Rest and Sleep

Definition-Polysomnography (PSG), a type of sleep study,is a multi-parameter study of sleep and a diagnostic tool in sleep medicine.

  • Rest-Rest is a condition in which the body is in a decreased state of activity without physical emotional stress and freedom from anxiety.
  • "A state of calmness, relaxation without emotional stress and freedom from anxiety"
  • Sleep- Sleep is a state of rest accompanied by altered level of consciousness and relative inactivity, and perception to environment are decreased.

  • "Sleep can be defined as a complex rhythmic state involving a progression of repeated cycles, each representing different phases of body and brain activity, and is crucial for physical, mental, and emotional well- being." Buysse, 2014

Types/ Stages/ Phases 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: 


A. Non Rapid Eye Movement (NREM) Sleep

  •  Stage 1
  •  Stage 2
  •  Stage 3
  •  Stage 4 

B. Rapid Eye Movement Stage(rem) Sleep.
 During sleep, NREM and REM sleep alternate in cycles

A. 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:

  • Stage 1
  • Stage 2
  • Stage 3
  • Stage 4

Stage 1: NREM

  •  Stage lasts a few minutes.
  •  It includes lightest level of sleep. 
  • Gradual fall in vital signs and metabolism.
  • General slowing of EEG frequency
  • Eyes tend to roll slowly from side to side
  • Sensory stimuli such as noise easily arouses person.
  • Sleeper may deny he is sleeping.
  • Theta waves are begins.

 Stage 2: NREM 

  • Stage lasts 10 to 20 minutes.
  • It is a period of sound sleep.
  • It is about 50-55% of total night sleep time.
  • Relaxation progresses.
  • Further slowing of EEG
  • Absent eye ball movements
  • Body functions continue to slow.
  • Arousal remains relatively easy

Stage 3: NREM

  • Stage lasts 15 to 30 minutes.
  • It involves initial stages of deep sleep.
  • Muscles are completely relaxed.
  • Large slow waves in EEG
  • Vital signs decline but remain regular.
  • Sleeper is difficult to arouse and rarely moves

Stage 4: NREM

  • Stage lasts approximately 15 to 30 minutes.
  • It is the deepest stage of sleep.
  • If sleep loss has occurred, sleeper spends considerable portion of night in this stage.
  • Vital signs are significantly lower than during waking hours.
  • Further slowing of EEG
  • 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.

B. REM(Rapid Eye Movement) Sleep

  • Stage usually begins about 90 minutes after sleep has begun.
  • The REM stage is approximately20-25% of total night sleep time of a normal adult. 
  • Dreaming occurs in this stage(also known as dream sleep)
  • 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.
  • EEG pattern resembles that of awake state.
  • REM sleep is essential for emotional as well as mental equilibrium and plays a role in memory.
  • It is very difficult to arouse sleeper.
  • Beta wave are Seen.

Note-

  • REM  also known as  Paradoxical sleep because Brain is Highly  active but person is still Asleep.
  • Also known as Desynchronised sleep in this synchronisation between Neurons are  poor Intensity decrease  and  Frequency  increase .

A person would begin a sleep cycle every 90- 120 minutes resulting in four to five cycles per sleep time, or hours spent asleep. A sleep cycle progress through the stages of non-REM sleep from light to deep sleep, then reverse back from deep sleep to light sleep, ending with time in REM sleep before starting over in light sleep again.

Difference between  NREM Sleep and REM Sleep

S/N NREM REM
1. 75-80% Of Sleep Cycle  20-25% of Sleep Cycle
2.
  • No Eye Movement
  • No Muscle Activity
  • Rapid eye Movement
  • Irregular  Muscle Activity but muscles  are virtually Paralysed
3. Dream may Appear but  Memory of dream does not Retain Vivid Dreaming
4. Heart Rate and Respiratory rate decreases  than from Wakefulness Heart Rate and Respiratory rate Increases  and becomes Irregular 
5. Blood Pressure Decreases  Blood Pressure Increases and becomes Irregular 
6.  Sympathetic Activity and BMR Decreases. Sympathetic Activity and BMR Increases.

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.
  • Neural maturation
  • 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-

  • Among children, inadequate sleep is linked with obesity and other health conditions.
  • Geriatric people often report difficulty falling asleep, early awakening and waking frequently during the night, napping, or not feeling rested after a night's sleep.
  • Older adults often require more time to fall asleep and are less able to cope with alterations in usual sleep patterns compared to younger people.

2. Illness/Disease condition 

  • Illness that causes pain or physical distress (e.g., arthritis, backpain) can result in sleep problems Examples: Respiratory conditions Pain need to urinate during the night.

  • End-stage renal disease (ESRD) often disturbs nocturnal sleep and leads to excessive daytime sleepiness.

  • Liver failure and encephalitis tend to lead reversal in day-night sleeping habits.

  • Hypothyroidism can decrease the amount of NREM sleep, while hyperthyroidism may result in difficulty falling asleep.

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
  •  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.

4. Lifestyle

  • The duration and quality of sleep often affected by watching some types of television shows, performing specific activities or exercise, etc.
  • 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.

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.

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.

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

9. Motivation

  • Motivation can increase alertness in some situations
  • Ex: During the time of examination Browsing internet in the late night

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.
  • Most Hypnotics suppresses REM sleep

11. Culture

  • A person's cultural practices and beliefs can affect rest and sleep. Bedtime rituals, sleeping position and place, and pattern of sleep may vary according to culture.
  • Methods to promote sleep may also be culturally influenced. A cultural orientation towards privacy and quiet environment.

12. Occupation

  • People working in shift duties often experience sleep difficulties. Based on the circadian cycle, the body prepares for sleep at night by producing melatonin and reducing physiological processes.
  • Working in night shift disrupts the natural process and can result in loss of sleep and other adverse effects. Nurses and others health care workers often experience difficulty in sleep due to frequent shift changes.

13. Physical Activity and Exercise

  • Activity and exercise increase fatigue and, in many instances, enhance relaxation followed by sleep.
  • It is reported that physical activity increases both REM and NREM sleep.
  • Moderate exercise is a healthy way to induce sleep, but physical exercise within a 3-hour interval before normal bedtime can hinder sleep.
  • The work related fatigue is also believed to contribute to a restful sleep, whereas excessive exercise or exhaustion can reduce the quality of sleep.

14. Psychological Stress

  • Psychological stress, such as stress from illness, relationship conflicts and various life situations tends to disturb sleep.
  • Psychological stress affects sleep by decreasing the duration of REM sleep, which further tends to increase anxiety and stress.

Physiology of Sleep

  • Sleep cycle is controlled by the systems of brainstem. Bulbar synchronizing region (BSR) and reticular activating system (RAS) are the two major systems of brainstem responsible for the control of sleep cycle.
  • Reticular activating system extends upward via the pons, medulla and midbrain into the hypothalamus.
  • RAS is responsible for cortical activities related to the state of alertness as well as reflex and voluntary movements. It is consists of numerous nerve cells and fibers.
  • These nerve fibers relay impulses into the cerebral cortex and the spinal cord. Bulbar synchronizing region are specialized cells in medulla and pons. It also works by controlling cyclic nature of the sleep.
  • During sleep, the RAS receives fewer stimuli from the cerebral cortex and the peripheral sensory organs. As stimuli to RAS reduces and a person try to fall asleep by closing eyes and assuming relaxed posture, the BSR takes over and cause sleep.

SLEEP DISORDERS

Sleep disorders are mainly classified into 3 categories

  • SLEEP DISORDERS DYSOMNIAS
  • PARASOMNIAS
  • DISORDERS DUE TO OTHER MEDICAL CONDITIONS

A. DYSOMNIAS

Dyssomnias are a broad classification of sleeping disorders involving difficulty getting to sleep, remaining asleep, or of excessive sleepiness.

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.
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 can result from physical 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


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.


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).
  •  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 is most frequently diagnosed in men and postmenopausal women, it may occur during childhood.

Three types of apnoea based on the cause

  • Obstructive Apnoea
  • Central Apnea
  • 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.

Mixed Apnea

  • 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.

B. PARASOMNIAS-Parasomnias are a category of sleep disorders that involve abnormal movements, behaviors, emotions, perceptions, and dreams that occur while falling asleep, sleeping, between sleep stages, or during arousal from sleep. 

  • 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

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

C. 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 Diagnosis

  • Disturbed sleep pattern possibly related to sleep apnea, disruption of circadian rhythm, discomfort or pain, changes in bedtime rituals or sleep environment, drug dependency and withdrawal and illness symptoms, etc
  • Risk for injury possibly related to somnambulism narcolepsy and sleep apnea.
  • Insomnia possibly related to inadequate sleep hygiene and anxiety, worries about family and lack of bedtime rituals.
  • Disturbed sleep pattern possibly related to noise of hospital environment and need for periodic treatments.
  • Sleep deprivation possibly related to frequent rotations of work shifts and overtime.
  • Deficient knowledge possibly related to lack of interest in learning, inadequate information and cognitive limitation.

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
  • If unable to sleep in 15 to 30 minutes, get out of bed and persue some relaxation activity.
  • 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.

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

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

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.

5. Scheduling of Nursing Activities

Many patients often complaint of being awakened to take night medications dose and are aroused in the early morning for breakfast and taking morning dose of medications. Consider these common complaints when scheduling nursing care to promote rest and sleep. Schedule nursing activities when patient is normally awake.

6. Respect Normal Sleep-Wake Patterns of Patients

Allow the patients to follow their normal sleep-wake pattern. In many cases, insisting all patients to sleep and wake up at similar schedule is not necessary. For example, wakening a patient at 6 am, if the patient normally sleeps until 8 am is inaccurate. The patient's normal napping pattern should also be followed when possible. REM sleep is more common during morning naps, whereas NREM sleep is more common during naps later in the day. 

7. Minimizing Sleep Disturbances in Health Care Settings

  • According to various research studies, excessive noise in patient care units interferes with sleep and that these noise-related disruptions can increase blood pressure decrease oxygen saturation and delay wound healing.
  • Behavioral manifestations such as disorientation, restlessness, and irritability are also possible consequences, particularly in older adults.
  • Patient surveys consistently report that noise and sleep deprivation are among the top concerns during a hospitalization.
  • The most commonly implicated sources of noise include staff conversations, roommates, and electronic sounds such as alarms and phones. 
  • Scheduling procedures together so as not to awakes patients multiple times for vital signs, blood draws bathing, or medication administration that can safely be postponed for a short-time.
  • Medicating for pain if needed.
  • Keeping the room cool and providing earplugs and eye masks if requested and as appropriate.

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