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Concept: Sleep
Sleep Concept: Objectives
1. Describe what the concept means (including definition, antecedents and
attributes).
2. Identify conditions that place an individual at risk of sleep imbalance.
3. Identify when sleep imbalance is developing or has developed.
4. Discuss exemplars of common sleep disorders.
5. Apply the nursing process with collaborative interventions and evaluation
for individuals experiencing sleep imbalance.
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Concept Definition
Sleep is a state of rest
accompanied by natural
altered consciousness.
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• How do you feel after good night’s sleep?
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Components of Sleep
Circadian Rhythms
Sleep Regulation
Sleep Cycle/Stages of Sleep
Sleep Architecture
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Circadian Rhythm
24 hour, day-night cycle
• Developed about the 6th week of life
• Triggered by light and darkness
• Biological rhythm of sleep synchronized with other bodily
functions
• Factors affecting Circadian Rhythm (and thereby sleep-wake
cycle) include
– Light, temperature, social activities, and work routines
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Circadian Rhythm
• Synchronized when biological clock coincides with
sleep-wake cycle
• Physiologic and psychological rhythms high when awake
and low when asleep
– e.g., person awake when body temp highest and
asleep when body temp is lowest
– temp usually peaks in the afternoon, tapers, and
declines significantly after asleep
– when cycle becomes disrupted other physiological
functions usually change as well and vice versa
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Sleep Regulation
• Hypothalamus
• Reticular Activating system (RAS)
– Catecholamines
norepinephrine
• Pons Medulla
– Serotonin
• Impulses received from
– Higher centers (thoughts)
– Peripheral sensory reception (sound, light, etc)
– Limbic system (emotions)
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Sleep Cycle/Pattern
(Attributes – Defining Characteristics)
Two Phases
o Nonrapid Eye Movement (NREM)
 Stage 1 - light sleep, lasts few minutes, easily aroused
 Stage 2 - period of sound sleep, body functions start to slow,
but still easily aroused, muscles start to relax, lasts 10 – 20
minutes
 Stage 3 - start of deep sleep, muscles relaxed, difficult to
arouse, lasts 15 - 30 minutes
 Stage 4 – Deepest stage of sleep, difficult to arouse,
sleepwalking occurs, lasts 15 – 30 minutes
1. How should this knowledge affect your patient care?
2. What will be the premise or focus for your interventions?
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Antecedents for Sleep
• Eustress
– Emotional
– Environmental
– Physical
• Adequate daytime functioning
• Normal circadian rhythm
• Sufficient uninterrupted time
• Normal upper airway physiology
• Age predicts amount
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How will knowing the Antecedents affect your
Nursing Assessment?
• Develop a Sleep Assessment Survey based on the
Antecedents for Sleep.
• Develop Nursing Interventions based on your findings.
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Risk Factors
• Illness
• Medications
• Environmental stress
• Obesity
• Lifestyle
• Pain
• Emotional stress
• Altered Circadian Rhythm
• Stimulants and alcohol
• Smoking
• Diet
How do the risk factors relate to the antecedents?
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Sleep Imbalance – Assessment
• How does the nurse recognize when an imbalance is
developing or has developed?
– Clinical findings
– Comprehensive Health History
– Sleep Pattern Assessment (sleep and health history)
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Assessment cont’d
– Physical and psychological clinical manifestations
– Excessive sleepiness, fatigue, attention and concentration
deficit, reduced vigilance and motivation, distractibility,
malaise, diplopia, irritability, altered thought process –
psychosis, slowed response
– Effects of Sleep deprivation cont’d.
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Assessment cont’d
Diagnostic tests
 Polysomnography (PSG)
 Electroencephalogram (EEG)
 Electromyogram (EMG)
 Electro-oculogram (EOG)
 Sleep study explained
http://www.youtube.com/watch?v=jZTzrVGSOvw
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Clinical Management …
• Primary (health promotion, prevention)
– How do you manage health promotion in your
patient?
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Clinical Management
• Secondary (screening/diagnosis)
– What can be done for screening and/or
diagnosis of sleep imbalance?
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Clinical Management
• Tertiary (rehabilitation)
In you learning group, discuss examples to complete the
table below.
Drug Therapy
Complementary/Alternative
therapy
Cognitive Behavior
Therapy
Patient Education
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Exemplars
• Sleep Deprivation
• Insomnia
• Sleep Apnea
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Sleep Deprivation
Prolonged inadequate quality or quantity
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Sleep Deprivation
Causes of:
Can lead to:
• Age
• Confusion
• Prolonged
hospitalization
• Seizures
• Drug/substance abuse
• Postoperative delirium
• Illness
• Frequent changes in
lifestyle pattern
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1. What are actions nurses can take to promote sleep in
the hospital?
2. What would you include in patient/family teaching
about promoting sleep?
Insomnia
• Difficulty falling asleep
• Difficulty staying asleep
• Waking up to early
• Poor quality of sleep
• Differ between acute vs chronic insomnia
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Clinical Manifestations
• How does insomnia relate to sleep?
• What are the daytime consequences of insomnia?
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Insomnia
• Interventions
• Sleep light
http://youtu.be/fPjWlBmTol4?list=UUgPoNP5uUO22v
hy1iU2VTmw
https://www.youtube.com/watch?v=-5cM2bpgnCk
This intervention may be based on which Sleep
Antecedent and why?
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Interventions
• What actions can a nurse perform to reduce barriers
to patients obtaining adequate rest in the hospital?
• How do these interventions compare or contrast with
the interventions for sleep deprivation?
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Insomnia Case
A 49 year old African American female is seen in the clinic for
complaints of chronic fatigue. She is postmenopausal, based on
self-report, overweight and has a blood pressure of 155/92 mm
Hg. She reports daily hot flashes, night sweats and that she can
not get to sleep or stay asleep. She reports of day time
tiredness and fatigue. On a typical work day she drinks two
cups of hot tea and one can of diet cola. Currently she is taking
over the counter diphenhydramine for sleep. Her partner states
her snoring has gotten worse and it is interfering with his sleep.
She denies any other health problems.
Insomnia case cont.
1. What interrelated concepts are present in this
situation?
2. What sub-concepts might be playing a role in this
situation?
3 What specific sleep hygiene practices could this
patient use to improve the quality of her sleep?
4. What are the consequences for this patient before and
after management?
Sleep Apnea
• Sleep Apnea :
http://www.youtube.com/watch?v=wk8c4rNrQ-A
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Sleep Apnea
• Sleep related breathing disorders - what are these?
• How do they interfere with sleep?
• What are the types of sleep apnea?
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Risk factors
• In your learning group identify the risk factors for
sleep apnea and how do they relate to the
antecedents for sleep?
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• In your learning group compare and contrast the types of sleep
apnea
Type
Pathology
Objective
Subjective
Complications
Central
Obstructive
Mixed
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Interventions: Learning Groups
• List interventions for the different types of apnea
– Medical
– Nursing
• What are the expected outcomes?
– Positive
– Negative
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Questions???
• Why does lack of sleep effect your mood?
• Why does it effect your ability to think?
• Think about the last time you didn’t get enough sleep—
– How did you feel the rest of the day?
– How did you interact with your friends?
– How well did you think?
– Did you have a test? How well did you do on it?
– Were you sleepy during the day?
Criteria for Completing Case Studies
1. What were the underlying risks for developing sleep
deprivation?
2. List signs and symptoms of sleep imbalance the patient
developed (negative consequences).
3. List the interventions (including education) which should
be used and the rationale for the intervention as well as
how the effectiveness of the intervention would be
measured.
4. What interrelated concepts are present in this situation.
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Sleep Deprivation
Case Studies
• Elderly male with pneumonia and is coughing at frequent
intervals
• Young mother with new baby
• Elderly person with insomnia
• Hospitalized teenager on orthopedic unit due to motor vehicle
accident
• Adult in the Critical Care Unit after surgical procedure, being
reassessed every 30 minutes.
• Overweight 65 year old man who wakes up every morning saying
“I am more tired now than when I went to bed last night.
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Altered Sleep Pattern
Case Studies
You are a nurse on a surgical unit who is meeting with Ann for
preoperative teaching. She is scheduled for a complete
hysterectomy next Monday. She has secondary diagnosis of
fibromyalgia, a chronic disorder characterized by widespread muscle
pain & nonrestorative sleep.
Anne is 49, married with 3 children. She works full time & manages
the family with her husband. She says, “I’m a little nervous about the
surgery, but I know I need it. But I haven’t been sleeping will
because of thinking about it.” Anne tells you that she has actually
had trouble sleeping for the last 20 years. “I take an Ambien pill, 10
mg, every night to help me sleep. Will I be able to get that in the
hospital? I really can’t sleep at all without it,” explains Anne,
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Altered Sleep Pattern
Case Studies
As you continue the interview, Anne explains that she suffered
from physical and emotional abuse as a young woman and has
had sleep problems ever since. She has been to counseling, but
that did not improve her sleep. Recently she sleep has been
even more troublesome.
Aside from her upcoming surgery, she has been coping with the
recent death of her father. After meeting with Anne, you realize
that sleep-promoting measures will be an important part of her
nursing care while she is in the hospital.
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Altered Sleep Pattern
Case Studies
• What clues in Anne’s situation would cause you to suspect
that she will have difficulty sleeping while in the hospital?
• What characteristics of the hospital environments might
interfere with Anne’s sleep?
• How much sleep might Anne need in a normal night?
• How will a good night of sleep benefit Anne while she is in
the hospital?
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Altered Sleep Pattern
Case Studies
• Anne’s doctor has prescribed Ambien for her. Ambien is a
sedative/hypnotic (non-barbiturate) used in the shortterm treatment of insomnia. Why do you think the doctor
ordered a sleeping medication even though Anne is
physiologically and psychologically dependent on the
medication?
• Anne will undoubtedly receive narcotic analgesics after
surgery. How do you think they will affect her sleep?
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