602

Risk for Shock

AUTHORS NOTE
This newly accepted diagnosis by NANDA-I represents several collaborative problems. In order to decide which
of the following collaborative problems is appropriate for an individual client, determine what you are monitoring
for.Which of the following describes the focus of nursing for this client?
U Risk for Complications of Hypertension
U Risk for Complications of Hypovolemia
U Risk fro Complications of Sepsis
U Risk for Complications of Decrease Cardiac Output
U Risk for Complications of Hypoxemia
U Risk for Complications of Allergic Reaction
U Refer to Section 3 for goals and interventions for each of the above collaborative problems.

DISTURBED SLEEP PATTERN

Disturbed Sleep Pattern
Insomnia
Sleep Deprivation

DEFINITION _____________________________________________________________
State in which a client experiences a change in the quantity or quality of ones rest pattern that causes
discomfort or interferes with desired lifestyle

DEFINING CHARACTERISTICS ______________________________________________

Major (Must Be Present)
Adults
Difficulty falling or remaining asleep

Minor (May Be Present)

Adults
Fatigue on awakening or during the day
Agitation

Dozing during the day

Mood alterations

Children
Reluctance to retire
Persists in sleeping with parents
Frequent awakening during the night

RELATED FACTORS _______________________________________________________

Many factors can contribute to disturbed sleep patterns. Some common factors follow.

Pathophysiologic
Related to frequent awakenings secondary to:
Impaired Oxygen Transport
Angina
Respiratory disorders
Circulatory disorders

Peripheral arteriosclerosis

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603

Impaired Elimination; Bowel or Bladder

Diarrhea
Retention
Constipation
Dysuria
Incontinence
Frequency
Impaired Metabolism
Hyperthyroidism
Hepatic disorders

Gastric ulcers

Treatment-Related
Related to difficulty assuming usual position secondary to (specify)
Related to excessive daytime sleeping or hyperactivity secondary to (specify medication)
Tranquilizers
Sedatives
Amphetamines
Monoamine oxidase inhibitors
Hypnotics
Barbiturates
Antidepressants
Corticosteroids
Antihypertensives

Situational (Personal, Environmental)

Related to excessive hyperactivity secondary to:
Bipolar disorder
Attention-deficit disorder
Illicit drug use
Related to excessive daytime sleeping
Related to depression
Related to inadequate daytime activities
Related to pain
Related to anxiety response
Related to discomforts secondary to pregnancy
Related to lifestyle disruptions
Occupational
Emotional
Sexual
Financial
Related to environmental changes (specify)
Hospitalization (noise, disturbing roommate, fear)
Travel
Related to fears
Related to circadian rhythm changes

Panic anxiety

Social

Maturational
Children
Related to fear of dark
Related to fear
Related to enuresis
Related to inconsistent parenteral responses
Related to inconsistent sleep rituals

Adult Women
Related to hormonal changes (e.g., perimenopausal)

AUTHORS NOTE
Sleep disturbances can have many causes or contributing factors. Some examples are asthma, tobacco use, stress,
marital problems, and traveling. Disturbed Sleep Pattern describes a situation that is probably transient due to a
change in the client or environment (e.g., acute pain, travel, hospitalization). Risk for Disturbed Sleep Pattern can
use used when a client is at risk due to travel or shift work. Insomnia describes a client with a persistent problem
falling asleep or staying asleep as chronic pain and multiple chronic stressors. It may be clinically useful to view
sleep problems as a sign or symptom of another nursing diagnosis such as Stress Overload, Pain, Ineffective Coping,
Dysfunctional Family Coping, or Risk-Prone Health Behavior.

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ERRORS IN DIAGNOSTIC STATEMENTS

1. Insomnia related to apnea
This diagnosis requires monitoring and co-management by nurses and physicians; thus, the nurse should write
it as the collaborative problem RC of Sleep Apnea.
2. Disturbed Sleep Pattern related to hospitalization
This diagnosis does not reflect the treatment needed. The effects of hospitalization on sleep should be specified, such as in Disturbed Sleep Pattern related to changes in usual sleep environment, unfamiliar noises, and interruptions for assessments.

KEY CONCEPTS
Generic Considerations
U Sleep involves two distinct stages: rapid eye movement (REM) and non-rapid eye movement (NREM). NREM
sleep constitutes about 75% of total sleep time; REM sleep accounts for the remaining 25% (Porth, 2006).
U The entire sleep cycle is completed in 70 to 100 min; this cycle repeats itself four or five times during the
course of the sleep period.
U Sleep is a restorative and recuperative process that facilitates cellular growth and repair of damaged and aging
body tissues. During NREM sleep, metabolic, cardiac, and respiratory rates decrease to basal levels and blood
pressure decreases. There is profound muscle relaxation, bone marrow mitotic activity, and accelerated tissue repair and protein synthesis. During REM sleep, the sympathetic nervous system accelerates, with erratic
increases in cardiac output and heart and respiratory rate. Perfusion to gray matter doubles, and cognitive and
emotional information is stored, filtered, and organized (Boyd, 2005).
U The active phase of the sleep cycle, REM sleep, is characterized by increased irregular vital signs, penile erections, flaccid musculature, and release of adrenal hormones. REM sleep occurs approximately four or five times
a night and is essential to a clients sense of well-being. REM sleep is instrumental in facilitating emotional
adaptation; a client needs substantially more REM sleep after periods of increased stress or learning (Blissitt,
2001).
U Percentage of time in bed at night actually spent asleep, or sleep efficiency, influences perception of the quality of
sleep. Studies report that younger people typically report sleep efficiency of 80% to 95%, whereas older people
report 67% to 70% (Hayashi & Endo, 1982).
U Sleep deprivation results in impaired cognitive functioning (memory, concentration, judgment) and perception,
mental fatigue, reduced emotional control, and increased suspicion, irritability, depression, and disorientation.
It also lowers the pain threshold and decreases production of catecholamines, corticosteroids, and hormones
(Boyd, 2001; Dines-Kalinowski, 2000).
U The average amount of sleep needed according to age follows:
Age
Hours of Sleep
Newborn
14 to 18
6 months
12 to 16
6 months to 4 years
12 to 13
5 to 13 years
7 to 8.5
13 to 21 years
7 to 8.75
Adults younger than 60
6 to 9
Adults older than 60
7 to 8
U Hammer (1991) identified three subcategories of Disturbed Sleep Pattern: latency or difficulty falling asleep,
interrupted, and early-morning awakening.
U People with depression report early-morning awakenings and inability to return to sleep. People with anxiety
complain of insomnia and multiple awakenings (Boyd, 2005).
U Hypnotics contribute to sleep disturbances through the following mechanisms:
U Requiring increasing dosage as a result of tolerance
U Depressing central nervous system (CNS) function
U Producing paradoxic effects (nightmares, agitation)
U Interfering with REM and deep sleep stages
U Causing daytime somnolence owing to a very long half-life
(continued)

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605

KEY CONCEPTS Continued

U Sleep disturbances are reported by 50% to 100% of peri- and postmenopausal women. These sleep disturbances are caused by hot flashes and sweating caused by hormonal changes (Landis & Moe, 2004).
Sleep disturbances in peri- and postmenopausal women are caused by the re-regulation of neuroendocrine hypothalamic function and changes in the amount and type of sex steroid hormones. These changes affect mood,
cognition, stress reactivity, body temperature, and sleep/wake cycles (Landis & Moe, 2004).

Pediatric Considerations
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Focus Assessment Criteria ________________________________________________

Subjective Data
Assess for Defining Characteristics
Sleep Patterns (Present, Past)
Rate sleep on a scale of 1 to 10 (10 = rested, refreshed)
Usual bedtime and arising time
Difficulty in getting to sleep, staying asleep, or awakening (number)
Naps

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Sleep Requirements
To establish the amount of sleep a client needs, have him or her go to bed and sleep until waking in the
morning (without an alarm clock). The client should do this for a few days. Calculate the average of the
total sleeping hours, subtracting 20 to 30 min, which is the time most people need to fall asleep.

History of Symptoms
Complaints of:
Sleeplessness
Depression
Anxiety

Fear (nightmares, dark, maturational situations)

Irritability

Assess for Related Factors

Refer to Related Factors.

Objective Data
Assess for Defining Characteristics
Physical characteristics
Drawn appearance (pale, dark circles under eyes, puffy eyes)
Yawning
Dozing during the day
Decreased attention span
Irritability
For more information on Focus Assessment Criteria, visit http://thepoint.lww.com.

NOC
Rest, Sleep, WellBeing, Parenting
Performance

Goal ______________________________________________________
The client will report an optimal balance of rest and activity.

Indicators:
U Describe factors that prevent or inhibit sleep.
U Identify techniques to induce sleep.

NIC

General Interventions ______________________________________

Energy
Management, Sleep
Enhancement,
Relaxation Therapy,
Exercise Promotion,
Environmental
Management,
Parent Education:
Childrearing Family

Because various factors can disrupt sleep patterns, the nurse should consult the index for specific interventions to reduce certain factors (e.g., pain, anxiety, fear). The following suggests general interventions for
promoting sleep and specific interventions for selected clinical situations.

Identify Causative Contributing Factors

Refer to Related Factors
Explain sleep cycles includes REM, NREM, and wakefulness and sleep requirements.
R: Sleep cycle. A client typically goes through four or five complete sleep cycles each night. Awakening
during a cycle may cause him or her to feel poorly rested in the morning.
R: Although many believe that a client needs 8 h of sleep each night, no scientific evidence supports this
belief. Individual sleep requirements vary greatly. In general, a client who can relax and rest easily
requires less sleep to feel refreshed. With age, total sleep time usually decreasesespecially stage 4
sleepand stage 1 sleep increases.

Reduce or Eliminate Environmental Distractions and Sleep Interruptions

Assess with client and family their usual bedtime routinetime, hygiene practices, rituals such as
readingand adhere to it as closely as possible.
Encourage or provide evening care:
U Bathroom or bedpan

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607

U Personal hygiene (mouth care, bath, shower, partial bath)

U Clean linen and bedclothes (freshly made bed, sufficient blankets)
R: Sleep is difficult without relaxation, which the unfamiliar hospital environment can hinder.

Noise
Close the door to the room.
Pull the curtains.
Unplug the telephone.
Use white noise (e.g., fan; quiet music; tape of rain, waves).
Eliminate 24-h lighting.
Provide night lights.
Decrease the amount and kind of incoming stimuli (e.g., staff conversations).
Cover blinking lights with tape.
Reduce the volume of alarms and televisions.
Place the client with a compatible roommate, if possible.

Interruptions
Organize procedures to minimize disturbances during sleep period (e.g., when the client awakens for
medication, also administer treatments and obtain vital signs).
Avoid unnecessary procedures during sleep period.
Limit visitors during optimal rest periods (e.g., after meals).
If voiding during the night is disruptive, have the client limit nighttime fluids and void before retiring.
R: Researchers have reported that the chief deterrents to sleep in critical care clients were activity, noise,
pain, physical condition, nursing procedures, lights, vapor tents, and hypothermia.

Increase Daytime Activities, as Indicated

Establish with the client a schedule for a daytime program of activity (walking, physical therapy).
Discourage naps longer than 90 min.
Encourage naps in the morning.
Limit the amount and length of daytime sleeping if excessive (i.e., more than 1 h).
Encourage others to communicate with the client and stimulate wakefulness.
R: Early-morning naps produce more REM sleep than do afternoon naps. Naps longer than 90 min long
decrease the stimulus for longer sleep cycles in which REM sleep is obtained.

Promote a Sleep Ritual or Routine

U Maintain a consistent daily schedule for waking, sleeping, and resting (weekdays, weekends).
U Arise at the usual time even after not sleeping well; avoid staying in bed when awake.
U Use the bed only for activities associated with sleeping; avoid TV watching.
U If the client is awakened and cannot return to sleep, tell him or her to get out of bed and read in another room for 30 min.
U Take a warm bath.
U Consume a desired bedtime snack (avoid highly seasoned and high-roughage foods) and warm milk
U Use herbs that promote sleep (e.g., lavender, ginseng, chamomile, valerian, rose hips, lemon balm passion flower [Milller, 2009]). Consult with the primary care provider prior to use.
U Avoid alcohol, caffeine, and tobacco at least 4 h before retiring.
U Go to bed with reading material.
U Get a back rub or massage.
U Listen to soft music or a tape-recorded story.
U Practice relaxation/breathing exercises.
R: Sleep rituals prepare the mind, body, and spirit for rest and decrease cortical responses.
R: Warm milk contains l-tryptophan, which is a sleep inducer.
R: Caffeine and nicotine are CNS stimulants that lengthen sleep latency and increase nighttime wakening
(Miller, 2009).

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Disturbed Sleep Pattern

R: Alcohol induces drowsiness but suppresses REM sleep and increases the number of awakenings
(Miller, 2009).
Use pillows for support.
R: Pillows can support a painful limb, pregnant or obese abdomen, or the back.
Ensure that the client has at least four or five periods of at least 90 min each of uninterrupted sleep every
24 h.
Document the amount of the clients uninterrupted sleep each shift.
R: To feel rested, a client usually must complete an entire sleep cycle (70 to 100 min) four or five times a
night.

Provide Health Teaching and Referrals, as Indicated

Teach an at-home sleep routine (Miller, 2009). See above for specifics.
Teach the importance of regular exercise (walking, running, aerobic dance) for at least 30 min three times
a week (if not contraindicated). Avoid exercise in the evening.
R: Regular exercise can reduce stress and promote sleep.
Explain risks of hypnotic medications with long-term use.
R: There is a risk for development of tolerance and interference with daytime functioning.
Refer a client with a chronic sleep problem to a sleep disorders center.
For peri- and postmenopausal women, explain the following:
U Sedative and hypnotic drugs begin to lose their effectiveness after 1 week of use, requiring increasing
dosages and leading to the risk of dependence.
U Warm milk contains l-tryptophan, which is a sleep inducer.
U Caffeine and nicotine are CNS stimulants that lengthen sleep latency and increase nighttime wakening
(Miller, 2009).
U Alcohol induces drowsiness but suppresses REM sleep and increases the number of awakenings (Miller,
2009).
U Early-morning naps produce more REM sleep than do afternoon naps. Naps longer than 90 min long
decrease the stimulus for longer sleep cycles in which REM sleep is obtained.
R: Sleep disturbances during the perimenopausal period are attributed to hot flashes and hormonal
fluctuations.

Pediatric
Interventions Explain the Sleep Differences of Infants and Toddlers
(Murray, Zentner, & Yakimo, 2009, p. 311)
15 months
17 to 24 months
18 months
19 months
20 months
21 months
24 months
2 to 3 years

Shorter morning nap, needs afternoon nap

Has trouble falling asleep
Has a favorite sleep toy, pillow, or blanket
Tries to climb out of bed
May awake with nightmares
Sleeps better, shorter afternoon naps
Wants to delay bedtime, needs afternoon nap, sleeps less time
Can change to bed from crib, needs closely spaced side rails

R: There are age-related sleep requirements and behavior.

Explain night to the child (stars and moon).
Discuss how some people (nurses, factory workers) work at night.
Explain that when night comes for them, day is coming for other people elsewhere in the world.
If a nightmare occurs, encourage the child to talk about it, if possible. Reassure the child that it is a
dream, even though it seems very real. Share with the child that you have dreams too.
(continued)

Disturbed Sleep Pattern

Pediatric
Interventions
Continued

609

R: Children need to understand nighttime and be assisted to prepare for it. Preparation for bedtime
involves switching the child from activity to bedtime gradually. It is a time for calmness, reassurance, and closeness.

Stress the Importance of Establishing a Sleep Routine

(Murray, Zentner, & Yakimo, 2009, p. 313)
U Set a definite time and bedtime routine. Begin 30 min before bedtime. Try to prevent an overtired,
agitated child.
U Establish a bedtime ritual with bath, story-reading,and soft music.
U Ensure that the child has his or her favorite bedtime object/toy, pillow, blanket, etc.
U Quietly talk and hold the child.
U Avoid TV and videos.
U If the child cries, go back in for a few minutes and reassure for less than a minute. Do not pick up
the child. If crying continues, return in 5 minutes and repeat the procedure.
U If extended crying continues, lengthen the time to return to the child to 10 minutes (p. 313).
Eventually the child will fatigue and fall asleep.
U The child should remain in his or her bed rather than co-sleep for part or all of the night with
parents (p. 313). Occasional exceptions can be made for family crises, trauma, and illness.
R: Bedtime rituals become a precedent for other separations and help the child strengthen a sense of
trust and build autonomy (p. 313). Co-sleeping with parents interferes with parental restorative
sleep and promotes the child as in charge.
Provide a night light or a flashlight to give the child control over the dark.
Reassure the child that you will be nearby all night.
R: Children can be helped to learn that their beds are safe places. Bedtime is often difficult with sleep
problems commonly related to resistance to separation and normal fears.

Maternal
Interventions

Discuss reasons for sleeping difficulties during pregnancy (e.g., leg cramps, backache, fetal
movements).
Teach the client how to position pillows in side-lying position (one between legs, one under abdomen, one under top arm, one under head).
R: Interventions that reduce discomfort of enlarging the uterus can promote sleep (Pillitteri, 2009).
Refer to General Interventions for Sleep Promotion Strategies.

Geriatric Explain the Age-Related Effects on Sleep

Interventions R: Older adults have more difficulty falling asleep, are more easily awakened, and spend more time in
the drowsiness stage and less time in the dream stages than do younger people (Miller, 2009).

Explain that Medications (Prescribed, Over-the-Counter) Should Be Avoided

Because of Their Risk for Dependence and the Risks of Drowsiness.
If the client needs sleeping pills occasionally, advise him or her to consult primary care provider for a
type with a short half-life.
R: Over-the-counter sleep aids contain antihistamines which can cause dizziness and risk for falls.