• A condition in which the body is inactive or engaging in mild activity, after which the person feels refreshed. 
• A person at rest is calm, at ease, relaxed, and free of anxiety and stress.

• A cyclically occurring state of decreased motor activity and perception. 
• Body functions slow, and metabolism falls by 20% to 30%, so the body conserves energy. 
• Sleep is characterized by altered consciousness: a sleeping person is unaware of the environment and responds selectively to external stimuli.

• A biorhythm based on the day–night pattern in a 24- hour cycle. 
• A person’s circadian rhythm is regulated by a cluster of cells in the hypothalamus of the brain stem that respond to changing levels of light. 
• Circadian rhythm affects our overall level of functioning; most people have a higher energy level in the daytime and less energy at night.

• People who work evening and night shifts ( e. g., healthcare workers, police officers) can suffer significant sleep deprivation until their bodies adjust to the new pattern. 
• Changing time zones can also disrupt sleep–wake cycles and can thus be troublesome for people who travel frequently. (jet lag)
• Hospitalization can also interfere with a patient’s circadian rhythm. Noises, lights, waking the patient for vital signs or medications, altered normal bedtime rituals, absence or presence of family members, recent losses, or fear of the unknown may compromise the patient’s quality of sleep the ability to fall and stay asleep.

• A light sleep from which the sleeper can easily be awakened. 
• The person is relaxed; breathing is regular and deep; the eyelids slowly open and close, and the eyes roll from side to side. 
• The person feels drowsy, the eyelids feel heavy, and suddenly without awareness the person falls asleep. 
• Within 5 to 10 min-utes, sleep progresses to stage II. 
• Stage I accounts for about 5% of our total sleep during the night. 
• Brain activity consists of alpha waves, with occasional low-frequency theta waves

• Also light sleep. 
• Brain activity slows, charcterized by sleep spindles. 
• The eyes are still, and body processes begin to slow down (e. g., temperature, pulse, and blood pressure decrease). 
• There are spontaneous periods of muscle tone mixed with periods of muscle relaxation. 
• Stage II usually lasts for 10 to 15 minutes.

• A deeper sleep. 
• Progressively more delta and slow-wave activity begins to occur in this stage. 
• The person is difficult to rouse, slow eye movement stops, skeletal muscles are very relaxed, and snoring may occur. 
• This stage may last 5 to 15 minutes. 
• A young adult spends about 8% of sleep time in Stage III.

• The deepest sleep. 
• In this stage, the delta waves are highest in amplitude, slowest in frequency, and highly synchronized. 
• The body, mind, and muscles are very relaxed. 
• It is difficult to awaken someone in stage IV slow- wave sleep, and if she is awakened, the person may appear confused and react slowly. 
• Some dreaming may occur in stage IV, but dreams are less vivid than those that occur in REM sleep. 
• Stage IV sleep appears to be especially important for restorative processes such as protein synthesis, cell division, and tissue renewal. 
• During this stage, the body releases human growth hormone, which is essential for repair and re-newal of brain and other cells.
• A young adult spends about 11% of sleep time in stage IV.

• About 90 minutes after the onset of sleep and after the deep sleep of stage IV, the brain becomes highly active, and the brain waves resemble those of a person who is fully awake. 
• This is REM sleep, so called because of its characteristic rapid eye movements, which can often be detected even though the sleeper’s eyelids are closed. 
• Metabolism, temperature, pulse, heart rate, and blood pressure increase, but muscle activity and deep tendon reflexes are depressed. Because most people awakened during REM sleep report that they have been dreaming, this loss of muscle tone is thought to be a protective response that prevents the person from acting out the dreams. 
• People are difficult to rouse during REM sleep; however, more spontaneous awakenings occur during this stage than any other. 
• For this reason, REM sleep is also called paradoxical sleep. 
• When sleepers are successfully awakened during this stage, they are usually alert and can react normally; in contrast, sleepers who are wakened during stages III or IV of slow- wave ( NREM) sleep take a few moments to wake up and react.

• A person who is deprived of REM sleep for several nights will usually experience REM rebound; 
• The person will spend a greater amount of time in REM sleep on successive nights, keeping the total amount of REM sleep constant over time.

• Older adults may feel displaced in the workforce and worry about their impending retirement. 
• Many suffer sleep disturbances because of nocturia, the side effects of medications, and discomfort or pain. 
• In addition, the levels of melatonin, the natural hormone that controls sleep, decline in the latter decades of life.

• If it occurs at least 2 hours before bedtime, exercise promotes sleep. 
• Fatigue from a normal physi-cally active day is thought to promote a restful night’s sleep.

• Foods can either promote or interfere with sleep. 
• A meal high in saturated fat near bedtime may interfere with sleep. 
• Dietary L-tryptophan, an amino acid found in milk and cheese, may help to induce sleep.
• Carbohydrates seem to promote relaxation through their effects on brain serotonin levels. 
• Satiation induces sleep, whereas many people, especially infants and children, have difficulty falling asleep when they are hungry.

• Central nervous system stimulants, such as nicotine and caffeine, interfere with sleep. 
• Smokers tend to have more difficulty falling asleep and are more easily roused than nonsmokers. 
• Caffeine blocks adenosine and thereby inhibits sleep. 

• Consumption of alcohol, especially if heavy, may hasten the onset of sleep; however, it disrupts REM and slow wave sleep and may cause spontaneous awakenings with difficulty returning to sleep. 
• Because alcohol is a diuretic, it can interrupt sleep by inducing nocturia. 

• Many of the medications people take cause either sleeplessness or excessive grogginess and sedation. 
• Medications to induce sleep ( i. e., hypnotics) tend to increase the amount of sleep while decreasing the quality. 
• Amphetamines, tranquilizers, and antidepressants reduce the amount of REM sleep; barbiturates, in addition, interfere with NREM sleep. 
• Opioids, such as morphine, suppress REM sleep and cause frequent awakening. Beta- blockers are reported to cause insomnia and nightmares.

• Illness increases the need for sleep and rest. At the same time, its associated mental and physical distress can cause sleep problems. 
• Fear of the unknown outcome of an illness and role changes associated with hospitalization can cause anxiety. 
• Disease symptoms, such as fever, pain, nausea, and respiratory conditions ( e. g., shortness of breath, dyspnea, sinus congestion), can also interfere with sleep. 
• Specific disease conditions altering the quality of sleep are allergies, hyperthyroidism, and Parkinson’s disease. 
• Anxiety increases gastric secretions, intestinal motility, heart rate, and respirations, all of which contribute to a restless night. 
• Anxiety also stimulates the sympathetic nervous system, increasing the level of norepinephrine. This decreases stage IV and REM sleep and leads to more awakenings. 
• Depression may be associated either with almost constant sleeping or with insomnia.

• Environmental factors can promote or inhibit sleep. Some people need a cool room, whereas others need warmth. Some prefer heavy blankets, and others like to sleep with just a light sheet. 
• Noise can also inhibit sleep, but a person can become habituated to noise over time and be less affected by it.
• Any change in the usual environmental stimuli can affect sleep. 

• The inability to fall asleep, remain asleep, or go back to sleep. 
• Insomnia may be transient/short term (less than a month) or chronic (longer than a month).
• People with insomnia usually report an insufficient quantity and quality of sleep and wake without feeling re-freshed, even though they are often observed to sleep more than they perceive that they do. 
• Most people are distressed by the daytime consequences of insomnia, which include symptoms of excessive daytime sleepiness, poor concentration, fatigue, lethargy, and irritability. 
• Insomnia is the most common sleep disorder. Two out of three people say they have insomnia at least once a week.
• It is more prevalent in women and in adults older than 60 years. 
• Insomnia may occur as a result of illness, depression, anxiety disorders, acute stress, substance abuse, side effects of medications (e.g., steroids, central adrenergic blockers, bronchodilating agents), or inadequate sleep hygiene (e.g., watching TV in bed, drinking caffeine-containing beverages before bedtime). 
• It may also be the presenting symptom of other primary sleep disorders, such as restless leg syndrome.

• Abnormalities in sleep–wake schedules may be caused by rapid time-zone changes (jet lag), shift work, or a change in total sleep time from day to day. 
• Symptoms include decreased vigilance, decreased ability to perform psychomotor tasks, and short sleep episodes (microsleeps) that the person is not aware of. 
• People suffering jet lag need several days to adjust their sleep–wake schedule.

• A disorder of the central nervous system characterized by an uncontrollable movement of the legs while resting or before sleep onset. 
• Especially common in older adults, and is sometimes associated with low levels of iron and use of some antidepressants. 
• Symptoms include unpleasant creeping, crawling, itching, or tingling sensations in the legs. 
• Symptoms are relieved only by moving the legs, which prevents the person from relaxing and falling asleep. 
• If RLS is severe, treatment may include neuroleptic agents and medication used to treat Parkinson’s disease.
• People with RLS should avoid stimulants (e.g., caffeine). Other self-care measures include walking, massaging, stretching, heat or cold compresses, medication, vibration, and acupressure.

• Sleep Deprivation is a NANDA-I nursing diagnosis. It is not actually a sleep disorder, but rather a result of prolonged sleep disturbances (e.g., insomnia and parasomnias). 
• It can result from NREM or REM deprivation, or both. 
• Signs and symptoms of sleep deprivation include daytime drowsiness, impaired cognitive functioning, restlessness, perceptual disorders, slowed reaction time, irritability, somatic (body) complaints (e.g., hand tremors), and a general feeling of malaise.  
• If sleep deprivation is severe and prolonged, delusions, paranoia, and other psychotic behavior may occur. 
• Going without sleep can weaken the body’s protection against infection.

• Excessive sleeping, especially in the daytime. 
• People with excessive daytime sleepiness doze, nap, or fall asleep at times and in situations when they need or wish to be awake and alert. 
• The sleep disorders that commonly cause hypersomnia are obstructive sleep apnea and narcolepsy. 
• Hypersomnia may also be caused by disorders of the central nervous system, kidney, or liver or by metabolic disorders (e.g., diabetic acidosis and hypothyroidism). 
• It can also be a symptom of depression.

• A periodic interruption in breathing during sleep— an absence of air flow through the nose or mouth during sleep. 
• Typically the soft tissue of the pharynx and soft palate collapse and obstruct the airway. 
• Episodes may occur several or a hundred times a night and may last for as long as 1 minute or longer.
• During periods of apnea, the oxygen level in the blood drops, and the carbon dioxide level rises, causing the person to wake up. This may result in cardiac dysrhythmias (irregularities) and increases in pulse and blood pressure. 
• Many people with sleep apnea complain of fatigue and morning headache; however, some may experience mild sleep apnea without any symptoms.
• Untreated sleep apnea is associated with polycythemia, hypertension, angina, coronary artery disease, right-sided heart failure, stroke, impotence, depression, personality changes, and mood swings.
• Obstructive sleep apnea (OSA) is caused by airway occlusion (usually by the tongue or palate) during sleep, but the person continues to try to breathe. The person is not aware of waking. Sleeping partners often report that the person snores, snorts grunts, or thrashes about during sleep.
• Treatment of OSA might involve surgery to remove any obstruction within the airway or applying CPAP (continuous positive airway pressure) treatment.
• Central sleep apnea (CSA) is a complete suspension of breathing resulting from a dysfunction in central respiratory control. Only about 10% of sleep apnea is central in origin. People with CSA tend to awaken during sleep and, therefore, experience daytime sleepiness.

• Narcolepsy is a chronic disorder caused by the brain’s inability to regulate sleep–wake cycles normally. 
• At various times, the person with narcolepsy experiences a sudden, uncontrollable urge to sleep lasting from seconds to minutes, even though the person sleeps well at night. 
• The person cannot avoid the sleep episodes but awakens easily. 
• Narcolepsy is characterized by sleepiness, slurred speech, slackening of the facial muscles, a feeling of impending weakness of the knees, paralysis, and hallucinations. Performance is impaired during these micro-sleep episodes. 
• Some have other symptoms, such as cataplexy, a sudden loss of muscle tone usually triggered by an emotional event (e.g., laughter, surprise, or anger), but most only have hypersomnia.

• Sleepwalking (somnambulism) occurs during stages III and IV of NREM sleep, usually 1 to 2 hours after the person falls asleep. 
• The sleeper leaves the bed and walks about, with little awareness of surroundings. 
• He may perform what appear to be conscious motor activities (e.g., brush his teeth, make coffee), but he does not wake up. 
• The person is not aware of sleepwalking and has no memory of the event on awakening. The event may last 3 to 4 minutes or longer. 
• Children sleepwalk more than adults do. If the child does not outgrow the condition or serious safety risks exist, drugs may be given to suppress stage IV sleep. 
• Stress, fatigue, and some drugs can trigger sleepwalking.

• Grinding and clenching of the teeth, usually occurs during stage II NREM sleep. 
• It can eventually erode tooth enamel and loosen the teeth. The noise can also disturb the bed partner’s sleep.

• Occur when a disease causes alterations in sleep stages or in quantity and quality of sleep. The following are the most common causes:
• Depression. Depressed people may spend a great deal of time in bed. However, in general, they have difficulty falling asleep, experience less slow-wave (deep) sleep, spend less time in REM sleep, awaken early, and have less total sleep time. 
• Hyperthyroidism or Hypothyroidism. An increase in thyroid secretion causes an increase in stage III and IV sleep; hypothyroidism causes a decrease in those stages. Hyper-thyroidism increases metabolic rate, making it difficult for the person to fall asleep. 
• Pain. Both acute and chronic pain interfere with sleep. Chronic pain affects both the quality and quantity of sleep. It inhibits sleep, increases arousals during sleep, and causes longer waking intervals during the night.

• Coronary Artery Disease. During REM sleep, dreams may increase heart rate and provoke angina and ECG changes. 
• Asthma. People with asthma may experience bronchospasm during REM sleep. In adults, asthma attacks frequently occur during the night as the esophageal sphincter relaxes and reflux results. In children, they occur mostly during the final two-thirds of the night, when there is less stage IV sleep. 
• Chronic Obstructive Pulmonary Disease (COPD). Persons with COPD experience lowered oxygen tension and increased carbon dioxide retention during sleep, especially during REM sleep, when neuromuscular control is normally depressed. This can result in pulmonary spasm and transient pulmonary hypertension. 
• Diabetes. Blood glucose levels vary during sleep. When diabetes is uncontrolled, it may profoundly affect the blood sugar level during sleep, when the person is not alert enough to deal with it. Therefore, patients with uncontrolled diabetes may need to have blood glucose levels monitored during sleep. 
• Gastric and Intestinal Ulcers. During REM sleep, people with duodenal ulcers secrete up to 20 times more gastric acid than do people who do not have duodenal ulcers. Peptic ulcers also contribute to increased acid, often producing nocturnal epigastric pain and sleep loss.

• Answer: False
• Rationale:The quality of sleep declines, but the total time slept does not. Older adults are more likely to nap during the day and sleep less at night. The quality of sleep changes with aging, including the REM and non-REM cycles. Other health disorders can reduce the restfulness of sleep, such as restless legs syndrome, sleep apnea, nocturnal enuresis (getting up at night to urinate), chronic pain, and many other conditions. However, waking up tired every day is not normal and a healthcare provider should investigate.

• Use Sleep Deprivation as the nursing diagnosis when the patient’s amount, consistency, or quality of sleep is decreased over prolonged periods of time. 
• Defining characteristics of Sleep Deprivation are more severe than those for Disturbed Sleep Pattern, so nursing activities may focus as much on relieving symptoms (e. g., confusion, paranoia) as on sleep promotion.

• Use Disturbed Sleep Pattern as the diagnosis when assessment data points to a time-limited sleep problem due to external factors (e. g., inability to sleep in the unfamiliar hospital environment).
• The problem should be one that can be treated by nursing therapy. 
• Add modifying words to specify the type of sleep problem. This will help you to focus goals appropriately.
  -Disturbed Sleep Pattern (difficulty falling asleep) related to worries about family
  -Disturbed Sleep Pattern (difficulty falling and remaining asleep) related to noise of hospital environment and need for scheduled treatments
  -Disturbed Sleep Pattern (premature awakening) related to sleeping aid dependence and lack of knowledge of nonpharmacological aids for insomnia
  -Disturbed Sleep Pattern (excessive daytime sleeping) related to effects of biological aging and depression
  -Disturbed Sleep Pattern (altered sleep–wake patterns) related to frequent rotations of shift and overtime 

Disturbed Sleep Pattern and Sleep Deprivation affect many areas of functioning, so they often are the etiology of other nursing diagnoses, as in these examples:

• Risk for Injury or Falls related to sleepwalking ( or REM sleep behavior disorder or narcolepsy) 
• Fatigue ( or Activity Intolerance) related to chronic in-suffi cient quality or quantity of sleep ( e. g., secondary to insomnia) 
• Ineffective Coping related to decreased cognitive functioning and awareness, secondary to lack of sleep 
• Disturbed Thought Processes related to decreased cognitive functioning, secondary to lack of sleep 
• Anxiety ( or Fear) related to fear of death from sleep apnea

• Difficulty sleeping may be one of the symptoms of another problem. 
• For example, a client may have Spiritual Distress related to challenges to belief system as manifested by nightmares, sleep disturbances, and verbalization of inner conflict about beliefs. In this instance, you would focus on interventions for Spiritual Distress, assuming that the sleep pattern would improve as the Spiritual Distress is resolved. 
• Other nursing diagnoses that may cause sleep loss include Anxiety, Chronic Sorrow, Death Anxiety, Decisional Conflict, Complicated Grieving, Diarrhea, Impaired Gas Exchange, Nausea, Pain, and Relocation Stress Syndrome.

• Schedule nursing care to avoid interrupting sleep
• Create a restful environment (temperature, noise, lighting)
• Promote comfort (relieve pain, itching)
• Support bedtime routines and rituals
• Offer appropriate bedtime snacks or beverages
• Promote relaxation (guided imagery, progressive muscle relaxation, music therapy)
• Teach about sleep hygiene
• Teach about medications to produce sleep

• This is the newest class of sedative/ hypnotics (sleep medicines). 
• These have a short half-life, which means that they are eliminated from the body quickly and do not cause “ hangover” (daytime sleepiness). 
• They are also selective, which means they target specific receptors that are thought to be associated with sleep rather than depressing the entire central nervous system.
• Examples are zolpidem tartrate (Ambien), zaleplon (Sonata), eszopiclone (Luesta). 
• Long-term effects of these medications are not yet known.

• This class of sedative/ hypnotics includes both long-acting and short-acting drugs. 
• Long-acting medications linger in the body and potentially cause daytime drowsiness. 
• Many benzodiazepines were originally formulated to treat anxiety. 
• Examples are diazepam (Valium), alprazolam (Xanax), flurazepam ( Dalmane), lorazepam (Ativan), and triazolam ( Halcion).

• These sedative/hypnotics and anticonvulsants are rarely prescribed for insomnia because of the risk of addiction, abuse, and overdose. 
• Examples are amobarbital (Amytal), pentobarbital (Nembutal), and secobarbital (Seconal).