Rest and Sleep: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills pf rest and sleep in order to:
- Assess client need for sleep/rest and intervene as needed
- Apply knowledge of client pathophysiology to rest and sleep interventions
- Schedule client care activities to promote adequate rest
Some of the terms and terminology that you should be familiar with in terms of rest and sleep are described below.
Insomnia, simply defined, is the absence of sleep. The two basic types of insomnia are inducement insomnia and maintenance insomnia. Clients affected with inducement insomnia have difficulty falling asleep and clients with maintenance insomnia have difficulty maintaining sleep and staying asleep once they have fallen asleep. Some clients are affected with both inducement insomnia and maintenance insomnia. Additionally, some clients may have an acute, short lived episode of insomnia, and other clients may have chronic insomnia. Both types of insomnia are caused by a number of different physical and psychological factors such as pain and anxiety. Insomnia, which is the most commonly occurring sleep disorder, can also be classified as chronic-intermittent which is a combination of periods of insomnia interspersed with period of restful sleep. The two populations that are at greatest risk for insomnia are females and members of the aging population.
Insomnia causes the affected person to wake up without feeling that they are rested as well as day time sleepiness, irritability and problems in terms of cognitive functioning such as decreased levels of mental concentration and poor problem solving.
Non REM Sleep
The sleep cycle consists of both non REM sleep and REM sleep. Non REM sleep is sleep that is not accompanied with rapid eye movements (REM). Non REM sleep has four phases which include the stage of very light sleep, the stage of very light sleep with the non movement of the eyes, the stage of deep sleep with delta waves and finally, the last stage with is deep sleep and increased delta brain waves. The vast majority of sleep is non REM sleep and this part of the sleep cycle can occur during about 80% of the time that the person is sleeping in a cyclical manner.
Some of the physiological changes that occur during non REM sleep include decreases in terms of the person's basal metabolic rate, intracranial pressure, blood pressure, cardiac rate and cardiac output in addition to the relaxation of the person's muscles and their peripheral circulatory vasculature.
Rapid eye movement sleep is a state of deep sleep that is accompanied with rapid eye movements and dreams. Some of the physiological changes that occur during REM sleep include increased brain activity dreams, and a decrease in terms of muscular and reflex activity.
Narcolepsy is defined as excessive day time sleepiness that a person can be affected with secondary to the paucity of hypocretin within the area of the central nervous system that controls sleep.
Hypersomnia, which can also be caused by a number of different factors and forces, is defined as the client's failure to stay awake during day time hours even when they have had enough sleep the night before. Some of the risk factors associated with hypersomnia, all of which are physical in nature, include disorders such as hypothyroidism, central nervous system dysfunction, and alterations of the client's metabolism including diabetic ketoacidosis.
Parasomnia is defined as a sleep disorder that interferes with sleep. There are a number of parasomnias including sleep walking, sleep talking, grinding of the teeth that is referred to as bruxism, nocturnal enuresis and restless leg syndrome.
Simply stated, sleep apnea is apnea that occurs during sleep. There are a couple of types of sleep apnea including obstructive sleep apnea that is typically caused by large anatomical structures such as the tongue and the collapse of the oropharynx when the client is sleeping, central sleep apnea which results from some deficit of the central nervous system such as an insult to the brain stem, and mixed sleep apnea, which occurs as the result of the combination of both central and obstructive sleep apnea, and results from multiple related disorders and diseases.
Circadian rhythm is the human's natural and innate 24 hour a day clock. Circadian rhythms are sometimes referred to as our body clock. In essence, humans take on cyclical 24 hour periods of time that are associated not only with sleep, but also in terms of their hormone secretion, their bodily temperature and other physiological and other psychological variations.
Good sleep habits and rest promote better health and well-being in people. A lack of sleep and rest do not. Poor sleep habits can lead to inability to mentally focus, adversely affect moods, and increase the risk of depression, heart attack, high blood pressure, obesity, and other health problems.
How much sleep is needed depends upon the individual, their age and their level of wellness. For example, some individuals just simply require and need more or less sleep than others do even when the person is not affected with a health related problem or disorder and it varies according to age and well-being. Clients who are ill and who are experiencing signs and symptoms related to the illness will need more sleep than they did prior to the illness. The amount of sleep that is needed also varies among the age groups. Below are some guidelines that you can use to determine whether or not a client is getting enough sleep and rest for physiological and psychological health.
- Neonates through 3 months of age typically sleep 14 to 17 hours a day
- Infants from 4 months of age to 11 months of age should normally sleep about 12 to 15 hours a day
- Older infants and toddlers up to 3 years of age should sleep 11 to 14 hours a day
- Preschool children from 3 to 5 years of age should sleep 10 to 13 years of age
- School age children from 6 to 12 years of age need 9 to 11 hours of sleep each day
- Adolescents from 13 to 17 years of age should sleep about 8 to 10 hours of sleep
- Young adults and middle aged adults need about 7 to 9 hours of sleep
- Older adults over 65 years of age tend to require slightly less sleep than the middle age adults and only 7 to 8 hours of sleep per night
The factors that impact on sleep, its duration and its quality are described below.
- Illnesses: Despite the fact that clients with physical diseases and disorders require more sleep than normal for recovery, they tend to get less because of some of the signs and symptoms of the illness or disorder that they are affected with. For example, pain, respiratory, genitourinary and gastrointestinal system disorders often interfere with the client's getting enough sleep, hypothyroidism can decrease stage IV sleep, and pyrexia can impair and reduce the amount of REM and delta sleep that the client gets.
- Medications: Some medications increase the client's sleepiness and the duration of sleep and other medications impair and impede the quality and quantity of the sleep that the client gets while they are on a particular medication. For example, beta blockers used for hypertension can lead to insomnia and a decrease in the amount of REM sleep that the client gets; and, narcotic medications, steroid medications, antidepressant medications, and bronchodilating medications can decrease the duration of sleep and also impair the onset of sleep and the quality of the person's REM sleep.
- Environment: The environmental factors and forces that can interfere with sleep include things like an uncomfortable environmental temperature, noise, sleeping in a strange bed, an uncomfortable mattress and/or pillows, the presence or absence of light, and a snoring partner, for example.
- Emotional and Psychological Distress and Stress: The National Sleep Foundation, states that stress is the number one cause of insomnia. Stress makes it more difficult to relax and, therefore, it can easily lead to sleep induction and sleep maintenance disorders.
- Lifestyle Choices: Consumption patterns such as cigarette smoking and alcohol use interfere with sleep and other life style choices such as those related to exercise also impact on sleep, the duration of sleep and the quality of sleep. Daily exercise facilitates sleep; however, exercise immediately before bed time may interfere with the client's sleep.
- Work Schedules: Long work hours and working night time hours interfere with sleep. For example, humans, including nurses, who work the night tour of duty, are often unable to go to sleep and stay asleep during day time hours when they are off from work. Night time work and activity disrupts the person's normal circadian rhythms in a similar manner that people suffer from jet lag when they travel across time zones.
Clients are assessed by the nurse for their sleep and rest patterns and any sleep disturbances. After a complete physical assessment of the client is assessed using other subjective and objective data, as discussed immediately below.
The physical assessment may reveal some data that can suggest a sleep disorder. Some of this data can include a deviated nasal septum, enlarged tonsils and obesity, all of which can lead to a sleep disorder or disturbance.
Other assessments can include:
The review of the client's reports about their sleep: The nurse may ask a client to record their sleep patterns and record it in a sleep log or diary for a week or more, after which, the nurse will assess and analyze this data to determine any sleep disturbances. Some of the data that is recorded in this sleep log can include:
- The extent of and time of exercise before sleep hours
- Consumption patterns like alcohol and cigarette smoking before sleep hours
- A list of all prescribed and over the counter drugs, herbs and supplements to determine if any of these substances has the potential to interfere with the client's sleep
- A daily recording of any sleepiness during the day time hours
- A daily recording of any stressors that are impacting on the client
- The time the person went to bed for sleep, how long it took to fall asleep, the duration of the sleep each night, and the duration and frequency of night time awakenings
- Reports by the sleep partner about any irregularities in terms of sleep such as snoring, periods of apnea, and restless leg movements which the client is most likely to be unaware of
Diagnostic studies, such as a polysomnography which is done in a sleep center by a respiratory therapist, is used to diagnose sleep disturbances. A polysomnography is done in the sleep laboratory by placing electrodes on the client's head is a combination of three diagnostic studies which are an electrocephalogram, an electro-oculogram and an electromyogram.
An electrocephalogram measures and displays the brain waves while the client is sleeping; an electro-oculogram measures and displays eye movements during sleep; and an electromyogram to measure muscular movements during sleep. These diagnostic tests, in combination with pulse oximetry and an electrocardiogram, are used to assess clients for sleep disorders such as sleep apnea, restless leg syndrome and bruxism.
Some of the nursing diagnoses that the nurse can arrive at after a complete and thorough assessment of the client are:
- Readiness for enhanced sleep
- Insomnia related to anxiety
- Insomnia related to the disruption in the amount and quality of sleep
- Sleep deprivation related to jet lag
- Sleep deprivation related to nocturnal work hours
- Sleep deprivation related to prolonged periods of time without sleep
- Impaired sleep related to obstructive sleep apnea
- Impaired sleep related to central sleep apnea
- At risk for injury and accidents relating to somnambulism
- Impaired gas exchange related to central or obstructive sleep apnea
- At risk for disturbed sleep secondary to alcohol use
- Insomnia related to unrelenting pain and the lack of comfort
Interventions for sleep disturbances are described below. These interventions are often referred to as sleep hygiene measures.
- Insomnia: The establishment of and adherence to a regular to bed routine, the avoidance of alcohol and exercise prior to sleep, using the bed for sleep only and not for watching television or doing work, the use of stress and relaxation techniques, arising from bed if sleep induction does not occur within a reasonable amount of time, pain management, the correction of any assessed sleep disorders, the avoidance of caffeine and heavy meals prior to bed time, cognitive behavioural therapy, and medications to promote sleep as the last resort, and then, only on a temporary basis.
- Hypersomnia: Since hypersomnia occurs as the result of a physical rather than a psychological cause, the underlying physical cause, such as hypothyroidism, should be corrected.
- Narcolepsy: Narcolepsy, which is caused by the lack of the chemical hypocretin in the area of the CNS that regulates sleep, leads to day time sleepiness and sleep attacks that cause the person to fall asleep at unpredictable times, such as when driving an automobile. The client who is assessed as having narcolepsy should be educated about the dangers of using heavy equipment and motor vehicles and they can also be treated with central nervous system stimulant medications like an amphetamine or an antidepressant to control this sleep disorder and its effects.
- Sleep Apnea: The treatment for sleep apnea depends on the cause. For example if the apnea is related to enlarged oropharyngeal anatomy such as the tongue, tonsils and pharynx, laser reduction may be indicated, if the cause of the sleep apnea is obesity, the client should be on a weight reduction diet, and if the cause is not treatable, the client will be given a CPAP machine for daily use while the client is sleeping. CPAP, which is continuous positive airway pressure, is delivered to the client with a CPAP machine, tubing and a full face mask, a nasal prong or a partial face mask. Full face masks are recommended for clients who are mouth breathers, however, some clients may reject a full face mask because they feel somewhat claustrophobic when they are in place. The treatment and correction of sleep apnea is necessary because, left untreated, sleep apnea can lead to complications such as pulmonary hypertension, hypertension and cardiac arrhythmias.
- Parasomnias: Parasomnias like bruxism can be treated with dental correction, stress management techniques, muscle relaxants, or a botulinum toxin A, which is Botox, in severe cases, and the use of a splint or mouth guard that is a dental appliance that prevents damage to the teeth as the result of bruxism.
- Nocturnal Enuresis: Nocturnal enuresis can be treated with a bed wetting alarm, positive reinforcement and medications such as imipramine and desmopressin.
- Sleepwalking: Sleepwalking can be treated with a sleep hygiene program to decrease sleep deprivation, the elimination of problematic medications, the avoidance of alcohol and the correction of any causal underlying illnesses, all of which can lead to sleep walking.
- Periodic Limb Movement and Restless Leg Syndrome: These sleep disrupting disorders can be treated with the correction of an underlying disorder, such as peripheral neuropathy, the avoidance of alcohol and tobacco, the use of some medications such as those that increase dopamine, benzodiazepines and anticonvulsant medications, when indicated.
As mentioned immediately above and in other sections of "Rest and Sleep", many interventions for sleep disorders and disturbances are based on the needs of the specific client as specific to their physiological and psychological pathologies. For example, stress and relaxation, in addition to other complementary and non pharmacological interventions are used when the client is adversely affected with anxiety that disrupts sleep, continuous positive airway pressure (CPAP) is used when the client's anatomical structures are abnormally large or they abnormally relax and collapse during sleep, and analgesics are administered to relieve pain as the result of an acute or chronic physical disorder or disease.
The promotion of sleep and adequate rest depends on correcting any underlying problems, including pain and alcohol use, and then planning activities and routines that will enhance the duration and the quality of sleep.
Some of these sleep promotion interventions and schedules include:
- Establishing and adhering to a regular sleep time and wake time for the client based on their patterns and needs
- Limiting the duration and frequency of day time naps
- The promotion of daily exercise
- The avoidance of alcohol, caffeine, heavy meals and exercise at least a couple of hours before bedtime
- The promotion of comfort using techniques such as white noise, dim lighting, pain management, stress reduction techniques, massage and the elimination of environmental noise
Many hospitals and nursing homes have established policies and procedures to promote sleep by decreasing the noisiness of client care areas. For example, the hospital may stop over head paging after a certain hour; they may turn down the telephone ringer volume after a certain hour and turn down the lights in the hallways.
- Assistive Devices
- Non Pharmacological Comfort Interventions
- Nutrition and Oral Hydration
- Personal Hygiene
- Rest and Sleep (Currently here)