Sleep and rest

SLEEP AND REST
Prepared By:
Krupa Mathew.M,
Associate Profesor

Definition
• Rest is a condition in which the body is in a decreased
state of activity without physical emotional stress and
freedom from anxiety.
• Sleep is a state of rest accompanied by altered level of
consciousness and relative inactivity, and perception to
environment are decreased

PHYSIOLOGY OF SLEEP
The cyclic nature of sleep is thought to be controlled
by Centers located in the brain and by Circadian
Rhythms.
Reticular activating system (RAS) located at the brain
stem and Cerebral Cortex plays an important role in
sleep wake cycle.

Sleep begins with the activation of
the pre optic area of the anterior
hypothalamus.
Sleep promoting neurons act over
wake promoting neurons by
releasing Gamma Amino Butyric
Acid (GABA).
The inhibition of wake promoting
neurons results in intensifying sleep
process.
Another key factor to sleep is
exposure to darkness.

Darkness and preparing for sleep
(e.g., lying down, decreasing noise)
cause a decrease in stimulation of
the RAS.
During this time, the Pineal gland
in the brain begins to actively
secrete the natural hormone
Melatonin, and the person feels less
alert.
With the beginning of daylight,
Melatonin is at its lowest level in
the body and the stimulating
hormone, Cortisol , is at its highest
causing wakefulness.

Circadian Rhythms
 It is a sort of 24-hour internal
biological clock. The term
circadian is from the Latin “circa
dies”, meaning “about a day.”
Biological rhythms exist in plants,
animals, and humans.
In humans, these are controlled
from within the body and
synchronized with environmental
factors, such as light and darkness.

Types/ Stages/ Phases Of Sleep
Electroencephalogram (EEG) patterns,
eye movements and muscle activity are used to
identify stages of sleep.
The stages of sleep are classified into two
stages:
1. Non Rapid Eye Movement (NREM) Sleep
 Stage 1
 Stage 2
 Stage 3
 Stage 4
2. Rapid Eye Movement Stage(rem) Sleep.
During sleep, NREM and REM sleep alternate
in cycles

Non Rapid Eye Movement
(NREM) Sleep
 First stage of sleep is known as
NREM sleep.
 About 75% to 80% of sleep during
a night is NREM sleep.
It consists of four stages:
Stage 1
Stage 2
Stage 3
Stage 4

NREM Sleep
Stage 1: NREM
 Stage lasts a few minutes.
It includes lightest level of sleep.
Gradual fall in vital signs and
metabolism.
General slowing of EEG frequency
Eyes tend to roll slowly from side
to side
 Sensory stimuli such as noise
easily arouses person.
Sleeper may deny he is sleeping.

Stage 2: NREM
Stage lasts 10 to 20 minutes.
It is a period of sound sleep.
Relaxation progresses.
Further slowing of EEG
Absent eye ball movements
Body functions continue to slow.
Arousal remains relatively easy

Stage 3: NREM
Stage lasts 15 to 30 minutes.
It involves initial stages of deep
sleep.
Muscles are completely relaxed.
Large slow waves in EEG
Vital signs decline but remain
regular.
Sleeper is difficult to arouse and
rarely moves

Stage 4: NREM
 Stage lasts approximately 15 to 30
minutes.
 It is the deepest stage of sleep.
 If sleep loss has occurred, sleeper spends
considerable portion of night in this
stage.
 Vital signs are significantly lower than
during waking hours.
 Further slowing of EEG
 Sleepwalking and enuresis (bed-wetting)
sometimes occur.
 It is very difficult to arouse sleeper

REM Sleep
 Stage usually begins about 90
minutes after sleep has begun.
Dreaming occurs in this stage
Stage is typified by rapidly moving
eyes, fluctuating heart and respiratory
rates, increased or fluctuating blood
pressure, loss of skeletal muscle tone,
and increase of gastric secretions.
EEG pattern resembles that of awake
state.
It is very difficult to arouse sleeper.

FUNCTIONS OF SLEEP
Conservation of energy
Restoration of tissues and growth
Thermoregulation
Regulation of emotions- sleep
deprivation causes emotional
disorders like irritability, anxiety,
depression etc.
 Neural maturation
Memory and learning- there will be
information transfer between
cerebral cortex and hippocampus
during sleep

Normal Sleep Requirements
Newborn: 16-18 hours /day
 Infants: 12-14 hours
Toddlers: 10-12 hours
Preschool: 11-12 hours
 School-Age: 8- 12 hours
Adolescents: 8-10 hours
Adult: 6-8 hours
Elders: 6 hours

FACTORS AFFECTING SLEEP
Both the quality and the quantity of sleep are
affected by a number of factors.
Sleep quality is a subjective characteristic
Quantity of sleep is the total time the individual
sleeps.
1. AGE
2. Illness - Illness that causes pain or physical
distress (e.g., arthritis, backpain) can result in
sleep problems
Examples: Respiratory conditions, Pain,
need to urinate during the night

3. Environment
• Environment can promote or hinder sleep
• Any change—for example, noise in the
environment—can inhibit sleep.
• The absence of usual stimuli or the
presence of unfamiliar stimuli can prevent
people from sleeping
• Discomfort from environmental
temperature (e.g., too hot or cold) and lack
of ventilation can affect sleep
• Light levels can be another factor
• Another influence includes the comfort
and size of the bed.
• A person’s partner who has different sleep
habits, snores, or has other sleep difficulties
may become a problem for the person also.

4. Lifestyle
• Following an irregular morning and
night time schedule can affect sleep.
• Night shift workers frequently obtain
less sleep than other workers and have
difficulty falling asleep.
5. Emotional Stress
• Stress is considered to be the major
cause of short-term sleeping difficulties .
• A person preoccupied with personal
problems (e.g., school- or job-related
pressures, family or marriage problems)
may be unable to relax sufficiently to get
to sleep.

6. Stimulants and Alcohol
• Caffeine-containing beverages act as
stimulants of the central nervous
system (CNS). • Drinking beverages
containing Caffeine in the afternoon
or evening may interfere with sleep.
• Even though alcohol induces sleep,
it disturbs REM sleep causing
irritability.
7. Diet
• Certain foods induces sleep
• Ex: the L- tryptophan present in the
milk induces sleep

8. Smoking
• Nicotine has a stimulating effect on
the body, and smokers often have
more difficulty falling asleep than non
smokers.
• Smokers can be easily aroused
9. Motivation
• Motivation can increase alertness in
some situations
• Ex: During the time of examination
Browsing internet in the late night

10. Medications:
• Beta-blockers have been known to
cause insomnia.
• Narcotics, such as morphine, are
known to suppress REM sleep and to
cause frequent awakenings and
drowsiness.
• Most Hypnotics suppresses REM
sleep

SLEEP DISORDERS
Sleep disorders are mainly classified into 3 categories
1. DYSOMNIAS
2. PARASOMNIAS
3. DISORDERS DUE TO OTHER MEDICAL
CONDITIONS

DYSOMNIAS
• The sleep itself is pretty normal.
• But the client sleeps too little, too much,
or at the wrong time.
• So, the problem is with the amount
(quantity), or with its timing, and
sometimes with the quality of sleep
Common Dysomnias are:
Insomnia
Hypersomnia
Narcolepsy
Sleep Apnea
Insufficient Sleep/ Sleep Deprivation

Insomnia
 Insomnia is described as the inability to fall
asleep or remain asleep.
 Persons with insomnia awaken not feeling
rested.
 Insomnia is the most common sleep
complaint.
 Acute insomnia lasts one to several nights and
is often caused by personal stressors or worry.
 If the insomnia persists for longer than a
month, it is considered Chronic insomnia
 Insomnia can result from physicl discomfort
and more often from mental tension or anxiety.
 People who are habituated to drugs or who
takes large amounts of alcohol are at high risk
for insomnia

Insomnia Clinical manifestations:
■ Difficulty falling asleep
■ Waking up frequently during the night
■ Difficulty returning to sleep
■ Waking up too early in the morning
■ Unrefreshing sleep
■ Daytime sleepiness
■ Difficulty concentrating
■ Irritability
Treatment is development of new
behavioral patterns that induces sleep
.Create a sleeping environment that
induces sleep . Create positive sleep
thoughts

Hypersomnia
Hypersomnia refers to conditions where
the affected individual obtains sufficient
sleep at night but still cannot stay awake
during the day.
Hypersomnia can be caused by medical
conditions, for example, CNS damage
and certain kidney, liver, or metabolic
disorders, such as diabetic acidosis and
hypothyroidism.
Treatment of hypersomnias include
treating the underlying disease conditions

Narcolepsy
• Narcolepsy is a disorder of excessive
daytime sleepiness caused by the lack of
the chemical hypocretin in the area of the
CNS that regulates sleep.
• Clients with narcolepsy have sleep
attacks or excessive daytime sleepiness,
and their sleep at night usually begins
with a sleep-onset REM period (dreaming
sleep occurs within the first 15 minutes of
falling asleep).
• People sleeps several times a day even
when they are conversing with people or
while driving.
• CNS stimulants and Antidepressants are
the drugs used to treat narcolepsy.

Sleep Apnea
• Sleep Apnea is characterized by frequent short
breathing pauses during sleep.
• Although all individuals have occasional
periods of apnea during sleep, more than five
apneic episodes longer than 10 seconds in an
hour is considered abnormal and should be
evaluated by a sleep medicine specialist.
• Sleep Apnea is most frequently diagnosed in
men and postmenopausal women, it may occur
during childhood.
Three types of apnoea based on the cause
1. Obstructive Apnoea
2. Central Apnea
3. Mixed Apnea

1. OBSTRUCTIVE APNOEA:
• Obstructive apnea occurs when the
structures of the pharynx or oral cavity
block the flow of air.
• Enlarged tonsils and adenoids, a
deviated nasal septum, nasal polyps, and
obesity predispose the client to obstructive
apnea
• Treatment includes surgical removal of
tonsills, correcting nasal septum, weight
loss may be helpful.

2. CENTRAL APNEA:
• Due to defect in the respiratory centre
of the brain.
• Clients who have brainstem injuries
and often have central sleep apnea.
3.MIXED APNOEA
• Mixed apnoea is combination of
obstructive and central apnea

Insufficient Sleep/ Sleep Deprivation
• A prolonged disturbance in quality and quantity
of sleep can lead to a syndrome called as sleep
deprivation.
• It is not a sleep disorder but result of prolonged
sleep disturbance.
• It produces various physiological and
behavioural symptoms based on the severity of
deprivation.
Insufficient Sleep/ Sleep Deprivation Individuals
may develop:
• Attention and concentration deficits
• Reduced vigilance
• Distractibility
• Reduced motivation
• Fatigue
• Diplopia and dry mouth

PARASOMNIAS
• Something abnormal occurs during
sleep itself, or during the times when
the client is falling asleep or waking up
• The quality, quantity, and timing of the
sleep are essentially normal.
• Most common DISORDERS are:
Bruxism
Enuresis
Periodic limb movement disorder
Sleep talking
Sleep walking

Bruxism
Usually occurring during stage II
NREM sleep, characterized by clenching
and grinding of the teeth. This clenching
and grinding of the teeth can eventually
erode dental crowns, cause teeth to come
loose, and lead to deterioration of the
temporomandibular (TMJ) joint, called
TMJ syndrome
Enuresis.
Bed-wetting during sleep occuring
in children over 3 years old. More males
than females are affected. It often occurs 1
to 2 hours after falling asleep.

Periodic limb movement disorder (PLMD).
In this condition, the legs jerk twice or
three times per minute during sleep. It is most
common among older adults. Respond well
to medications such as levodopa,
pramipexole , ropinirole, and gabapentin
Sleeptalking.
Talking during sleep occurs during
NREM sleep before REM sleep. It rarely
presents a problem to the person unless it
becomes troublesome to others
Sleepwalking.
Sleepwalking (somnambulism) occurs
during stages III and IV of NREM sleep. It is
episodic and usually occurs 1 to 2 hours after
falling asleep. Sleepwalkers tend not to notice
dangers (e.g., stairs) and often need to be
protected from injury

Disorders due to other medical
conditions
• These disorders are associated with
Medical or Psychiatric or other illness
Usually the disorders that cause sleep
disturbance includes:
• Depression
• Alcolism
• Thyroid dysfunction
• Peptic ulcer
• COPD- chronic obstructive pulmonary
disease

Nursing Interventions To
Promote Sleep
1. Sleep-Wake Pattern
• Maintain a regular bedtime and wake-
up schedule
• Eliminate day time naps. If naps are
taken, limit to 20 minutes or less twice a
day
• Instruct the client to go to bed when
sleepy.
• Use warm bath and relaxation
techniques
• If unable to sleep in 15 to 30 minutes,
get out of bed and persue some
relaxation activity.

• Establish a regular, relaxing
bedtime routine before sleep such
as reading, listening to soft music,
taking a warm bath, or doing some
other quiet activity.
• Avoid dealing with office work or
family problems before bedtime
• Get adequate exercise during the
day to reduce stress, but avoid
excessive physical exertion at least
3 hours before bedtime.

2. Environment:
• Create a sleep-conducive
environment that is dark, quiet,
comfortable, and cool.
• Keep noise to a minimum; block out
extraneous noise as necessary with
white noise from a fan, air
conditioner.
• Sleep on a comfortable mattress and
pillows.
• Listen to relaxing music
• Increase exposure to bright light
during the day

3. Diet:
• Limit alcohol, caffeine, and nicotine
in late afternoon and evening
• Consume carbohydrates or milk as a
light snack before bedtime.
• Avoid heavy and spicy foods. Heavy
or spicy foods can cause
gastrointestinal upsets that disturb
sleep
• Decrease fluids 2 to 4 hours before
sleep

4.Medications:
• Use sleeping medications only as a
last resort • Minimize the usage of
medicines as much as possible
because many contain antihistamines
that cause daytime drowsiness.
• Take analgesics 30 mins before
bedtime to relieve aches and pains.
• Consult the health care provider
about adjusting other medications that
may cause insomnia

Sleep and rest

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