SLEEP &

REST
Fundamentals of nursing
Aligarh college of nursing
Nursing instructor: sana zafar
Objectives
At the end of this unit, the learners will be able
to:
•Define rest and sleep pattern
•Define terms related to rest and sleep
•Compare the characteristics of sleep and
rest
•Discuss characteristics of two kinds of sleep
•Enumerate the function of sleep
Objectives
•Discuss factors effecting sleep
•Identify common sleep disorders
•Identify conditions necessary to promote sleep
•Discuss nursing process for a patient to
promote sleep
 Defination
• Rest is a condition in which the body is in a
decreased state of activity without physical
emotional stress and freedom from anxiety.

• Sleep is a state of rest accompanied by

altered level of consciousness and relative
inactivity, and perception to environment are
decreased
Comparison of rest and sleep
The difference between rest and sleep is
that rest is considered a period of bodily
inactivity such as relaxing at home or on
vacation and not doing much in terms of
psychical activity. Sleep is characterized by
variable level of consciousness , changes in
physiological process, and decrease
responsiveness to external stimuli.
Rest is what we do to let stress subside.
 Physiology of sleep
• The cyclic nature of sleep is thought to be
controlled by Centers located in the brain and
by Circadian Rhythms.

• Reticular activating system (RAS) located at

the brain stem and Cerebral Cortex plays an
important role in sleep wake cycle.
Physiology of sleep
•Neurotransmitters, located within the neurons
in the brain effect the sleep wake cycle . For
example serotonin is thought to lessen the
response to sensory stimulation and GABA
gamma aminobutyric acid to shut off the
activity of neurons in RAS.
•Another key factor to sleep is exposure to
darkness.
•Pineal gland in brain secrete melatonin , and
the person feel less alert.
 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.
 Stages of sleep
• Electroencephalogram (EEG) patterns, eye movements
and muscle activity are used to identify stages of sleep.
The stages of sleep are classified into two stages:
• Non Rapid Eye Movement (NREM) Sleep
o Stage 1
o Stage 2
o Stage 3
o Stage 4
• Rapid Eye Movement Stage(rem) Sleep.
During sleep, NREM and REM sleep alternate in cycles
 Non Rapid Eye Movement (NREM) Sleep

• First stage of sleep is known as NREM sleep.

• About 75% to 80% of sleep during a night is
NREM sleep.
• It consists of four stages:
o Stage 1
o Stage 2
o Stage 3
o Stage 4
 NREM sleep
• Stage 1: NREM
• Stage lasts a few minutes.
• It includes lightest level of sleep.
• Gradual fall in vital signs and metabolism.
• Eyes tend to roll slowly from side to side
• Sensory stimuli such as noise easily arouses
person.
• Sleeper may deny he is sleeping.
 NREM Sleep
• Stage 2: NREM
• Stage lasts 10 to 15 minutes.
• 44% to 55 %of total sleep
• It is a period of sound sleep.
• Relaxation progresses.
• Absent eye ball movements
• Body functions continue to slow.
• Arousal remains relative easy
 NREM Sleep
• Stage 3: NREM
• Stage lasts 15 to 30 minutes.
• It involves initial stages of deep sleep.
• Muscles are completely relaxed.
• Vital signs decline but remain regular.
• Sleeper is difficult to arouse and rarely moves
 NREM Sleep
• Stage 4: NREM
• Stage lasts approximately 15 to 30 minutes.
• It is the deepest stage of sleep.
• Vital signs are significantly lower than during waking
hours.
• Sleepwalking and enuresis (bed-wetting) sometimes
occur.
• It is very difficult to arouse sleeper
Physiological changes during NREM sleep

Arterial blood pressure falls

Pulse rate decreases
Peripheral blood vessels dilate
Cardiac output decreases
Skeletal muscles relax
Basal metabolic rate decreases 10 % to 30%.
Growth hormone level peak
Intracranial pressure decreases.
Loss of NREM sleep
In a sleep deprived client, the loss of NREM
sleep causes
•Immunosuppressant
•Slows tissue repair
•Lowers pain tolerance
•Triggers profound fatigue
•And increase susceptibility to infection
 REM Sleep
• Stage usually begins about 90 minutes after sleep
has begun.
• Dreaming occurs in this stage
• During REM the brain is highly active and the brain
metabolism as much as increase 20%
• Stage is typified by rapidly moving eyes, fluctuating
heart and respiratory rates, increased or fluctuating
blood pressure, loss of skeletal muscle tone, and
increase of gastric secretions..
• It is very difficult to arouse sleeper.
 FUNCTIONS OF SLEEP
• Conservation of energy
• Restoration of tissues and growth
• Thermoregulation
• Regulation of emotions- sleep deprivation
causes emotional disorders like irritability,
anxiety, depression etc.
• Sleep is also necessary for protein synthesis
• Memory and learning- there will be information
transfer between cerebral cortex and
hippocampus during sleep
Normal Sleep Requirements
• Newborn: 16-18 hours /day
• Infants: 12-14 hours
• Toddlers: 10-12 hours
• Preschool: 11-12 hours
• School-Age: 8- 12 hours
• Adolescents: 8-10 hours
• Adult: 6-8 hours
• Elders: 6 hours
FACTORS AFFECTING SLEEP
• Both the quality and the quantity of sleep are
affected by a number of factors.
• Sleep quality is a subjective characteristic
• Quantity of sleep is the total time the
individual
sleeps.
• 1. AGE
• 2. Illness
• Illness that causes pain or physical distress (e.g.,
arthritis, backpain) can result in sleep problems
FACTORS AFFECTINGSLEEP
• Examples: Respiratory conditions
• Pain
• need to urinate during the night
FACTORS AFFECTING SLEEP
• 3. Environment
• Environment can promote or hinder 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
• Discomfort from environmental temperature
(e.g., too hot or cold) and lack of ventilation can
affect sleep
FACTORS AFFECTING SLEEP
• Light levels can be another factor
• Another influence includes the comfort and
size of the bed.
• A person’s partner who has different sleep
habits, snores, or has other sleep difficulties
may become a problem for the person also.
FACTORS AFFECTING SLEEP
• 4. Lifestyle
• Following an irregular morning and night time
schedule can affect sleep.
• Night shift workers frequently obtain less
sleep than other workers and have difficulty
falling asleep.
FACTORS AFFECTING SLEEP
• 5. Emotional Stress
• Stress is considered to be the major cause of
short-term sleeping difficulties .
• A person preoccupied with personal problems
(e.g., school- or job-related pressures, family
or marriage problems) may be unable to relax
sufficiently to get to sleep.
FACTORS AFFECTING SLEEP
• 6. 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.
• Even though alcohol induces sleep, it disturbs
REM sleep causing irritability.
FACTORS AFFECTING SLEEP
• 7. Diet
• Certain foods induces sleep
• Ex: the L- tryptophan present in the milk
induces sleep
• 8. 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
Factor AFFECTING SLEEP
• 9. Motivation
• Motivation can increase alertness in some
situations
• Ex: During the time of examination
Browsing internet in the late night
FACTORS AFFECTING SLEEP
• 10. 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.
 SLEEP DISORDERS
• Sleep disorders are mainly classified into 3
categories
SLEEP
DISORDERS

DISORDERS DUE
TO OTHER
DYSOMNIAS PARASOMNIAS
MEDICAL
CONDITIONS
 DYSOMNIAS
• The sleep itself is pretty normal.
• But the client sleeps too little, too much, or at
the wrong time.
• So, the problem is with the amount (quantity),
or with its timing, and sometimes with the
quality of sleep.
 DYSOMNIAS
• Common Dysomnias are:
• Insomnia
• Hypersomnia
• Narcolepsy
• Sleep Apnea
• Insufficient Sleep/ Sleep Deprivation
 Insomnia
• Insomnia is described as the inability to fall
asleep or remain asleep.
• Persons with insomnia awaken not feeling
rested.
• Insomnia is the most common sleep
complaint.
• 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
 Insomnia
• Insomnia can result from physicl discomfort
and more often from mental tension or
anxiety.
• People who are habituated to drugs or who
takes large amounts of alcohol are at high risk
for insomnia.
 Insomnia
Clinical manifestations:
■ Difficulty falling asleep
■ Waking up frequently during the night
■ Difficulty returning to sleep
■ Waking up too early in the morning
■ Unrefreshing sleep
■ Daytime sleepiness
■ Difficulty concentrating
■ Irritability
 Insomnia
• Treatment is development of new behavioral
patterns that induces sleep
• Create a sleeping environment that induces
sleep
• Create positive sleep thoughts
 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.
 Hypersomnia
• Treatment of hypersomnias include treating
the underlying disease conditions
 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.
• Clients with narcolepsy have sleep attacks or
excessive daytime sleepiness, and their sleep
at night usually begins with a sleep-onset REM
period (dreaming sleep occurs within the first
15 minutes of falling asleep).
 Narcolepsy
• People sleeps several times a day even when
they are conversing with people or while
driving.
• CNS stimulants and Antidepressants are the
drugs used to treat narcolepsy.
 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 longer than 10 seconds in an
hour is considered abnormal and should be
evaluated by a sleep medicine specialist.
 Sleep Apnea
• 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
 Sleep Apnea
• 1. 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.
 Sleep Apnea
• 2. 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
 Insufficient Sleep/ Sleep Deprivation
• A prolonged disturbance in quality and
quantity of sleep can lead to a syndrome
called as sleep deprivation.
• It is not a sleep disorder but result of
prolonged sleep disturbance.
• It produces various physiological and
behavioural symptoms based on the severity
of deprivation.
 Insufficient Sleep/ Sleep Deprivation
Individuals may develop:
• Attention and concentration deficits
• Reduced vigilance
• Distractibility
• Reduced motivation
• Fatigue
• Diplopia and dry mouth.
 PARASOMNIAS
• 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
 PARASOMNIAS
■ 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.
 PARASOMNIAS
• 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
 PARASOMNIAS
• 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
 PARASOMNIAS
• 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
 Disorders due to other medical
conditions
• These disorders are associated with Medical
or Psychiatric or other illness
• Usually the disorders that cause sleep
disturbance includes:
• Depression
• Alcolism
• Thyroid dysfunction
• Peptic ulcer
• COPD- chronic obstructive pulmonary
disease
Nursing management
Assessment;
it includes complete sleep history, health
history and physical examination.
Diagnosis ;
•Sleep disturbed pattern ( insomnia)
•Risk for injury related to somnambulism
•Fatigue related to insufficient sleep
•Risk for impaired gas exchange related to sleep
apnea
•Anxiety related to sleep apnea
Planning
•The major goal for client with sleep
disturbances is to maintain or develop a
sleeping pattern that provide sufficient energy
for daily activities
•The other goal may relate to enhance the
client’s feeling of wellbeing or improving the
quality and quantity of client’s sleep
Nursing intervention

•Reducing environmental distraction

•Promoting bedtime rituals
•Providing comfort measures
•Scheduling nursing care to provide for
uninterrupted sleep periods
•Teaching stress reduction, relaxation
techniques or good sleep hygiene
 Nursing Interventions 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
 Nursing Interventions 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.
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
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
 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.
 Refrences
• Kozier& Erb‘s. Fundamentals of
Nursing: concepts, process and
practice, 8th Edition.