Sleep and Rest

Sleep and Rest
For Health Science Students
FON – I
By
BITEW M
(Lecturer, Arbaminc
University)

SLEEP AND REST
7/22/2016 2
By
Bitew

“Sleep is a natural repeated
unconsciousness that we do not even
know the reason for.”
Popper & Eccles 1977

SLEEP AND REST
• Sleep and rest are fundamental components of
well being.
• All individuals require certain periods of calm
and lesser activity so that their bodies can
regain energy and rebuild stamina.
• The need for rest and sleep varies with age,
developmental level, health status, activity
level, and cultural norms.
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Rest
• Rest refers to a state of relaxation and
calmness, both mental and physical.
• Nurses should try to understand what
activities and environments the client defines
restful.
• Activity during rest periods can range from
lying down to reading a book to taking a quiet
walk.
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Sleep
• Sleep refers to a state of altered consciousness
during which an individual experiences minimal
physical activity and a general slowing of the
body’s physiological processes.
• Sleep generally occurs in a periodic cycle and
usually lasts for several hours at a time.
• As a restorative function, sleep is necessary for
physiological and psychological healing to occur.
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Electro-physiologic Approach
• Polygraph recordings of Electro physiologic
changes in the brain waves
Electroencephalogram(EEG), eye movements
(electrooculogram),Electromyogram which
measures muscle tone known as polysomnogram
shows five sleep stages.
• The 1st four classified as non rapid eye
movement(NREM)spleep
• The other stage is called REM(rapid eye
movement)
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Measurement and Stages of Sleep
Three principle measures of sleep:
(i) Electro-encephalogram (Head)
(ii) Electro-oculogram (Eye)
(iii) Electro-myogram (Neck)

Reticular activating system (RAS):-
• are located in the upper brain stem contains
special cells that maintain.
–alertness,
–wakefulness,
– rapid eye mov’t &
–concentration; by releasing catecholamine’s
such as NE from neurons.
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• The RAS receives visual, auditory, pain, &
tactile sensory stimuli
• The specialized cells in the sleep system
release serotonin w/c produces sleep.
• Sleep is a cyclical physiological process
– Circadian rhythm
– Biological clocks
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Q : What are the types of sleep ?
• Depending on EEG criteria , during each night we go
through 2 types of sleep that alternate with each
other. They are :
• (1) SWS (Slow-Wave Sleep),
• because in this type of sleep EEG waves are generally of
low frequency .
• It is also called Non-Rapid Eye Movement (NREM) sleep
because , unlike the other type of sleep , it is not
associated with rapid eye movements .
• (2) REM sleep (Rapid Eye Movement ),
• because in this type of sleep the the person makes
rapid movements by his eyes , in spite of the fact that
he is sleeping .
11

Sleep cycle has two phases:-
a) Non-rapid eye movement (NREM)
• because, it is not associated with rapid
eye movements .
• Sleeper progresses through 4 stages for
typical 90-minute sleep cycle,
• It accounts 75-80% of sleep time.
• Less vivid dreaming occurs.
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Stage-1 NREM
–Lightest level of sleep
–Eyes tend to roll slowly side to side
–Lasts a few minutes,10 min
–Decreased physiological activities, gradual
fall in V/s.
–Sensory stimuli such as a noise easily
arouses person.
–If a person awakened, day dreaming may
occur.
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Stage-2 NREM
–Period of sound sleep, but still fairly
light sleep
–Loss of slow rolling eye movements
–Relaxation progress
–Arousal is relatively easy
–Lasts from 10 to 20 Minutes
–Body functions continue to slow
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Stage -3 NEM
–Initial stages of deep sleep
–Sleeper is difficult to arouse and rarely
moves.
–Muscles are completely relaxed
–V/s decline but remains in normal range
–Lasts 15-30 minutes.
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Stage 4-NREM
–Deepest stage of sleep
–Very difficult to arouse sleeper
–V/s is significantly lower than during waking
hours.
–Lasts 15- 30 minutes.
–Sleep walking & enuresis ( bed-wetting )
sometime occur.
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N.B- The amount of time spent in each stage
varies over the life span.
– new born & a child spend more time in
deep sleep,
–Aging persons spends more time in lighter
stages.
• Shifts to light sleep or wakefulness occurs
suddenly, whereas shifts to deep sleep tend to
be gradual.
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b) REM- sleep
– because in this type of sleep the the person
makes rapid movements by his eyes , in spite of
the fact that he is sleeping .
– Full color dreaming occurs- ( Vivid dreams)
– Rapid eye movements
– Stages usually begin 90 minutes after sleep has begun
– Typified by autonomic response of REM, Fluctuating HR
& RR.
– Increased or fluctuating BP.
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–Loss of skeletal muscle tone
–Gastric secretions increase
–Very difficult to arouse sleeper
–Duration of REM sleep increases with each
cycle & averages 20 minutes.
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Sleep cycles
• Sleep cycle refers to the sequence sleep that
begins with four stages NREM sleep in order,
with a return to stage 3, then 2 and then
passage into the 1st REM stage.
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1 - 2 - 3 - 4 - 3 - 2 - REM - 2 - 3 - 4

• This cycle is repeated at intervals of about 90
minutes throughout the 8 hours or so of a
night sleep.
• Therefore , there are 4-6 sleep cycles per night
( and 4-6 REM periods per night)
• 2 sleep stages.FLV
7/22/2016 22

Sleep pattern
• Difference between NREM & REM sleep
• Begins with deepening NREM sleep
• Interrupted about every 90 min by REM
• Sleep 4-6 NREM-REM cycles/night
• More REM towards morning

Dreams
Dreams: - occur as the brain filter stored information
about the day’s activities during a sleep.
– occur during both phases
– dreams of REM sleep are more vivid & elaborate.
– Dreams are influenced by personality
e.g. A creative has elaborate & complex dreams,
while a depressed person dreams of helplessness.
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Functions of sleep
it restores physiological & psychological
function
Rest full sleep preserves
• cardiac function
• Respiration
• BP & Muscle tone.
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HGH released during stage 4
Protein synthesis & cell division
conserves energy
REM sleep is important for cognitive
restoration, brain tissue restoration.
7/22/2016 26

Factors Affecting Rest & Sleep
• Comfort
• Anxiety
• Environment

Factors Affecting Rest and Sleep
• Lifestyle
–Work
–Exercise
–Travel
–Diet
–Drugs
–Medications

Factors Affecting sleep
1. Drug & substances:
• Medications alter sleep & weaken day time
alertness.
Hypnotics
Antidepressants & stimulants
Alcohol
Diuretics e.g Furosemide
Caffeine
7/22/2016 32

2. Lifestyle: An individual working a
rotating shift
3. Usual sleep pattern
4. Emotional stress: worry , loss of loved
one etc
5. Environment: - ventilation, Noise in
sleeping place, light levels.
-The size, firmness & position of
bed.
.
7/22/2016 33

6. Exercise & fatigue:- excess fatigue resulting
from exhausting or stressful exercise/work
makes falling asleep difficult.
7. Food & caloric intake: - eating a large, heavy
& spicy meal at night
- Coffee, tea, cola, chocolate contain caffeine
xanthenes that cause sleeplessness
7/22/2016 34

8. Physical illness
• Respiratory disease causes SOB=OSA.
• hypertension causes early morning
awakening & fatigue,
• hypothyroidism ↓ses stage 4 sleep,
• hyperthyroidism causes persons to take
more time to fall asleep.
7/22/2016 35

Alterations in Sleep patterns
Dyssomnias
• Dyssomnias
–Insomnia
–Sleep-wake Schedule disorder
–Restless Leg Syndrome
–Sleep Deprivation
–Hypersomnia
–Narcolepsy

Nocturia
–Urination during the night,
–disrupts the sleep cycle.
–The condition is most common with
reduced bladder tone, cardiac diseases,
diabetes….
• Older adults often experience restless leg
syndrome (RLS) which occurs before sleep
onset.
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Primary Sleep Disorders
1. Insomnia:- is difficulty of falling in sleep,
frequent awakenings from sleep, short or
non restorative sleep.
Don't feel refreshed on arising.
–It is the most common sleep-related
compliant.
–It signals an underlying physical or
psychological disorder.
–It is the most common sleep problem for
women & occurs frequently in women’s.
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• it may related:-
• Situational stresses such as family,
– work, school problems ,
– illness or looses of loved one,
– Poor sleep hygiene
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Three types of Insomnia
1. Initial Insomnia
difficulty in falling asleep
2. Intermittent/maintenance Insomnia
 difficulty in staying asleep because of frequent or
prolonged waking.
3. Terminal Insomnia
Early morning/premature waking
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S/S -persons with chronic insomnia
–feel sleepy,
–fatigue,
–depressed &
–anxious during day time.
Rx- is symptomatic includes:-
- Improving sleep hygiene
-Cognitive techniques &
-Relaxation techniques
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2. Sleep Apnea
• A disorder characterized by the lack of air flow
though the nose & mouth for periods of 10
seconds or longer during sleep.
• It is a periodic cessation of breathing during
sleep.
• types
a) central,
b) obstructive and
c) mixed apnea
7/22/2016 42

Sleep Apnea
• Obstructive Sleep Apnea – caused by
occlusion of the airway during sleep.
– TX: CPAP – Continuous Positive Air Pressure
• Central Sleep Apnea – Dysfunction in central
respiratory control
• Mixed Apnea – combination of Obstructive
and Central Sleep Apneas

i. Obstructive sleep apnea
- is the most common form
- situations like obesity, smoking, alcohol
increases risk of getting OSA.
- Structural abnormalities = deviated septum,
nasal polyps, or enlarged tonsils
S/S -Excessive day time sleep,
-fatigue and
-loud snoring sounds
Rx- correct underlines cause
7/22/2016 44

ii. Central Sleep Apnea (CSA)
involves dysfunctions in the brains respiratory
control center.
common in clients with
brainstem injury
muscular dystrophy and
encephalitis, & it’s less than 10%
7/22/2016 46

s/s -excessive daytime sleepiness.
-sleep attacks
-fatigue
-morning headaches
-Irritability, depression, difficulty in
concentration
-decreased sex drive is common
• RX- therapy for underling causes
7/22/2016 47

3. Narcolepsy
- is a dysfunction of mechanisms that regulate the
sleep & wake states.
- referred to as “sleep attack”
- lack of hypocretin in CNS which regulates sleep.
- they nod off several times a day even when
conversing with someone or doing their work.
- Sleep well at night
s/s -suddenly feels sleepiness & falls sleep;
- REM sleep occurs within 15 min. of falling
sleep.
7/22/2016 48

• Cataplexy:-sudden muscle weakness, during
intense emotion such as anger, sadness, or
laugher.
Characteristics of Narcolepsy
vivid dreams that are difficult to
distinguish from reality.
asleep uncontrollable at inappropriate
times, places.
Sleep paralysis
7/22/2016 49

Management
Supportive:-regular exercise program.
Avoiding factors that increase drowsiness
e.g:-alcohol, long distance driving
avoiding shifts in sleep
eating light meals high in proteins
practicing deep breathing
chewing gum
7/22/2016 50

- Strategically timed day time snaps, taking
vitamins.
Medication: - stimulants
-Antidepressants
7/22/2016 51

4) Sleep Deprivation
-is a problem of many clients experience as a
result of dyssomnia.
Causes
–Illness:-fever, pain, difficulty of breathing
–Emotional stress
–Medications
–Environmental disturbance
–Variability in the timing of sleep
7/22/2016 52

–Physicians and nurses are particularly
prone to sleep deprivation due to long
working schedule & rotating shifts
Mgt
–Elimination of factors that disrupt the
sleep pattern
7/22/2016 53

5. Parasomnias
are disruptive sleep related disorders.
is sleep problem that is common in
children.
• The Parasomnias that occur in older children include
–somnambulism =sleep walking,
– night terrors,
–nightmare, and
– bruxism
• If the problem occurs in adults, it often indicates more
serious disorders
7/22/2016 54

• The Parasomnias that occur in older
children include
–somnambulism =sleep walking, night
terrors, nightmare, and bruxism
• If the problem occurs in adults, it often
indicates more serious disorders
7/22/2016 56

Altered Sleep Patterns -Parasomnias
• Sleepwalking (Somnambulism)
–Occurs during Stage 3-4 of sleep
• Sleep talking
• Bruxism-teeth grinding or clenching
• Night Terrors
• Nocturnal Enuresis

Sleep Hygiene Practices
• Assessment of Sleep Patterns and rituals
• Relaxation
–Eliminate stressful situations before bed
–Muscle relaxation
–Activities that relax rather than stimulate
–Warm bath

Sleep Hygiene
• Environment
–Adjust light, noise, temp to promote
sleep
–Use bedroom for sleep & sex only
–Go to bed at same time each night
–Help client to understand what things
can affect sleep patterns

Sleep Hygiene
• Avoid sleeping long hours during weekend or
holiday
• Bedroom should not be used for intensive
studying, snacking, TV watching, or other
nonsleep activity
• Avoid worrisome thinking when going to bed
• Avoid heavy meals for 3 hours before bedtime

Promoting Bedtime Routines
• Help client to relax in preparation for sleep
• Avoid mental stimulation before bedtime
• Relaxation exercises
• Guided imagery
• Good sleep hygiene

Promoting comfort
• Encourage client to wear loose-fitting
nightwear
• Instruct family on ways to position client and
support dependent body parts to aid in
muscle relaxation
• Have client void before going to bed
• Back massage
• Keep bed linens dry

Activity
• If client is at home, encourage physical activity
during daytime
• Avoid rigorous exercise at least several hours
before bedtime

Control of noise in hospital
• Close doors to client’s room
• Keep doors to work areas closed
• Reduce volume of nearby telephones and
paging equipment
• Avoid abrupt loud noises
• Keep necessary conversations at low levels

Pharmacologic Interventions for Sleep
• Be aware of potential side effects
and possible dependency issues
• Shouldn’t mix with alcohol and most
are not recommended for long-term
use

Pharmacologic Interventions
• Non-benzodiazepines: Ambien, Sonata,
Lunesta
• Benzodiazepines: Valium, Ativan,
Klonopin, Xanax
–Caution: Hazardous in elderly; must
use cautiously in children; can cause
ADDICTION

Pharmacologic Interventions, cont.
• Barbiturates: sedative/hypnotic/anticonvulsants;
Seconal, Luminal, Nembutal
• Tricyclic Antidepressants: major side effect is
drowsiness. Elavil, Tofranil
• OTC Sleep aids
– Antihistamines
– Herbal remedies
– Melatonin

Nutrition Impact on Sleep
• No large fatty meals before sleep
• L-tryptophan increases sleep (milk &
cheese)
• Protein – increases alertness (not a good
before bed snack)
• Carbohydrates promote sleep
– crackers, bread, cereal

Nursing Diagnoses for Sleep
• Sleep Deprivation: Occurs over long periods
of time and symptoms more severe
(confusion, even psychosis)
• Disturbed Sleep Pattern: time limited sleep
pattern. Ex.: related to hospitalization – can
be treated by nursing therapy

Nursing Process
• Assessment
– Sleep history
– Observation for behaviors of sleep deprivation
• Nursing Diagnosis
– Sleep Pattern Disturbances
– Risk for Injury
– Altered Thought Processes
– Ineffective Coping

Nursing Process
• Planning
– Goal will be made to promote normal, restful
sleep for clients having sleep disturbances and/ or
difficulties

Nursing Process
• Interventions to promote sleep and rest
– Environmental controls
– Promote bedtime rituals or routines
– Client education
• Evaluation determines whether the
interventions have promoted a normal sleep
pattern, minimized sleep deprivation
symptoms, and improved client understanding
of how to promote sleep.

• A patient is diagnosed with narcolepsy. The
nurse’s primary intervention should address
the patient’s:
• A. Inability to provide self-care
• B. Impaired thought processes
• C. Potential for injury
• D. Excessive fatigue

Correct Answer: C
• Narcolepsy is excessive sleepiness in the
daytime that can cause a person to fall asleep
uncontrollably at inappropriate times (sleep
attach) and result in physical harm to self or
others

• The nurse is planning a teaching program for a
patient with a diagnosis of obstructive sleep apnea.
Which is the most common intervention that the
nurse should plan to discuss with this patient?
• A. Encouraging sleeping in the supine position
• B. Using devices that support airway patency
• C. Positioning two pillows under the head
• D. Administering sedatives

Answer: B.
• A continuous positive airway pressure (CPAP)
mask worn over the nose when sleeping keeps
the upper airway patent through continuous
positive airway pressure.

• Which is the most important nursing
intervention that supports a patient’s ability
to sleep in the hospital setting?
• A. Providing an extra blanket
• B. Limiting unnecessary noise on the unit
• C. Shutting off lights in the patient’s room
• D. Pulling curtains around the bed at night.

Answer: B
• Noise is a serious deterrent to sleep in a hospital.
The nurse should limit environmental noise
(distributing fluids, providing treatments, rolling drug
and linen carts) and staff communication noise.
• (Turning off the lights is unsafe. You may dim the
lights or put a night light on to provide enough
illumination for safe ambulation to the bathroom)

• What concept associated with sleep should
the nurse consider to best plan nursing care
for a hospitalized patient?
• A. People require eight hours of
uninterrupted sleep to meet energy needs
• B. Frequency of nighttime awakenings
decreases with age
• C. Fear can contribute to the need to stay
awake.
• D. Bed rest decreases the need for sleep.

Answer: C
• Fear of loss of control, the unknown, and
potential death results in the struggle to stay
awake, which interferes with the ability to
relax sufficiently to fall asleep.

Summary
why do we sleep?
7/22/2016 84

Fatigue: A health problem
CELEBRATIONS® Rest 3

Tired people become inefficient

Involuntary sleep

Sleep deprivation

Decision making from the frontal lobe

Sleep debt

Sleep debt can alter metabolic state

Sleep deprivation leads to
decreased performance

How much sleep do we need?

Students often study most of the night

Two major types of sleep:
• Non-rapid eye movement sleep
• Rapid eye movement sleep

Rapid-eye-movement sleep

Both types of sleep are necessary

Steps to getting to sleep
• Learn to value sleep
• Establish a regular bedtime

• Exercise every day

• Establish regular time for rising and retiring
• Use a comfortable bed in quiet bedroom

• Eat lightly in evening
• Avoid exciting or depressing TV…soon
before bedtime

• Rx accordingly

Remember: Tonight’s sleep builds tomorrow’s energy!
Sleep is as important as diet and exercise, only easier!

Rest instituted by God/Allah

LIFE APPLICATION
QUESTIONS

How many times in the
last three days have I
fallen asleep
involuntarily?

How many hours of
nightly sleep have I
had during that same
time?
Do I need to reassess
my sleeping habits?

Am I staying up too late at
night?
What delays my
preparation for bed?

Do I need to exercise more,
or perhaps earlier in the day?

Have I had too big a meal
in the evening, or eaten too late?

Am I worrying about
something that is
keeping me awake?

Am I choosing to
watch too much
TV or play too
many games?

Do I need to see my
physician about a
sleep disorder, such
as sleep apnea?

A husband and
wife worked late
and then went out
to dinner with
friends. The meal
was delicious, but
the couple ate too
much.

Neither slept well when
they eventually got to
bed. The next evening
they arrived home late
again and then watched
a late-night TV show.

The next morning the
couple had a heated
argument about who
should fetch the dry
cleaning. Why would they
argue about such an
inconsequential thing?

Were they thinking
clearly? How can I
prevent something
like that from
happening to me?

How many of the following
symptoms have I observed in
myself lately?
• lower productivity
• short attention span

• inability to solve
complex problems,
think clearly, or
remember quickly

How do I demonstrate
that I value my sleep?
What choices do I have
to make in order to get
adequate and restful
sleep?

Should I choose to get up
at the same time on
weekends as I do during
the week so that I establish
good-habit patterns?

THE END
THANK YOU
7/22/2016 123

Sleep and Rest

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