Rest and Sleep
Rest and Sleep
Rest and Sleep
REST AND
SLEEP
Rest and Sleep
Introduction
Rest and sleep are two fundamental human needs that contribute to the
physical well-being and quality of life of every individual. Maslow’s hierarchy of
needs indicates sleep as one of our physiological requirements. Getting
enough quality of sleep at the right times according to our circadian rhythms
can protect mental and physical health, safety and quality of life. Nurses can
help clients recognise the importance of rest and learn how to promote it at
home or any health care facility.
Definitions
Rest
Rest is a “condition in which the body is in a decreased state of activity without
physical, emotional stress and freedom from anxiety.”
Sleep
Sleep can be defined as “a normal state of altered consciousness during
which the body rests; it is characterised by decreased responsiveness to
the environment, but a person can be aroused from sleep by external
stimuli”
Functions of sleep
Conservation of energy
Thermoregulation
Regulation of emotions
a) Stage 1 NREM
This is the traditional stage between wakefulness and sleep last
about 10 to 15 minutes.
Lightest level of sleep, gradual fall in vital signs and metabolism.
The person can still be woken by any slight stimulus.
Slowing of EEG waves.
Sleeper may deny he is sleeping.
Eyes tend to roll slowly from side to side.
b) Stage 2 NREM
Usually last for 10 to 20 minutes.
Greater relaxation than first stage, muscle relaxation intensifies,
body functions are slowing down.
Absent eyeball moments, further slowing of EEG.
It is a period of sound sleep.
Arousal remains relatively easy.
C) Stage 3 NREM
Stage last 15 to 30 minutes. This stage occurs about 30 minutes
after the person goes to sleep.
It involves initial stages of deep sleep.
Complete relaxation of muscles.
Large slow waves in EEG.
Vital signs declined because of the domination of parasympathetic
nervous system, but remains regular.
Sleeper is difficult to arouse and rarely moves.
D) Stage 4 NREM
Last approximately 15 into 30 minutes.
It is the deepest stage of sleep.
Body is relaxed and body functions are markedly decreased.
This stage is also known as slow wave sleep.
It is associated with the physical repair and restoration.
Further slowing of an EEG.
It is very difficult to arouse sleeper.
Sleep walking and enuresis sometimes occur.
NREM STAGE IV
NREM STAGE II (Deepest Stage
of Sleep)
Physiology of sleep
The amount and timing of sleep is regulated by 2 major factors:
homeostatic drive and circadian rhythm. Homeostatic drive is
basically the body’s need for sleep, or pressure to sleep. The part of
brain most important in regulating sleep is the hypothalamus. Human
have a sleep centre in the anterior hypothalamus and basal forebrain
and a wake centre in the posterior thalamus. The onset of sleep of each
subsequent stage is an active process involving delicate shifts in the
balance of several neuro transmitters.
According to metabolite theory of sleep, wake promoting area of
posterior hypothalamus, Tuberomammillary nucleus (TMN) produces
histamine, which activate Locus Coeruleus and Raphe nucleus of
Ascending Reticular Activating System (ARAS). These releases
Norepinephrine and Serotonin to activate thalamocortical fibres to
promote awake state. The sleep-promoting region is located in the
ventrolateral preoptic nucleus, VLPO (is a small cluster of neurons
situated in the anterior hypothalamus). The VLPO is activated by
Adenosine which is thought to be a substance that accumulates with
waking hours and drives the pressure to sleep. The VLPO releases
inhibitory neurotransmitter, GABA which inhibit neurons of the
ascending arousal system that are involved in wakefulness. As the
VLPO is also inhibited by neurotransmitters released by components of
the arousal systems, such as acetylcholine and norepinephrine and
serotonin. The hypocretin neurons, also called Orexin neurons in the
posterior lateral hypothalamus potentiate neurons in the ascending
arousal system and help stabilize the brain in the waking state and
consolidated wakefulness, which builds up homeostatic sleep drive,
helps stabilize the brain during later sleep. The TMN also produces
GABA that inhibits VLPO in return. This mutual inhibition is the basis of
the “switch” between sleep and wake. VLPO and the arousal system
form a "flip-flop" circuit. The hypocretin neurons stimulate the TMN, and
are crucial for maintaining wakefulness.
Circadian rhythm is the body’s biological clock for the sleep-wake
cycle. It determines the timing of sleep. The master clock is controlled by
the Suprachiasmatic nucleus (SCN, is the central pacemaker of
circadian rhythm) in the anterior hypothalamus. It receives light inputs
from the retina and resets the clock everyday accordingly to the day-
night cycle. During darkness the SCN controls the production of pineal
hormone melatonin which is believed to be a potent sleep inducer by
inhibiting RAS (Reticular Activating System). The RAS is believed to
contain diffuse network of neurones that cause arousal from sleep and
maintains alertness and wakefulness.
Norepinephrine
Neurotransmitte Acetylcholine Serotonin GABA
r Histamine
Awake
/
NREM
REM
Pre-schooler
The pre-schoolers usually have difficulty relaxing after long active days.
Pre-schoolers rarely takes daily naps and also has problem with bedtime fears
and nightmares. Parents are most successful in getting a pre-schooler to bed
by establishing a consistent bedtime ritual. A child should not be allowed to
become manipulated with by sleeping with parents.
School age children
The amount of sleep needed during the school years is highly
individualised because of varying states of activity and level of health. The
school age child usually does not require a gap.
Adolescents
An adolescent’s day is usually active and mentally and physically
exhausting. Often the desire to spend time with peers prevents adolescents to
sleep. Because of staying up late, an adolescent frequently sleeps late in the
morning.
Young adults
Healthy young adults require rest and sleep to participate in the busy
activities that fill their days. However, it is common for busy lifestyles to
interrupt. Approximately 20% of sleep time is spent in REM sleep, which
remains consistent through life.
Middle adults
During adulthood, the total time spent sleeping at night begins to
decline. Also the amount of stage begins to fall continuing through out older
age. Sleep disturbances are common. Insomnia is particularly common
because of the changes and stresses of middle age. Sleep disturbances can
be caused by anxiety, depression, or certain physical ailments. Women
experiencing menopausal symptoms may have insomnia.
Older adults
The total amount of sleep does not change as age increases. However,
quality of sleep deteriorates and REM sleep shortens. There an older adult
has almost no stage 4 sleep. An older adult awakens more often during the
night and total wake time increases. It may also take more time for an older
adult to fall asleep. The changes in an older person’s sleep pattern are due
changes in CNS that affect the regulation of sleep. Sensory impairment,
common with aging, may reduce sensitivity to time cues that maintain
circadian rhythm. An older adult’s chronic illness may also impair the quality of
sleep.
f) Stress
Anxiety and depression frequently disturb sleep. The person
experiencing stress may find it difficult to obtain the amount of sleep he or she
needs. A person preoccupied with the personal problems may be unable to
relax sufficiently to get sleep.
g) Diet
Certain food induces sleep. Eg: - the amino acid L-tryptophan is thought
to induce sleep which is present in the milk. Protein intake may increase
alertness and concentration, whereas carbohydrate appear to affect the brain
serotonin levels and promote calmness and relaxation.
h) Caloric intake
Weight loss or gain influences sleep pattern. When a person gains
weight sleep periods becomes longer with fewer interruptions. Weight loss can
cause short and fragmented sleep. Certain sleep disorders maybe the result
of semistarvation diets population in a weight conscious society.
i) Medication
Sleep quality also influenced by certain drugs. Drugs that decrease
REM sleep includes barbiturates, amphetamines, antidepressants, diuretics,
antihypertensives, steroids, decongestants, narcotics, etc. Hypnotics and
sedatives can interfere stage 3 and 4 of NREM sleep and suppress REM
sleep.
j) Motivation
Motivation can increase alertness in some situations. Eg: - during
browsing internet and a late night. And also, when there is minimal motivation
to be awake sleep generally follows. Eg: - a student who is bored and not
interested in a lecture or class may sleep during the lecture.
A. DYSSOMNIAS
Dyssomnias include sleep disorder characterised by difficult initiating or
maintaining sleep (insomnia) or by excessive sleepiness. The client sleeps too
little or too much or at the wrong time. So the problem is with the amount or
quantity or with its timing and sometimes with quality of sleep. The disorders
may arise predominantly from within the body (intrinsic), from external sources
(extrinsic) or disruption of circadian rhythm.
a) Insomnia
Insomnia is defined as difficulty with initiating or maintaining sleep, that
is the inability to fall asleep or remain asleep. It is the most common sleep
disorder. People with insomnia do not feel refreshed on a rising. Insomnia, the
most common sleep disorder.
b) Hypersomnia
Hypersomnia is a condition characterised by excessive sleep, particularly
in the daytime.
The affected person may fall asleep for intervals during work, while eating
or even during conversation.
These naps do not usually relieve their symptoms. When they awake they
are often disoriented, irritated, restless, and have slower speech and
thinking process.
Hypersomnia can be caused by medical conditions like central nervous
system damage, depression and certain kidney, liver, or metabolic
disorders, such as diabetic acidosis and hypothyroidism.
It can have some serious consequences such as motor vehicle accidents,
because of drowsiness or falling asleep while driving.
Treatment includes antidepressants, attention to diet like controlling coffee
intake, avoidance of work and social activities later in the evening.
c) Narcolepsy
Narcolepsy is one of the disorders characterised by excessive
daytime sleepiness. It is a sudden wave of overwhelming sleepiness that
occurs during the day; thus, it is referred to as a sleep attack. It is believed to
be a genetic defect of the CNS in which REM sleep cannot be controlled.
Sleep starts with REM sleep.
Common features of narcolepsy include the following: -
Sleep attacks: irresistible urge to sleep, regardless of the type of activity in
which the patient is engaged
Cataplexy: sudden loss of motor tone that may cause the person to fall
asleep; usually experienced during a period of strong emotion
Hypnagogic hallucinations: nightmares or vivid hallucinations Sleep-onset
REM periods: during a sleep attack, the person moves directly into REM sleep
Sleep paralysis: skeletal paralysis that occurs during the transition from
wakefulness to sleep.
Treatment includes A central nervous system stimulant (eg, methylphenidate
[Ritalin]) that causes wakefulness may be used to control narcolepsy. Newer
medications such as modafinil (Provigil), a wakefulness-promoting compound,
and gamma-hydroxybutyric acid (GHB), a sedative used for treat- ing
disturbed nocturnal sleep, have proved effective in treating.
• Mixed apnea:
combination of obstructive and central apnea. Treatment directed
towards the treatment of the cause of apnea. Eg:- enlarged tonsils can be
removed. The use of nasal CPAP device at night is often effective.
Diagnostic assessment
The primary diagnostic test for sleep disorder is polysomnography.
Polysomnography
Is a comprehensive recording of the biophysiological changes that
occurs during sleep. It is usually performed at night, when most people sleep,
though some laboratories can accommodate, shifts workers and people with
circadian rhythm sleep disorders. The PSG monitors many body functions
including brain (EEG), eye movement (electro oculatory EOG) and muscle
activity electromyography (EMG)
Nursing management
Assessment
To promote the restful sleep for clients, nurse can assess the sleep
pattern.
Usually, patients are the best resources for describing their sleep problem.
Some time we can take history from the partner.
In case of children, older children or mother can best describe the pattern
of sleep and its problem.
The tools for sleep assessments are:
Sleep history including -Description of client's sleep problem; nature,
sign/symptoms, onset, duration, predisposing factors,
severity, effects on client. -Usual sleep pattern prior to sleep problem
Recent changes in sleep pattern
Physical illness
Bedtime routine and sleeping environment
Pattern of dietary intake or any substance
Use of any medication
Current emotional and mental status
Sleep diary including
- times when patient tries to fall asleep
- approximate time that patient fall asleep
- time of awakening during night -record of food, physical activity, worries,
mental
Nursing diagnosis
Disturbed sleep pattern
Insomnia
Sleep deprivation
Impaired comfort
Fatigue
Disturbed energy field
Risk for injury
Anxiety
Interventions….
The nurse can implement all the measures to improve the quality of sleep
which collectively called sleep hygiene which includes the following: -
Sleep hygiene
Sleep hygiene refers to healthy habits, behaviours and environmental
factors that can be adjusted to help you have a good night’s sleep.
Some sleeping problems are often caused by bad sleep habits reinforced
over years or even decades.
Improved sleep will not happen as soon as changes are made. But if
good sleep habits are maintained, sleep will certainly get better.
Paying attention to sleep hygiene is one of the most straightforward ways
that you can set yourself up for better sleep.
Strong sleep hygiene means having both a bedroom environment and
daily routines that promote consistent, uninterrupted sleep. Keeping a
stable sleep schedule, making your bedroom comfortable and free of
disruptions, following a relaxing pre-bed routine, and building healthy
habits during the day can all contribute to ideal sleep hygiene
Why Is Sleep Hygiene Important?
Obtaining healthy sleep is important for both physical and mental
health, improving productivity and overall quality of life. Everyone, from
children to older adults, can benefit from better sleep, and sleep hygiene can
play a key part in achieving that goal. Forming good habits is a central part of
health. Crafting sustainable and beneficial routines makes healthy
behaviours feel almost automatic, creating an ongoing process of positive
reinforcement. On the flip side, bad habits can become engrained even as
they cause negative consequences. Sleep hygiene encompasses both
environment and habits, and it can pave the way for higher-quality sleep and
better overall health. Improving sleep hygiene has little cost and virtually no
risk, making it an important part of a public health strategy to counteract the
serious problems of insufficient sleep and insomnia
Don’t Smoke:
Nicotine stimulates the body in ways that disrupt sleep, which helps
explain why smoking is correlated with numerous sleeping problems.
Reduce Alcohol Consumption:
Alcohol may make it easier to fall asleep, but the effect wears off,
disrupting sleep later in the night. As a result, it’s best to moderate alcohol
consumption and avoid it later in the evening.
Cut Down on Caffeine in the Afternoon and Evening:
Because it’s a stimulant, caffeine can keep you wired even when you
want to rest, so try to avoid it later in the day. Also be aware if you’re
consuming lots of caffeine to try to make up for lack of sleep.
Don’t Dine Late:
Eating dinner late, especially if it’s a big, heavy, or spicy meal, can mean
you’re still digesting when it’s time for bed. In general, any food or snacks
before bed should be on the lighter side.
Restrict In-Bed Activity:
To build a link in your mind between sleep and being in bed, it’s best to
only use your bed for sleep with sex being the one exception.
Optimize Your Bedroom
A central component of sleep hygiene beyond just habits is your sleep
environment. To fall asleep more easily, you want your bedroom to
emanate tranquillity.
While what makes a bedroom inviting can vary from one person to the
next, these tips may help make it calm and free of disruptions:
Have a Comfortable Mattress and Pillow:
Your sleeping surface is critical to comfort and pain-free sleep, so
choose the best mattress and best pillow for your needs wisely.
Use Excellent Bedding:
The sheets and blankets are the first thing you touch when you get into
bed, so it’s beneficial to make sure they match your needs and
preferences.
Set a Cool Yet Comfortable Temperature:
Fine-tune your bedroom temperature to suit your preferences, but err on
the cooler side (around 65 degrees Fahrenheit).
Block Out Light:
Use heavy curtains or an eye mask to prevent light from interrupting your
sleep.
Review of literature
Abstract
Objectives
Pain can have a negative impact on sleep and emotional well-being.
This study investigated whether this may be partly explained by
maladaptive sleep-related cognitive and behavioural responses to pain,
including heightened anxiety about sleep and suboptimal sleep hygiene.
Methods
This cross-sectional study used data from an online survey that
collected information about pain (Brief Pain Inventory), sleep (Pittsburgh
Sleep Quality Index; Sleep Hygiene Index; Anxiety and Preoccupation
about Sleep Questionnaire) and emotional distress (PROMIS
measures; Perceived Stress Scale). Structural equation modelling
examined the tenability of a framework linking these factors.
Results
Of 468 survey respondents (mean age 39 years, 60% female), 29%
reported pain, most commonly in the spine or low back (28%). Pain
severity correlated with poor sleep quality, poor sleep hygiene, anxiety
about sleep and emotional distress. In the first structural equation
model, indirect effects were identified between pain severity and sleep
quality through anxiety about sleep and sleep hygiene. In the second
model, an indirect effect was identified between pain severity and
emotional distress through sleep quality. Combining these models,
indirect effects were identified between pain severity and emotional
distress through anxiety about sleep, sleep hygiene and sleep quality.
Conclusion
A good night’s sleep and decreased stress level are the best for many
illness. Moreover, if we want to be in good mood the whole day we need to
sleep well and long enough. The adequacy of sleep and rest is important to
consider in caring for clients with acute or chronic illness. The nurse can play
a pivotal role in environmental modifications and client teaching to minimize
the impact of sleep, fatigue and sensory disturbances.
Bibliography
Siegel JM. The neurotransmitters of sleep. J Clin Psychiatry. 2004 Jan
1;65(Suppl 16):4-7.
Rakhimov A, Whibley D, Tang NK. Cognitive-behavioural pathways from
pain to poor sleep quality and emotional distress in the general population:
The indirect effect of sleep-related anxiety and sleep hygiene. PloS one.
2022 Jan 21;17(1):e0260614.
Lynn pamela, Lemone Prisulla, Lillis Carol, Taylor Carol. Fundamentals of
Nursing, the art and science of nursing care. 6 th edition(vol 2). Philadelphia:
Lippincott Williams and Wilkins publication; 2006. p. 1337-63.
Berman Jean Audrey, Erb Glenora, Kozier Barbara, Burke Karen.
Fundamentals of nursing, concepts, process and practice. 6 th edition.
California: Pearson education publications; 2003. p. 1061-79.
Kizilay E Africia, Leahy M Julia. Foundations of nursing practices, a nursing
process approach. Philadelphia: WB Saunders company; 1998. p. 699-
736.
Joyce M Black, Hawks. Medical Surgical Nursing, clinical management for
positive outcomes. 8th edition(vol 1). Elsevier India. 2009.
GG Reddemma. Advance concept of nursing practice. 1st edition.
India.Jaypee medical publishers. 2021.