Sleep/Sleep Disorders Flashcards
Recumbency
laying down
Sleep general descriptions
-physiological process
- body’s rest cycle
- associated with recumbency and immobility
- lacks conscious awareness but is easily awakened
- essential for healthy functioning and survival
Insufficient sleep def
is obtaining less than 7-8 hours of sleep in 24 hour period
Fragmented def
-frequent arousals or awakening that interrupt sleep
Nonrestorative Sleep def
sleep that is adequate duration but does not result in the individual feeling refreshed and alert the next day
Sleep def
state in which an individual lacks conscious awareness of environmental surroundings but can be easily aroused
Sleep disturbance
conditions of poor sleep quality
Sleep disorders
abnormalities unique to sleep
- insomnia
- nacrolepsy
Sleep-Wake Cycle
controlled by the brain
wake behavior
- RAS and various neurotransmitters
- Orexin (hypocretin
RAS stands for
Reticular Activating System
RAS controls
sensory stimuli within the cerebral cortex
- regulates the sleep-wake cycle
- motor, sensory, visceral, consciousness
Orexin
neuro peptide comes out of the hypothalamus by helping keep people awake
Pt has low levels of orexin are prone to have
narcolepsy
Activation of RAS
causes alertness and attention
Circadian Rhythm is managed by
suprachiasmatic nucleus (SCN) in hypothalamus
Circadian Rhythm is synchronized through
light detectors in the retina
What is the strongest time cue for circadian rhythm?
light
Phases of Sleep
- sleep latency 5%
- NREM Stages 1-3
= Stage 1 5%
= Stage 2 50%
= Stage 3 15% - REM (25%)
Sleep Latency
- Time it takes for a person to fall asleep
- starts when eyes are closed for sleep
- ends when NREM is entered
- time varies usually 10-40 mins
ICU Sycosis
caused by not being able to distinguish between day and night
Majority of sleep phase is in
NREM 75%
REM 25%
T/F: Sleep latency is technically not a phase.
True
NREM (Non-rapid eye movement) is what percentage of sleep time overall?
75-80 % of sleep time
NREM: Stage 1
- slow eye movements
- person can be easily awaken
NREM: Stage 2
HR and temp decrease
NREM: Stage 3
- a person is difficult to awaken and may have parasomnias, which decreases with age
- deep or slow wave sleep (SWS) delta waves, parasomnias
Parasomnias
-Unusual and often undesirable behaviors while falling asleep, transitioning between sleep stages, or during arousal from sleep
-Due to CNS activation
Examples of Parasomnias
- sleep walking
- sleep terrors
- nightmares
- sleep paralysis
- sleep hallucinations
REM Sleep
20-25% of the sleep cycle
- occurs 3 to 4 times a night
- greatly reduced skeletal muscle tone
- period when most vivid dreaming occurs
What phase of sleeping of the brain is very active but mentally restful?
REM
Middle Age Changes in sleep
-More stage shifts - ↓ in NREM3 and REM
-Resistant to sleep deprivation
-Increased awakenings
-Changes in sleep efficiency
Older Age Changes in sleep
- Phase changes – go to bed earlier and arise earlier
Which statement is true regarding REM sleep? Select all that apply.
a. Muscle tone is greatly reduced
b. It occurs only once in the night
c. It is separated by distinct physiologic stages
d. The most vivid dreaming occurs at this phase
a. Muscle tone is greatly reduced
d. The most vivid dreaming occurs at this phase
What is the best description for sleep?
a. Quiet state in which there is little brain
activity
b. Loosely organized state similar to a coma
c. State in which pain sensitivity decreases
d. State in which the individual lacks
conscious awareness of the environment
d. State in which the individual lacks conscious awareness of the environment
Neurologic changes with lack of sleep
- cognitive impairment
- behavior changes ( irritability and moodiness)
Immunity changes with lack of sleep
- impaired condition
Respiratory changes with lack of sleep
- asthma exacerbated during sleep
Cardiovascular changes with lack of sleep
heart disease ( hypertension, dysrhythmia)
increase in BP with hypertension
stroke
Gastrointestinal changes with lack of sleep
increase risk for obesity and GERD
Endocrine changes with lack of sleep
- increase risk for type 2 diabetes
- increase insulin resistance
- decrease in growth hormones
Sleep disturbances in the hospital and factors
hospitalization associated with decreased sleep time
- environmental sleep-disruptive factors
- psychoactive medications
- acute and critical illness
Insomnia symptoms
difficulty falling asleep (long sleep latency)
frequent awakening (fragmented sleep)
prolonged nighttime awakening
waking up too early
c/o feeling unrefreshed on awakening (nonrestorative sleep)
fatigue, trouble with concentration
forgetfulness, confusion
anxiety
Acute insomnia
diffculty falling asleep or remaining asleep for at least 3 night/week for less than a month
Chronic insomnia
- same symptoms as acute
- daytime symptoms that persist for 1 month or longer
Insomnia causes are aggravated by
- inadequate sleep hygiene
~ stimulants
~ medications
~ using alcohol to induce sleep
~ irregular sleep schedule - nightmare
- exercising near bedtime
- jet lag
Alcohol reduces/increases REM sleep
reduces
Avoid strenuous exercise __ hours before bed
6
Melatonin
-hormone help induce sleep
-can be suitable for patients but designed for short-term use (if used for more than 2 weeks to a month: lessen the effect)
- side effect: cause prolonged QT syndrome
Etiology of Chronic Insomnia
often NKA
- stressful life event
- psychiatric illness or medical condition
- medications or substance abuse
Insomnia Diagnosis
self-report (sleep log for 2 weeks)
actigraphy
polysomnography (PSG)
Actigraphy
noninvasive technique that measures the physical activity levels of a subject by means of a wristwatch-like motion-sensing device that can be worn for 14 days
Polysomnography
sleep study
records your brain waves, the oxygen level in your blood, heart rate and breathing, as well as eye and leg movements during the study
Insomnia Interprofessional Care
education
track sleep
sleep hygiene
cognitive-behavioral therapy for insomnia
complementary and alternative therapies
drug therapy
Sleep Hygiene (Table 7.3)
- Do not go to bed unless sleepy
- If not asleep after 20 mins, do a non-stimulating activity and return when sleepy
- Regular sleep pattern
- Rituals
- Full Night’s sleep
- Environment is quiet, dark, and a little bit cold
- do not read, or be on the phone in bed
- avoid caffeine, nicotine, and alcohol 4-6 hours before bed
- don’t go to bed hungry but no big meal before
- avoid exercising within 6 hours of bedtime
- avoid sleeping pills and use them cautiously
- practice relaxation techniques to cope with stress
Insomnia causes
psychiatric
medical illness, medications
stress: finances, employment, school, life
substances: caffeine, alcohol, nicotine
exercise
age, gender
travel
Insomnia Treatment
begin with least invasive
cognitive behavior therapy
therapist: counseling
Insomnia: Drug Therapy
Benzodiazepines
Benzodiazepines-receptor-like agents
Melatonin-receptor agonist
Antidepressants
Antihistamines
Sedative-Hypnotic drugs
Alternative therapies
Sedative-Hypnotic Drugs
depress CNS function
primarily used to treat anxiety and insomnia
antianxiety agents or anxiolytics
distinction between antianxiety effects and hypnotic effects depends on dosage
Benzodiazepines
Used to treat anxiety and insomnia
Used to induce general anesthesia
Used to manage seizure disorders, muscle spasms, panic disorder, and alcohol withdrawal
Potential for abuse (watch pt. very carefully)
Can produce physical dependence
If taking benzodiazepines, then you have to see your healthcare provider every?
3 months
Benzodiazepines used specifically for sleep
temazepam (Restoril)
triazolam (Halcion)
Common Benzodiazepines
diazepam (Valium)
lorazepam (Ativan)
alprazolam (Xanax)
- commonly used for anxiety and panic attacks but causes sleepiness
Pharmacologic effects Benzodiazepines
CNS: reduce anxiety and promote sleep
Cardiovascular system: Oral vs. intravenous
Respiratory system: Weak respiratory depressants
Therapeutic effects Benzodiazepines
Anxiety
Insomnia
Seizure disorders, muscle spasm
EtOH withdrawal, perioperative applications
Adverse effects Benzodiazepines
CNS depression
Amnesia
Sleep driving
Paradoxical effects
Respiratory depression
Abuse
Benzodiazepines Overdose effects
Acute toxicity
oral overdose = drowsiness, lethargy, and confusion
IV toxicity = life-threatening reactions, profound hypotension, respiratory arrest, and cardiac arrest
Benzodiazepines general treatment measures
Oral
gastric lavage
activated charcoal
dialysis
Benzodiazepines treatment with flumazenil (Romazicon)
- competitive benzodiazepine receptor agonist
- reverses sedative effects for benzodiazepines but may not reverse respiratory depression - monitor for seizures when benzo. is stopped
- effects fade an hour after administration: monitor for sedation
Benzodiazepine-Receptor-Like agents
Zolpidem (Ambien)
Zaleplon (Sonata)
Eszopiclone (Lunesta)
Zolpidem (Ambien)
Sedative-hypnotic
Short-term management of insomnia
Side effects: daytime drowsiness and dizziness
Zaleplon (Sonata)
Approved for short-term management of insomnia
Most common side effects: headache, nausea, drowsiness, dizziness, myalgia, and abdominal pain
Eszopiclone (Lunesta)
Approved for treating insomnia
No limitation on how long it can be used
Generally well tolerated
Adverse effect: bitter aftertaste, headache, somnolence, dizziness, and dry mouth
Low potential for abuse
Antidepressants
Trazodone (Oleptro)
Doxepin and Amitriptyline
Trazodone (Oleptro)
Atypical antidepressant with strong sedative actions
Can decrease sleep latency and prolong sleep duration
Does not cause tolerance or physical dependence
Doxepin and Amitriptyline
Old tricyclic antidepressant with strong sedative actions
Used to treat patients who have trouble staying asleep
Antihistamines
Diphenhydramine (Benadryl)
Doxylamine (Unisom)
Diphenhydramine (Benadryl)
May be added to nighttime cold/pain preparations
Doxylamine (Unisom)
Can be purchased without prescription
Less effective
Tolerance develops quickly (1 to 2 weeks)
Adverse effects: daytime drowsiness and anticholinergic effects
Not intended for long-term use
Alternative Medicine
Melatonin: effectively related to jetlag and shift work
Valerian root, chamomile, passionflower, lemon balm, and lavender: have very mild sedative effects, proof of benefits for insomnia is lacking
White noise and relaxation strategies
Insomnia: nursing management
sleep hx
asses diet, caffeine, and alcohol intake
ask about sleep aids
sleep diary for 2 weeks
medical hx: factors that affect sleep
Insomnia: Diagnosis
sleep deprivation
disturbed sleep pattern
readiness for enhanced sleep
Insomnia: nursing implementation
Assume primary role in teaching sleep hygiene
-Decrease caffeine intake
-Bedtime routine
-Decreased blue light before bedtime
-Reduce light and noise
Teach patient about sleep medications
What is a way to measure your sleepiness?
Epworth Sleepiness Scale
OSA
Obstructive Sleep Apnea
- airway closes when asleep by tongue
Respiratory and Sleep Problems
Sleep apnea
Snoring and hypoventilation
Obesity hypoventilation syndrome
Reduced chest wall compliance
↑ work of breathing
↓ total lung capacity and functional residual capacity
Also called obstructive sleep apnea-hypopnea syndrome (OSAHS)
Partial or complete upper airway obstruction during sleep
Apneic period may include hypoxemia and hypercapnia.
Respiratory and Sleep Problems: Complications result in
Hypertension
Cardiac changes
Poor concentration/memory
Impotence
Depression
Apnea is the
cessation of spontaneous respirations for longer than 30 seconds
- each obstruction may last 10-90 secs.
How many cycles of apnea and arousal occur repeatedly during 6-8 hours of sleep?
200-400 times
S/S Apnea
Frequent arousal during sleep
Insomnia
Excessive daytime sleepiness
Witnessed apneic episodes
Loud snoring
Morning headache
Irritability
Sleep apnea although underreported occurs in what percentage of Americans?
2-10
Risk Factors of Sleep Apnea
obesity (body mass index >28 kg/m2)
age >65 years
neck circumference >17 inches
craniofacial abnormalities that affect the upper airway, and acromegaly.
Smokers are more likely to have OSA.
OSA is more common in men than in women until after menopause, when the prevalence of the disorder is the same in both genders. Women with OSA have higher mortality rates
Apnea Lab and Diagnostic Testing
1-2 nights for complete diagnosis depends
Polysomnography aka sleep study
Mild sleep Apnea Tx
Sleeping on one’s side
Elevating HOB
Avoiding sedatives and alcohol 3 to 4 hours before sleep
Weight loss
Oral appliance
Severe sleep apnea Tx
CPAP
-Possible compliance issues
BiPAP (one pressure on inspiration and one pressure expiration with full face mask)
-For sicker patients and before the ventilator
Surgery
-Uvulopalatopharyngoplasty (UPPP or UP3)
-Genioglossal advancement and hyoid myotomy (GAHM)
What is considered severe sleep apnea?
more than 15 apnea/hypopnea events/hour
If patients on CPAP or BiPAP remind them
to always take with them if overnight trips are planned.
Patient teaching on Apnea
Explain benefit of losing weight
Explain benefit of sleeping on side
Explain the need to avoid sedatives or alcohol 3-4 hours prior to bedtime
Stress reduction
Stress importance of exercise
Avoid smoking
Self imagine disturbance
Discharge Planning
Case manger- need for equipment
Nutritional consult
Spiritual consult
Narcolepsy
Brain unable to regulate sleep-wake cycles normally
Causes uncontrollable urges to sleep, often going directly into REM sleep
Causes of Narcolepsy
Unknown cause
=Associated with the destruction of neurons that produce orexin
=Orexin – neuropeptide that regulates sleep/wake cycles
Low levels of orexin lead to difficulty staying awake
Typical diagnosis age of narcolepsy
adolescent to 30s
Different types of narcolepsy
Type 1: with cataplexy
Type 2: w/o cataplexy
Cataplexy
brief and sudden loss of skeletal muscle tone that can manifest as muscle weakness or complete postural collapse and falling
S/S Narcolepsy
sleep paralysis
cataplexy
fragmented nighttime sleep
Narcolepsy Nursing Management
Teach about sleep and sleep hygiene
Take naps (3 15 min naps throughout the day)
Avoid heavy meals and alcohol
Ensure patient safety
Lifestyle changes
Narcolepsy: drug therapy
Modafinil (Provigil)
Armodafinil (Nuvigil)
Modafinil (Provigil) and Armodafinil (Nuvigil) are what type of drugs?
wake-promotion drugs
Older age is associated with
Overall shorter total sleep time
Decreased sleep efficiency
More awakenings
Insomnia symptoms
Sleep Gerontologic Considerations
Awakenings during the night increases risk for falls
Medications used by older adults can contribute to sleep problems
Avoid long-acting benzodiazepines
Nurse Fatigue
inadequate sleep
extended work hours
increased risk for errors
Who is at risk when a nurse is fatigued?
Patients and nurses
A nurse awake for 17 hours has the same cognition as BAC of
0.05%
A nurse awake for more than 24 hours has the same cognition as BAC of
0.1%
National Academy of Medicine (Institute of Medicine)
Nonprofit organization devoted to safety and evidence-based practice in healthcare
Recommendations
No more than 12 hours in 24 hour period
Limit to 60 hours in 7 day period
Nurse Fatigue Management Do’s
Take at least one break in addition to lunch break
Use caffeine therapeutically as a stimulant to stay awake
Nutrition: complex carbs and protein
Exercise
Nurse Fatigue Management Don’ts
DO NOT drink alcohol (depressant)
Shift Work Sleep Disorder is characterized by:
insomnia
excessive sleepiness
Shift Work Sleep Disorder S/S
Fatigue or malaise
Difficulty paying attention or concentrating
Memory impairment
Mood disturbance or irritability
Excessive daytime sleepiness
Hyperactivity, impulsivity, aggression, and other behavioral problems
Reduced motivation, energy, or initiative
Higher risk of errors or accidents
Feelings of sleep dissatisfaction
Nurses on _______ _________ shifts are at increased risk of experiencing shift work sleep disorder
rapidly rotating
What strategies for nurses help reduce the distress associated with shift work?
On-site napping
consistent sleep-wake schedule
How many times can you enter REM sleep in a single night?
3-4
