INTRODUCTION

Sleep is the state of natural rest observed throughout the animal kingdom, in all mammals and
birds, and in many reptiles, amphibians, and fish. In humans, other mammals, and many other
animals that have been studied - such as fish, birds, ants, and fruit-flies - regular sleep is
necessary for survival. The capability for arousal from sleep is a protective mechanism and also
necessary for health and survival.
DEFINITION
Sleep can e defined as a normal state of altered consciousness during which the body rests; it is
characterized by decreased responsiveness to the environment, and a person can be aroused from
it by external stimuli.
INCIDENCE & CHARACTERISTICS:
Sleep is generally characterized by a reduction in voluntary body movement, temporary
blindness, decreased reaction to external stimuli, loss of consciousness, a reduction in audio
receptivity, an increased rate of anabolism (the synthesis of cell structures), and a decreased rate
of catabolism (the breakdown of cell structures.
Almost a third of the general population has some problems with sleep during any given year.
More than half of the 9000 participants in a study of sleep in elderly persons (65 years or older)
reported the following as sleep pattern disturbance that they experience most of the time:

Trouble falling asleep

Frequent awakening

Waking too early

Needing to nap

Not feeling rested

These disturbances may be secondary to situational, environmental or developmental stressors,

or they may be associated with illness or with pre-existing disorders. The relationship is often
reciprocal, in that the disorder decreases sleep & the decreased sleep affects the disorder.
STAGES OF SLEEP

Sleep can be defined behaviorally, functionally and electro physiologically. Electro physiologic
monitoring of sleep is called Polysomnography includes at least 3 parameters L1) brain wave
activity, (2) eye movements and (3) muscle tone. Polysomnography shows that sleep can be
divided into REM and NREM. NREM sleep can be further divided into 4 stages. The stages
vary in depth, but are characterized by slow rolling eye movements, low level and fragmented
cognitive activity, maintenance of moderate muscle tone, and slower, but generally rhythmic
respirations and pulse rate.
NREM sleep is characterized as follows:
Stage 1:

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

Stage 2:

includes period of sound sleep

relaxation progresses

arousal is still relatively easy

stage lasts 10 20 mts

body functions continue to slow

the brain waves are frequently mixed and low voltage in pattern, with bursts of activity
called sleep spindles and large amplitude waves called K complexes

Stage 3:

it involves initial stages of deep sleep

sleeper is difficult to arouse and rarely moves

oxygen consumption

muscles are completely relaxed

vital signs decline, but remain regular

stage lasts 15 30 mts

Stage 4:

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 mts

Sleep walking and enuresis sometimes occur

Stage 3 and 4 known as slow wave sleep, named for the characteristic high voltage and
low frequency delta waves

REM sleep:

Vivid, full- color dreaming occurs

Stage usually begins about 90 mts after sleep has begun

Stage typified by autonomic responses of rapidly moving eyes, fluctuating heart and
respiratory rates, and increased or fluctuating blood pressure

Loss of skeletal muscle tone occurs

Gastric secretion increase

It is very difficult to arouse sleeper

Duration of REM sleep increases with each cycle and averages 20 mts

Stage is characterized by low voltage, random fast waves, as in stage 1 NREM

SLEEP CYCLE
Normally an adults routine sleep pattern begins with a pre-sleep period during which the person
is aware only of a gradually developing sleepiness. This period normally lasts 10 30 mts.
individuals experiencing difficulty in falling asleep often remain in this stage for an hour or
more.
Once asleep, the person passes through 4 6 complete sleep cycles; each consists of 4 stages of
NREM sleep and a period of REM sleep. The cyclical pattern usually progresses from stage 1
through stage 4 of NREM, followed by a reversal from stage 4 to 3 to 2, ending with a period of
REM sleep.

With each successive cycle, stages 3 and 4 of NREM sleep shorten and the period of REM
lengthens. REM sleep lasts up to 60 mts during the last sleep cycle. The number of sleep cycle
depends on the amount of time that the person spends sleeping, in an average of 90 mts.

FUNCTIONS OF SLEEP
The purpose of sleep is still unclear. Theories suggest that:

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 for cognitive restoration

The benefits of sleep often go unnoticed until a person develops a problem resulting from sleep
deprivation. A loss of REM sleep leads to feelings of confusion. Various body functions ( eg.
Motor performance, memory and immune function) alter when prolonged sleep loss occurs
NORMAL SLEEP REQUIREMENTS & PATTERNS
Sleep duration and quality vary among persons of all age groups

Infants

16 Hours /Day

Toddlers

12 Hours /Day

Preschoolers

11 Hours /Day

Schoolers

9 - 10 hours /day

Adolescents

8 9 hours /day

Adults

6 8 hours /day

As people age, their circadian clock advances, causing advanced sleep phase syndrome. The
syndrome is common in older adults and often is the reason behind the complaint of waking
early in the morning and unable to get back to sleep. They get sleepy early in the evening.
FACTORS AFFECTING SLEEP
A number of factors affect the quality and quantity of of sleep. Often more than one factor
combined to cause a sleep problem.

Physical illness (eg. Nausea, mood disorders, breathing difficulty, pain)

Drugs and substances (eg. Tryptophan)

Lifestyle (eg. Daily routines, exercises)

Usual sleep patterns and excessive daytime sleepiness

Emotional stress

Environment ( ventilation)

Sound

Exercise and fatigue

Food and caloric intake

SLEEP DISORDERS
Sleep pattern disturbance is a nursing diagnosis that is defined as a disruption of sleep time that
causes discomfort or interferes with a desired life cycle. A sleep pattern disturbance may be
related to one of more than 80 sleep disorders identified in the international classification of
sleep disorders, a partial list of which is given below:
I, DYSSOMNIAS
The Dyssomnias include sleep disorders characterized by difficulty in initiating or maintaining
sleep (insomnia) or by excessive sleepiness. These disorders may arise predominantly from
within the body (intrinsic), from external sources (extrinsic), or from disruption of circadian
rhythm.
A. Intrinsic sleep disorders
1. Insomnia:
It is the persistent difficulty in initiating or maintaining sleep. The difficulty does not respond
readily to improved sleep habits or removal of precipitating factors. Idiopathic insomnia is a
rare disorder characterized by a lifelong history of inability to obtain adequate sleep. Its cause is
thought to be an abnormality in the neurologic control of sleep. Psycho physiologic insomnia is
more common and is characterized by learned sleep preventing associations and heightened
physiologic response to stress. It can be confirmed by polysomnographic recording, which
usually shows the same pattern of long sleep latency or fragmentation that the client describes.
The total sleep time is often within normal range but is felt to be inadequate. They will fall asleep
unintentionally in low stimulus situations, such as watching TV, but feel increased arousal when
they go to bed. It is difficult to get sleep in places , other than their usual bedroom.

Management of insomnia is complex. Sleep should be restricted by curtailing time bed to the
minimum believed necessary with a consistent rising time. Relaxation exercises can be helpful,
but they should initially be practiced at times other than bedtime so that by the time they are
introduced at bedtime, they are effective. Referral to a sleep specialist or mental health
professional who can work with the client over a period of time should be considered.
2. Narcolepsy
Narcolepsy is one of the disorders characterized by excessive daytime sleepiness. The client also
experiences disturbed nocturnal sleep and repeated episodes of almost irresistible daytime
drowsiness followed by brief periods of sleep, especially when engaged in monotonous
activities. Many Narcoleptic clients also experience cataplexy,a sudden loss of muscle tone at
times of unexpected emotion (eg. Fright). Malfunctioning of the mechanism controlling REM
sleep leads to sleep paralysis for one to several minutes, and hypnagogic hallucinations i.e.
Hallucinatory experiences that occur at sleep onset or awakening.
On polysomnography, the most characteristic finding is sleep onset REM periods.
3, Sleep apnea syndrome:
Sleep apnea is characterized by cessation of breathing for 10 seconds or longer occuring at least
5 times / hour. Sleep apnea can be classified as obstructive and central nervous system apnea. A
combination of the two may be seen.
Obstructive Sleep apnea syndrome: In Obstructive Sleep apnea syndrome, respiratory efforts
of the diaphragm and intercostals muscles are apparent but ineffective against a collapsed or
obstructed upper airway. Snoring indicates partial obstruction. As hypoxia ensues; the person
eventually awakens to breathe. The frequent awakenings impair the normal sleep cycle. Repeated
micro arousals lead to daytime sleepiness.
4. Periodic limb movement disorder
It may also contribute to daytime sleepiness and frequent nocturnal wakening. Originally
described as nocturnal myoclonus, it is characterized by periodic episodes of repetitive,
stereotypic leg movements that occur during sleep, causing partial arousals. It is common in the
elderly population. Clonazepam, a benzodiazepine, or baclofen, a skeletal muscle relaxant, may
be ordered to diminish the magnitude of the movement and frequency of arousals. For some
clients the use of transcutaneous electrical nerve stimulation (TENS) before sleep has been
helpful.
5. Restless leg syndrome:

Restless leg syndrome involves anything crawling, itching or tingling sensations of the leg
while at rest and causes an almost irresistible urge to move. The syndrome is often most severe
before sleep onset. Clients always have periodic limb movements during sleep. Treatment is
similar to that of Periodic limb movement disorder.
B. Extrinsic sleep disorders
It encompasses a range of factors, from environmentally to chemically induced. Some
environmental factors temporarily present during hospitalization.
1. Circadian rhythm sleep disorders
In the general population, the Circadian rhythm sleep disorders, such as time zonechange
syndrome and shift work sleep disorder are not uncommon. Elderly and chronically ill clients
who live alone may be vulnerable to irregular sleep- wake patterns. In this disorder, prolonged
ignoring or absence of external cues to time, such as regular meal timings, work periods and
daylight leads to erratic periods of sleeping and wakefulness. Internal circadian cues may also be
damped as a result of ageing or diffuse brain disease.
II. PARASOMNIAS:
The Parasomnias are disorders that occur during sleep but that usually do not produce insomnia
or excessive sleepiness. It may be due to partial arousal or abnormalities in sleep-wake transition.
A. Arousal disorders
Partial arousal occur during slow- wave sleep. Sleepwalking, also known assomnambulism, may
include semi purposeful behaviour, such as dressing. However the behaviour may be lacking in
coordination and appropriateness, such as voiding in the closet. . The occurrence of sleep
walking in adults is associated with anxiety. Sleep terrors are sudden arousals from slow wave
sleep accompanied by screaming, tachycardia, tachypnea, diaphoresis, and other manifestations
of fear. If awakened, the person is often disoriented and has little recall of the nature of the dream
image. Sleep terrors usually occurs in young children.
B. Sleep-wake transition disorders
Sleep-wake transition disorders are common in the general population. Sleep startsrefers to the
sudden jerking movement of the legs that often occurs as a person is falling asleep. Nocturnal leg
cramps also common. The frequency andand intensity may be greater with high caffeine intake,
stress, or intense physical activity before going to bed. . Sleep talking also may occur during
times of stress.

C. Parasomnias usually associated with REM sleep

Nightmares are frightening dreams that arise in REM sleep and are often vividly recalled on
awakening. Sleep [paralysis is one of the classic signs of narcolepsy, but can occur in isolation.
This effect may be an extension of the normal state of low muscle tone during REM sleep.
D. Other Parasomnias
Other Parasomnias are not specifically associated with particular sleep
stage. Sleepbruxism refers to grinding of the teeth during sleep and may lead to dental
damage.Sleep enuresis, or bed wetting, may occur in adult in association with other disorders,
such as Obstructive Sleep apnea syndrome. Primary snoring is distinguished from Obstructive
Sleep apnea syndrome by its rhythmic nature without episodes of apnea or hypoventilation.
ASSESSMENT AND MANAGEMENT
Diagnostic assessment:

Polysomnography

Electroencephalogram

Multiple sleep latency test (MSLT)

MSLT is performed to assess the impairment of daytime alertness. It is performed a day after a
standard polysomnogram. The time required for clients to fall asleep when in a relaxed state is
evaluated at 2 hour intervals, with each nap limited to 20 minutes. The type of sleep also is
assessed.
NURSING PROCESS
A. Assessment: Assess clients usual sleep habits and recent sleep quality as part of the initial
nursing history. If sleep quality is reported to be poor, explore the nature of
disturbances by noting the following:

Usual activities in the hour before retrieving

Sleep latency

Number and perceived cause of awakenings

Regularity of sleep pattern

Consistency of rising time

Frequency and duration of naps

Events associated with initial onset of sleep disturbances

Ease of falling asleep in places other than the usual bedroom

Situations in which client fights sleepiness

Daily caffeine intake

Use of alcohol, sleeping pills,and other medications

Incidence of morning headaches

Frequency of snoring, apparent pauses in breathing, and kicking movements

Objective data may include visible signs of fatigue and lack of sleep, such as circles
under the eyes, lack of coordination, drowsiness and irritability.

B. Nursing diagnosis:
1. Disturbed sleep pattern related to changes in routine due to hospitalization and pain
Or
Disturbed sleep pattern related to lack of cues for day- night schedule; manifested by erratic
sleep schedule, frequent naps and nocturnal wandering
C. Client Outcome criteria:
client increases nocturnal sleep time by 20% over next 2 weeks.

D. Nursing intervention

Rationale

*offer meals at regular times,

*mealtimes are important

corresponding to clients
previous pattern

social cues, that reinforce

circadian rhythms, which
tend to weaken with
advancing age

*provide active meaningful

activities during daytime hours,
including exposure to natural
*light exposure is
light, and an outdoor
communicated through the
environment when possible
retina to the
suprachiasmatic nucleus,
*monitor frequency and duration helping to set the circadian
of naps
clock
*create an individualized
bedtime ritual that includes a
quieting activity, a light
carbohydrate snack, going to the
bathroom and settling a routine

*napping is not
contraindicated but is best
at the time of day opposite
to the midpoint of the
nocturnal sleep period.
Short naps are preferable to
avoid deep sleep

* Do not waken even if

incontinent. Change and assist
the client to the bathroom when *reduced stimulation and
he or she spontaneously awakens rituals associated with sleep
enhance sleep onset
*if turning or other care is
necessary, try to provide for
*older adults who can turn
periods up to 2 hours of
themselves generally do
undisturbed sleep time whenever better to have their sleep
possible
undisturbed and tend to
waken spontaneously if wet
when their sleep cycle
lightens
* Sleep cycles average 90
mts. A sleep latency of 2030 mts mean it would take
about 2 hours to experience
a full sleep cycle.

SUMMARY

The adequacy of sleep is important factor in caring for clients with acute and chronic illness.
Some sleep disturbances are temporary and related to the stress of hospitalization. It is possible
that temporary stress problems will be corrected only after the clients return home. Clients with
sleep disturbances may need follow up care with repeated assessments to determine whether the
problem was corrected. Clients with long term sleep disorders may need ongoing support to
maintain the effectiveness of treatment. The nurse can play a pivotal role in environmental
modification and client teaching to minimize the impact of sleep.
REFERENCES
1. Black JM, Hawks JH. Medical Surgical Nursing clinical management for positive
outcomes. Vol 1.7th edition. Saunders; India 2005 Pp 461-500.
2. Potter PA, Perry AG. Basic nursing- essentials for practice. 6th edition. Missouri: Mosby
publishers; 2007
3. Brunner. Medical surgical nursing. 6th edition. London: Mosby publishers; 2005.
4. Lewis SM, Heitkemper MM, Dirksen SR. Medical surgical nursing. 6th edition.
Philadelphia: Mosby publishers; 2004.
5. Tylor C, Lillis C, Le Mone P. fundamentals of nursing- the art and science of nursing
care. 5th edition. London: Lippincott Williams & Wilkins publishers; 2006
6. Lewis, Heitkemper, Dirksen. Medical Surgical nursing.6th edition. Mosby. Page no 131157