Sleep disorder

INTRODUCTION

 Sleep is the state of natural rest observed throughout

the animal kingdom, in all mammals and birds, and in
many reptiles, amphibians, and fish.
 In humans, other mammals, and many other animals

that have been studied - such as fish, birds, ants, and

fruit-flies - regular sleep is necessary for survival.
 The capability for arousal from sleep is a protective

mechanism and also necessary for health and survival.

DEFINITION

 Sleep can e defined as a normal state of altered

consciousness during which the body rests; it is
characterized by decreased responsiveness to the
environment, and a person can be aroused from it by
external stimuli.
STAGES OF SLEEP

 Sleep can be defined behaviorally, functionally and electro physiologically.  Electro

physiologic monitoring of sleep is called Polysomnography includes at least 3
parameters L
 1) brain wave activity,
 (2) eye movements and
 (3) muscle tone. Polysomnography shows that sleep can be divided into REM and
NREM.  NREM sleep can be further divided into 4 stages. The stages vary in depth,
but are characterized by slow rolling eye movements, low level and fragmented
cognitive activity, maintenance of moderate muscle tone, and slower, but generally
rhythmic respirations and pulse rate.
 NREM sleep is characterized as follows:
 Stage 1:
 includes lightest level of sleep
 stage lasts a few minutes
 decreased physiological activity begins with gradual fall in vital signs and metabolism
 sensory stimuli such as noise, easily arouse sleeper
 if awakened, person feels as though daydreaming has occurred
 Stage 2:
 includes period of sound sleep
 relaxation progresses
 arousal is still relatively easy
 stage lasts 10 – 20 mts
 body functions continue to slow
 the brain waves are frequently mixed and low voltage

in pattern, with bursts of activity called sleep spindles 

and large amplitude waves called K complexes
 Stage 3:
 it involves initial stages of deep sleep
 sleeper is difficult to arouse and rarely moves
 oxygen consumption
 muscles are completely relaxed
 vital signs decline, but remain regular
 stage lasts 15 – 30 mts
 Stage 4:
 it is deepest stage of sleep
  it is very difficult to arouse sleeper
 If sleep loss has occurred, sleeper will spend considerable portion  of night in
this stage
 Vital signs are significantly lower than during waking hours
 Stage lasts approximately 15 – 30 mts
 Sleep walking and enuresis  sometimes occur
 Stage 3 and 4 known as slow wave sleep, named for the characteristic high
voltage and low – frequency delta waves
REM sleep:

 Vivid, full- color dreaming occurs

 Stage usually begins about 90 mts after sleep has begun
 Stage typified by autonomic responses of rapidly  moving eyes,
fluctuating heart and respiratory rates, and increased or fluctuating
blood pressure
 Loss of skeletal muscle tone occurs
 Gastric secretion increase
 It is very difficult to arouse sleeper
 Duration of REM sleep increases with each cycle and averages 20
mts
 Stage is characterized by low voltage, random fast waves, as in
stage 1 NREM
NORMAL SLEEP REQUIREMENTS & PATTERNS

 Sleep duration and quality vary among persons of all

age groups
 Infants            16 Hours /Day
 Toddlers          12 Hours /Day
 Preschoolers     11 Hours /Day
 Schoolers         9 - 10 hours /day
 Adolescents      8 – 9  hours /day
 Adults              6 – 8  hours /day
FACTORS AFFECTING SLEEP

 A number of factors affect the quality and quantity of of sleep. Often

more than one factor combined to cause a sleep problem.
 Physical illness (eg. Nausea, mood disorders, breathing difficulty,
pain)
 Drugs and substances (eg. Tryptophan)
 Lifestyle (eg. Daily routines, exercises)
 Usual sleep patterns and excessive daytime sleepiness
 Emotional stress
 Environment ( ventilation)
 Sound
 Exercise and fatigue
 Food and caloric intake
Types
I]Dyssomnias
Intrinsic sleep disorders
 Psycho physiologic insomnia
 Narcolepsy
 Obstructive sleep apnea syndrome
 Central sleep apnea syndrome
 Periodic limb movement disorder
 Restless leg syndrome
 Extrinsic sleep disorders
Inadequate sleep hygiene
Environmental sleep disorder
 Circadian rhythm sleep disorder

II] Parasomnias
Arousal disorders
Sleep walking
Sleep terrors
Sleep – wake transition disorders
Parasomnias usually associated with  REM sleep
Nightmares
Sleep paralysis
Other Parasomnias
Sleep bruxism
Sleep enuresis
Primary snoring
III ]Sleep disorders associated with medical or
psychiatric disorders
 A. Neurotransmitter imbalances
 B. Head injury
 C. Hormonal imbalances
 D. Respiratory disorders
 E. Cardiovascular disorders
 F. Gastrointestinal disorders
 G, Other disorders
 Associated with mental disorders
Associated with neurologic disorders
Associated with medical disorders
Proposed sleep disorders
TYPES A)STAGE 4 SLEEP DISORDERS
  These are disorders occuring during deep sleep.
  The common stage 4 parasomnias are:
 1)sleep-walking(somnambulism)
 2)sleep-terrors or night terrors(pavor nocturnus)

3)sleep-related enuresis
 4)bruxism
 5)sleep-talking(somniloquy)
 1)SLEEP-WALKING(SOMNAMBULISM)
 The patient carries out autonomic motor activities that
range from simple to complex.
 He may leave the bed,walk about or leave the house. 
Arousal is difficult and accidents may occur during sleep-
walking
 2)SLEEP-TERRORS OR NIGHT TERRORS(PAVOR

NOCTURNUS)
 The patient suddenly gets up screaming,with autonomic
arousal(tachycardia,sweating,and hyperventilation).
 He may be difficult to arouse and rarely recalls the episode
on awakening.
 In contrast,nightmares(which occur during REM sleep) are
clearly remembered in the morning.
 3)SLEEP-RELATED(BED WETTING)
 4)BRUXISM

 The patient has involuntary,and forceful grinding of

teeth during sleep.
 It causes the destruction of the tooth enamel.
 The patient remains completely unaware of the episode.
 5)SLEEP-TALKING(SOMNILOQUY)

 The patient talks during the stage 3 and 4 of sleep but

doesnot remember anything about it in the morning on
awakening.
TREATMENT  Since benzodiazepines suppress stage 4 of
NREM sleep,a single dose at bedtime usually provides
relief from stage 4 parasomnias.
B)OTHER SLEEP DISORDERS
  Nocturnal angina
  Nocturnal asthma
  Nocturnal seizures
  Sleep paralysis
SLEEP HYGIENE
  Avoid naps except for a brief 10-15 min nap 8 hrs after rising but check with
the physician first because in some sleep disorders naps can be beneficial.
  Get regular exercise at least 40 min each day that causes sweating
  Take a warm bath or warm shower about 2 hrs before bedtime.  Don’t use
bright light even you have to remain awake for long during nighttime
  Expose to half an hour of sunlight during 30 min of rising should be useful to
prevent drowsiness in the morning
  Take regular time out of bed for 7 days a week
  Don’t smoke to get sleep
  Give up smoking entirely or don’t smoke after 7 p.m.
  Avoid caffeine entirely or limit no more than 3 cups per day and not after 10
a.m.
  Too much time in bed is not good Remember that quality of sleep is
important.
  Keep the clock face turned away. Don’t see what time of night you are
awake.
  Don’t eat heavily or drink 3 hrs before bedtime. A light bedtime

snacks is o.k.
  Incase of problem of regurgitation, elevate the head of bed and

prevent spicy as well as oily meal before bedtime

  Keep your room well ventilated, dark and quiet during nighttime.
  Reading non-professional materials may be useful. Perform bedtime

rituals.
  Use stress management technique in daytime.
  Make sure that mattress isn’t too firm or too soft. Ensure that the

pillow is of appropriate height and firmness.

  An occasional sleeping pill is alright but use only after consultation

with doctor.
  Use bedroom only for sleep. Avoid activities that lead to prolonged

arousal.
FOR PATIENT WITH SLEEP
DISORDER
 Assessment
 To promote the restful sleep for clients, nurse can

assess the sleep pattern.

 Usually patients are the best resources for describing

their sleep problem. Some time we can take history
from the partner.

 In case of children, older children or mother can best

describe the pattern of sleep and its problem.
The tools for sleep assessments are:
  Sleep history including -Description of client’s sleep
problem; nature, sign/symptoms, onset, duration,
predisposing factors, severity, effects on client. -Usual sleep
pattern prior to sleep problem -Recent changes in sleep
pattern -Physical illness -Bedtime routine and sleeping
environment -Use of any medication
  Pattern of dietary intake or any substance -symptoms

experienced during waking hours -recent life event -

Current emotional and mental status
  Sleep diary including -times when patient tries to fall

asleep -approximate time that patient fall asleep -time of

awakening during night -record of food, physical activity,
worries, mental activity
NURSING PROCESS

 A. Assessment:  Assess client’s usual sleep habits and recent sleep quality as

part of the initial nursing history. If sleep quality is reported to be poor,
explore the nature of
 disturbances by noting the following:
 Usual activities in the hour before retrieving
 Sleep latency
 Number and perceived cause of awakenings
 Regularity of sleep pattern
 Consistency of rising time
 Frequency and duration of naps
 Events associated with initial onset of sleep disturbances
 Ease of falling asleep in places other than the usual bedroom
 Situations in which client fights sleepiness
 Daily caffeine intake
 Use of alcohol, sleeping pills,and other medications
 Incidence of morning headaches
 Frequency of snoring, apparent pauses in breathing, and kicking movements
 Objective data may include visible signs of fatigue and lack of sleep, such as
circles under the eyes, lack of coordination, drowsiness and irritability.
NURSING DIAGNOSIS
Sleep Pattern Disturbance Related To:
 1. Impaired oxygen transport
 2. Impaired elimination
 3. Immobility
 4. Medication
 5. Hospitalization
 6. Lack of exercise
 7. Anxiety response
 8. Life-style disruptions
 As evidenced by: Major: (Must be present )  Difficulty

falling or remaining asleep Minor: (May be present)  Fatigue

on awakening or during the day  Dozing during the day 
Agitation  Mood alterations
NURSING DIAGNOSIS
 Sleep pattern disturbance related to decreased physical

activity, fear, anxiety, inability to assume usual sleep

position, frequent assessments or treatments, unfamiliar
environment, and discomfort resulting from current
illness/injury.
EXPECTED OUTCOME
 The client will attain optimal amounts of sleep as

evidenced by:
 statements of feeling well rested
 usual mental status
 absence of frequent yawning and dark circles under

eyes
INTERVENTION
  Assess for signs and symptoms of a sleep pattern
disturbance. (e.g. statements of difficulty falling asleep,
not feeling well rested, or interrupted sleep; irritability;
disorientation; lethargy; frequent yawning; dark circles
under eyes).
  Determine the client's usual sleep habits.
  Implement measures to promote sleep:
 perform actions to reduce fear and anxiety.
  Discourage long periods of sleep during the day
unless signs and symptoms of sleep deprivation exist or
daytime sleep is usual for client
 Perform actions to relieve discomfort if present (e.g.

reposition client; administer prescribed analgesics,

antiemetics, or muscle relaxants
  discourage intake of foods and fluids high in caffeine

(e.g. chocolate, coffee, tea, colas) in the evening.

  offer client an evening snack that includes milk or

cheese unless contraindicated (the L-tryptophan in milk

and cheese helps induce and maintain sleep)
  allow client to continue usual sleep practices (e.g.
position; time; presleep routines such as reading,
watching television, listening to music, and meditating)
whenever possible.
  satisfy basic needs such as comfort and warmth

before sleep.
  encourage client to urinate just before bedtime.
  reduce environmental distractions
  ensure good room ventilation
  encourage client to avoid drinking alcohol in the evening (alcohol
interferes with REM sleep)
  if possible, administer medications that can interfere with sleep (e.g.
steroids, diuretics) early in the day rather than late afternoon or evening
  administer prescribed sedative-hypnotics if indicated.
  perform actions to reduce interruptions during sleep (80 - 100 minutes
of uninterrupted sleep is usually needed to complete one sleep cycle)
  restrict visitors
  group care (e.g. medications, treatments, physical care, assessments)
whenever possible.
  Consult appropriate health care provider if signs and symptoms of
sleep deprivation persist or worsen.
  Evaluation
  Reassessment