REST AND SLEEP

rest – condition in which the body is in a decreased state of activity, with the
consequent feeling of being refreshed

sleep – state of rest accompanied by altered consciousness and relative inactivity

- complex rhythmic state involving progression of repeated cycles, each a
different phase of body and brain
activity
- sleep loss that results in fatigue and decreased competence may be a
contributing factor in accidents
- discomfort produced by illness and need for hospitalization and treatment my
interfere dramatically with a
patient’s ability to sleep

I. PHYSIOLOGY OF SLEEP
A. CIRCADIAN RHYTHMS - complete a full cycle every 24 hours
- fluctuations in a person’s heart rate, blood pressure, body temperature,
hormone secretions,
metabolism, and performance and mood depend in part on
circadian rhythms
- synchronization exists when an individual’s sleep wake patterns follow
the inner biologic clock
- rhythms are most active when person is awake - rhythms are low
when person is sleeping
- regulating mechanism is person’s individual biologic clock

B. STAGES OF SLEEP
1. NREM Sleep
a. Stage I – transitional stage (5% of total sleep)
- person is in relaxed state but still somewhat aware and can
be aroused easily
- involuntary muscle jerking may occur

b. Stage II = person falls into a stage of sleep (10% of total sleep)

- person can be aroused with relative ease

c. Stage III – depth of sleep increases and arousal become

increasingly difficult (10% of sleep)

d. Stage IV = deep sleep state (delta or slow-wave sleep) (10% of

sleep)
- arousal threshold (intensity of stimulus required to awaken)
is usually greatest
- parasympathetic nervous system dominates and decreases
brain waves, pulse,
respiratory, blood pressure, muscles are relaxed,
metabolic rate, and body
temperature
 2. REM Sleep - eyes dart back and forth, small muscle twitching, large
muscle immobility, respirations
irregular, rapid or irregular pulse, blood pressure increases or
fluctuates, increase in gastric secretions, metabolism and body
temperature increase - difficult to arouse a person
- consumes 20 – 25% of nightly sleep time
- essential to mental and emotional equilibrium and plays a role in
learning, memory and
adaptation
- a person deprived of REM sleep for several nights, then spends
more time in REM sleep on
successive nights (REM rebound) – maintains fairly constant
REM

C. SLEEP CYCLE – person passes consecutively through four stages, reverses pattern
and enters REM on return
- if person is awakened from sleep at any time, he/she returns to sleep
again by starting at Stage I of
NREM
- most go through 4 or 5 cycles of sleep each night - cycles tend to
become longer as morning nears
- more sleep occurs in delta stage in 1st half of night, especially if one is
tired or has lost sleep
D. SLEEP REQUIREMENTS AND PATTERNS – 8 hrs a night has been accepted standard for
adults; however, each
person follows a pattern of rest that maintains well-being
- on average, infants sleep 14 – 20 hrs ea. day - growing children require
10 – 14 hrs
- those who are able to relax and rest easily, even while awake, find that
less sleep is needed
- fatigue can be considered a normal, protective body mechanism and
nature’s warning that sleep is
necessary
- chronic fatigue is abnormal and often a symptom of illness
- older people often need more time to fall asleep, wake earlier and more
frequently during the night,
and are less able to cope with changes in sleep patterns
- many take a nap during the day resulting in fewer hours of sleep
at night

II. FACTORS AFFECTING SLEEP

A. DEVELOPMENTAL CONSIDERATIONS
1. Infants – sleep an average of 16 hrs/day (approx. 4 hrs at a time)
- usually be 8 – 16 weeks, sleeps through the night
- REM constitutes much of the sleep cycle

2. Children – need for sleep declines

- initially may need 12 hrs/night with 2 naps/day and end of this
stage sleeping 8 – 10
hrs/night and napping once
 - toddlers may begin to resist naps and going to bed at night
- may move from crib to youth bed to regular bed around 2 yrs old

3. Preschoolers – generally sleep 9 – 16 hrs/night (12 being the average)

- REM sleep pattern is similar to that of an adult
- daytime napping decreases (by age of 5, no longer napping)
- may continue to resist going to bed at night

4. School-Aged Children – may require 10 – 12 hrs/night (older children

average 8 – 10 hrs/night)
- sleep needs usually increase when physical growth peaks

5. Adolescents – sleep needs of teenagers vary widely

- growth spurt that may necessitate the need for more sleep;
however, stresses of school,
activities, and part-time employment may cause restless
sleep
- many do not get enough sleep

6. Young Adults – average amt of sleep required 8 hrs, many require less
- sleep is affected by many factors (physical health, type of
occupation, exercise, lifestyle
demands)
- REM sleep averages about 20% of sleep

7. Middle-Aged Adults – total sleep time decreases with a decrease in

Stage IV sleep
- percentage of time spent awake in bed begins to increase

8. Older Adults – average of 5 – 7 hrs is usually adequate

- sleep is less sound and Stage IV is absent or considerably
decreased with periods of REM shortened
- great difficulty falling asleep and problems sleeping
- decline in physical health, psychological factors, effects of drug
therapy, or environmental
factors may be implicated as causes of inability to sleep

B. PSYCHOLOGICAL STRESS
- generally affect sleep in two ways:
person experiencing stress may find it difficult to obtain amount of
sleep he/she needs
REM sleep decreases in amount, adding to anxiety and stress

C. MOTIVATION
- a desire to be wakeful and alert helps overcome sleepiness and sleep
- minimal motivation to be awake, sleep generally follows

D. LIFESTYLE AND HABITS

- shift work other than day shift requires reorganization of priorities or
sleep difficulties will occur
 - can result in anxiety, personal conflicts, loneliness, depression,
gastrointestinal symptoms,
and substance abuse
- especially difficult if shift changes periodically
- watching some types of t.v. shows, participating in stimulating outside
activities, and taking part in
activity or exercise can affect sleep

1. Physical Activity and Exercise – activity and exercise increase fatigue,

promote relaxation, followed
by sleep
- physical activity increases both REM and NREM
- moderate exercise is a healthy way to promote sleep, but if it is
within a 2-hr interval before
normal bedtime, can hinder sleep
- fatigue that results from normal work activities or exercise is
believed to contribute to a
restful sleep, whereas excessive exercise or exhaustion can
decrease quality of sleep

2. Dietary Habits – protein may actually increase alertness and

concentration, whereas, carbohydrates
appear to affect brain serotonin levels and promote calmness and
relaxation
- small protein- and carbohydrates-containing snack may be
effective

a. Alcohol Intake – when used in moderation, appears to induce sleep

in some people
- large quantities have been found to limit REM and delta
sleep
b. Caffeine-Containing Beverages – interfere with ability to fall asleep
- examples include coffee, tea, most cola drinks, and
chocolate
c. Smoking – smokers usually have a more difficult time falling asleep
and are easily aroused
- eliminating cigarette smoking after the evening meal
appears to improve ability to fall
asleep
- total withdrawal from smoking may be associated with
temporary sleep disturbances
- more daytime sleepiness and significantly more
restlessness at night

E. ENVIRONMENTAL FACTORS
- most people sleep best in their usual home environments
- sleeping in a strange or new environment tends to influence both REM
and NREM
- people accustomed to sleeping in a noisy environment have a hard time
falling asleep in an area that
 is extremely quiet (visa versa)

F. ILLNESS
- gastric secretions increase during REM sleep
- many with peptic ulcers wake at night with pain
- eating a snack or using antacids to neutralize acidity relieves
discomfort and promotes sleep
- pain associated with coronary artery disease and MI is more likely with
REM sleep
- epilepsy seizures are more likely to occur during NREM and appear to be
depressed by REM
- liver failure and encephalitis tend to cause reversal in day-night
sleeping habits
- hypothyroidism tends to decrease amt of NREM, especially Stages II and
IV
- certain treatments for disease are more effective when body rhythms
are taken into account
- larger midafternoon dose of asthma med may be more effective in
preventing attacks commonly
occurring during sleep
- antihypertensive med administration may need to be adjusted to
provide peak protection during early
morning hours
- cancer chemotherapy appears less toxic when administered at certain
times of day
- biologic rhythms may influence drug tolerance and med effectiveness

G. MEDICATIONS
- drugs that decrease REM include barbiturates, amphetamines, and
antidepressants
- drugs that cause sleep problems include diurtetics, antiparkinsonian
drugs, some antidepressants
and antihypertensives, steroids, decongestants, caffeine, and
asthma meds
- chloral hydrate and zolpidem tartrate (Ambian) appear to influence
quality of sleep and promote
normal sleep

H. COMMON SLEEP DISORDERS

1. Dyssomnias – sleep disorders characterized by insomnia or excessive
sleepiness

a. Insomnia – characterized by difficulty falling asleep, intermittent sleep,

or early awakening from sleep
- most common disorder
- older than 60, women (especially after menopause), and those
with a history of depression
are more likely to experience
- can occur during periods of stress, in situations involving some
change in normal
 environment, after traveling across time zones (jet lag), and
as a result of side effects
of meds
- feelings of being tired, lethargic, and irritable during day, difficulty
concentrating

b. Hypersomnia – characterized by excessive sleep, particularly during the

day
- frequently occurs as a coping mechanism in someone who has no
desire or energy to face a
new day

- treatment of insomnia is usually unnecessary because most episodes

last only a short period
- chronic insomnia lasts longer (3 – 4 wks) or even for a lifetime
- depression is the common cause - misuse of alcohol or caffeine
are often causes

- pharmacologic therapy may include the use of sedatives and hypnotics;

however, only short-term
use is recommended at the lowest dose
- nonpharmacologic therapy may include
• stimulus control – using bedroom for sex and sleep only
- leave room and return only when feeling sleepy
- getting up at the same time every day, no matter what time
the patient fell asleep
and refraining from napping during the day are
recommended
• sleep restriction – based on theory of limiting time in bed to actual
sleep time
- time in bed should not be decreased to less than 5 hrs/night
- brief midday naps are permitted
• sleep hygiene – restricting intake of caffeine, nicotine, and alcohol,
especially later in day
- not engaging in activities that may stimulate the person after 5
p.m.
- avoiding any other factors that may affect sleep pattern
- very successful when used in conjunction with another
complementary therapy
• cognitive therapy – meeting with therapist to discuss what is
normal and abnormal
- very successful when used in conjunction with another
complementary therapy
• multicomponent therapy – combination of two or more therapies
- choice of combination depends on what is best for the patient
• relaxation therapy – any type of relaxation (progressive muscle
relaxation, imagery training, or
meditation)
 c. Narcolepsy – characterized by uncontrollable desire to sleep
- person can literally fall asleep standing up, while driving a car, in
the middle of conversation,
or while swimming
- person falls asleep quickly, finds it difficult to wake up, sleeps
fewer hours than others, and
sleeps restlessly
- considered a neurologic disorder
- usually begins in susceptible people during adolescence or early
adulthood and continues
through life

Common Features:
sleep attacks = irresistible urge to sleep regardless of type of
activity person is engaged
cataplexy = sudden loss of motor tone
hypnagogic hallucinations = nightmares or vivid hallucinations
sleep-onset REM periods = during a sleep attack, person moves
directly into REM
sleep paralysis = skeletal paralysis that occurs during transition
from wakefulness to sleep

- presence of any two helps confirm diagnosis

- potentially dangerous

d. Sleep Apnea – patient experiences absence of breathing between

snoring intervals
- breathing may cease for 10 – 20 secs., possibly as long as 2
minutes
- blood oxygen level drops, pulse becomes irregular, and blood
pressure often increases
- many experience condition without symptoms
- occurs mostly in middle-aged men who are obese and have short
thick necks
- obstructive sleep apnea can result when airway is occluded due to
collapse of hypopharynx
or other structural abnormalities (enlarged tonsils and
adenoids, deviated nasal
septum, thyroid enlargement)
- may become irritable during the day, fall asleep during
monotonous activities, have
difficulty concentrating and exhibit slower reaction
times
- polysomnography is only method that can confirm diagnosis

e. Restless Leg Syndrome – cannot lie still and report unpleasant

creeping, crawling, or tingling
sensations in the legs (usually in calf) causing the irresistible urge
to move
 - massaging the legs, walking, doing knee bends, moving legs
sometimes bring relief
- treatment options include eliminating the use of caffeine, tobacco,
alcohol; taking a mild
analgesic at bedtime; and using antiembolism stockings at
onset of symptoms

f. Sleep Deprivation – decrease in amt, consistency, or quality of sleep

- may result from decreased REM or NREM
- manifestations progress from irritability and impaired mental
abilities to total disintegration of
personality
- become increasingly apparent after 30 hrs of continual
wakefulness
- excessive daytime sleepiness

2. Parasomnias – patterns of waking behavior that appear during sleep

somnambulism (sleep walking), sleep talking, nocturnal erections,
bruxism (grinding of teeth
during sleep) and enuresis (urinating during sleep)
- commonly seen in children and outgrown before adulthood
- safety and prevention of injury are paramount concerns

III. NURSING PROCESS

A. ASSESSING
1. Sleep History – identify sleep-wakefulness patterns, effect of patterns
on every day functioning, use
of sleep aids, and presence of sleep disturbances and contributing
factors
- if patient is being admitted, asses usual times of retiring and
waking, bedtime rituals, and
preferences regarding sleep environment so that these can
be added to care plan, if
possible
- assistance from patient’s bed partner may be needed

2. Sleep Diary – provides more specific data on sleep-wakefulness patterns

- generally kept for 14 days

3. Physical Assessment
a. Snoring – caused by obstruction to airflow through nose and mouth
- not ordinarily a sleeping disorder but accompanied by
apnea can present a problem
- changes from characteristic sawing-wood sound to more
irregular silence followed
by a snort indicates obstructive apnea

b. Nocturnal Myoclonus – marked muscle contractions that result in

jerking of one or both legs during sleep
- jerking may last about 28 seconds on average
 - may arouse sleeper and contribute to insomnia

B. DIAGNOSING / ANALYSIS
- sleep data indicate problem, contribute to different problem or are signs
or symptoms of problem
- no diagnoses is more correct than the other
- with each patient, nurse must review each cluster of significant data
and identify the key problem,
contributing factors, and related signs and symptoms

C. PLANNING
- rest and sleep are essential components of well-being
- planning with patient suitable measures to promote rest and sleep

Expected Outcomes: maintain sleep—wake pattern that provides

sufficient energy for day’s tasks
demonstrate self-care behaviors that provide healthy
balance between rest
and activity
identify stress-relieving rituals that promote falling
asleep easily
demonstrate decreased signs of sleep deprivation
verbalize feeling less fatigued and more in control of
life activities

D. IMPLEMENTING
- in most cases, sleep problems are not primary reason for healthcare
- communicating with patient while displaying nonjudgmental caring
attitude is key to detecting sleep
problem

1. Preparing Restful Environment- comfortable bed helps promote rest

and sleep
- bottom linen should be tight and clean
- upper linen should allow freedom of movement and not
exert pressure
- good body alignment is conductive to relaxation
- quiet and darkened room with privacy is relaxing
- make every effort to reduce disturbances and promote relaxation
and sleep
- identify sources of noise, adjust care to limit interruptions to
sleep, and modify
equipment to create quieter ventilation
- temperature of room, amt of ventilation and amt of bed
covering are individual
choices
- thermal blankets or comforters, insulated bed socks, cotton
flannel sheets, leg
warmers, long underwear, and stockinette cap help
promote comfort and
 sleep

2. Promoting Bedtime Rituals – reading, listening to radio, watching t.v.,

talking to family members,
praying are common activities
- children may take a favorite doll, stuffed toy, or blanket to bed;
listen to a bedtime story; kiss
everyone good night; and say prayers before bed
- readiness for sleep follows personal hygiene routine (brushing
teeth, washing hands and
face, voiding, or taking bath / shower)
- snacks are important; however, eating the wrong foods may
produce a bad night’s sleep

3. Offering Appropriate Bedtime Snacks and Beverages – carbs seem

to promote sleep (toast, small
bagel, crackers, or glass of fruit juice)
- alcoholic beverage helps promote sleep; however, after dinner it
may interrupt sleep cycle
and interfere with deep sleep
- caffeine should be avoided for at least 4 – 5 hrs before bedtime
- take fluids during day but avoid excessive fluid intake before
bedtime

4. Promoting Relaxation – stress and anxiety interfere with ability to

relax, rest and sleep
- deal with worry by dealing with problems as they arise; condition
yourself to consider
stressful issues only at certain times; teach yourself that
worrying never solves
problems and is counterproductive; giving the worries over to
another
- backrub, warm bath, and washing the face if patient is bedridden
are typical nursing
measures

5. Promoting Comfort – pain is the greatest deterrent to rest and sleep

- appropriate measures include remaining with lonely and
frightened child or adult, using the
simple strategy of caring presence and touch, offering a back
massage, obtaining
extra blanket, or administering analgesics
- be sensitive to discomfort to recognize and relieve it

6. Respecting Normal Sleep-Wake Patterns – make every effort to allow

patient to experience normal
period of sleep
- insisting that all patients retire and awaken at specific times is not
necessary
- napping habits should also be followed when possible
 - REM is more common during morning naps
- NREM is more common during naps later in the day

7. Scheduling Nursing Care to avoid Unnecessary Disturbances –

consider the complaints that
patients are awakened to take sleeping pills and aroused early to
prepare for breakfast long
before it is served
- provide care during periods when patient is normally awake - -
avoid waking patient during
REM sleep, when rapid eye movements can be observed
- consider whether checking vitals or carrying out a particular
measure is more important than
the patient’s sleep

8. Teaching About Rest and Sleep – well-informed patient is better able

to cope with distressing
situations
- teach patients and families about nature of rest and sleep and
their importance to well-being
- normal variations in sleep patterns and common measures to
promote relaxation and sleep
- discuss care plan with patient and make sure it is acceptable

E. EVALUATION
- care is considered effective if patient is able to
• verbalize feeling rested or having had a restful night’s sleep
• identify factors that interfere with or disrupt normal sleep pattern
• use techniques that promote sleep and provide a restful
environment
• concentrate and function effectively during waking hours
• eliminate behaviors related to sleep deprivation