LULLABY AND GOOD NIGHT….Lisa B. Flatt, RN, MSN, CHPN

REST VS. SLEEP

Calm state Relaxation Physical activity No physical activity

Altered state of consciousness

Perception and reaction are decreased

Varying levels of reaction (dog barking, lawn mower, smoke detector)

Rest Sleep

TYPES OF SLEEP

25% of sleep in young adults

Recurs every 990 minutes and lasts 5-30 minutes

Increases as you become more rested Active dreaming,

remembered dreams, difficulty awakening, depressed muscle tone, irregular heart, respiratory rates and muscle movements, increased brain activity

Most sleep is non-REM slow-waves 4 Stages

I:last few minutes; drowsy, relaxed, eyes roll side to side; RR and HR decrease

II: 10-15 minutes, eyes still; HR, RR and T decrease

III: HR, RR, T decrease; MS relaxes; decreased reflexes; snoring

IV: deep sleep; HR and RR drop to 20-30% waking rate; some dreaming, eye rolling; decreased BP; blood vessels dilate; MS relax; decreased BMR; increased GI activity

Rapid Eye Movement (REM) Non-rapid Eye Movement (NREM)

HOW LONG DO THEY LAST? NOT LONG ENOUGH!

REM – recurs every 990 minutes, lasts 5-30 minute

NREM - about one hour in adults Stage II and III – 20-30 minutes total Stage IV – 30 minutes Cycle REM, St I,II and III then IV – then III, II and

REM --- cycle4-6 times every 7-8 hours Each cycles lasts about 70 minutes If you wake up, start all over again! More rested, cycles last longer, less time in

Stages II and IV and NREM Different developmental levels, different time

lengths

CIRCADIAN RHYTHM – NOT TO BE CONFUSED WITH CICADAS

24 hour – Daily cycle, all living things do it! Biorhythms – humans only. These are

controlled with light and darkness, gravity and electromagnetic stimuli.

Infants as young as 6 months have circadian rhythms very much likeadults!

HOW WELL DO YOU SLEEP? WHAT TO ASSESS AND CONSIDER……

Age and developmental level Individual preferences Physical condition Cultural, spiritual and religious practices Living conditions and socioeconomic status Environmental factors Psychological factors Medications

AGE AND DEVELOPMENTAL LEVEL – THE NEED FOR SLEEPAge Hours/day Other

Newborns 16-18 50%REM mostly St III and IV NREM

Infants 12-22 Light sleep, end of 1st year 14 of 24 hrs with 1-2 naps

Toddlers 10-12 20-30%REM, 1 nap, bedtime resistance

Preschoolers 11-12 20-30%REM,less St I NREM, consistency, may need naps

School-age 8-12 20% REM

Adolescents 8-12 20% REM

Young adult 7-8

Middle-age adult 6-8 St IV decreases, aroused more easily

Older adult Awaken more frequently, longer to get back to sleep

PREFERENCES

Sleep patterns Lifestyle Work schedule and changes – sleep pattern

changes Caffeine Alcohol – speeds up REM sleep Smoking – nicotine is a stimulant Vigorous exercise at ‘wrong times’ – releases

endorphins

WHAT KIND OF SHAPE ARE YOU IN?

Illnesses – require more sleep Altered health status Obesity – difficulty breathing Nocturia Activity level Ineffective breathing

AND MORE……

Co-sleeping (babies and young children sleeping with parents)

Sanitation Safety Noise Temperature

extremes ventilation

Cultural, Spiritual, Religious Socieeconomic, Living conditions, Environmental

….. AND MORE……

Anxiety Stress Depression

Beta blockers Sedatives Narcotics Diuretics Amphetamines Bronchodilators Decongestants Steroids

Psychiatric Medications

Disturbing my Sleep! Primary Sleep Disorders

Narcolepsy – excessively sleepy during day; could be in middle of driving, talking, etc..; starts with REM

Unknown, possible genetic defect

Insomnia – unable to fall asleep; psychological (anxiety, etc); pain; nocturia; environmental (lights, etc.); chemical (medicine, caffeine, etc.)

Full assessment needed, usually no med’s; modification of habits, etc.

Secondary Sleep Disorders Hypersomnia – excessive

sleeping during the day, r/t CNS damage, kidney, liver or metabolic disorders

Sleep apnea – periods of apnea during sleep; last 10 sec – 2 min; 50-600 x/night; tired during day; middle-aged overwt males and post-menopausal women

Parasomnia-behaviors that interfere with sleep

Sleep deprivation – decrease in amount, consistency and quality of sleep

Sleep Apnea

Three types _Obstructive – tongue, tonsils_ __Central Apnea- chest movement, air flow stops,

respiratory center defect in brain__ __Mixed – both combined_____

Causes ___remove and hopefully correct__________ ___modify reasons as above__________

Treatments __CPAP_____ __BiPAP____________ ___Surgery, adjust body habitus, sleep sitting

up____

Parasomnia- behaviors

Somnambulism - ___sleep walking______ Sleeptalking - ___holler out, tell

secrets_______ Nocturnal enuresis - __pee at night___ Nocturnal erections - ___speaks for itself_____ Bruxism - ___teeth grinding____

Assessment

Medications Age Activity - patterns Diet Alcohol/drugs Disease process - labs Sleep patterns Stress, anxiety, depression

Nursing Diagnosis

Insomnia R/T ____anxiety, stress, depression Impairment of normal sleep pattern R/T

_____shift work, SOB, ________ Sleep deprivation R/T _____fan running at

night for wife to sleep, dementia, nightmares, narcolepsy, sleep walking, idiopathic CNS disease_______

Plan

Collaborate with team to get an ideas on how to promote sleep

Assess sleep pattern daily Client will verbalize plan to sleep at night,

wake in am Reduce environmental noise Monitor fluid intake after 6PM Instruct family on sleep patterns and disease

Interventions

Provide Calm environment by closing door at night

Rub lotion on back before bed at 10PM Turn off tv at 8pm Administer sleeping pill by 9pm Keep sleep log Educate family on need to give diuretic

before 4pm

Evaluation

6 of 7 nights closed door before 9PM Did not rub patient’s hairy back at all Wife turned off tv at night before 11pm Gave extra sleeping pills and benadryl to

keep patient off call light 7 of 7 nights Sleep log kept by nurse first two days, family

kept last 5 days (instructed not to hit patient with sleep log)

Wife took patients diuretic related to her swollen ankles – discuss this with social work