For nursing students Fundamental of Nursing Based on curriculum of B.Sc. Nursing First Year of Kathmandu University

1. Rest, Sleep and Comfort
measures
Prepared by: Geeta Rai

2. Course content
★ Definition of rest and sleep
★ Physiology , types, cycles and function of sleep
★ Normal patterns of sleep and requirement
★ Factors affecting sleep
★ Common sleep disorders
★ Nursing management for promotion of sleep

3. Contd…
★ Comfort measures
❖ Bed making; purposes, types and procedure of
bed making
❖ Back care and back massage
❖ Positioning of client

4. Introduction
Sleep is a basic human need; it is a universal
biologic process common to all people. Humans
spend about one third of their lives asleep.

5. Contd…
We require sleep for many reasons:
➔to cope with daily stresses,
➔to prevent fatigue, to conserve energy,
➔to restore the mind and body, and
➔to enjoy life more fully.

6. Contd…
Sleep enhances daytime functioning, and is vital
for cognitive, physiological, and psychosocial
function (Gruber, 2013).

7. Contd…
Sleep is an important factor in a person’s quality of
life, yet sleep disorders and sleep deprivation are
an unmet public health problem, as reported by the
Centers for Disease Control and Prevention (CDC)
(2014).

8. Definition of rest and sleep
Rest :cease work or movement in order to relax,
sleep, or recover strength.
Sleep is a cyclical physiological process that
alternates with longer periods of wakefulness. The
sleep-wake cycle influences and regulates
physiological function and behavioral responses.

9. Physiology of sleep
More recently, sleep has come to be considered an
altered state of consciousness in which the
individual’s perception of and reaction to the
environment are decreased.

10. Contd…
Sleep is characterized by minimal physical activity,
variable levels of consciousness, changes in the
body’s physiological processes, and decreased
responsiveness to external stimuli.

11. Contd…
Some environmental stimuli, such as a smoke
detector alarm, will usually awaken a sleeper,
whereas many other noises will not.
It appears that individuals respond to meaningful
stimuli while sleeping and selectively disregard non
meaningful stimuli. For example, a mother may
respond to her baby’s crying but not to the crying of
another baby.

12. Contd…
The upper part of the reticular formation consists of
a network of ascending nerve fibers called the
reticular activating system (RAS), which is
involved with the sleep/wake cycle.
An intact cerebral cortex and reticular formation
are necessary for the regulation of sleep and waking
states.

14. Contd…
Neurotransmitters, located within neurons in the
brain, affect the sleep/wake cycles.
For example, serotonin is thought to lessen the
response to sensory stimulation and gamma-
aminobutyric acid (GABA) to shut off the activity in
the neurons of the reticular activating system.

15. Contd…
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.

16. Contd…
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.

17. Contd…
During this time, the pineal gland in the brain
begins to actively secrete the natural hormone
melatonin, and the person feels less alert.
Wakefulness is also associated with high levels of
acetylcholine, dopamine, and noradrenaline.

18. Contd…
Acetylcholine is released in the reticular formation,
dopamine in the midbrain, and noradrenaline in the
pons.
These neurotransmitters are localized within the
reticular formation and influence cerebral cortical
arousal.

19. Circadian Rhythm
Biologic 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.

20. Contd…
The most familiar biologic rhythm is the circadian
rhythm. It is a sort of 24-hour internal biological
clock.
The term circadian is from the Latin “circa dies”,
meaning “about a day.”

21. Contd…
Although sleep and waking cycles are the best
known of the circadian rhythms, body temperature,
blood pressure, and many other physiological
functions also follow a circadian pattern.

22. Contd…
Sleep is a complex biologic rhythm. When a
person’s biologic clock coincides with the
sleep/wake cycles, the person is said to be in
circadian synchronization; that is, the person is
awake when the body temperature is highest, and
asleep when the body temperature is lowest.

23. Contd…
Circadian regularity begins to develop by the sixth
week of life, and by 3 to 6 months most infants have
a regular sleep/wake cycle.

25. Types of Sleep

26. Types of Sleep
The two types of sleep are
1. NREM (non–rapid-eye-movement) sleep and
2. REM (rapid-eye-movement) sleep
During sleep, NREM and REM sleep alternate in
cycles.

27. NREM sleep
In the classical definition of NREM sleep, people
progress through four stages during a typical 90-
minute sleep cycle.
The American Academy of Sleep Medicine defines
three stages in NREM sleep, combining stages 3
and 4.

28. REM sleep
REM sleep is the phase at the end of each 90-
minute sleep cycle.
During REM sleep there is increased brain activity
associated with rapid eye movements and muscle
atonia.

29. Stages of the Sleep Cycle
1. NREM, Non rapid eye movement;
2. REM, rapid eye movement.

30. NREM (75% of Night)
N1 (Formerly Stage 1)
• Stage of lightest level of sleep, lasting a few
minutes.
• Decreased physiological activity begins with
gradual fall in vital signs and metabolism.
• Sensory stimuli such as noise easily arouse
sleeper.
• If awakened, person feels as though daydreaming
has occurred.

31. Contd…
N2 (Formerly Stage 2)
• Stage of sound sleep during which relaxation
progresses.
• Arousal is still relatively easy.
• Brain and muscle activity continue to slow.

32. Contd…
N3 (Formerly Stages 3 and 4)
• Called slow-wave sleep.
• Deepest stage of sleep.
• Sleeper is difficult to arouse and rarely moves.
• Brain and muscle activity are significantly
decreased.
• Vital signs are lower than during waking hours.

33. REM Sleep (25% of Night)
• Vivid, full-color dreaming occurs.
• Stage usually begins about 90 minutes after sleep
has begun.
• Stage is typified by autonomic response of rapidly
moving eyes, fluctuating heart and respiratory rates,
and increased or fluctuating blood pressure.

34. Contd…
• Loss of skeletal muscle tone occurs.
• Gastric secretions increase.
• It is very difficult to arouse sleeper.
• Duration of REM sleep increases with each cycle
and averages 20 minutes

35. Sleep Cycle
Normally an adult’s routine sleep pattern begins with
a pre sleep period during which the person is
aware only of a gradually developing sleepiness.
This period normally lasts 10 to 30 minutes.

36. Contd…
Individuals who have trouble falling asleep often
remain in this stage for an hour or more.
Once asleep a person usually passes through four
to six complete sleep cycles, each cycle
consisting of three stages of NREM sleep and a
period of REM sleep, for a total of 90 to 110
minutes.

37. Contd…
With each successive cycle, stage 3 (combined 3
and 4) of NREM sleep shortens, and REM sleep
lengthens.
REM sleep lasts up to 60 minutes during the last
sleep cycle.
Not all people progress consistently through the
usual stages of sleep.

40. Contd…
For example, a sleeper fluctuates back and forth for
short intervals between NREM stages 2, and 3
before entering REM sleep. The amount of time
spent in each stage varies. The number of sleep
cycles depends on the total amount of time that the
person spends sleeping.

41. Function of sleep
➢ Sleep exerts physiological effects on both the
nervous system and other body structures.
➢ Sleep in some way restores normal levels of
activity and normal balance among parts of the
nervous system.

42. Contd…
➢ Sleep is also necessary for protein synthesis,
which allows repair processes to occur.
➢ The role of sleep in psychological well-being is
best noticed by the deterioration in mental
functioning related to sleep loss.

43. Contd…
➢ Individuals with inadequate amounts of sleep
tend to become emotionally irritable, have poor
concentration, and experience difficulty making
decisions.

44. Normal patterns of sleep and
requirement
Although it used to be believed that maintaining a
regular sleep/wake rhythm is more important than
the number of hours actually slept, recent research
has shown that sleep deprivation is associated with
significant cognitive and health problems.

45. Contd…
Although reestablishing the sleep/wake rhythm (e.g.,
after the disruption of surgery) is important, it is
appropriate to allow and encourage daytime napping
in hospitalized clients.

46. Contd…
❏ Newborns sleep 12 to 18 hours a day, on an
irregular schedule with periods of 1 to 3 hours
spent awake.
❏ At the end of the first year, an infant usually takes
two naps per day and should get about 9 to 12
hours of sleep in 24 hours.

47. Contd…
❏ The school-age child (5 to 12 years of age) needs
10 to 11 hours of sleep per night, but most
receive less because of increasing demands
(e.g., homework, sports, social activities).
❏ Between 12 and 14 hours of sleep are
recommended for children 1 to 3 years of age.

48. Contd…
❏ The preschool-age child (3 to 5 years of age)
requires 11 to 13 hours of sleep per night,
particularly if the child is in preschool.
❏ Adolescents (12 to 18 years of age) require 9 to
10 hours of sleep each night; however, few
actually get that much sleep.

49. Contd…
❏ A hallmark change with age is a tendency toward
earlier bedtime and wake times. Older adults (65
to 75 years) usually awaken 1.3 hours earlier and
go to bed approximately 1 hour earlier than
younger adults (ages 20 to 30).

50. Factors affecting sleep

51. Factors affecting sleep
➔Illness
➔Environment
➔Lifestyle
➔Emotional Stress
➔Stimulants and
Alcohol
➔Diet
➔Smoking
➔Motivation
➔Medications

52. Illness
Illness that causes pain or physical distress (e.g.,
arthritis, back pain) can result in sleep problems.
Certain endocrine disturbances can also affect
sleep. Hyperthyroidism lengthens presleep time,
making it difficult for a client to fall asleep.
Hypothyroidism, conversely, decreases stage 3
sleep.

53. Environment
Environment can promote or hinder sleep. The
person must be able to achieve a state of relaxation
prior to entering a period of 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

54. Lifestyle
Following an irregular morning and nighttime
schedule can affect sleep. Moderate exercise in the
morning or early afternoon usually is conducive to
sleep, but exercise late in the day can delay sleep.

55. Contd…
The person’s ability to relax before retiring is an
important factor affecting the ability to fall asleep. It
is best, therefore, to avoid doing homework or office
work before or after getting into bed.

56. Emotional Stress
Stress is considered by most sleep experts to be the
one of the greatest causes of difficulties in falling
asleep or staying asleep.
Anxiety increases the norepinephrine blood levels
through stimulation of the sympathetic nervous
system. This chemical change results in less deep
and REM sleep and more stage changes and
awakenings.

57. 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.
Alcohol disrupts REM sleep, although it may hasten
the onset of sleep.

58. Diet
Dietary L-tryptophan—found, for example, in cheese
and milk—may induce sleep, a fact that might
explain why warm milk helps some people get to
sleep.

59. Smoking
Nicotine has a stimulating effect on the body, and
smokers often have more difficulty falling asleep
than nonsmokers.

60. Motivation
Motivation can increase alertness in some situations
(e.g., a tired person can probably stay alert while
attending an interesting concert or surfing the web
late at night). Motivation alone, however, is usually
not sufficient to overcome the normal circadian drive
to sleep during the night.

61. Contd…
Nor is motivation sufficient to overcome sleepiness
due to insufficient sleep. A combination of boredom
and lack of sleep can contribute to feeling tired.

62. Medications
Some medications affect the quality of sleep. Most
hypnotics can interfere with deep sleep and
suppress REM sleep.
Beta-blockers have been known to cause
insomnia and nightmares.

63. Contd…
Narcotics, such as morphine, are known to
suppress REM sleep and to cause frequent
awakenings and drowsiness.
Tranquilizers interfere with REM sleep. Although
antidepressants suppress REM sleep, this effect is
considered a therapeutic action.

64. Drugs That Disrupt Sleep
These drugs may disrupt REM sleep, delay onset of
sleep, or decrease sleep time:
• Alcohol •
Caffeine
• Amphetamines •
Decongestants
• Antidepressants • Narcotics
• Beta-blockers • Steroids
• Bronchodilators

65. Drugs That May Cause
Excessive Daytime Sleepiness
• Antidepressants
• Antihistamines
• Beta-blockers
• Narcotics

66. Common Sleep Disorders
● Insomnia
● Excessive Daytime Sleepiness
○ Hypersomnia
○ Narcolepsy
○ Sleep apnea
○ Insufficient sleep
○ Parasomnia

67. Insomnia
Insomnia is described as the inability to fall asleep
or remain asleep. Individuals with insomnia do not
awaken feeling rested.
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.

68. Excessive Daytime Sleepiness
Clients may experience excessive daytime
sleepiness as a result of hypersomnia, narcolepsy,
sleep apnea, and insufficient sleep.

69. 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

70. 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.

71. 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 or five
breathing pauses longer than 10 seconds per hour is
considered abnormal and should be evaluated by a
sleep medicine specialist.

72. Contd…
Symptoms suggestive of sleep apnea include loud
snoring, frequent nocturnal awakenings, excessive
daytime sleepiness, difficulties falling asleep at night,
morning headaches, memory and cognitive
problems, and irritability.

73. Contd…
Three common types of sleep apnea are
obstructive apnea, central apnea, and mixed
apnea.
Obstructive apnea occurs when the structures of
the pharynx or oral cavity block the flow of air. The
person continues to try to breathe; that is, the chest
and abdominal muscles move.

74. Insufficient sleep
Healthy individuals who obtain less sleep than they
need will experience sleepiness and fatigue during
the daytime hours.

75. Contd…
Depending on the severity and chronicity of this
voluntary, albeit unintentional sleep deprivation,
individuals may develop attention and concentration
deficits, reduced vigilance, distractibility, reduced
motivation, fatigue, malaise, and occasionally
diplopia and dry mouth.

76. Parasomnia
A parasomnia is behavior that may interfere with
sleep and may even occur during sleep.
It is characterized by physical events such as
movements or experiences that are displayed as
emotions, perceptions, or dreams.

77. Nursing Management

78. Assessing
A complete assessment of a client’s sleep difficulty
includes a sleep history, health history, physical
exam, and, if warranted, a sleep diary and
diagnostic studies.
All nurses, however, can take a brief sleep history
and educate their clients about normal sleep.

79. Contd…
Sleep History
A brief sleep history, which is usually part of the
comprehensive nursing history, should be
obtained for all clients entering a health care facility.
It should, however, be deferred or omitted if the
client is critically ill.

80. Key questions to ask include the following:
● When do you usually go to sleep?
● And when do you wake up?
● Do you nap?
● If so, when?
If the client is a child, it is also important to ask about
bedtime rituals.

81. Contd…
● Do you have any problems with your sleep?
● Has anyone ever told you that you snore loudly or
thrash around a lot at night?
● Are you able to stay awake at work, when driving,
or engaging in your usual activities?

82. Health History
A health history is obtained to rule out medical or
psychiatric causes of the client’s difficulty sleeping.
It is important to note that the presence of a
medical or psychiatric illness (e.g., depression,
Parkinson’s disease, Alzheimer’s disease, or
arthritis) does not preclude the possibility that a
second problem (e.g., obstructive sleep apnea) may
be contributing to the difficulty sleeping.

83. Contd…
Because medications can frequently cause or
exacerbate sleep disturbances, information should
be obtained about all of the prescribed and
nonprescription medications, including herbal
remedies, that a client consumes.

84. Physical Examination
Rarely are sleep abnormalities noted during the
physical examination unless the client has
obstructive sleep apnea or some other health
problem.

85. Contd…
Common findings among clients with sleep apnea
include an enlarged and reddened uvula and soft
palate, enlarged tonsils and adenoids (in
children), obesity (in adults), and in male clients a
neck size greater than 17.5 inches.
Occasionally a deviated septum may be noted, but
it is rarely the cause of obstructive sleep apnea.

87. Sleep Diary
A sleep specialist may ask clients to keep a sleep
diary or log for 1 to 2 weeks in order to get a more
complete picture of their sleep complaints.

88. Contd…
A sleep diary may include all or selected aspects of
the following information that pertain to the client’s
specific problem:

89. Contd…
• Time of
(a) going to bed,
(b) trying to fall asleep,
(c) falling asleep (approximate time),
(d) any instances of waking up and duration of these
periods,
(e) waking up in the morning, and
(f) any naps and their duration

90. Contd…
• 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, OTC medications,
and herbal remedies taken during the day

91. Contd…
• Bedtime rituals before sleep
• Any difficulties remaining awake during the day
and times when difficulties occurred
• Any worries that the client believes may affect
sleep
• Factors that the client believes have a positive or
negative effect on sleep

92. Contd…
If the client is a child, the sleep diary or log may be
completed by a parent.

93. Diagnostic Studies
Diagnostic Studies Sleep is measured objectively in
a sleep disorder laboratory by polysomnography
(Sleep Study that monitors several parameters to
diagnose sleep disorders) in which an
electroencephalogram (EEG), electromyogram
(EMG), and electro-oculogram (EOG) are recorded
simultaneously.

94. Contd…
Electroenchephalogram: An electroencephalogram
(EEG) is a test that detects electrical activity in
your brain using small, metal discs (electrodes)
attached to your scalp.
Electromyography (EMG) is a diagnostic
procedure to assess the health of muscles and
the nerve cells that control them (motor neurons).

95. Contd…
Electrooculography (EOG) is a technique for
measuring the corneo-retinal standing potential
that exists between the front and the back of the
human eye. The resulting signal is called the
electrooculogram.

97. Electroencephalogram

98. Electromyogram

99. Electro-oculogram

100. Diagnosis
Insomnia, the NANDA (The North American Nursing
Diagnosis Association) International (Herdman &
Kamitsuru, 2014) diagnosis given to clients with
sleep problems, is usually made more explicit with
descriptions such as “difficulty falling asleep” or
“difficulty staying asleep”;
for example, Insomnia (delayed onset of sleep)
related to overstimulation prior to bedtime

101. Nursing Diagnosis
★ 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

102. Contd…
★ Deficient Knowledge (non prescription remedies
for sleep) related to misinformation
★ Anxiety related to sleep apnea and/or the
diagnosis of a sleep disorder
★ Activity Intolerance related to sleep deprivation or
excessive daytime sleepiness

103. Planning
The major goal for clients with sleep disturbances is
to maintain (or develop) a sleeping pattern that
provides sufficient energy for daily activities.
Other goals may relate to enhancing the client’s
feeling of well-being or improving the quality and
quantity of the client’s sleep.

104. Contd…
The nurse plans specific nursing interventions to
reach the goal based on the etiology of each nursing
diagnosis.

105. Contd…
These interventions may include
● reducing environmental distractions,
● promoting bedtime rituals,
● providing comfort measures,
● scheduling nursing care to provide for
uninterrupted sleep periods,
● and teaching stress reduction, relaxation
techniques, or good sleep hygiene.

106. Implementing
The term sleep hygiene refers to interventions used
to promote sleep.
Nursing interventions to enhance the quantity and
quality of clients’ sleep involve largely
nonpharmacologic measures.

107. Contd…
These involve health teaching about sleep habits,
support of bedtime rituals, the provision of a restful
environment, specific measures to promote comfort
and relaxation, and appropriate use of hypnotic
medications.

108. Contd…
For hospitalized clients, sleep problems are often
related to the hospital environment or their
illness.
Assisting the client to sleep in such instances can be
challenging to a nurse, often involving scheduling
activities, administering analgesics, and providing a
supportive environment. Explanations and a
supportive relationship are essential for the fearful or
anxious client.

109. Contd…
Different types of hypnotics may be prescribed
depending on the type of sleep problem (e.g.,
difficulties falling asleep or difficulties maintaining
sleep).
Drugs with longer half-lives are often prescribed for
difficulties maintaining sleep, but must be used with
caution in older adults.

110. Contd…
Client Teaching
Healthy individuals need to learn the importance of
sleep in maintaining active and productive
lifestyles.

111. Contd…
(a) the conditions that promote sleep and those that
interfere with sleep,
(b) safe use of sleep medications,
(c) effects of other prescribed medications on sleep,
(d) effects of their disease states on sleep, and
(e) importance of long periods of uninterrupted sleep

112. Contd…
Supporting Bedtime Rituals
Creating a Restful Environment
Promoting Comfort and Relaxation
Enhancing Sleep with Medications

113. Evaluating
If the desired outcomes are not achieved, the nurse
and client should explore the reasons, which may
include answers to the following questions:
● Were etiologic factors correctly identified?
● Has the client’s physical condition or medication
therapy changed?

114. Contd…
● Did the client comply with instructions about
establishing a regular sleep/wake pattern?
● Did the client avoid ingesting caffeine?
● Did the client participate in stimulating daytime
activities to avoid excessive daytime naps?

115. Contd…
● Were all possible measures taken to provide a
restful environment for the client?
● Were the comfort and relaxation measures
effective?

116. Reference
● Berman, Audrey T., Synder, S. and
Frandsen, G. 2016. Kozier and Erb’s
Fundamentals for Nursing: concepts and
practice 10th Edition.USA: Pearson
● Potter , P., Perry, A. Stockert P. and Hall,
A. 2013. Fundamentals of Nursing . 8th
edition. Canada : Mosby Elsevier