Sleep and Rest

Sleep versus rest

Rest is a condition in which the body is in a decreased state of activity, with the consequent feeling of being refreshed. Sleep is a state of rest accompanied by altered consciousness and relative inactivity. It is a complex rhythmic state involving a progression of repeated cycles each representing different phases of body and brain activity.

Circadian rhythms
Circadian rhythms complete a full cycle every 24 hours. Fluctuations that partially depend on circadian rhythms include: Heart rate Blood pressure Body temperature Hormone secretions Metabolism Performance Mood When physiologic and psychological rhythms are high or most active, the person is awake; when these rhythms are low the person is asleep. Although light and dark appear to appear to be powerful regulators of the sleep-wake circadian rhythms they do not exert primary control. The regulating mechanism is the persons individual biologic clock, which is subject to numerous influences such as: Occupational demands Social pressures Example: Nurses who work the night shift routinely sleep from 2 p.m. to 8 p.m., and peak physiologic activity may occur between 10 p.m. and 6 a.m. during work. Problems of desynchronization occur when: Sleep-wake patterns are frequently altered Attempting to sleep during high-activity Working when the body is physiologically prepared to rest

Stages of sleep
There are 2 major stages of sleep: 1. Non-rapid eye movement (NREM) sleep

2. Rapid eye movement (REM) sleep Equipment used to study the different stages of sleep include: Electroencephalogram (EEG): records electrical currents from the brain

Electrooculogram (EOG): records eye movements Electromyograph (EMG): records muscle tone

Sleep Requirements and Patterns

Average Sleep Requirements Infants 14 20 hrs. Growing children 10 14 hrs. Adults 7 9 hrs.

Factors affecting sleep

Factors that influence both quality and quantity of sleep include: Age Lifestyle Illness Environment

Age
Variations in sleep pattern are related to age. - Children at 3 years of age who sleep less than 12 hours nightly are more likely to be overweight - Insufficient sleep may also Affect normal growth & development Contribute to performance deficits & behavior problems Routine assessment of sleepiness or short sleep patterns in children is the first step in identifying the existence of a sleep problem and factors interfering with a childs sleep.

Motivation A desire to be wakeful and alert helps overcome sleepiness and sleep. Example: A tired person may be wakeful during a party or doing something of interest to them Culture A persons cultural beliefs and practices can influence sleep, examples include: Childrens bedtime rituals Sleeping position Location Sensitivity to a patients culture must be included in the plan of care for preparing the patient for an evening sleep.

Lifestyle and Habits

Lifestyle factors than affect a persons ability to sleep well include: Working the night shift Working long hours Working the night shift disrupts the natural sleep process and can result in loss of sleep and other adverse effects, such as: Anxiety Personal conflicts Loneliness Depression Gastrointestinal problems Substance abuse Physical Activity and Exercise Activity and exercise increase fatigue and, in many instances promote relaxation that is followed by sleep. It appears that physical activity increases both REM and NREM sleep. Moderate exercise is a

healthy way to promote sleep, as long as its not done within a 2-hour interval before normal bedtime as this may hinder sleep. Dietary Habits A small protein- and carbohydrate-containing snack may be effective in promoting sleep Alcohol Intake Moderate alcohol intake seem to induce sleep in some people Large alcohol consumption limit REM and delta sleep Recommendations to promote effective sleep recommend that alcohol not be consumed within 6 hours of sleep

Caffeine Caffeine is a CNS stimulant, for many people caffeine consumption interferes with the ability to fall asleep. Examples of products containing caffeine include: Coffee Tea Most cola drinks Chocolate Smoking Nicotine has a stimulating effect. Smokers usually: Have a difficult time falling asleep Easily aroused once asleep Describe themselves as light sleepers *Patients who stop smoking often have more daytime sleepiness and report significantly more restlessness at night.

Environmental Factors
Most people sleep best in their regular home environments. If a patient is accustomed to sleeping in a quiet environment, a room next to a high-traffic area, such as the nurses station may not be the best place for this patient to rest.

Psychological Stress
Psychological stress affects sleep in 2 ways: 1. Person experiencing stress may find it difficult to obtain the amount of sleep he or she needs 2. REM sleep decreases in amount, which tends to add to anxiety and stress

Illness
Illness, a physiologic as well as a psychological stressor, influences sleep. Certain illnesses are more closely related to sleep disturbances than others for example: GI secretions increase during REM sleep. Many people with peptic ulcers awaken at night with pain. The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep. Epilepsy seizures more likely to occur during NREM sleep, and appear to be depressed by REM sleep Liver failure and encephalitis tend to cause reversal in day night sleeping habits Hypothyroidism decreases amount of NREM sleep Hyperthyroidism may result in difficulty falling asleep End stage renal disease (ESRD) disrupts nocturnal sleep leading to excessive daytime sleepiness. Patients with ESRD who receive dialysis also have a higher incidence of restless leg syndrome

Medications
Drugs that disrupt sleep Alcohol Amphetamines Antidepressants Antihypertensive Bronchodilators Steroids Caffeine Decongestants Narcotics Diuretics Antiparkinsonian

Common sleep disorders

A nurse obtaining patient sleep history needs to understand common sleep disturbances to recognize significant data. Sleep disorders includes four major categories of sleep disturbances: Dyssomnias

Parasomnias Sleep disorders associated with medical or psychiatric disorders Other proposed disorders

Dyssomnias
Insomnia: characterized by difficulty falling asleep, intermittent sleep, or early awakening from sleep. - It is the most common of all sleep disorders People most likely to experience insomnia include: People older than 60 Women (especially after menopause) Persons with history of depression Persons going through a period of stress involving some change in normal environment. Person with insomnia often reports feeling: Tired Lethargic Irritable during the day Difficulty concentrating is also a common manifestation Health conditions associated with chronic insomnia include: Obesity Type II diabetes Psychiatric disorders such as depression Cardiovascular disorders Nonpharmacological approaches should be attempted initiall y to resolve insomnia. Sleep hygiene refers to nonpharmacological recommendations that may help an individual get a better nights sleep. Sleep hygiene suggestions include the following: Restricting alcohol, nicotine and caffeine intake especially later in the day Avoiding stimulating activities after 5pm Avoiding naps Eating a light meal before bedtime Sleeping in cool, dark room Eliminating use of a bedroom clock Taking a warm bath before bedtime Keep sleep environment as quiet as possible Getting up at the same time everyday no matter what time you fell asleep Stimulus control involves using the bedroom for sex and sleep only Relaxation therapy involves any type of relaxation such as progressive muscle relaxation, imagery training, and meditation

Hypersomnia

Hypersomnia: a condition characterized by excessive sleep, particularly during the day. A person may fall asleep for intervals during work while eating, or even during conversations. These naps do not usually relieve their symptoms. When awake, they are often disoriented, irritated, restless, and have slower speech and thinking processes. Causes of hypersomnia although varied may include: Another sleep disorder such as sleep apnea Drug or alcohol abuse Head trauma or other injury to the CNS Effect of certain medications Depression Obesity Other medical conditions (multiple sclerosis, epilepsy)

Narcolepsy
Narcolepsy: a condition characterized by an uncontrollable desire to sleep. A person with narcolepsy can literally fall asleep standing up, while driving a car, in the middle of a conversation or while swimming. Individuals with narcolepsy tend to fall asleep quickly, find it difficult to wake up, sleep fewer hours than others, and sleep restlessly First symptom of narcolepsy usually is: - Sleepiness during the day *Narcolepsy is considered a neurological disorder

Sleep Apnea
Sleep Apnea: condition in which a person experiences the absence of breathing (apnea) or diminished breathing efforts (hypopnea) during sleep between snoring intervals. Breathing may cease for 10 20 seconds, or for as long as 2 minutes. During long periods of apnea Oxygen level in the blood drops Pulse becomes irregular BP often increases

Restless Leg Syndrome

People with restless leg syndrome cannot lie still, and report unpleasant creeping, crawling, or tingling sensation in the legs. Patients describe an irresistible urge to move legs when these sensations occur. Acronym URGE summarizes the symptoms and criteria for RLS. U urge to move legs R rest-induced G gets better with activity E evening symptoms more severe

Sleep Deprivation
Sleep deprivation refers to decrease in the amount of consistency or quality of sleep. It may be a result from decreased REM or NREM sleep. Total sleep deprivation is rarely seen other than in experimental settings. In general, the effects of sleep deprivation become increasingly apparent after 30 hours of continual wakefulness

Parasomnias
Parasomnias: are patterns of waking behavior that appear during REM and NREM stages of sleep. Common examples are: Somnambulism (sleepwalking) Enuresis (urinating during sleep)