Sleep Pattern & Its Disturbances: Nursing Implications

Prepared by: Asha P Mathew. MSN, Manipal College of Nursing, Manipal University
INTRODUCTION
Sleep is the state of natural rest observed throughout the animal kingdom, in all mammals and birds, and in many reptiles, amphibians, and fish. In humans, other mammals, and many other animals that have been studied - such as fish, birds, ants, and fruit-flies - regular sleep is necessary for survival. The capability for arousal from sleep is a protective mechanism and also necessary for health and survival.

DEFINITION
Sleep can e defined as a normal state of altered consciousness during which the body rests; it is characterized by decreased responsiveness to the environment, and a person can be aroused from it by external stimuli.

INCIDENCE & CHARACTERISTICS
Sleep is generally characterized by a reduction in voluntary body movement, temporary blindness, decreased reaction to external stimuli, loss of consciousness, a reduction in audio receptivity, an increased rate of anabolism (the synthesis of cell structures), and a decreased rate of catabolism (the breakdown of cell structures.
Almost a third of the general population has some problems with sleep during any given year. More than half of the 9000 participants in a study of sleep in elderly persons (65 years or older) reported the following as sleep pattern disturbance that they experience most of the time:
* Trouble falling asleep
* Frequent awakening
* Waking too early
* Needing to nap
* Not feeling rested
These disturbances may be secondary to situational, environmental or developmental stressors, or they may be associated with illness or with pre-existing disorders. The relationship is often reciprocal, in that the disorder decreases sleep & the decreased sleep affects the disorder.

CHRONOBIOLOGY
Chronobiology refers to the study of biologic changes as they occur in relation to time. The sleep wake cycle is one of the circadian rhythms of the body. Circadian rhythms follow an approximate 24 hour cycle through a complex process linked to light & dark. The effect of illness & hospitalization may disrupt these rhythms, particularly in older persons. Ultradian cycles are circadian rhythms of less than 24 hours. The recurrent pattern of sleep stages, repeating approximately 90 minutes in adults, is an example. Chronopharmacology refers to the study of how biorhythms affect the absorption, metabolism, & excretion of drugs. E.g.the blood level achieved by a continuous infusion of heparin varies throughout the day.

FUNCTIONS OF SLEEP
The purpose of sleep is still unclear. Theories suggest that:
* It is a time of restoration and preparation for the next period of wakefulness
* During NREM stage 4 body releases human growth hormone for the repair and renewal of epithelial and specialized cells such as brain cells
* Protein synthesis and cell division for the renewal of tissues occur during rest and sleep
* REM sleep appears to be important for cognitive restoration
The benefits of sleep often go unnoticed until a person develops a problem resulting from sleep deprivation. A loss of REM sleep leads to feelings of confusion. Various body functions ( eg. Motor performance, memory and immune function) alter when prolonged sleep loss occurs

NORMAL SLEEP REQUIREMENTS & PATTERNS
Sleep duration and quality vary among persons of all age groups
* Infants 16 Hours /Day
* Toddlers 12 Hours /Day
* Preschoolers 11 Hours /Day
* Schoolers 9 - 10 hours /day
* Adolescents 8 – 9 hours /day
* Adults 6 – 8 hours /day
As people age, their circadian clock advances, causing advanced sleep phase syndrome. The syndrome is common in older adults and often is the reason behind the complaint of waking early in the morning and unable to get back to sleep. They get sleepy early in the evening.

FACTORS AFFECTING SLEEP
A number of factors affect the quality and quantity of of sleep. Often more than one factor combined to cause a sleep problem.
* Physical illness (eg. Nausea, mood disorders, breathing difficulty, pain)
* Drugs and substances (eg. Tryptophan)
* Lifestyle (eg. Daily routines, exercises)
* Usual sleep patterns and excessive daytime sleepiness
* Emotional stress
* Environment ( ventilation)
* Sound
* Exercise and fatigue
* Food and caloric intake

SLEEP DISORDERS
Sleep pattern disturbance is a nursing diagnosis that is defined as a disruption of sleep time that causes discomfort or interferes with a desired life cycle. A sleep pattern disturbance may be related to one of more than 80 sleep disorders identified in the international classification of sleep disorders, a partial list of which is given below:
International classification of sleep disorders
Dyssomnias
Intrinsic sleep disorders
* Psycho physiologic insomnia
* Narcolepsy
* Obstructive sleep apnea syndrome
* Central sleep apnea syndrome
* Periodic limb movement disorder
* Restless leg syndrome
Extrinsic sleep disorders
* Inadequate sleep hygiene
* Environmental sleep disorder
Circadian rhythm sleep disorders
Parasomnias
Arousal disorders
* Sleep walking
* Sleep terrors
Sleep – wake transition disorders
Parasomnias usually associated with REM sleep
* Nightmares
* Sleep paralysis
Other Parasomnias
* Sleep bruxism
* Sleep enuresis
* Primary snoring
Sleep disorders associated with medical or psychiatric disorders
Associated with mental disorders
Associated with neurologic disorders
Associated with medical disorders
Proposed sleep disorders

ASSESSMENT AND MANAGEMENT
Diagnostic assessment:
* Polysomnography
* Electroencephalogram
* Multiple sleep latency test (MSLT)
MSLT is performed to assess the impairment of daytime alertness. It is performed a day after a standard polysomnogram. The time required for clients to fall asleep when in a relaxed state is evaluated at 2 hour intervals, with each nap limited to 20 minutes. The type of sleep also is assessed.

NURSING PROCESS
A. Assessment: Assess client’s usual sleep habits and recent sleep quality as part of the initial nursing history. If sleep quality is reported to be poor, explore the nature of disturbances by noting the following:
* Usual activities in the hour before retrieving
* Sleep latency
* Number and perceived cause of awakenings
* Regularity of sleep pattern
* Consistency of rising time
* Frequency and duration of naps
* Events associated with initial onset of sleep disturbances
* Ease of falling asleep in places other than the usual bedroom
* Situations in which client fights sleepiness
* Daily caffeine intake
* Use of alcohol, sleeping pills,and other medications
* Incidence of morning headaches
* Frequency of snoring, apparent pauses in breathing, and kicking movements
* Objective data may include visible signs of fatigue and lack of sleep, such as circles under the eyes, lack of coordination, drowsiness and irritability.

B. Nursing diagnosis:
1. Disturbed sleep pattern related to changes in routine due to hospitalization and pain
Or
Disturbed sleep pattern related to lack of cues for day- night schedule; manifested by erratic sleep schedule, frequent naps and nocturnal wandering

C. Client Outcome criteria:
client increases nocturnal sleep time by 20% over next 2 weeks.

D. Nursing intervention
*offer meals at regular times, corresponding to client’s previous pattern
*provide active meaningful activities during daytime hours, including exposure to natural light, and an outdoor environment when possible
*monitor frequency and duration of naps
*create an individualized bedtime ritual that includes a quieting activity, a light carbohydrate snack, going to the bathroom and settling a routine
* Do not waken even if incontinent. Change and assist the client to the bathroom when he or she spontaneously awakens
*if turning or other care is necessary, try to provide for periods up to 2 hours of undisturbed sleep time whenever possible
Rationale
*mealtimes are important social cues, that reinforce circadian rhythms, which tend to weaken with advancing age
*light exposure is communicated through the retina to the suprachiasmatic nucleus, helping to set the circadian clock
*napping is not contraindicated but is best at the time of day opposite to the midpoint of the nocturnal sleep period. Short naps are preferable to avoid deep sleep
*reduced stimulation and rituals associated with sleep enhance sleep onset
*older adults who can turn themselves generally do better to have their sleep undisturbed and tend to waken spontaneously if wet when their sleep cycle lightens
* Sleep cycles average 90 mts. A sleep latency of 20- 30 mts mean it would take about 2 hours to experience a full sleep cycle.

SUMMARY
The adequacy of sleep is important factor in caring for clients with acute and chronic illness. Some sleep disturbances are temporary and related to the stress of hospitalization. It is possible that temporary stress problems will be corrected only after the client’s return home. Clients with sleep disturbances may need follow –up care with repeated assessments to determine whether the problem was corrected. Clients with long term sleep disorders may need ongoing support to maintain the effectiveness of treatment. The nurse can play a pivotal role in environmental modification and client teaching to minimize the impact of sleep.

REFERENCES
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