Lullaby and Good Night

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Lullaby and Good Night.

• Lisa B. Flatt, RN, MSN, CHPN

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Rest vs. Sleep

• Rest

• Sleep

• Calm state
• Relaxation
• Physical activity
• No physical activity

• Altered state of consciousness
• Perception and reaction are decreased
• Varying levels of reaction (dog barking, lawn
  mower, smoke detector)

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Types of Sleep

• Rapid Eye Movement (REM)

• Non-rapid Eye Movement (NREM)

• 25 of sleep in young adults
• Recurs every 990 minutes and lasts 5-30 minutes
• Increases as you become more rested
• Active dreaming, remembered dreams, difficulty
  awakening, depressed muscle tone, irregular
  heart, respiratory rates and muscle movements,
  increased brain activity

• Most sleep is non-REM
• slow-waves
• 4 Stages
• Ilast few minutes drowsy, relaxed, eyes roll
  side to side RR and HR decrease
• II 10-15 minutes, eyes still HR, RR and T
  decrease
• III HR, RR, T decrease MS relaxes decreased
  reflexes snoring
• IV deep sleep HR and RR drop to 20-30 waking
  rate some dreaming, eye rolling decreased BP
  blood vessels dilate MS relax decreased BMR
  increased GI activity

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How long do they last? Not Long enough!

• REM recurs every 990 minutes, lasts 5-30 minute
• NREM - about one hour in adults
• Stage II and III 20-30 minutes total
• Stage IV 30 minutes
• Cycle REM, St I,II and III then IV then III,
  II and REM --- cycle4-6 times every 7-8 hours
• Each cycles lasts about 70 minutes
• If you wake up, start all over again!
• More rested, cycles last longer, less time in
  Stages II and IV and NREM
• Different developmental levels, different time
  lengths

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Circadian Rhythm Not to be confused with Cicadas

• 24 hour Daily cycle, all living things do it!
• Biorhythms humans only. These are controlled
  with light and darkness, gravity and
  electromagnetic stimuli.
• Infants as young as 6
• months have circadian rhythms very much like
• adults!

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How well do you sleep? What to assess and
consider

• Age and developmental level
• Individual preferences
• Physical condition
• Cultural, spiritual and religious practices
• Living conditions and socioeconomic status
• Environmental factors
• Psychological factors
• Medications

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Age and Developmental Level the need for sleep
Age Hours/day Other
Newborns 16-18 50REM mostly St III and IV NREM
Infants 12-22 Light sleep, end of 1st year 14 of 24 hrs with 1-2 naps
Toddlers 10-12 20-30REM, 1 nap, bedtime resistance
Preschoolers 11-12 20-30REM,less St I NREM, consistency, may need naps
School-age 8-12 20 REM
Adolescents 8-12 20 REM
Young adult 7-8
Middle-age adult 6-8 St IV decreases, aroused more easily
Older adult Awaken more frequently, longer to get back to sleep
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Preferences

• Sleep patterns
• Lifestyle
• Work schedule and changes sleep pattern changes
• Caffeine
• Alcohol speeds up REM sleep
• Smoking nicotine is a stimulant
• Vigorous exercise at wrong times releases
  endorphins

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What kind of shape are you in?

• Illnesses require more sleep
• Altered health status
• Obesity difficulty breathing
• Nocturia
• Activity level
• Ineffective breathing

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And more

• Cultural, Spiritual, Religious

• Socieeconomic, Living conditions, Environmental

• Co-sleeping (babies and young children sleeping
  with parents)

• Sanitation
• Safety
• Noise
• Temperature extremes
• ventilation

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.. And more

• Psychiatric

• Medications

• Anxiety
• Stress
• Depression

• Beta blockers
• Sedatives
• Narcotics
• Diuretics
• Amphetamines
• Bronchodilators
• Decongestants
• Steroids

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Disturbing my Sleep!

• Primary Sleep Disorders
• Narcolepsy excessively sleepy during day could
  be in middle of driving, talking, etc.. starts
  with REM
• Unknown, possible genetic defect
• Insomnia unable to fall asleep psychological
  (anxiety, etc) pain nocturia environmental
  (lights, etc.) chemical (medicine, caffeine,
  etc.)
• Full assessment needed, usually no meds
  modification of habits, etc.

• Secondary Sleep Disorders
• Hypersomnia excessive sleeping during the day,
  r/t CNS damage, kidney, liver or metabolic
  disorders
• Sleep apnea periods of apnea during sleep last
  10 sec 2 min 50-600 x/night tired during day
  middle-aged overwt males and post-menopausal
  women
• Parasomnia-behaviors that interfere with sleep
• Sleep deprivation decrease in amount,
  consistency and quality of sleep

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Sleep Apnea

• Three types
• _Obstructive tongue, tonsils_
• __Central Apnea- chest movement, air flow stops,
  respiratory center defect in brain__
• __Mixed both combined_____
• Causes
• ___remove and hopefully correct__________
• ___modify reasons as above__________
• Treatments
• __CPAP_____
• __BiPAP____________
• ___Surgery, adjust body habitus, sleep sitting
  up____

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Parasomnia- behaviors

• Somnambulism - ___sleep walking______
• Sleeptalking - ___holler out, tell secrets_______
• Nocturnal enuresis - __pee at night___
• Nocturnal erections - ___speaks for itself_____
• Bruxism - ___teeth grinding____

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Assessment

• Medications
• Age
• Activity - patterns
• Diet
• Alcohol/drugs
• Disease process - labs
• Sleep patterns
• Stress, anxiety, depression

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Nursing Diagnosis

• Insomnia R/T ____anxiety, stress, depression
• Impairment of normal sleep pattern R/T _____shift
  work, SOB, ________
• Sleep deprivation R/T _____fan running at night
  for wife to sleep, dementia, nightmares,
  narcolepsy, sleep walking, idiopathic CNS
  disease_______

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Plan

• Collaborate with team to get an ideas on how to
  promote sleep
• Assess sleep pattern daily
• Client will verbalize plan to sleep at night,
  wake in am
• Reduce environmental noise
• Monitor fluid intake after 6PM
• Instruct family on sleep patterns and disease

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Interventions

• Provide Calm environment by closing door at night
• Rub lotion on back before bed at 10PM
• Turn off tv at 8pm
• Administer sleeping pill by 9pm
• Keep sleep log
• Educate family on need to give diuretic before
  4pm

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Evaluation

• 6 of 7 nights closed door before 9PM
• Did not rub patients hairy back at all
• Wife turned off tv at night before 11pm
• Gave extra sleeping pills and benadryl to keep
  patient off call light 7 of 7 nights
• Sleep log kept by nurse first two days, family
  kept last 5 days (instructed not to hit patient
  with sleep log)
• Wife took patients diuretic related to her
  swollen ankles discuss this with social work