Rest & Sleep - 2015

10/6/2015
Shauna Winchester, MSN, RN
Explain why rest and sleep are important.

Describe the functions and physiology of
sleep.
Explain circadian rhythms and how they relate
to sleep.
Identify factors that influence rest and sleep.
Describe nursing implications for age-related
differences in the sleep cycle.
Identify at least five common sleep disorders.

Perform a comprehensive sleep assessment
using appropriate interview questions, a sleep
diary, and a sleep history.
Formulate nursing diagnoses that identify
sleep problems that may be treated through
specific nursing interventions.
Plan, implement, and evaluate nursing care
related to specific nursing diagnoses
addressing sleep problems.
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Describe the therapeutic actions, indications,

pharmacokinetics, contraindications, most
common adverse reactions, and important
drug-drug interactions associated with each
class of hypnotic agent.
Outline the nursing considerations and
teaching needs for patients receiving each
class of hypnotic agent.
Sleep Versus Rest

Sleep
Cyclical states/altered
consciousness
Decreased motor activity/perception
Selective response to external
stimuli
Rest
Mild to no activity
Relaxation; stress-free
Leads to feeling refreshed
Which of the following is the main difference

between sleep and rest?
A. In sleep, the body may respond to
external stimuli.
B. Short periods of sleep do not restore the
body as much as do short periods of rest.
C. Sleep is characterized by an altered level
of consciousness.
D. The metabolism slows less during sleep
than during rest.
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Benefits of Sleep
Increases mental performance
Improves learning
Helps the storage of long-term memory
Restores energy
Improves ability to cope
Strengthens the immune system
Newborns: 16-20 hrs

Infants: 14-16 hrs
Toddlers: 12-14 hrs
Preschoolers: 11-13 hrs
Middle and late childhood: 10-11 hrs
Adolescents: 8-9 hrs
Young adults: 7-8 hrs
Middle-aged adults: 7 hrs
Older adults: 5-7 hrs
Nursing students
Biorhythms
Circadian
rhythm
formation
Reticular activation system (RAS)
Electroencephalogram (EEG)
Reticular
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Alpha
waves
Beta waves
Spindles or K-complexes
Theta waves
Delta waves
Terms to Know
Circadian rhythm
Internal clock
24-hour day-night sleep/wake
pattern
Affects overall level of
functioning
Reticular activating system

Stages of sleep
NREM
REM
Stage 1 (NREM Sleep)
Very light sleep

Lasts 5-10 mins
Groggy
Easily awakened
Relaxed but aware
of surroundings
Stage 2 (NREM)
10-15 mins
Light sleep
Easily aroused (not
as easily as Stage 1)
VS & metabolism
diminish
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Stage 3 (NREM)
Stage 4 (NREM)
Deep
20-50 mins
sleep 5-15 mins
Difficult
to arouse
TPR
and BP decrease
more
Deepest sleep
Difficult to awaken
Muscles
relaxed
May be confused if
awakened in this state
Snoring
may occur
11% of total sleep
Lest restful than NREM sleep

Eyes move rapidly
Small muscles twitch
Metabolism, temp, and BP increase
Pulse may be rapid and irregular
Apnea may occur
Dreaming occurs
25% of total sleep
Stage at which mental rest and restoration
occur
Light sleep and slowing brain and body processes

are associated with which stage of NREM sleep?
a.
b.
c.
d.
I
II
III
IV
10/6/2015
Factors Affecting Sleep

Age
Lifestyle factors
Physical activity
Food and alcohol
Medications
Caffeine
Sleep habits
An illness
Environmental factors
Temperature and humidity
Noise and light
noxious odor
Comfort of bedding
Dyssomnias
Sleep disorders characterized by difficulty falling or

staying asleep, early awakening, or excessive sleepiness.
They include insomnia, sleep-wake schedule (circadian
disorders) sleep apnea, restless leg syndrome,
hypersomnia, and narcolepsy.
Parasomnias
Patterns of waking behavior that appear during
sleep (sleepwalking)
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Common Sleep Disorders

Insomnia
Inability to fall or remain asleep or go back to
sleep
Sleep-wake schedule (Circadian) disorders

Abnormality in sleep/wake times
(e.g., jet lag, working night shift, rotating

shifts)
The nurse is caring for a hospitalized patient who normally

works the night shift at his job. The patient states, I dont
know what is wrong with me. I have been napping all day
and cant seem to think clearly. The nurses best response
is
a. You are sleep deprived, but that will resolve in a few
days.
b. You are experiencing hypersomnia, so it will be
important for you to walk in the hall more often.
c. There has been a disruption in your circadian rhythm.
What can I do to help you sleep better at night?
d. I will notify the doctor and ask him to prescribe a
hypnotic medication to help you sleep.

Restless Leg Syndrome
Uncontrollable movement of legs during sleep/rest
Hypersomnia
Excessive sleeping (especially during daytime)
Sleep-related or disease-related
Can be related to depression
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Sleep Deprivation
Result of prolonged sleep disturbances
s/s
Daytime drowsiness, impaired cognitive function,
restlessness, perceptual disorders, irritability,
malaise.
Severe and prolonged- delusions, paranoia,

psychotic behavior
Decreased immunity

Sleep Apnea
Periodic breathing cessation for at least 10 seconds
during sleep
Disorder when there are more than 5 apneic episodes
lasting longer than 10 secs/hr.(ATI)
Obstructive sleep apnea (OSA)
Central sleep apnea (CSA)
Snoring
Narcolepsy
Chronic disorder caused by the brains ineffectiveness
in regulating sleep-wake cycles normally
Uncontrollable episodes of sleep during the day
Participate in regular exercise

Eat small meals that are high in protein
Avoid activities that increase sleepiness
Avoid activities that would cause injury
should the client fall asleep (driving)
Take stimulants as prescribed by provider
10/6/2015

Parasomnias
Sleepwalking (sonmambulism)
Sleeptalking
Bruxism
Night terrors
REM sleep behavior disturbances
Enuresis
Depression
Hyperthyroidism
Hypothyroidism
Pain
Airway passage obstruction or CNS
dysfunction
Coronary artery disease

Asthma
COPD
Diabetes
Gastric and intestinal ulcers
10/6/2015
For which sleep disorder would the nurse most

likely need to include safety measures in the
clients plan of care?
a.
b.
c.
d.
snoring
enuresis
narcolepsy
hypersomnia
Assess usual sleep patterns and sleep rituals
Sleep history
Sleep diary
Sleep study
Determine if sleep is a problem if it is.

NANDA approved nsg dx include:
Disturbed Sleep Pattern

Sleep Deprivation
Insomnia
10
10/6/2015
Reports sleeping a 9 on a 0-10 scale by

10/9/14.
Demonstrates decreased signs of sleep
deprivation by 10/9/14.
Falls asleep within 30 mins; sleeps 6 hours
without awakening by 10/9/14.
Promoting Sleep: Nursing

Interventions
Cluster/schedule nursing
care to avoid interrupting sleep
Create a comfortable/restful
environment
Promote comfort/relaxation
Support bedtime rituals/routines
Promoting Sleep: Nursing

Interventions
Offer foods that help promote sleep

Maintain safety of the client
Teach about sleep hygiene
Administer/complete client teaching about
sleep-inducing medications
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10/6/2015
Regular routine for bedtime and morning

Go to bed each night at the same time
Use relaxation methods
Avoid caffeine
Use your bedroom only for sleep
Keep bedroom as dark as possible
Take a warm bath before bed
Exercise in early evening
Use earplugs
Which patient teaching would be most

therapeutic for someone with sleep
disturbance?
A. Give yourself at least 60 minutes to fall
asleep.
B. Avoid eating carbohydrates before going
to sleep.
C. Catch up on sleep by napping or sleeping
in when possible.
D. Do not go to bed feeling upset about a
conflict.
Prototype: diazepam
Pharm Phlash #135
Action
Act in the limbic system and the RAS

Make GABA more effective
Causes interference with neurons firing
Lower doses cause anxiolytic effects
Higher doses cause sedation and hypnosis
12
10/6/2015
Well absorbed from GI tract

Peak levels achieved in 30 minutes to 2 hours
Lipid soluble and distributes well throughout
the body
Cross placenta
Enter breast milk
Metabolized in the liver
Excretion is primarily in the urine
Allergy to benzodiazepine
Psychosis
Acute narrow angle glaucoma
Shock
Coma
Acute alcohol intoxication
Pregnancy
Sedation
Drowsiness
Depression
Lethargy
Blurred Vision
Confusion
Dry Mouth
Constipation
Nausea
Vomiting
Hypotension
Urinary Retention
Abrupt cessation can lead

to withdrawal
Nausea
Vertigo
Malaise
Nightmares
13
10/6/2015
Increase CNS depression when taken with

alcohol
Increase in effect when taken with cimetidine,
oral contraceptives, or disulfiram
Decrease in effect if given with theophylline
or ranitidine
If overdose antidote=flumazenil
temazepam (Restoril)
diazepam (Valium)
lorazepam (Ativan)
alrpazolam (Xanax)
triazolam (Halcion)
estazolam (ProSom)
flurazepam (Dalmane)
quazepam (Doral)
Prototype: phenobarbital
Pharm Phlash # 115
Rarely prescribed for insomnia
If so, only short term
Risk for adverse effects, addiction, abuse, and

overdose
Used as a general anesthetic
Examples:
amobarbital (Amytal sodium)
secobarbital (Seconal)
butabarbital (Butisol)
phenobarbital (Luminal)
pentobarbital (Nembutal)
14
10/6/2015
Table 20.3 pg 336 Karch

Pharm Phlash: # 117
zolpidem tartrate (Ambien)
eszopiclone (Lunesta)
zalepon (Sonata)
Short half-life (dont cause hang-over effect)
Action
Neurotransmitter inhibition
Use
Treat short-term (less than 10 days) insomnia
Chloral Hydrate (Aquachloral): Produces nocturnal

sedation or preoperative sedation
Antihistamines (promethazine [Phenergan],
diphenhydramine [Benadryl]): Preoperative
medications and postoperative to decrease the
need for narcotics
Not FDA approved for insomnia but have been

shown to promote sleep
amitriptyline (Elavil)
doxepin (Sinequan)
imipramine (Tofranil)
nortriptyline (Pamelor)
15
10/6/2015
Diphenhydramine hydrochloride (Benadryl)

Tylenol PM
Nytol
Melatonin
Herbal sleep aids
Chamomile tea
Valerian root
Hops
Lavender
passionflower
Pharm Phlash: # 118

Ramelteon (Rozerem)
Activation of melatonin receptors
Rapidly absorbed
A patient states that many of his friends told him

to ask for diazepam or lorazepam to help him
sleep while hospitalized. The nurse knows that
other hypnotic drugs or nonbenzodiazepines (such
as zolpidem) are often preferred over
benzodiazepines (diazepam or lorazepam). Why is
this?
A. Benzodiazepines are eliminated from the body faster than
are nonbenzodiazepines, so they do not provide a full night
of sleep.
B. Nonbenzodiazepines cause daytime sleepiness, allowing
people to rest throughout the day.
C. Benzodiazepines produce daytime sleepiness and alter the
sleep cycle.
D. Nonbenzodiazepines remain in the body longer than do
benzodiazepines.
16

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10/6/2015

Shauna Winchester, MSN, RN

Explain why rest and sleep are important.

Identify at least five common sleep disorders.

Describe the therapeutic actions, indications,

Sleep Versus Rest

Which of the following is the main difference

Newborns: 16-20 hrs

Reticular activating system

Stage 1 (NREM Sleep)

Very light sleep

sleep 5-15 mins

11% of total sleep

Lest restful than NREM sleep

Light sleep and slowing brain and body processes

Factors Affecting Sleep

Sleep disorders characterized by difficulty falling or

Common Sleep Disorders

Sleep-wake schedule (Circadian) disorders

(e.g., jet lag, working night shift, rotating

The nurse is caring for a hospitalized patient who normally

Common Sleep Disorders

Severe and prolonged- delusions, paranoia,

Common Sleep Disorders

Participate in regular exercise

Common Sleep Disorders

Coronary artery disease

For which sleep disorder would the nurse most

Assess usual sleep patterns and sleep rituals

Determine if sleep is a problem if it is.

Disturbed Sleep Pattern

Reports sleeping a 9 on a 0-10 scale by

Promoting Sleep: Nursing

Promoting Sleep: Nursing

Offer foods that help promote sleep

Regular routine for bedtime and morning

Which patient teaching would be most

Act in the limbic system and the RAS

Well absorbed from GI tract

Abrupt cessation can lead

Increase CNS depression when taken with

Risk for adverse effects, addiction, abuse, and

Table 20.3 pg 336 Karch

Short half-life (dont cause hang-over effect)

Treat short-term (less than 10 days) insomnia

Chloral Hydrate (Aquachloral): Produces nocturnal

Not FDA approved for insomnia but have been

Diphenhydramine hydrochloride (Benadryl)

Pharm Phlash: # 118

A patient states that many of his friends told him

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