy tend to fall asleep very quickly, and
this is considered the best test for detected these
sleeping disorders.
 The polysomnogram test measures the subject’s
brain waves and bodily movements during sleep
phases, and this is good for detecting other sleep
disorders that may be leading to the daytime
sleepiness.

31. TREATMENT
 Hypersomnia is most commonly treated with
stimulants like amphetamine and modafinil.
 Antidepressants, Behavioral changes are also
instituted in most cases, and for those with idiopathic
hypersomnia, this is one of the only treatment
methods available at present.
 Proper sleep hygiene is the most important
behavioural change that must be implemented.

32. 3. Narcolepsy-
 It is a neurological disorder caused by the brain's inability
to regulate sleep-wake cycles normally.
 The main features of narcolepsy are fatigue and cataplexy.
 Its prevalence in the developed world is approximately the
same as that of multiple sclerosis or Parkinson's disease.
 Despite the perception that people with narcolepsy are
perpetually sleepy, they do not typically sleep more than
the average person.
 Narcolepsy is considered a "state boundary" control
abnormality.

33. SYMPTOMS-
The main symptoms associated with narcolepsy are:
 Excessive daytime sleepiness
 Cataplexy
 Hypnogogic hallucinations
 Sleep paralysis
 Disturbed nocturnal sleep
 Leg jerks, nightmares, and restlessness.

34. TREATMENT-
Treatment for narcolepsy includes the use of medication
as well as behavioral therapy.
 Behavioral therapies
 Counseling
 Antidepressants are also often used to treat
cataplexy, hypnagogic hallucinations and sleep
paralysis.
 sodium oxybate, a strong sleep-inducing agent, may
be given at night to improve disturbed nocturnal sleep
and reduce daytime sleepiness and cataplexy.

35. 4. Sleep Apnea -
 Obstructive sleep apnea is a sleep disorder in which
breathing is briefly and repeatedly interrupted during
sleep.
 Obstructive sleep apnea occurs when the muscles
in the back of the throat fail to keep the airway open,
despite efforts to breathe.

36. Symptoms-
 Chronic snoring
 Difficulty concentrating
 Depression, irritability
 Sexual dysfunction
 Learning and memory difficulties
 Falling asleep while at work
 On the phone or driving.

37. TREATMENT-
 The treatment of choice for obstructive sleep apnea is
continuous positive airway pressure device (CPAP).
 Second-line methods of treating sleep apnea include
dental appliances, which reposition the lower jaw and
tongue, and upper airway surgery to remove tissue in
the airway. In general, these approaches are most
helpful for mild disease or heavy snoring.
 Lose weight
 Avoid alcohol
 Quit smoking

38. 5. Restless Legs Syndrome (RLS)-
 Restless Legs Syndrome (RLS), also known as
Willis-Ekbom Disease, is a neurologic sensorimotor
disorder that is characterized by an overwhelming
urge to move the legs when they are at rest.
 The urge to move the legs is usually, but not always,
accompanied by unpleasant sensations.
 RLS symptoms occur during inactivity and they are
temporarily relieved by movement or pressure

39. CAUSES
 The exact cause of RLS is unknown.
 Primary RLS is the most common type of RLS. It is
also referred to as familial (because it is hereditary) or
idiopathic (because the causes are unknown) RLS.
 Secondary RLS, on the other hand, is believed to be
caused by a separate underlying medical condition or
in association with the use of certain drugs.

40. Symptoms-
 The urge to move the legs is usually, but not always,
accompanied by unpleasant sensations.
 The symptoms of restless legs syndrome (RLS) are
often difficult to put into words, as each person’s
experience with RLS is different. Some people use
comparisons, such as "like ants crawling through my
legs" or "like soda running through my veins" to try to
describe the symptoms and feelings

41. Treatment-
 Lifestyle changes
 Underlying iron or vitamin deficiency
 Healthy and balanced
 Horizant® (gabapentin enacarbil) was approved by
the FDA in 2011 for the treatment of moderate-to-
severe primary RLS.
 Mirapex® was approved by the fda in 2006 for the
treatment of moderate-to-severe primary rls.
 Requip® (ropinirole hydrochloride), a drug
commonly used to treat Parkinson disease, was
given fda approval at lower doses for the treatment
of moderate-to-severe primary rls in 2005.

42. HOME REMEDIES-
 walking
 massaging the legs
 stretching
 hot or cold packs
 vibration
 acupressure.
 Practicing relaxation techniques such as meditation
or yoga have been known to alleviate symptom

43. 6. Sleep Deprivation-
 Sleep deprivation occurs when an individual fails to
get enough sleep.
CAUSES:
• Voluntary behavior People who engage in voluntary,
but unintentional, chronic sleep deprivation are
classified as having a sleep disorder called
behaviorally induced insufficient sleep syndrome.
• Work hours
• Personal obligations

44. SYMPTOMS
 Mood
 Irritability
 Lack of motivation
 Anxiety
 Symptoms of depression
 Performance
 Lack of concentration
 Attention deficits
 Reduced vigilance
 Longer reaction times

45.  Distractibility
 Lack of energy
 Fatigue
 Restlessness
 Lack of coordination
 Forgetfulness
TREATMENT:
The only sure way for an individual to overcome
sleep deprivation is to increase nightly sleep time
to satisfy his or her biological sleep need; there is
no substitute for sufficient sleep.

46. PARASOMNIAS-
 The term “parasomnia” refers to all the abnormal things
that can happen to people while they sleep, apart from
sleep apnea.
 Some examples are sleep-related eating disorder,
sleepwalking nightmares, sleep paralysis, REM sleep
behavior disorder, and sleep aggression. Sexsomnia,
sometimes called “sleepsex,” is also a parasomnia. It
refers to sexual acts that are carried out by a person
who is sleeping. Parasomnias can have negative
effects on people during the daytime, including
sleepiness.
 Parasomnias can occur as a person is falling asleep or
at any point in the sleep cycle.
 Sleep paralysis can be quite frightening, especially
when it occurs with hallucinations.

47. ASSESSMENT OF PATIENTS WITH SLEEP
DISORDERS-
 Usual sleep
 Time of sleeping and waking time
 Number of hours of undisturbed sleep
 Quality of sleep
 No. of naps
 Effect on daily chores
 Energy level
 Means of relaxing before bedtime
 Bedtime rituals

48.  Sleep environment
 Pharmacological aids
 Nature of sleep disturbance
 Onset
 Cause
 Severity
 Symptoms
 Interventions attempted and its result