sleep pattern and its disturbances

2. SLEEP PATTERN AND ITS
DISTURBANCES
-BY SHWETA SHARMA
M.SC. NURSING
I YEAR
AIIMS,JODHPUR

3. OBJECTIVES
THE GROUP WILL BE ABLE TO:
DEFINE SLEEP.
DESCRIBE PHYSIOLOGY OF SLEEP.
ENUMERATE THE STAGES OF SLEEP.
EXPLAIN THE SLEEP REQUIREMENTS AND PATTERN.
DESCRIBE THE SLEEP CYCLE.
LIST AND EXPLAIN THE LIFESPAN CONSIDERATIONS GROWTH VIA.
UNDERSTAND AND ENUMERATE THE COMMON SLEEP DISORDERS OR
DISTURBANCES.
ENLIST AND DESCRIBE THE ASSESSMENT, NURSING DIAGNOSIS AND
MANAGEMENT OF SLEEP.

4. DEFINITION
SLEEP IS A CONDITION OF BODY AND MIND WHICH TYPICALLY
RECURS FOR SEVERAL HOURS EVERY NIGHT, IN WHICH THE
NERVOUS SYSTEM IS INACTIVE, THE EYES CLOSED, THE
POSTURAL MUSCLES RELAXED, AND CONSCIOUSNESS
PRACTICALLY SUSPENDED.
IT IS A PERIODIC STATE OF REST ACCOMPANIED BY VARYING
DEGREE OF UNCONSCIOUSNESS AND RELATIVE INACTIVITY.

5. SOME FACTS ABOUT SLEEP
•NEARLY 1/3RD OF OUR LIFE IS SPENT IN SLEEP.
•THE RECORD FOR THE LONGEST PERIOD WITHOUT SLEEP IS 18 DAYS, 21
HOURS, 40 MINUTES DURING A ROCKING CHAIR MARATHON. THE RECORD
HOLDER REPORTED HALLUCINATIONS, PARANOIA, BLURRED VISION, SLURRED
SPEECH AND MEMORY AND CONCENTRATION LAPSES.
•A NEW BABY TYPICALLY RESULTS IN 400-750 HOURS LOST SLEEP FOR
PARENTS IN THE FIRST YEAR.
•17 HOURS OF SUSTAINED WAKEFULNESS LEADS TO A DECREASE IN
PERFORMANCE EQUIVALENT TO A BLOOD ALCOHOL-LEVEL OF 0.05%.
•EXPERTS SAY ONE OF THE MOST ALLURING SLEEP DISTRACTIONS IS THE 24-
HOUR ACCESSIBILITY OF THE INTERNET.

6. FACTORS AFFECTING SLEEP
•Environmental factors (e.g.
ventilation)
•Psychological and emotional
stress
•Physical illness (e.g. nausea,
mood disorders, breathing
difficulty, pain)
•Drugs and substances (e.g.
Tryptophan)
•Lifestyle (e.g. daily routines,
exercises)
• Usual sleep patterns
•Excessive daytime sleepiness
•Sound
•Exercise and fatigue
•Food and caloric intake
•Smoking and alcohol

7. FUNCTIONS OF SLEEP
•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

8. NORMAL SLEEP REQUIREMENTS
•INFANTS -16 HOURS /DAY
•TODDLERS -12 HOURS /DAY
•PRE-SCHOOLERS -11 HOURS
/DAY
•SCHOOLERS- 9 TO 10 HOURS
/DAY
•ADOLESCENTS -8 TO 9 HOURS
/DAY
•ADULTS- 6 TO 8 HOURS /DAY

9. CIRCADIAN CYCLE
• PEOPLE EXPERIENCE CYCLICAL RHYTHMS AS PART OF THEIR EVERYDAY LIFE. THE
MOST FAMILIAR RHYTHM IS THE 24 HR, DAY-NIGHT CYCLE KNOWN AS THE
DIURNAL OR CIRCADIAN RHYTHM (DERIVED FROM LATIN: CIRCA, “ABOUT,” AND
DIES, “DAY”). CIRCADIAN RHYTHMS INFLUENCE THE PATTERN OF MAJOR BIOLOGICAL
AND BEHAVIOURAL FUNCTIONS.

10. PHYSIOLOGY OF SLEEP
• THERE ARE TWO STAGES OF SLEEP:
• 1.RAPID EYE MOVEMENT (REM)
SLEEP OR D- SLEEP
(DESYNCHRONIZED SLEEP OR
DREAMING SLEEP) OR ACTIVE SLEEP.
(COMPRISING ABOUT 20-25% OF
TOTAL SLEEP)
• 2.NON-RAPID EYE MOVEMENT
SLEEP (NREM), OR S- SLEEP
(SYNCHRONIZED SLEEP) OR QUITE
SLEEP OR ORTHODOX SLEEP.
(COMPRISING ABOUT 75% OF TOTAL
SLEEP)

11. SLEEP CYCLE

12. NREM STAGE I
• INCLUDES LIGHTEST LEVEL OF SLEEP
• STAGE LASTS A FEW MINUTES
• DECREASED PHYSIOLOGICAL ACTIVITY BEGINS WITH
GRADUAL FALL IN VITAL SIGNS AND METABOLISM
• SENSORY STIMULI SUCH AS NOISE EASILY AROUSE
SLEEPER
• IF AWAKENED, PERSON FEELS AS THOUGH
DAYDREAMING HAS OCCURRED

13. NREM STAGE II
•INCLUDES PERIOD OF SOUND SLEEP
•RELAXATION PROGRESSES
•AROUSAL IS STILL RELATIVELY EASY
•STAGE LASTS 10 – 20 MINUTES
•BODY FUNCTIONS CONTINUE TO SLOW

14. NREM STAGE III
•IT INVOLVES INITIAL STAGES OF DEEP SLEEP
•SLEEPER IS DIFFICULT TO AROUSE AND
RARELY MOVES
•MUSCLES ARE COMPLETELY RELAXED
•VITAL SIGNS DECLINE, BUT REMAIN REGULAR
•STAGE LASTS 15 – 30 MINUTES

15. NREM STAGE IV
• IT IS DEEPEST STAGE OF SLEEP
• IT IS VERY DIFFICULT TO AROUSE SLEEPER
• IF SLEEP LOSS HAS OCCURRED, SLEEPER WILL SPEND
CONSIDERABLE PORTION OF NIGHT IN THIS STAGE.
• VITAL SIGNS ARE SIGNIFICANTLY LOWER THAN DURING
WAKING HOURS
• STAGE LASTS APPROXIMATELY 15 – 30 MINUTES.
• SLEEP WALKING AND ENURESIS SOMETIMES OCCUR

16. REM SLEEP
•IT IS MORE DIFFICULT TO AROUSE A PERSON DURING REM SLEEP
THAN DURING NREM SLEEP.
•BREATHING BECOMES MORE RAPID, IRREGULAR AND SHALLOW, EYES
JERK RAPIDLY AND LIMB MUSCLES ARE TEMPORARILY PARALYZED.
•HEART RATE INCREASES, BLOOD PRESSURE RISES AND THE BODY
LOSES SOME OF THE ABILITY TO REGULATE ITS TEMPERATURE.
•THIS IS THE TIME WHEN MOST DREAMS OCCUR, AND, IF AWOKEN
DURING REM SLEEP, A PERSON CAN REMEMBER THE DREAMS. MOST
PEOPLE EXPERIENCE THREE TO FIVE INTERVALS OF REM SLEEP
EACH NIGHT.

18. 8 COMMON SLEEP DISORDERS
• INSOMNIA
• SLEEP APNEA
• RESTLESS LEG SYNDROME
• REM SLEEP BEHAVIOR DISORDER
• NARCOLEPSY
• SLEEPWALKING
• SLEEP TERRORS
• BRUXISM (TEETH GRINDING)

19. INSOMNIA
CHARACTERIZED BY DIFFICULTY FALLING
ASLEEP, STAYING ASLEEP, OR GETTING GOOD
QUALITY SLEEP.
CAUSES-
• STRESS
• TRAUMATIC EVENTS
• ANXIETY OR PHYSIOLOGICAL CAUSES SUCH AS
CAFFEINE OR ALCOHOL.
SYMPTOMS- DAYTIME SLEEPINESS, LACK OF
ENERGY AND TROUBLE LEARNING.
TREATMENT- COGNITIVE BEHAVIORAL THERAPY
AND/OR MEDICATION ARE OFTEN PRESCRIBED.

20. SLEEP APNEA
• SLEEP DISORDER THAT OCCURS WHEN A PERSON’S BREATHING IS
INTERRUPTED DURING SLEEP. THEY STOP BREATHING REPEATEDLY
DURING THEIR SLEEP, SOMETIMES HUNDREDS OF TIMES.
• TYPICALLY WHEN NORMAL BREATHING STARTS AGAIN, IT STARTS WITH A
LOUD SNORT OR A CHOKING SOUND. THERE ARE TWO TYPES OF SLEEP
APNEA:
• OBSTRUCTIVE SLEEP APNEA (OSA)
• CENTRAL SLEEP APNEA (CSA)

21. • TREATMENT: CPAP (CONTINUOUS POSITIVE AIRWAY
PRESSURE) MACHINE, WHICH KEEPS A PERSON’S THROAT
OPEN VIA A STEADY STREAM OF AIR.

22. RESTLESS LEG SYNDROME
RESTLESS LEGS SYNDROME (RLS) IS A CONDITION THAT CAUSES AN
UNCONTROLLABLE URGE TO MOVE YOUR LEGS, USUALLY BECAUSE
OF AN UNCOMFORTABLE SENSATION.
IT TYPICALLY HAPPENS IN THE EVENING OR NIGHTTIME HOURS
WHEN YOU'RE SITTING OR LYING DOWN.
SYMPTOMS-
• URGE TO MOVE THE LEGS
• SENSATIONS THAT BEGIN AFTER REST
• RELIEF WITH MOVEMENT
• WORSENING OF SYMPTOMS IN THE EVENING
• NIGHT-TIME LEG TWITCHING

23. • TREATMENT: REGULAR EXERCISE; REDUCTION IN
CAFFEINE AND ALCOHOL. FOR SEVERE CASES,
MEDICATION CAN BE PRESCRIBED.

24. REM SLEEP BEHAVIOR DISORDER
• IN A PERSON WITH REM SLEEP BEHAVIOR DISORDER
(RBD), THE PARALYSIS THAT NORMALLY OCCURS DURING
REM SLEEP IS INCOMPLETE OR ABSENT, ALLOWING THE
PERSON TO "ACT OUT" HIS OR HER DREAMS.
• RBD IS CHARACTERIZED BY THE ACTING OUT OF DREAMS
THAT ARE VIVID, INTENSE, AND VIOLENT.
• DREAM-ENACTING BEHAVIORS INCLUDE TALKING,
YELLING, PUNCHING, KICKING, SITTING, JUMPING
FROM BED, ARM FLAILING, AND GRABBING.

25. • CAUSE: THE MECHANISM IN THE BRAIN THAT PREVENTS
MOTOR MOVEMENT WHILE SLEEPING DOESN’T FUNCTION
PROPERLY.
• TREATMENT: MEDICATION IS OFTEN ADVISED.

26. NARCOLEPSY
• NARCOLEPSY IS A CHRONIC, NEUROLOGICAL SLEEP DISORDER
THAT CAUSES EXCESSIVE SLEEPINESS AND FREQUENT DAYTIME
SLEEP ATTACKS.
• THE EXACT CAUSE IS UNKNOWN BUT IT IS LINKED TO REDUCED
AMOUNTS OF A PROTEIN MADE IN THE BRAIN CALLED
HYPOCRETIN.
• SYMPTOMS-
• SLEEP PARALYSIS – A PERSON CANNOT MOVE AS THEY START
FALLING ASLEEP OR WHEN THEY WAKE UP. IT MAY LAST 15 MIN.
THIS CAN BE A FRIGHTENING EXPERIENCE FOR THE PATIENT.

27. • CATAPLEXY – SUDDEN LOSS OF MUSCLE TONE WHEN AWAKE THAT
MAKES YOU UNABLE TO MOVE, MOST OF THESE ATTACKS LAST LESS
THAN 30 SECONDS AND CAN SOMETIMES BE MISSED. THE HEAD
WILL SUDDENLY FALL FORWARD, JAW BECOMES LOOSE, AND KNEES
BECOME WEAK. IN SEVERE CASES, A PERSON MAY FALL AND STAY
PARALYZED FOR SEVERAL MINUTES.
• TREATMENT: MEDICATION IS OFTEN ADVISED.

28. SLEEPWALKING/SOMNAMBULISM
IT IS A BEHAVIOUR IN WHICH A CHILD APPEARS TO WAKE UP DURING THE NIGHT
AND WALK OR DO OTHER ACTIVITIES WITHOUT ANY MEMORY OF HAVING
ENGAGED IN THE ACTIVITIES.
SLEEPWALKING TENDS TO OCCUR WITHIN AN HOUR OR TWO OF FALLING
ASLEEP AND MAY LAST ON AVERAGE BETWEEN 5 AND 15 MINUTES.
CAUSES -
• HEREDITARY (I.E., THE CONDITION MAY RUN IN FAMILIES)
•INTERRUPTED SLEEP OR INEFFICIENT SLEEP (INCLUDING FROM DISORDERS
LIKE SLEEP APNEA)
•ILLNESS OR FEVER
•STRESS, ANXIETY
•GOING TO BED WITH FULL BLADDER
•NOISY SLEEP ENVIRONMENT/DIFFERENT SLEEP ENVIRONMENT

29. SYMPTOMS-
•GETTING OUT OF BED AND WALKING AROUND.
•SITTING UP IN BED AND REPEATING MOVEMENTS, SUCH AS RUBBING EYES
OR TUGGING ON PYJAMAS.
•LOOKING DAZED (SLEEPWALKERS' EYES ARE OPEN BUT THEY DO NOT SEE
THE SAME WAY THEY DO WHEN THEY ARE FULLY AWAKE).
•NOT RESPONDING WHEN SPOKEN TO.
•BEING DIFFICULT TO WAKE UP.
•SLEEP TALKING.
•URINATING IN UNDESIRABLE PLACES.
TREATMENT: REDUCING LIQUIDS NEAR BEDTIME, A QUIET SLEEP
ENVIRONMENT AND MAINTAINING A REGULAR SLEEP SCHEDULE

31. SLEEP TERRORS
SLEEP TERRORS/NIGHT TERRORS ARE EPISODES OF SCREAMING, INTENSE FEAR
AND FLAILING WHILE STILL ASLEEP.
A SLEEP TERROR EPISODE USUALLY LASTS FROM SECONDS TO A FEW MINUTES,
BUT EPISODES MAY LAST LONGER.
DURING A SLEEP TERROR EPISODE, A PERSON MAY:
•BEGIN WITH A FRIGHTENING SCREAM OR SHOUT
•SWEAT, BREATHE HEAVILY, AND HAVE A RACING PULSE, FLUSHED FACE AND DILATED
PUPILS
•KICK AND THRASH
•BE INCONSOLABLE
•HAVE NO OR LITTLE MEMORY OF THE EVENT THE NEXT MORNING
•POSSIBLY, GET OUT OF BED AND RUN AROUND THE HOUSE OR HAVE AGGRESSIVE
BEHAVIOUR IF BLOCKED OR RESTRAINED

32. CAUSES-
•SLEEP DEPRIVATION AND
EXTREME TIREDNESS
•STRESS
•SLEEP SCHEDULE
DISRUPTIONS, TRAVEL OR
SLEEP INTERRUPTIONS
•FEVER
TREATMENT: IMPROVE SLEEP
ENVIRONMENT, MEDICATION IS
GIVEN IF THE TERRORS ARE
EXTREME.

33. BRUXISM (TEETH GRINDING)
• BRUXISM IS A CONDITION IN WHICH YOU GRIND OR CLENCH YOUR TEETH
DURING SLEEP.
• CAUSES: MOST EXPERTS BLAME EXCESSIVE STRESS AND ANXIETY.
• SYMPTOMS: HEADACHES AND/OR A SORE JAW WHEN WAKING IN THE
MORNING. COMPLAINTS FROM ANNOYED BEDMATES.
• TREATMENT: AVOIDING CHEWING ANY ITEMS THAT AREN’T FOOD, AS IT
TRAINS THE JAW TO CLENCH. MOST PEOPLE WITH BRUXISM END UP
GETTING FITTED WITH A MOUTH GUARD THAT CAN BE PROVIDED BY A
DENTIST.

35. TREATMENT OF SLEEP DISORDERS
1. KEEP A SLEEP DIARY.
2. IMPROVE SLEEP HYGIENE AND DAYTIME HABITS
- KEEP A REGULAR SLEEP SCHEDULE
- SET ASIDE ENOUGH TIME FOR SLEEP
- MAKE SURE THAT THE BEDROOM IS DARK, COOL AND
QUIET
- TURN OFF TV, SMARTPHONE AND COMPUTER
DIARY.

36. 3. EAT RIGHT AND GET REGULAR EXERCISE
- STAY AWAY FROM BIG MEALS AT NIGHT
- AVOID ALCOHOL BEFORE BED
- CUT DOWN ON CAFFEINE
- AVOID DRINKING TOO MANY LIQUIDS IN THE
EVENING
- QUIT SMOKING

37. 4. GET ANXIETY AND STRESS IN CHECK
-A RELAXING BEDTIME ROUTINE
-ABDOMINAL BREATHING
-PROGRESSIVE MUSCLE RELAXATION
5. SLEEPING PILLS
-ONLY TAKE A SLEEPING PILL WHEN THERE IS ENOUGH TIME
TO GET A FULL 7 TO 8 HOURS OF SLEEP.
-PAY CAREFUL ATTENTION TO THE POTENTIAL SIDE
EFFECTS, DOSAGE INSTRUCTIONS.

38. -NEVER MIX ALCOHOL AND SLEEPING PILLS.
-NEVER DRIVE A CAR OR OPERATE MACHINERY AFTER
TAKING A SLEEPING PILL.
EXAMPLES OF SLEEPING PILLS-
ANTIHISTAMINES: DIPHENHYDRAMINE
BENZODIAZEPINE: ESTAZOLAM
NON-BENZODIAZEPINE: ESZOPICLONE
ANTIDEPRESSANTS: IMIPRAMINE, AMITRIPTYLINE

39. NURSING MANAGEMENT OF PATIENTS WITH
SLEEP DISORDERS
• ASSESSMENT
•Usual sleep
•Time of sleeping and waking
•Number of hours of undisturbed
sleep
•Quality of sleep
•Number of naps
•Effect on daily chores
•Energy level
•Means of relaxing before bedtime
•Bedtime rituals
•Sleep environment
•Pharmacological aids
•Nature of sleep disturbance
•Onset
•Cause
•Severity
•Symptoms
•Interventions attempted and its
result

40. NURSING DIAGNOSIS
1.DISTURBED SLEEP PATTERN RELATED TO (SPECIFIC
MEDICAL CONDITION); USE OF, OR WITHDRAWAL FROM,
SUBSTANCES; ANXIETY OR DEPRESSION; CIRCADIAN RHYTHM
DISRUPTION; FAMILIAL PATTERNS; EVIDENCED BY INSOMNIA,
HYPERSOMNIA, NIGHTMARES, SLEEP TERRORS, OR
SLEEPWALKING.
GOAL- CLIENT WILL BE ABLE TO ACHIEVE ADEQUATE,
UNINTERRUPTED SLEEP.
2.RISK FOR INJURY RELATED TO EXCESSIVE SLEEPINESS,
SLEEP TREMORS OR SLEEPWALKING.
GOAL- CLIENT WILL BE FREE FROM RISK OF INJURY.

41. RESEARCH ARTICLES
1. INSOMNIA AND ITS ASSOCIATED FACTORS: A CROSS-SECTIONAL STUDY
IN RURAL ADULTS OF NORTH INDIA
A COMMUNITY-BASED CROSS-SECTIONAL STUDY WAS CONDUCTED BY RASHMI
KUMARI ET AL ON 405 RURAL ADULTS OF NORTH INDIA TO DETERMINE THE
PREVALENCE OF INSOMNIA IN RURAL ADULTS AND TO FIND OUT VARIOUS ASSOCIATED
RISK FACTORS AND COMORBIDITIES. A 13-ITEM SELF-REPORTED INSOMNIA
SYMPTOM QUESTIONNAIRE WAS USED TO DETERMINE THE PREVALENCE OF
INSOMNIA. CHI-SQUARE TEST WAS USED TO FIND OUT THE ASSOCIATION OF
VARIOUS FACTORS. THE PREVALENCE OF INSOMNIA WAS FOUND TO BE 12.8%.
OCCUPATION, TYPE OF FAMILY, AND SOCIOECONOMIC STATUS EMERGED TO BE
SIGNIFICANT DETERMINANTS OF INSOMNIA. THE PRESENCE OF DIABETES, CHRONIC
RESPIRATORY DISORDERS, THYROID DISORDERS, AND ANY FORM OF STRESS WAS
SIGNIFICANTLY ASSOCIATED WITH HIGHER PREVALENCE OF INSOMNIA (P < 0.05). THE
STUDY CONCLUDED THAT INSOMNIA IS A COMMON SLEEP DISORDER WHICH
IS MANY TIMES MISSED BY A PRIMARY CARE PHYSICIAN UNTIL/UNLESS
ASKED FOR. HEALTH-CARE PROFESSIONALS SHOULD ASSESS THE SLEEP PATTERN
OF EVERY PATIENT AND GIVE ADEQUATE COUNSELLING OR TREATMENT FOR THE
SAME.

42. 2.SLEEP QUALITY AND QUANTITY IN INTENSIVE CARE UNIT PATIENTS: A CROSS-
SECTIONAL STUDY.
A CROSS-SECTIONAL STUDY WAS PERFORMED BY NAIK RD ET AL IN MEDICAL ICU OF A
TERTIARY CARE HOSPITAL. A TOTAL OF 32 PATIENTS ADMITTED TO THE ICU FOR AT LEAST
24 H WERE SELECTED. A 72-H ACTIGRAPHY WAS DONE FOLLOWED BY A SUBJECTIVE
ASSESSMENT OF SLEEP QUALITY BY THE RICHARDS-CAMPBELL SLEEP
QUESTIONNAIRE (RCSQ). PATIENT'S PERSPECTIVE OF SLEEP QUALITY AND QUANTITY
AND POSSIBLE RISK FACTORS FOR POOR SLEEP WERE RECORDED. POOR SLEEP WAS
FOUND IN 15 OUT OF THE 32 PATIENTS (47%). THE PREVALENCE OF POOR SLEEP WAS
HIGHER AMONG PATIENTS ON MECHANICAL VENTILATION. PATIENTS WITH POOR SLEEP
HAD HIGHER AGE, ACUTE PHYSIOLOGY, AND WORSE ACTIGRAPHY PARAMETERS. ONLY
55.63% OF TOTAL SLEEP TIME WAS IN THE NIGHT. ALL PATIENTS HAD DISCOMFORT FROM
INDWELLING CATHETERS AND SUCTIONING OF ENDOTRACHEAL TUBES. ALL PATIENTS
SUGGESTED THAT THERE BE A MINIMUM INTERRUPTION IN THE SLEEP FOR
INTERVENTIONS OR MEDICATIONS. THE STUDY CONCLUDED THAT THERE IS A HIGH
PREVALENCE OF POOR SLEEP AMONG PATIENTS ADMITTED TO THE ICU. THERE IS
A NEED TO MINIMIZE UNTIMELY INTERVENTIONS AND DESIGN NON-PHARMACOLOGICAL
TECHNIQUES TO ALLOW PATIENTS TO SLEEP COMFORTABLY.

43. THANK YOU FOR
CONCENTRATING
WITHOUT FALLING
ASLEEP!!!