This document discusses sleep patterns and sleep disturbances. It begins by defining sleep and describing the sleep-wake cycle which is regulated by circadian rhythms. It then outlines the stages of sleep including non-REM and REM sleep. Key factors that affect sleep like age, illness, lifestyle and environment are mentioned. Common sleep disorders are introduced including insomnia, narcolepsy, sleep apnea, and parasomnias. Assessment methods like questionnaires, sleep diaries and polysomnography are covered. Nursing management strategies to promote better sleep are provided. Research evidence on sleep enhancement interventions for hospitalized patients is briefly summarized.

2. Sleep pattern and its
disturbance
Evaluator: Dr Mahalingham V Presenter: Shruti Shirke
[Asst. professor, CON AIIMS BBSR] M.Sc Neuroscience Nursing

3. Introduction
• Nearly one third of our life is spent in sleep.
• Sleep is a cyclic physiological process that alternate with longer
period of wakefulness by decreased ability to react to stimuli.
• The sleep wake cycle influences and regulates the physiological
and behavioural response, restores immunity, vital processes,
mood etc

4. Definition: ‘Sleep’
• According to baillier’s nurses dictionary
• “A period of rest for the body and mind, during which bodily
functions are partially suspended”.
• Sleep can be defines as the state of consciousness characterized by
decreased awareness and responsiveness to stimuli”.

5. ‘Circadian Rhythm’
• The word circadian rhythm is taken from Latin word ‘circa’ means
about and ‘dian’ means day.
• “biological rhythms that follow a cycle of about 24hours is termed
as circadian rhythm”.
Sleep
Wakefulness

6. Circadian Rhythm
The circadian
rhythm is the
body’s innate
timing device. It
provide the timing
for our sleep-wake
cycle, hormone
release, our eating
habits, and more.

7. Physiology of Sleep
Retinal ganglion cells:
Supra chiasmatic nucleus:
Melatonin:

10. Stages of Sleep
• Polysomnographic profiles and electrophysiologic changes in brain waves,
eye moment and muscle tone shows 5 sleep stages and 2 types of sleep.
•S- Sleep (NREM)
•D- Sleep (REM)

11. Stage
1
Stage
2
Stage
3
Stage
4
Stage
5

12. Pre sleepiness
Stage 1 Stage 2 Stage 3 Stage 4
REM Sleep
Stage 2 Stage 3
1-7min
Light sleep
Easily aroused, day dreaming
20-40mins
Initial of deep sleep
Difficult to arouse
SWS
SWS
20-40mins
Deepest sleep
Difficult to arouse
5-30mins
Occurs in every 90mins
Intense dreaming occurs
Variations in vital signs
Increase in vaginal secretions
and erection may occurs in
men
cycle
repeats
every 90-
120 mins

13. Stages of sleep

15. Normal sleep requirement
Age Hours/day
Infant 16 hours/day
Toddler 12 hours/day
Pre-school 11 hours/day
Schooler 9-10 hours/day
Adolescent 8-9 hours/day
Adult 6-8 hours/day

16. Functions of sleep
•Human growth.
•Repair and renewal of epithelial.
•Protein synthesis and cell division.
•Physical restoration and preparation for the next period.
•Restoration of cognitive functions.

17. Factors affecting sleep
Physical illness
Drug and substance abuse
Life style
Emotional stress
Environmental factors
Food and caloric intake

18. Sleep pattern
disturbances


20. 1)Dyssomnias
Intrinsic Extrinsic

21. Intrinsic sleep disorders
Insomnia
Narcolepsy
Sleep apnea
Periodic limb movement disorder
Restless legs syndrome

22. Insomnia
• According to national sleep foundation - 30-40% of Americans have
insomnia
Insomnia is perception of inadequate sleep, characterized by difficulty
in initiating sleep and frequent awakening from sleep
Idiopathic insomnia:
Psycho-physiological insomnia:

23. Narcolepsy
Chronic
Neurological disorder
Age between 15-25 years
Orexin deficiency
Unknown cause
Hallucinations, sleep paralysis
etc

24. Narcolepsy cont..
• Daytime sleepiness
• Cataplexy: strong transient muscle weakness(triggered by
emotions)
• Hypogogic (fall asleep)/ Hypnopompic (wakeup) hallucination
• Sleep paralysis

25. Sleep apnoea
Obstructive sleep apnea Central sleep apnea
It is a period of no breathing between snoring intervals. The person may not
breath for 10-20 seconds or more, leads to drop in O2 saturation, irregular pulse
and sometimes increase BP causes brief period of awakening throughout night.

27. Periodic limb movement(PLMD)
• Nocturnal myoclonus consist of
stereotyped sleep related movements
of the lower limbs and occasionally
of upper limbs, ranging from simple
to the dorsiflexion of the big toe and
entire leg.
Restless leg syndrome(WED)
• It is a condition that causes an
uncontrollable urge to move legs
usually because of unpleasant
sensation, moving eases unpleasant
sensation.
• Typically happens while sleep,
evening, lying down and sitting.

30. Extrinsic sleep disorders:
a) Adjustment sleep disorder.
b) Limit setting sleep disorder.
c) Alcohol dependent sleep disorder.
d) Altitude insomnia.
e) Environmental sleep disorder.

32. Circadian rhythm sleep disorders
• Jet- lag syndrome
• Shift work disorder

34. 2)Parasomnias
Sleep walking
Nightmares
Night terror
Teeth grinding
REM sleep
behavior
disorder
Nocturnal
sleep related
eating disorder

35. 3) Sleep disorder associated with medical and
psychiatric disorders

37. Hospital acquired sleep disturbances
•

38. Nursing interventions Rationale
Offer meal at regular times. Meal time are important social cues,
that reinforce circadian rhythms.
Provide active meaningful activities
during daytime hours, including
exposure to natural sunlight and an
outdoor environment when possible.
Light exposure is communicated
through the retina to the
superchiasmatic nucleus, helping to set
the circadian clock.
Monitor the frequency and duration of
naps
Naps are not contraindicated but short
naps are preferable.
If turning or other care is necessary try
to provide for periods upto 2 hour of
undisturbed sleep time when ever
possible.
Sleep cycle average 90minutes. And a
sleep latency of 20-30 minutes, thus it
would take about 2 hours to experience
a full sleep cycle.

39. Others type of sleep disorders
• Hypersomnia
• Sleep deprivation
• Early morning awakening
• Sleep maintenance disturbance
• Sleep onset difficulty

40. Hypersomnia (EDS)
• It is a condition in
which person feel
excessive sleepiness
during day time.
• It can be primary and
secondary

42. Sleep Assessment
Sleep questionnaires
Sleep diary
Nocturnal polysomnography
EEG

43. Sleep questionnaires

45. Sleep diary

47. Nocturnal polysomnography (PSG)

48. EEG:

52. Management

53. Nursing Management
Prepare restful environment.
Promoting bedside rituals.
Offering appropriate bedtime snacks and beverages.
Promoting relaxation.
Promoting comfort.
Schedule nursing care to avoid unnecessary
disturbance

54. Tips for better sleep
• Maintain regular time
• Regular exercise
• Maintain comfortable environment at the time of sleep
• Use bed for relaxing or sleeping only
• Don’t nap during the day or evening
• Don’t dwell into intense thoughts or feelings before sleep
• Don’t rely on sleeping pills

55. Management
• Antidepressants: Trazodone
• Benzodiazepines: lorazepam
• Doxepin: (Trouble staying in sleep)(blocks histamine receptor) Silenar
• Ramelteon: (Trouble falling asleep) Rozerem
• CNS stimulants: Modafinil (Used in Narcolepsy)
• SSRI: (It supress REM sleep)

56. Research evidence

58. The effectiveness of ‘Sleep enhancement nursing
intervention’ in hospitalized mental health patient.
• Tool: Oviedo sleep questionnaire (OSQ), nursing outcome classification
(NOC) sleep scale score
• Intervention: Sleep enhancement nursing intervention.
• Conclusion: Sleep enhancement nursing intervention was effective for
patient admitted to a mental health inpatient unit with disturbed sleep
pattern, regardless of drug administered during the hospital stay.

60. External strategies for
promoting sleep
• Noise
• Temperature
• Light
• Layout
• Nursing care
combined
interventions
Internal strategies for
promoting sleep
• Relaxation (massage
or guided imagery)
• Music(calming
music)
• Aromatherapy
• Daytime light

61. Summary:
• Definition of sleep
• Sleep cycle
• Factors affecting sleep
• Sleep disorders
• Dysomnia
• Parasomnia
• Other sleep disorders
• Sleep Assessment
• Management
• Research evidence

62. Conclusion:

63. Reference:
• www.sleepcouncil.org.uk
• Black JM, Hawks JH. Medical surgical nursing clinical management for
positive outcomes. Vol 1. 7th edition. Saunders, India 2005 pp 461-500
• Brunner and suddarths. ‘textbook of medical surgical nursing’, volume-
2, 13th edition,wolter kluwer(India),pvt,ltd.pg:189
• Basavanthappa BT. ‘medical surgical nursing’ 2ndedition, jaypee brother
medical publisher, New Delhi. pvt ltd. pg:931

64. Reference: cont..
• Surekha Anbazhagan, Naveen Ramesh, Catherine Nisha, Bobby Joseph Indian
Environ Med. 2016 Jan-Apr; 20(1): 35–38. doi: 10.4103/0019-5278.183842
PMCID: PMC4922274
• https://www.sccm.org/ICULiberation/Resources/PADIS-Guidelines-
Teaching-Slides-Sleep
• Pisani MA, Friese RS, Gehlbach BK, et al. Sleep in the intensive care
unit. Am J Respir Crit Care Med. 2015;191:731–738. [PMC free
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65. •Thankyou