REST & SLEEP

Fundamental components of
wellbeing
• Rest – is a condition in which the body is in a
decreased state of activity without physical
emotional stress and freedom from anxiety
• Sleep – refers to a state rest accompanied by
altered level of consciousness during which an
individual experiences minimal physical
activity & a general slowing of the body’s
physiological processes
 Physiology of Rest & Sleep
• The cycles of wakefulness & sleep are
controlled by centers in the brain & influenced
by routines & environmental factors.
• Reticular Activating System (RAS)located at the
brain stem & cerebral cortex plays an
important role in sleep awake cycle
• Sleep begins with the activation of the pre
optic area of the anterior hypothalamus.
• Sleep promoting neurons act over wake
promoting neurons by releasing Gamma
Amino Butyric Acid (GABA)
• The inhibition of wake promoting neurons
results in intensifying sleep process.
• Another key factor to sleep is exposure to
darkness.
• Darkness and preparing for sleep cause a
decrease in stimulation of the RAS
• During this time, the Pineal gland in the brain
begins to actively secrete the natural hormone
melatonin, & the person feels less alert
• With the beginning of daylight, Melatonin is
its lowest level in the body & stimulating
hormone Cortisol, is at its highest causing
wakefulness.
• An individual’s biological clock
(internal mechanisms) also helps
determine the specific cycles that
will be followed for wakefulness &
sleep.
 Biological Clock
• An endogenous mechanism that measures
time, controls the daily fluctuations in
hundreds of physiological process, including
body temperature, RR, performance, alertness
& hormone levels.
 Circadian Rhythms
• It is a sort of 24-hour internal biological clock.
The term circadian is from Latin “circa dies”,
meaning “about a day.”
• Biological rhythms exists in plants, animals, &
humans.
• In human, these are controlled from within
the body & synchronized with environmental
factors, such as light & darkness.
• Although circadian rhythms tend to be
synchronized with cycles of light and dark,
other factors - such as ambient temperature,
meal times, napping schedule and duration,
stress and exercise - can influence the timing
as well.
 Stages of Sleep:
1. Non-rapid eye movement (NREM) sleep
– Stage 1
– Stage 2
– Stage 3
– Stage 4
2. Rapid eye movement (REM) sleep

 During sleep, NREM & REM sleep alternate in

cycles
 1. Non-rapid eye movement (NREM)

• The period of NREM sleep is made up of

stages 1-4. Each stage can last from 5 to 15
minutes.
• A completed cycle of sleep consists of a
progression from stages 1-4 before REM sleep
is attained, then the cycle starts over again
Stage 1
• Sleep is a very light quality, the sleepers can
be awaken easily.
• There is a general slowing of EEG frequency
but appearance of wave spikes;
• The eyes tends to roll slowly from side to side,
& muscle tension remain absent except in the
facial & neck muscle.
Stage 2
• is still fairly light sleep, with a further slowing
of electroencephalograph (EEG) patterns &
loss of slow rolling eye movements.
• 50% of normal adult sleep may be spent in
this stage.
• After an initial 20 minutes or so of stage 2
sleep, a deep form of sleep called stage 3 to 4
is entered.
Stage 3
• Stage 3 refers to medium-depth sleep, last for
15 to 30 minutes
• Muscle s are completely relax
• Large slow waves in EEG
• Vital signs decline but remain regular
• Sleeper is difficult to arouse & rarely moves
• If aroused from sleep during these stages, a
person may feel disoriented for a few minutes.
Stage 4
• stage 4 signals deepest sleep, last approximately 15 t0
30 minutes
• If sleep loss has occurred, sleeper spends considerable
portion of night in this stage.
• V/S signs are significantly lower than during waking
hours
• Further slowing of EEG
• Sleepwalking & enuresis (bed-wetting) sometimes occur
• It is very difficult to arouse sleeper
2. Rapid Eye Movement (REM)
• After the initial 90 minutes or so of NREM
sleep in adults, the client enters rapid eye
movement sleep.
• The first period of REM typically lasts 10
minutes, with each recurring REM stage
lengthening, and the final one may last up to
an hour.
• EEG pattern resembles that of the awake
state; there are rapid conjugate eye
movement;
• HR & RR are irregular & often higher than
when awake;
• Muscles, including those of the face & neck,
are flaccid, leaving body immobilized
• Intense dreaming occurs during REM sleep as
a result of heightened brain activity, but
paralysis occurs simultaneously in the major
voluntary muscle groups.
• REM is a mixture of encephalic (brain) states
of excitement and muscular immobility. For
this reason, it is sometimes called paradoxical
sleep
• The percentage of REM sleep is highest during
infancy and early childhood.
• During adolescence and young adulthood, the
percentage of REM sleep declines.
• Infants can spend up to 50% of their sleep in
the REM stage of sleep, whereas adults spend
only about 20% in REM
 Sleep Cycle
• Refers to the sequence of sleep that begins
with the four stages of NREM sleep in order,
with a return of stage 3, then 2, then passage
into the first REM stage
 Phase One:
• Phase one begins as soon as the sun sets,
when the pineal gland starts to release
melatonin, a hormone released in the absence
of light and responsible for making us sleepy.
• When you lay down in your bed at this time,
your muscles relax, heart rate and breathing
slow down, and body temperature drops.
• The brain also relaxes but still remains alert.
Phase Two:
Phase two occurs
a moment after
phase one and in
this stage the
sleeper lays still
for about 10 to 15
minutes
 Phase Three:
• After Phase two is over, the sleeper falls into a
deeper sleep.
• During this stage, the sleeper falls deeper into
phase three which lasts about 5 to 15 minutes.
 Phase Four:
• The eyes move back and forth very quickly in
what's called rapid eye movement, or REM.
• This is the point at which the first dream
occurs. After this dream has ended, the
sleeper then goes right back to phase two and
starts the whole process over again.
• These processes repeat themselves about five
times during the night.
 Functions of Sleep
• Conservation of energy
• Restoration of tissue & growth
• Thermoregulation
• Regulation of emotions – sleep deprivation
causes emotional disorders like irritability,
anxiety, depression etc.
• Neural maturation
• Memory & learning
 Normal sSeep rRquirements:
• NB :16 -18 hours
• Infants: 12 tp 14 hours
• Toddlers: 10 to 12 hours
• Preschool: 11to 12 hours
• School-age: 8 to 12 hours
• Adolescents: 8 to 10 hours
• Adult: 6 to 8 hours
• Elders 6 hours
 Factors Affecting Rest & Sleep
1. Degree of comfort. Whenever basic needs
are unmet, the person experiences
discomfort which leads to physiological
tension, resultant anxiety, & potential
impairment in sleep/rest
2. Anxiety - A restless body & mind interfere
with the ability to sleep
3. Environment -Environmental factors can
either enhance or impair sleep
4. Lifestyle - Individuals who frequently change
work shift have a real challenge in trying to
stabilize biological rhythm s & rest
comfortably.
5. Diet - The type of food consumed has an
impact on the quality & quantity of sleep
6. Drugs & other substances

• Alcohol & nicotine can impair sleep

• Nicotine an stimulant may also impair sleep
cycle by stimulating the body, resulting in
difficulty falling & staying asleep
7. Lifespan Consideration -A person’s need for
sleep changes with age in a fairly predictable
pattern.
8. Cultural norms

• Some people perceive sleep as a luxury to be

indulged in when they are not too busy with
“important” activities.
• Others view sleep as an absolute necessity
• The amount of sleep that a person considers
to be necessary is partially determined by the
attitudes of family & culture.
Illness Associated with Sleep Disturbances

A. peptic ulcer (GI secretions ↑during REM sleep)

B. coronary artery disease – pain
C. epilepsy – seizures occur during NREM sleep
D. liver failure & encephalitis – reversal in day and
night sleep
E. hypothyroidism ↓NREM sleep, especially stage II
and stage IV
F. ESRD (end-stage renal disease) – disrupt nocturnal
sleep, want to sleep in daytime
Sleep Disturbance Assessment Parameters

A. nature & cause of problem

B. signs & symptoms
C. Date & occurrence & effect on everyday living
D. severity of problem
E. treatment of problem
F. how the patient is coping with the problem
 Sleep Characteristics to Assess

A. restlessness
B. sleep posture – ie. pillows, on back, vs stomach
C. sleep activities – smoking in bed (need to
educate patient)
D. snoring – obstruction to airflow through nose /
mouth
E. leg jerking – nocturnal "nyoclomus" muscle
contraction
 Alteration in Sleep Patterns
1. Primary sleep disorders- those in which the
sleep alteration is the fundamental problem.
2. Secondary Sleep disorders- those in which
alteration has a medical or clinical cause that
results in or contributes to sleep alteration.
 Sleep Disorders
I. Dysomnias
II. Parasomnias
III. Disorders due to other medical conditions
 I. DYSOMNIAS
• The sleep itself is pretty normal
• But client sleeps to little, too much or at the
wrong time
• So, the problem is with the amount or with its
timing, & sometimes with the quality of sleep
 Common Dysomnias:
• Insomnia
• Hypersomnia
• Narcolepsy
• Sleep apnea
• Insufficient sleep/sleep deprivation
1. Insomnia
• Refers to chronic inability to sleep or
inadequate quality of sleep due to
prematurely ended or interrupted by periods
of wakefulness
• Acute insomnia lasts one to several nights & is
often caused personal stressors or worry.
 Clinical manifestations:
• Difficulty in sleeping • TREATMENT
• walking up frequently • Developing of new
during the night behavioral patterns that
• Difficulty returning to induces sleep
sleep • Create sleeping
• Daytime sleepiness environment that
• Difficulty concentrating induces sleep
• irritability • Create positive sleep
thought
2. Hypersomnia

• Hypersomnia An alteration of sleep pattern

characterized by excessive sleep, especially in
daytime
• Can be caused by medical conditions, e.g.: CNS
damage & certain kidney, liver, or metabolic
disorders, such as diabetic acidosis &
hypothyroidism
• Treatment include treating the underlying
disease conditions
3. Narcolepsy
• sudden uncontrollable urges to fall asleep
during day time caused by the lack of chemical
hypocretin in the area of the CNS that
regulates sleep
• They have sleep attacks or excessive daytime
sleepiness, & their sleep at night usually begins
with a sleep-onset REM period (dreaming
sleep occurs within the first 15 minutes of
falling asleep)
• People sleep several times a day even when
they are conversing with people or while
driving
• CNS stimulants & antidepressants are the
drugs used to treat narcopepsy
4. Sleep Apnea
• Refers to period of sleep during which airflow
stops for 10 seconds or more.
• Sleep apnea give rise to complications as a
result of oxygen desaturation & carbon dioxide
retention
• More than 5 apneic episodes longer than 10
seconds in an hour is considered abnormal &
should be evaluated by a sleep medical
specialist
• Most frequently diagnosed in men &
postmenopausal women, it may occur during
childhood
• Three types:
– Obstructive apnea
– Central apnea
– Mixed apnea
 Obstructive Apnea
• Anpea occurs when the structures of the
pharynx or oral cavity block the flow of air
• Enlarged tonsils & adenoids, a deviated nasal
septum, nasal polyps & obesity predispose the
client to obstructive apnea
• TREATMENT includes surgical removal of
tonsils, correcting nasal septum, weight loss
may be helpful
Central Apnea
• Due to defect in the respiratory center of the
brain
• Clients who have brainstem injuries & often
have central sleep apnae
• MIXED APNEA
• Combination of obstructive & central apnea
5. Sleep Deprivation
• Prolonged inadequate quality & quantity of
sleep, either of the REM or the NREM type.
• Result from age, prolonged hospitalization,
drug & substance use, illness, & frequent
change in lifestyle pattern.
 Individuals may develop:
• Attention & concentration deficits
• Reduced vigilance
• Distractibility
• Reduced motivation
• Fatigue
• Diplopia & dry mouth
II. Parasomnia
• patterns of waking behavior that appear
during sleep (sleepwalking)
• Refers to sleep alterations resulting from “an
activation of physiological systems at
inappropriate times during the sleep-wake
cycle”
 Most common DISORDERS:
• Bruxism
• Enuresis
• periodic limb movement disorder
• Sleep talking
• Sleep walking
Bruxism

• Usually occurs during stage II NREM sleep,

characterized by clenching & grinding of the
teeth
• This clenching & grinding of the teeth can
eventually erode dental crowns, cause teeth
to come loose, & lead to deterioration of the
temporomandibular joint(TMJ) called TMJ
syndrome
• Enuresis- bed wetting durins sleep occuring in
children over 3 years old
• More males than females are affected
• Often occurs 1 to 2 hours after falling aslep
• PERIODIC LIMB MOVEMENT DISORDER
(PLMD) – a condition that 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 &
gabapentin
• SLEEP TALKING- talking durin sleep occurs
during NREM sleep before REM sleep
• Rarely present a problem to the person unless
it become troublesome to others
• SLEEP WALKIN (SONAMBULISM) –occurs
during stages III & IV of NREM sleep
• It is episodic & usually occurs 1 to 2 hours
after falling asleep
• Sleep walkers tend not to notice dangers &
often need to be protected from injury
 III. Disorders due to other Medical
conditions
• Depression
• Alcoholism
• Thyroid dysfunction
• Peptic ulcer
• COPD
 Intervention to Promote Rest & Sleep

1. Initiate Relaxation techniques

2. Ensure appropriate nutrition
3. Initiate pharmacological Interventions
4. Provide client education
 Evaluation:
• When evaluating the care of sleep disordered
client, consider the following variables:
– Client’s basic needs were met
– Client education included the family or significant
others
– An environment conducive to rest was maintained
 References:
• Daniel, Rick, Nursing Fundamentals caring and
Clinical Decision Making
• Udan, Josie, RN, MAN, Mastering
Fundamentals in Nursing; Concepts & Clinical
Application
• https://www.slideshare.net