SLEEP

Sleep is a basic physiological need that is necessary for survival. It

can be defined as a period of reduced consciousness, diminished muscular
activity and depressed metabolism. Sleep provides the greatest degree of
rest, with all body systems functioning at a reduced level. Although sleep is
a state of reduced consciousness, certain stimuli, for example, a sudden
loud noise, will usually rouse the person.

Purposes of sleep

sleep promotes the growth and repair of body cells.

It appears that the level of circulating hormones, such as growth hormone

and those secreted by the adrenal glands, vary during sleep.

The alteration in the amount of these hormones circulating during sleep is

considered to facilitate cell growth and repair.

Sleep is also a time that allows for conservation of energy,

prevention of fatigue, and provision of organ respite.

It is therefore of particular importance that the person who is ill or

hospitalised has the opportunity to benefit from the restorative nature of
sleep.

People who suffer from chronic illness or chronic pain syndrome that
disturbs effective sleep may spend much time in bed but not wake feeling
rested or restored.

Factors affecting sleep

7 hours a night being the average required for an adult.

The quality of sleep is equally as important as the quantity of sleep
achieved.

Age

Sleep patterns change throughout the life cycle and the quantity of sleep
diminishes from about 20 hours a day in infancy to about 8 hours a day in
adolescence, to perhaps as little as 4 hours in older adulthood

As a person ages, the amount of time spent sleeping at night is usually

decreased from earlier in life. Many older adults will wake more often during
the night, and report an inability to return to sleep after rousing. They may
then report ‘napping’ more often during the day.

Factors that influence a person’s sleep and wakefulness include medical

conditions, medications, stress, sleep environment, and foods and fluids
consumed, but the greatest influence is exposure to light.

Night shift workers often have trouble falling asleep when they go to bed and
may have trouble staying awake at work because their natural circadian
rhythm and sleep-wake cycle are disrupted.

Jet lag also disrupts circadian rhythms. When flying to a different time zone,
a mismatch is created between a person’s internal clock and the actual time
of day.

Diet • Certain foods induces sleep • Ex: the L- tryptophan present in the
milk induces sleep
Smoking • Nicotine has a stimulating effect on the body, and smokers often
have more difficulty falling asleep than non smokers. • Smokers can be
easily aroused

Motivation • Motivation can increase alertness in some situations • Ex:

During the time of examination Browsing internet in the late night

Medications: • Beta-blockers have been known to cause insomnia. •

Narcotics, such as morphine, are known to suppress REM sleep and to
cause frequent awakenings and drowsiness. • Most Hypnotics suppresses
REM sleep

Physiology of sleep

With the beginning of daylight, Melatonin is at its lowest level in the body
and the stimulating hormone, Cortisol , is at its highest causing
wakefulness.

. Circadian Rhythms • It is a sort of 24-hour internal biological clock. The

term circadian is from the Latin “circa dies”, meaning “about a day.” •
Biological 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.

Sleep is described as being of two major types, non-rapid eye-movement

sleep (NREM), and rapid eye-movement sleep (REM). Normally a period of
sleep consists of about 4–6 cycles, each lasting around 100 minutes. It is
generally recognised that each sleep cycle consists of five stages. The first
four stages are stages of NREM sleep, while the fifth stage is REM sleep. The
five stages of sleep are:

• Stage 1: this stage is characterised by general relaxation and drowsiness

and is the transitional stage between wakefulness and sleep. During this
stage, which lasts about 15 minutes, the person can still be woken by any
slight stimulus (e.g. the sound of a dog barking in the distance)

• Stage 2: during this stage, muscle relaxation intensifies, brain activity

decreases and body functions are slowing down. During this stage, which
usually lasts 10–20 minutes, the person can still be woken easily but there
is greater relaxation than in stage 1

• Stage 3: this stage occurs about 30 minutes after the person goes to sleep.
During this stage the person is not usually roused by familiar noises. There
is complete relaxation in which most body systems slow down. Some effects
are that the pulse rate is reduced, gastrointestinal function decreases and
muscles are relaxed
• Stage 4: during this stage the person is in a deep sleep, is difficult to
rouse, the body is relaxed and body functions are markedly decreased. This
stage is also known as slow-wave sleep (little brainwave activity occurs), and
is associated with physical repair and restoration

• Stage 5: this is a period of light sleep during which most dreaming is

thought to occur, and the eyes move rapidly back and forth (REM). If
awakened during this stage, the person may recall vivid dreams. It is
possible to reach this stage of sleep within 90 minutes of sleep initiation.
REM sleep is thought to be necessary for mental restoration and adaptation
to stress. The act of dreaming, while not fully understood, is considered by
some as necessary for the promotion of psychological integration. Dreams
can be described as a sequence of thoughts, images and emotions that pass
through the mind during the REM stage of sleep.

It is thought that to achieve high-quality restorative sleep most people

complete several sleep cycles. With each successive cycle, stages 1 and 2 are
normally not re-entered, and so continuing sleep tends to fluctuate between
stages 3 and 4, with lengthening periods of REM sleep.

Promoting sleep

To Promote Sleep • 1. Sleep-Wake Pattern • Maintain a regular bedtime and

wake-up schedule • Eliminate day time naps. If naps are taken, limit to 20
minutes or less twice a day • Instruct the client to go to bed when sleepy. •
Use warm bath and relaxation techniques • If unable to sleep in 15 to 30
minutes, get out of bed and persue some relaxation activity.

TO Promote Sleep • Establish a regular, relaxing bedtime routine before

sleep such as reading, listening to soft music, taking a warm bath, or doing
some other quiet activity. • Avoid dealing with office work or family problems
before bedtime • Get adequate exercise during the day to reduce stress, but
avoid excessive physical exertion at least 3 hours before bedtime.

56. …….Nursing Interventions To Promote Sleep • 2. Environment: •

Create a sleep-conducive environment that is dark, quiet, comfortable, and
cool. • Keep noise to a minimum; block out extraneous noise as necessary
with white noise from a fan, air conditioner. • Sleep on a comfortable
mattress and pillows. • Listen to relaxing music • Increase exposure to
bright light during the day

57. ……..Nursing Interventions To Promote Sleep • 3. Diet: • Limit alcohol,

caffeine, and nicotine in late afternoon and evening • Consume
carbohydrates or milk as a light snack before bedtime. • Avoid heavy and
spicy foods. Heavy or spicy foods can cause gastrointestinal upsets that
disturb sleep • Decrease fluids 2 to 4 hours before sleep

58. ……Nursing Interventions To Promote Sleep • 4.Medications: • Use

sleeping medications only as a last resort • Minimize the usage of medicines
as much as possible because many contain antihistamines that cause
daytime drowsiness. • Take analgesics 30 mins before bedtime to relieve
aches and pains. • Consult the health care provider about adjusting other
medications that may cause insomnia.

SLEEP DISORDERS

There are several sleep disorders that can cause sleep deficiency, such as
insomnia, sleep apnea, and narcolepsy.
Insomnia
Insomnia is a common sleep disorder that causes trouble falling asleep,
staying asleep, or getting good quality sleep. Insomnia interferes with daily
activities and causes the person to feel unrested or sleepy during the day.
[33]
Short-term insomnia may be caused by stress or changes in one’s
schedule or environment. It can last for a few days or weeks. Chronic
insomnia occurs three or more nights a week, lasts more than three months,
and cannot be fully explained by another health problem or a medication.
Chronic insomnia raises the risk of high blood pressure, coronary heart
disease, diabetes, and cancer.[34]
Symptoms of insomnia include the following:
Lying awake for a long time before falling asleep. This is more common in
younger adults.
Sleeping for only short periods due to waking up often during the night or
being awake for most of the night. This is the most common symptom and
typically affects older adults.
Waking up too early in the morning and not being able to get back to sleep.
Having poor-quality of sleep that causes one to wake up feeling unrested.
The person often feels sleepy during the day and has difficulty focusing on
tasks. Insomnia can also cause irritability, anxiousness, and depression.
To diagnose insomnia, the health care provider asks about a person’s sleep
habits and may request the person to keep a sleep diary for 1-2 weeks.
A sleep diary records the time a person goes to sleep, wakes up, and takes
naps each day. Timing of activities such as exercising and drinking caffeine
or alcohol are also recorded, as well as feelings of sleepiness throughout the
day.[37] A sleep study may be ordered to look for other sleep problems, such
as circadian rhythm disorders, sleep apnea, and narcolepsy.
TREATMENT
Lifestyle changes often help improve short-term insomnia. The patient
should be educated about healthy sleep habits, such as the following:
Make your bedroom sleep-friendly. Sleep in a cool, quiet place. Avoid
artificial light from the TV or electronic devices, as this can disrupt your
sleep-wake cycle.
Go to sleep and wake up around the same times each day, even on the
weekends. If you can, avoid night shifts, irregular schedules, or other things
that may disrupt your sleep schedule.
Avoid caffeine, nicotine, and alcohol before bedtime. Although alcohol can
make it easier to fall asleep, it triggers sleep that tends to be lighter than
normal. This makes it more likely that you will wake up during the night.
The effect of caffeine can last as long as eight hours.
Get regular physical activity during the daytime (at least 5 to 6 hours before
going to bed). Exercising close to bedtime can make it harder to fall asleep.
Avoid daytime naps, especially in the afternoon. This may help you sleep
longer at night.
Eat meals on a regular schedule and avoid late-night dinners to maintain a
regular sleep-wake cycle.
Limit how much fluid you drink close to bedtime. This may help you sleep
longer without having to use the bathroom.
Learn new ways to manage stress. Follow a routine that helps you wind
down and relax before bed. For example, read a book, listen to soothing
music, or take a hot bath. Your doctor may also recommend massage
therapy, meditation, or yoga to help you relax. Acupuncture may also help
improve insomnia, especially in older adults.
Avoid certain over-the-counter and prescription medicines that can disrupt
sleep (for example, some cold and allergy medicines).[38]
A type of counseling called cognitive behavioral therapy for insomnia is
usually the first treatment recommended for chronic insomnia. Several
prescription medications may also be prescribed to treat insomnia. Some are
meant for short-term use while others are meant for long-term use. Some
insomnia medications can be habit-forming, and they all can cause
dizziness, drowsiness, or worsening of depression or suicidal thoughts.
[39]
Common medications prescribed to treat insomnia are as follows:
Benzodiazepines, such as lorazepam (Ativan). Benzodiazepines can be habit-
forming and should be taken for only a few weeks. They can interfere with
REM sleep.
Benzodiazepine-receptor agonists, such as zolpidem (Ambien). Side effects
may include anxiety. Rare side effects may include a severe allergic reaction
or unintentionally doing activities while asleep such as walking, eating, or
driving.
Melatonin-receptor agonists, such as ramelteon (Rozerem). Rare side effects
may include doing activities while asleep, such as walking, eating, or
driving, or a severe allergic reaction.
Orexin-receptor antagonists, such as suvorexant (Belsomra). This medicine
is not recommended for people who have narcolepsy. Rare side effects may
include doing activities while asleep, such as walking, eating, or driving, or
not being able to move or speak for several minutes while going to sleep or
waking up.[40]
Some patients use over-the-counter (OTC) products as sleep aids. Many
contain antihistamines that cause sleepiness. However, they can be unsafe
for some people and may not be the best treatment for insomnia. Melatonin
supplements are lab-made versions of the sleep hormone melatonin. Many
people take melatonin supplements to improve their sleep. However,
research has not proven that melatonin is an effective treatment for
insomnia. Side effects of melatonin may include daytime sleepiness,
headaches, upset stomach, and worsening depression. It can also affect the
body’s control of blood pressure, causing high or low blood pressure. [41]
Narcolepsy is an uncommon sleep disorder that causes periods of extreme
daytime sleepiness and sudden, brief episodes of deep sleep during the day.
Signs and symptoms of narcolepsy include extreme daytime sleepiness;
falling asleep without warning, called sleep attacks; difficulty focusing or
staying awake; and waking frequently at night. Individuals may experience
hallucinations while falling asleep or waking up or sleep paralysis, a feeling
of being awake but being unable to move for several minutes. Narcolepsy is
diagnosed based on medical history, family history, a physical exam, and a
sleep study. The sleep study looks at daytime naps to identify disturbed
sleep or a quick onset of rapid eye movement (REM) sleep. Treatment for
narcolepsy combines medications and behavior changes. Medications used
to treat narcolepsy include stimulants, modafinil, and sodium oxybate to
treat daytime sleepiness, and sedatives to improve nighttime sleep. Daytime
sleepiness is often improved by promoting good quality sleep at night with
scheduled naps during the day

• 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 longer than 10 seconds in an hour is
considered abnormal and should be evaluated by a sleep medicine
specialist.
Sleep Apnea is most frequently diagnosed in men and postmenopausal
women, it may occur during childhood. • Three types of apnoea based on the
cause • 1. Obstructive Apnoea • 2. Central Apnea • 3. Mixed Apnea
OBSTRUCTIVE APNOEA: • Obstructive apnea occurs when the structures of
the pharynx or oral cavity block the flow of air. • Enlarged tonsils and
adenoids, a deviated nasal septum, nasal polyps, and obesity predispose the
client to obstructive apnea • Treatment includes surgical removal of tonsills,
correcting nasal septum, weight loss may be helpful.
CENTRAL APNEA: • Due to defect in the respiratory centre of the brain. •
Clients who have brainstem injuries and often have central sleep apnea. •
3.MIXED APNOEA • Mixed apnoea is combination of obstructive and central
apnea

Something abnormal occurs during sleep itself, or during the times when
the client is falling asleep or waking up • The quality, quantity, and timing of
the sleep are essentially normal. Most common DISORDERS are: • Bruxism
• Enuresis • Periodic limb movement disorder • Sleep talking • Sleep walking
…….PARASOMNIAS Bruxism. Usually occurring during stage II NREM
sleep, characterized by clenching and grinding of the teeth. • This clenching
and grinding of the teeth can eventually erode dental crowns, cause teeth to
 come loose, and lead to deterioration of the temporomandibular (TMJ) joint,
called TMJ syndrome
Enuresis. Bed-wetting during sleep occuring in children over 3 years old.
• More males than females are affected. • It often occurs 1 to 2 hours after
falling asleep.
• Periodic limb movement disorder (PLMD). In this condition, the legs jerk
twice or three times per minute during sleep. • It is most common among
older adults. • Respond well to medications such as levodopa, pramipexole ,
ropinirole, and gabapentin
……• Sleeptalking. Talking during sleep occurs during NREM sleep before
REM sleep. • It rarely presents a problem to the person unless it becomes
troublesome to others
. ……. • Sleepwalking. Sleepwalking (somnambulism) occurs during stages
III and IV of NREM sleep. It is episodic and usually occurs 1 to 2 hours after
falling asleep. • Sleepwalkers tend not to notice dangers (e.g., stairs) and
often need to be protected from injury

PAIN

Pain has been defined as, “Whatever the patient says it is, experienced
whenever they say they are experiencing it.

International Association for the Study of Pain (IASP) released a revised

definition of pain as, “An unpleasant sensory and emotional experience
associated with, or resembling that associated with, actual or potential
tissue damage,”

 Nocireceptors that transmit pain sensation. 2. Neurotransmitters are the

chemicals which allow the transmission of signals from one neuron to the
next across synapses.
 3. Substance P a substance that functions as a neurotransmitter and as a
neuromodulator. To be specific, substance P is an undecapeptide - a peptide
composed of a chain of 11 amino acid residues.
 5. Serotonin •Serotonin is a chemical created by the human body that
works as a neurotransmitter. It is regarded by some researchers as a
chemical that is responsible for maintaining mood balance, and that a
deficit of serotonin leads to depression.
 6. 1. Prostaglandin The prostaglandins are a group of lipids made at sites
of tissue damage or infection that are involved in dealing with injury and
illness. They control processes such as inflammation, blood flow, the
formation of blood clots and the induction of labour. Mechanism of action of
the drug aspirin.
 7. 5. Bradykinin Peptide formed from the degradation of protein enzymes.
It is a powerful vasodilator that also cause contraction of smooth muscle. 6.
Histamine An enzyme that cause local vasodilatation and increase
permeability of the blood vessel walls.
 8. Physiology of Pain NOCICEPTION The peripheral nervous system
includes primary sensory neurons specialized to detect tissue damage and
to evoke the sensation of touch, heat, cold, pain and pressure. The receptors
that transmit pain sensation are called Nociceptors.
 9. The pain receptors or nociceptors can be excited by mechanical,
thermal, or chemical stimuli. The physiologic processes related to pain
perception are described as nociception. There are four processes involved in
nociception: transduction, transmission, perception and modulation.
 10. i. Transduction: • During the transduction phase, noxious stimuli
(tissue injury) triger the release of biochemical mediators i.e. prostaglandins,
bradykinin, serotonin, histamine and Substance P that sensitize receptors. •
The painful stimulation also cause movement of movement of ions across
cell membranes, which excites nociceptors.
 11. • Pain medications can work during this phase by blocking the
production of prostaglandin (e.g. ibrufen) or by decreasing the movement of
ions across the cell membranes (e.g. local anaesthetic).
 12. ii. Transmission: The second phase of nociception, transmission of
pain, includes three segments. • The first segment the pain impulse travel
from the peripheral nerve fibres to the spinal cord. Substance P serves as
neurotransmitter. Two types of nociceptors cause this transmission to
dorsal horn of the spinal cord: C fibres transmit dull pain and A- delta fibres
which transmit sharp, localized pain.
 15. • The second segment is transmission from the spinal cord to the brain
stem and thalamus. • The third segment involves transmission of signals
between the thalamus to the somatic sensory cortex where pain perception
occurs. • Pain control can take place during this second process of
transmission. For example block of release of neurotransmitters,
particularly substance P, which stops the pain at the spinal level.
 16. iii. Perception It is the third process of nociception. It is when a person
becomes conscious of the pain. It is believed that pain perception occurs in
the cortical structures, which allows for different cognitive behavioural
strategies to be applied to reduce the sensory and affective component of
pain
 17. • For example, non-pharmacological interventions such as distraction,
guided imagery, and music can help direct the client’s attention away from
pain.
 18. iv. Modulation This is the fourth system, often describes as the
“descending system,”. This fourth system occurs when neurons in the
brainstem send signals back down to the dorsal horn of the spinal cord.
These descending fibres release substances such as endogenous opioids,
serotonin and norepinephrine which can inhibit the ascending of noxious
impulses in the dorsal horn
 19. GATE CONTROL THEORY •Peripheral nerve fibres carrying pain to the
spinal cord can have their input modified at the spinal cord level before
transmission to the brain. •Synapses in the dorsal horn act as gates that
close to keep impulses from reaching the brain or open to permit impulses
to ascend to the brain
 20. • Small-diameter nerve fibres carry pain stimuli through a gate, but
large-diameter nerve fibres going through the same gate can inhibit the
transmission of the pain impulses, that is, close the gate. • The gate
mechanism is thought to be situated in in the substantia gelatinosa cells in
the dorsal horn of the spinal cord.
 21. • Because s limited amount of sensory information can reach the brain
at any given time. • The brain also appears to influence whether the gate is
open or closed. For example previous experience with pain are known to
affect the way an individual response to pain.
 22. RESPONSES TO PAIN Body’s response to pain is a complex process
rather than a specific action. It has both physiologic and psychological
aspects. Initially the sympathetic nervous system responds, resulting in the
fight-or-flight response. As pain continues, the body adopts as the
parasympathetic nervous system takes over,
 23. reversing many of the initial physiologic responses.

TYPES OF PAIN

Pain can be divided into visceral, deep somatic, superficial, and neuropathic pain.
 Visceral structures are highly sensitive to stretch, ischemia, and inflammation.
Visceral pain is diffuse, difficult to locate, and often referred to a distant, usually
superficial, structure. It may be accompanied by nausea and vomiting and may be
described as sickening, deep, squeezing, and dull.[8]

 Superficial pain is initiated by the activation of nociceptors in the skin or other
superficial tissue and is sharp, well-defined, and clearly located. Examples of injuries
that produce superficial somatic pain include minor wounds and minor (first-degree)
burns.[10]
 Neuropathic pain is defined by the International Association for the Study of Pain
(IASP) as pain caused by a lesion or disease of the somatosensory nervous system. It
is typically described by patients as “burning” or “like pins and needles.” Neuropathic
 pain can be caused by several disease processes, such as diabetes mellitus, strokes,
and HIV, and is generally undertreated because it typically does not respond to
analgesics. Medications such as tricyclic antidepressants and gabapentin are typically
used to manage this type of pain

 ACUTE PAIN

Pain of short duration, usually less than 6 months • It usually protective

and has an identifiable cause • It has limited tissue damage • Physical
manifestations include-increased heart rate, respiratory rate, blood
pressure, and anxiety .

Chronic Pain • May start as acute pain but last longer beyond the normal
time of recovery usually more than 6 months • Cause may not be known •
Physical manifestations include flat affect, reduced physical
movement/activity, fatigue and withdraw from others and social
interactions.

CHRONIC NON MALIGANT PAIN: VERY SLOW HEALING LIKE BURNS

Chronic intermittent pain : recurrent condition ,difficult to manage ,client

anticipates the continual exaceberation

Chronic malignant pain : neuropathic,deep ,visceral and bone pain

Idiopathic Pain Chronic pain in the absence of an identifiable physical or

emotional cause.

Referred Pain • Form of visceral pain which is felt in an area distant from
the from the site of stimulus

 14. Psychogenic Pain • Pain not caused by nociception but by

psychological factors. • Patient will usually report pain that does not match
the underlying disorder • Its diagnosed after ruling out all the other causes
of pain.