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The Importance of Sleep

Promoting restful sleep in patients as well as the nurses who care for them

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Learning Scope #522
1 contact hour
Expires April 27, 2017

You can earn 1 contact hour of continuing education credit by: 1) Taking the test online. Go to www.advanceweb.com/NurseCE. 2) Send the answer sheet to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406, with a self-addressed, stamped envelope; fax 610-278-1426. (Answer sheets can be downloaded from www.advanceweb.com/NurseCE.) If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70% or better.

Merion Matters is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

The planners and authors have completed a disclosure form and report no relationships relevant to the content of this article.

 
Learning Objectives
The purpose of this article is to educate nurses about the importance of quality sleep, particularly for themselves. After reading this article, the learner should be able to:
1. State the stages of sleep.
2. Discuss health problems associated with non-restful sleep.
3. Describe interventions to improve sleep.

Non-restful sleep is a major health complaint experienced by 30% or more of the U.S. adult population.1 Chronic sleep loss and sleep disorders cost the nation an estimated $16 billion in healthcare expenses and $50 billion in lost productivity.1 Lost work productivity and associated health problems, such as drowsy driving, are responsible for an estimated 1,500 fatalities and 40,000 non-fatal injuries each year.1

Sleep is more important than most people realize. The body's ability to survive depends on healthy sleep.2 Humans spend about one-third of their lives asleep, and if sleep is not restful, the consequences can be severe.3 Benefits of restorative sleep include: clearer concentration; improved learning ability; enhanced memory; feeling physiologically refreshed; better problem solving ability; improved mood; proper utilization of hormones; better appetite; stronger immune system; and healthy breathing, blood pressure and cardiovascular functioning.2

Stages of Sleep
Sleep is a time of reduced activity during which a person has decreased responsiveness to the environment, allowing the body and mind to rest. It has been described as a "state between wakefulness and death."4

Sleep is described in two basic categories: rapid eye movement (REM) sleep and non-REM sleep. Non-REM sleep is composed of three stages (non-REM stage 1, non-REM stage 2 and non-REM stage 3). Under normal circumstances, an adult person first goes into non-REM stage 1, during which sleep is easily disturbed by low-decibel sounds or noises in the environment. During this stage, a person's muscles start to relax. In non-REM stage 2, the brain waves slow, but an occasional surge of rapid brain waves occurs. In non-REM stage 3, brain waves diminish further or are slowed; these are delta waves.

While in non-REM stage 3 sleep, people are more difficult to awaken. Tactile stimulation is often necessary to wake up someone who is in this stage of sleep. In non-REM stage 3, restorative sleep can be achieved. During REM sleep, which typically occurs 90 minutes after initially falling asleep (and alternates with non-REM sleep stages), the REM becomes longer and the non-REM stage 3 sleep becomes shorter in duration. REM sleep is demonstrated by rapid eye movements, irregular breathing, and an increase in apical heart rate and blood pressure. During REM sleep, a person's muscles are temporarily paralyzed.5

Factors Modifying Sleep Stages
Several factors can influence sleep stages. Age is a major factor in quality of sleep. Newborns experience REM sleep and transition into normal sleep stages as they grow older. In the older population, arousals from sleep are more prominent. REM sleep has been correlated with intellectual functioning, thus poor sleep often occurs in patients experiencing organic brain syndromes.6

A person's prior sleep history can also influence sleep stages. Chronic sleep deprivation, having alternate or irregular shift work, or experiencing frequent disturbances in nighttime sleep cause premature REM sleep. Premature REM sleep may lead to hallucinations or hypnic myoclonia (muscle contractions often associated with vivid imagery). These factors can contribute to how patients experience restful sleep.6

Circadian rhythms can also influence stages of sleep. For example, the circadian distribution of REM sleep occurs when the body temperature is at its lowest. If sleep onset is delayed until the peak of the circadian rhythm (early morning), REM sleep predominates and often may be the first stage of sleep onset. This is common in people who are shift workers or people who are traveling across time zones. It can cause nonrestorative sleep.6

Temperature extremes also influence sleep stages. A cool, dark room is best for sleep. The control of body temperature is poikilothermic in REM sleep, which means the temperature setting for sleep initiation is important. A delay in sleep initiation can lead to insomnia.

In addition, many types of medications can affect sleep stages. For example, tricyclic antidepressants and MAOIs tend to suppress REM sleep. Withdrawal from these drugs can produce an increase in REM sleep, which may cause a misdiagnosis of narcolepsy.3

Functions of Sleep
Sleep has many theoretical functions. These include:2
  • restoring the body's energy, a result of experiencing a lower metabolic rate during sleep
  • promoting the immune system to fight possible infections related to the release of cytokines, which makes us sleepy and helps improve immune system function
  • enhancing memory and learning skills.

During sleep, it is thought that we memorize important events from the day but discard unessential memories.2

Physiological Changes During Sleep
Many physiological changes occur with sleep, particularly REM stage sleep. Key changes are increased blood pressure and heart rate. Additional physiologic or behavioral changes many people do not recognize include:6
 

  • Perceptual disengagement: In this period, a person starts to lose recognition of his or her environment and requires tactile stimulation (i.e., a tap on the shoulder) to be awakened.
  • Absent reaction time: This is the period when a person who is starting to get drowsy and fall asleep reacts more slowly than when fully awake. It explains why some people have car accidents when driving while drowsy.
  • Decreased olfactory response: A lack of smell or recognition of odors is present in REM stage sleep. This may explain why some people do not awaken during a house fire until heat from the fire is felt.
  • Diminished memory: People have difficulty remembering events that occur during sleep, such as the inability to recognize the exact time you fall asleep.

Health Problems of Non-Restful Sleep
Many health problems can add to or cause non-restful sleep. Some health problems, such as insomnia, are easily understood as contributors to poor sleep. Other factors, such as specific co-morbidities, may not be as easily recognizable. The following are a few common health problems associated with poor sleep:5

  • Insomnia: the inability to initiate or maintain sleep
  • Obstructive Sleep Apnea: a condition in which air flow is blocked at the oropharyngeal area, causing hypopneas or hypoxemia
  • Restless Legs Syndrome: a condition in which people feel they need to move their legs to relieve disturbing sensations; often related to decreased iron levels; causes disruption of normal sleep patterns
  • Post-Traumatic Stress Disorder: results from a debilitating experience that can be relived through nightmares, often prompting people to try and stay awake to prevent vivid, disturbing dreams
  • Behavior Movement Disorder: a condition that causes a person to act out dreams, interfering with restful sleep and often leading to safety issues for the patient and/or bed partner
  • Narcolepsy: a medical disorder in which the patient falls quickly into REM sleep, often at inopportune times such as during work hours; causes productivity problems.

Co-morbidities such as mood disorders (anxiety or depression), along with additional health problems (i.e., bipolar disorder) can also alter sleep patterns, causing a non-restful sleep. Other medical conditions, such as chronic obstructive pulmonary disease or chronic pain, may lead to hypoxemia, which contributes to frequent awakenings secondary to shortness of breath or changes in positioning.

Nursing Considerations for Hospitalized Patients
Nurses strive to promote restorative sleep for patients, but this is often difficult due to the hospital environment and common procedures that take place at night. When people are recovering from illness, sleep is essential. Poor sleep places patients at risk for additional infections and complications during the hospital stay.7 Poor sleep contributes to poor concentration and difficulty managing anxiety, and it can contribute to change in mood.7

A significant reason for poor sleep in hospitalized patients is elevated noise levels. This noise may be from monitor alarms, conversations at nearby nursing stations, patient care activities or limited light exposure.8

Insomnia can also cause hospitalized patients to have a delayed recovery from illness.7 Most people require 6 to 8 hours of sleep, but as we age, this becomes more difficult. During non-REM stage 3 and REM sleep, growth hormones (which assist with cell regeneration and activation of the immune system) are released.7 Wounds are healed by cell division and through protein synthesis, which controls the secretion of growth hormone.7 Healing processes in the body are at their peak during sleep.7 Considering this fact, sleep is essential for wound repair and healing.

A descriptive, qualitative study in Sweden that examined patients' views on sleep while hospitalized included 10 subjects who had a length of stay of 3 days or longer.7 Results included themes and categories of bedside manner, physical factors and integrity. When reviewing bedside manner, patients stated that if nurses made them feel secure and not abandoned (meaning the nurses talked to them and explained procedures and believed what patients were telling them), they slept better. Physical factors included having clean linens, ability to choose pillow type (plastic covers on pillows disrupted sleep), and beeping sounds or nurses' footsteps preventing restful sleep. Other factors, such as catheters, intravenous lines and tubings, limited patients' ability to move easily, thus creating difficulty in achieving restful sleep. Additional physical factors included pain and specific drugs that disrupt sleep.

Patients said they wanted the hospital environment to be more home-like, so that sleep routines were not disrupted. Patients said they felt that if they had some control over the environment, such as picking their bedtime hours, their sleep could be improved.

Integrity was described by patients as being allowed to be themselves, which was often difficult if they shared a room with other patients. Patients said their integrity could be compromised if nurses discussed care of one patient while in the room with another patient. Privacy can be limited, however, based on the number of patients in one room and the physical layout or design of the room. Sometimes patients reported that their contact with roommates elicited feelings of compassion or concern for the other patient, which also affected their sleep.7

Many patients who are ill have co-morbid sleep disorders such obstructive sleep apnea, which prohibits healthy responses to illness. A study conducted in 2014 found that 2 in 5 patients hospitalized in general medicine had undiagnosed sleep apnea, which resulted in shorter sleep times, poorer sleep and more reports of poor sleep quality.9 One way nurses can promote sleep is to routinely screen patients upon admission for symptoms of sleep apnea, and to have available treatment for these patients while hospitalized. Upon discharge, these patients should be referred to a sleep specialty provider for a more thorough assessment and possible clinical testing.

Hospital nurses have noticed a phenomenon in intensive care units in which patients experience delirium. Approximately 80% of ICU patients have delirium, which is exhibited as agitation or severe withdrawal.10 The physical environment, physical stressors, pain and mechanical ventilation can lead to the development of poor sleep and delirium. Numerous issues can lead to delirium, such as medications or electrolyte imbalances, however, sleep deprivation can also be the origin for delirium. The sleep pattern in a critically ill patient is characterized by long periods of wakefulness, and sleep occurs primarily in stages 1 and 2 of non-REM sleep (light sleep). Components of poor sleep that cause delirium include decreased acetylcholine levels and increased dopamine levels (which is also seen with intoxication of opioids, cocaine or hypoxemia). Delirium during hospitalization is associated with increased length of stay, poorer physical and psychological outcomes up to 12 months post-discharge, and a higher mortality rate.10

Understanding the circumstances that lead to poor sleep equips nurses to help control the hospital environment, making it conducive for restful sleep. Noise should be kept to a minimum, and light should be introduced into the patient's room during the day. For patients who experience insomnia, medications such as short-acting hypnotics and sedating antidepressants or antipsychotics could be used. For patients who are on mechanical ventilators requiring constant sedation, nocturnal propofol administration has been suggested: "resolution of sleepiness known to occur under natural sleep may also occur under sedation with propofol."10

Ways To Improve Sleep
As a nurse, how do we help promote restful sleep in our patients - and ourselves? The first thing to be aware of is that an adult requires 6 to 8 hours of sleep each night to feel rested by the final sleep awakening. A good practice to promote sleep is sleep hygiene. A consistent bedtime and awakening time, along with a slightly cool (around 65 degrees Fahrenheit or 18 degrees Celsius) and dark environment, are essential. If feelings of tiredness creep up during the day, avoid napping close to bedtime. An occasional midday nap may help, but daily naps may indicate a sleep problem and should be evaluated for purpose and their influence on nightly rest.

Avoid bright lights near bedtime. Light suppresses melatonin, which is a natural hormone that promotes sleep. Lighting from televisions also suppresses melatonin. No TVs should be in the bedroom. Even when people mute the sound on a TV, the brain remains active to instinctively interpret color changes on the screen.

To promote restful sleep, a person should forget about the day's events and what he or she needs to do tomorrow. The bed is for sleep and sexual activity - nothing else. Allowing the mind to "rest" promotes healthy sleep. Deep breathing may help people who find it difficult to relax at bedtime. Patients should have a comfortable mattress and may need to experiment with various levels of firmness to promote sleep.

Exercise is a healthy habit, but it is considered stimulating. Thus, exercise should not be done late in the evening or near bedtime. Gentle stretching or yoga may promote muscle relaxation and enhance sleep, however, and can therefore be a good choice.

Patients should also be warned about eating heavy meals prior to sleep. Foods high in fat cause difficulty in proper digestion. Spicy foods may cause or contribute to heartburn, which can interfere with positioning and sleep. People who go to bed hungry can have problems sleeping, so a small snack containing carbohydrates with tryptophan is advisable since tryptophan promotes sleep.11

Many people believe a glass of alcohol can be relaxing at bedtime. But alcohol is a depressant, and although it can cause relaxation and sleep initiation, it interferes with normal sleep patterns and thus leads to non-restful sleep.11

Another concern is caffeine consumption. Caffeine acts a stimulant and a diuretic, so its consumption in excess or late in the day will delay or alter sleep and cause awakenings to urinate. Smokers should also know that nicotine is a stimulant that interferes with sleep initiation. When nicotine levels drop during sleep, the patient undergoes a temporary withdrawal that also interferes with sleep.11,12

Sleep is a vital component of health. It is our responsibility as nurses to assess our sleep patterns as well as patients' sleep patterns, and to provide education about ways to promote a restorative sleep. For chronic sleep disorders, patients should be referred to a sleep specialty clinic for assessment and treatment.

Marquetta Flaugher is a dually certified family and psychiatric-mental health nurse practitioner. She practices in the sleep disorders clinic at Bay Pines Veterans Affairs Medical Center and is a member of the adjunct nursing faculty at St. Petersburg College in St. Petersburg, Fla.


References
1. National Institutes of Health. Are you sleep deprived? Learn more about healthy sleep. http://www.nlm.nih.gov/medlineplus/magazine/issues/summer12/articles/summer12pg16.html
2. National Heart, Lung, and Blood Institute. National Center on Sleep Disorders Research. Sleep, Sleep Disorders, and Biological Rhythms. http://science.education.nih.gov/supplements/nih3/sleep/guide/nih_sleep_curr-supp.pdf
3. Institute of Medicine Committee on Sleep Medicine and Research. Sleep disorders and sleep deprivation: an unmet public health problem. http://www.ncbi.nlm.nih.gov/books/NBK19956/
4. Kryger M, et al. In: Principles and Practices of Sleep Medicine. 5th ed. Philadelphia: W.B. Saunders; 2010: 16-26.
5. National Institute of Health. National Heart, Lung, and Blood Institute. Your guide to healthy sleep. NIH Publication #11-5271. 2011. http://www.nhlbi.nih.gov/health/resources/sleep/healthy-sleep
6. Carskadon MA, Dement WC. Monitoring and staging human sleep. In: Kryger MH, et al, eds. Principles and Practices of Sleep Medicine. 5th ed. St Louis: Elsevier Saunders; 2011: 16-26.
7. Gellerstedt L, et al. Patients' experiences of sleep in hospital: A qualitative interview study. J Research Nurs. 2014;19:176-188.
8. Koch S, Noble H. Use of sleep care guidelines in a surgical intensive care unit reduces noise levels and improves patient-reported sleep quality. Evid Based Nurs. 2011;14(4):99-100.
9. Shear T, et al. Risk of sleep apnea in hospitalized older patients. J Clin Sleep Med. 2014;10(10):1061-1065.
10. Weinhouse G, et al. Bench-to-bedside review: Delirium in ICU patients -- importance of sleep deprivation. Crit Care. 2009;13(6):234.
11. How to sleep better.http://www.helpguide.org/articles/sleep/how-to-sleep-better.htm
12. National Sleep Foundation. Healthy sleep tips. http://sleepfoundation.org/sleep-tools-tips/healthy-sleep-tips




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