Sleep Disorders

15. Sleep Disorders

A. dyssomnias – characteristics by insomnia or excessive sleepiness

B. parasomnias – patterns of waking behavior that appear during sleep (sleepwalking)

16. Dyssomnias

A. insomnia – inability to fall asleep, remain asleep, or go back to sleep

B. hypersomnia – excessive sleep

C. narcolepsy – uncontrolled desire to sleep

D. sleep apnea – absence of breathing or diminished breathing

E. sleep deprivation ↓amount, consistency, and quality of sleep

17. Obstructive Sleep Apnea

A. upper airway obstructed, tongue relaxes & falls back

B. can treat by removing tonsils, oral appliance, or CPAP – continuous positive air pressure

18. Parasomnias

A. somnambulism – sleep walking

B. sleep talking

C. nocturnal erections

D. bruxism

E. enuresis

F. sleep-related eating disorder – patient not remember eating in morning (sleep drug "Ambien"

may cause)

19. Treatment for Dyssomnias

A. pharmacologic therapy – sedatives & hypnotics (can disturb REM or NREM sleep don't use

long term). Non benzohypnotics (sleep meds.), & benzohypnotics ↓anxiety. Barbituates

can have withdrawal symptoms: Nambutol & Seconal

B. Nonpharmacologic Therapy

a. stimulus control ↓noise, temperature adjusted to comfortable level

b. sleep restriction – no napping, awaken at same time each day

c. sleep hygiene – avoid caffeine, alcohol, nicotine, have regular routine

d. cognitive therapy – stress & anxiety reduction

e. multicomponent therapy – combination

f. relaxation therapy – guided imagery, progressive muscle relaxation

20. Common Etiologies for Nursing Diagnoses

A. physical or emotional discomfort or pain

B. changes in bedtime rituals or sleep environment

C. disruption of circadian rhythm

D. exercise and diet before sleep

E. drug dependency & withdrawal

F. symptoms of physical illness & pain

21. Nursing Interventions to Promote Sleep

A. prepare a restful environment – dim lights

B. promote bedtime rituals

C. offer appropriate bedtime snacks and beverages (small protein, peanut butter & crackers)

D. promote relaxation & comfort

E. respect normal sleep-wake patterns

22. Interventions – con't

A. schedule nursing care to avoid disturbances

B. use medications to produce sleep

C. teach about sleep & rest

Factors Affecting Sleep

5. Factors Affecting Sleep

A. developmental considerations – how many hrs. sleep each dev. stage sleeps.

B. psychological stress – may not get proper sleep, with stress REM sleep ↓, so anxiety ↑

C. motivation – desire to be wakeful, alert

D. culture – ie. kids who sleep with parents, bedtime rituals, place, position, pattern of sleep

E. lifestyle & habits – physical activity & exercise (exercise at least 2 hrs. prior to bedtime

contributes to sleep, if exercise ½ hr before bedtime, not help sleep. nicotine is a stimulant

6. Factors affecting sleep – con't.

A. dietary habits: L-tryptophan in cheese, milk, carbohydrates promote relaxation through

effects on brain serotonin

B. environmental factors – lighting, odors, ventilation, noise

C. medications – barbituates, amphetamines, antidepressants all ↓REM sleep, caffeine is CNS

stimulant. diuretics should not be given at bedtime, anti-Parkinsonian meds. and some

antihypertensives, caffeine, steroids, decongestants, or asthma meds can cause sleep problem

D. illness or large quantities of alcohol intake limit REM & Delta sleep

7. Medications

A. Tricyclic antidepressants – Amitriptyline & Doxepin

B. Antihistamines – Benadryl, Vistaril, & Atarax

C. Sedatives / Hypnotics – Lunesta, Ambien, & Sonata (all for sleep)

D. Benzodiazapine – Dalmane, Restoril (for sleep & anxiety)

E. Melatonin – Rozerem

8. Illness Associated with Sleep Disturbances

A. peptic ulcer (GI secretions ↑during REM sleep)

B. coronary artery disease – pain

C. epilepsy – seizures occur during NREM sleep

D. liver failure & encephalitis – reversal in day and night sleep

E. hypothyroidism ↓NREM sleep, especially stage II and stage IV

F. ESRD (end-stage renal disease) – disrupt nocturnal sleep, want to sleep in daytime

9. Sleep Disturbance Assessment Parameters

A. nature & cause of problem

B. signs & symptoms

C. Date & occurrence & effect on everyday living

D. severity of problem

E. treatment of problem

F. how the patient is coping with the problem

*hypothyroidism can alter stage II and stage IV sleep

10. Sleep Characteristics to Assess

    A. restlessness – can use Requip

    B. sleep posture – ie. pillows, on back, vs stomach

    C. sleep activities – smoking in bed (need to educate patient)

    D. snoring – obstruction to airflow through nose / mouth

    E. leg jerking – nocturnal "nyoclomus" muscle contraction

11. Information Recorded in a Sleep Diary

A. time patient retires

B. time patient tries to fall asleep

C. Approximate time patient falls asleep

D. Time of any awakening during the night & resumption of sleep

E. time awakening in the morning

F. presence of any stressors affecting sleep

12. Information Recorded in a Sleep Diary – con't

A. record of food, drink, or medications affecting sleep

B. record of physical & mental activities

C. record of activities 2-3 hrs before bedtime

D. presence of worries or anxieties affecting sleep

13. Key Findings of Physical Assessment

A. energy level – lethargic

B. facial characteristics – eyes glazed

C. behavioral characteristics – yawn, rub eyes, slumped, speech slow

D. physical data suggestive of sleep problems – very obese, enlarged neck, deviated septum

14. Classification of Sleep Disorders

A. dyssomnias

B. parasomnia

C. sleep disorders associated with medical or psychiatric disorders

D. other proposed disorders

Physiology of sleep

Rest – definition: relaxation, mental & physical calmness

Sleep – definition: altered state of consciousness, very little physical activity, slowing of body's

physiological processes

1. Physiology of sleep

   A. Facilitates reflex (reticular activating system "RAS") & voluntary movements

   B. Controls cortical activities related to state of alertness

   C. Bulbar synchronizing region works with RAS to control cyclic nature of sleep

   D. Hypothalamus – control center for sleeping & walking (injury to hypothalamus: person will

   sleep for abnormally long time)

   E. Neurotransmitters in brain – some excite: norepinephrine, histamine, acetylcholine, serotonin,

   and dopamine. some inhibit: GABA

   F. wakefulness occurs when peripheral sensory organs & cerebral cortex activates

2. Stages of sleep – Non-rapid eye movement (NREM)

   A. Stage I 5-10 minutes, transition between wakefulness & sleep, easily awakened, relaxed,

   aware of surroundings, regular deep breathing, 5% of total sleep time

   B. Stage II 10-15 minutes, light sleep, easily aroused physiologic changes to temp., BP.,

   HR, all ↓slightly. 50% of total sleep time.

   C. Stage III 5-15 minutes. deep sleep, difficult to arouse, parasympathetic N.S. causes temp.,

   pulse, resp., BP., to slow even more. skeletal muscles relaxed. 10% of total sleep time.

   D. Stage IV 20-50 minutes. (Delta). difficult to awaken, arousal threshold is greatest, body,

   mind, muscles relax. parasympathetic causes temp., BP ↓. If aroused, person is confused.

   10% total sleep time.

3. Stages of sleep – Rapid eye movement (REM)

   A. less restful than NREM

   B. eyes move rapidly, small muscles twitch, GI secretions ↑, large muscle activity & deep

   tendon reflex depression, dreaming, metabolism, BP, pulse ↑, breathing rapid, irregular,

   apnea may occur

4. Sleep cycle

   A. the person passes consequently through four stages of NREM sleep

   B. pattern is reversed – return from stage IV to III to II

   C. then enter REM sleep instead of reentering stage I

   D. the person reenters NREM sleep at stage II and moves on to III and IV

   E. if sleep is interrupted, person goes to stage IA Single Normal Sleep Cycle:

   Wakefulness→NREM Stage I→NREM Stage II→NREM Stage III→NREM Stage IV→

   NREM Stage III→NREM Stage II→REM→NREM Stage II

Nursing assessment for Pain Management

A. Nursing assessment

1. Subjective data - review past family history in terms of pain & review lifestyle & health

habits to determine how the pain interferes with the client's life. Ask open-ended

questions and quote as you document.

2. Objective data (see in Weber or Taylor)

Verbal-descriptor Scale (VDS)

Wong-Baker Faces Scale (FACES)

Numeric Rating Scale (NRS) 0-10

Visual Analog Scale (VAS)

B. WILDA scale

1. words that describe pain

2. intensity of pain

3. location of pain

4. duration of pain

5. aggravating or alleviating factors

6. any other symptom or sign nausea or vomiting (associated factors)

C. COLDSPA

1. character

2. onset

3.location

4. duration

5. severity

6. pattern

7. associated factors

D. Assessment procedure

1. observe posture, facial expression

2. measure vitals signs

3. perform physical assessment (inspect first, palpate last)

4. utilize exact client statements (quote)

5. validate & document data

E. General assessments of pain

1. patient's verbalization & description of pain

2. duration of pain

3. location of pain

4. quantity & intensity of pain

5. quality of pain

6. chronology of pain

7. aggravating & alleviating factors

8. physiologic indicators of pain (ie. respirations)

9. behavioral responses

10. effect of pain on activities & lifestyle

* 1379 Taylor assessment of special populations ie age-related, cognitive-impaired.

F. Nursing Interventions

1. establishing trusting nurse-patient relationship * most important

2. initiating nonpharmacologic pain relief measures. ie. ambulate, massage

3. considering ethical & legal responsibility to relieve pain

4. teaching patient about pain

G. Non medicinal pain control:

1. relaxation

2. distraction

3. meditation

4. massage

5. therapeutic touch

6. hypnosis subconscious state

7. biofeedback non-medicinal, machine monitors physiological values. Patient taught

relaxation, ie deep breathing, guided imagery. leads to changes in settings on machine,

used for pain control

8. acupuncture- needles inserted at pressure points

9. acupressure pressure points used (no needles) releases endorphins

10. cutaneous stimulation (TENS) external, low-frequency electrical stimulation used

to inhibit nerve transmission, ↓pain. Gate Control Theory, inhibits transmission of

local pain stimuli

11. heat & cold application

H. Invasive Medicinal Pain Control: pg 1395

1. Patient-Controlled Analgesia (PCA) calibrated by anesthesiologist, locked in

pump. Patient can control delivery of narcotic analgesic with calibrated pump by

pushing pump. Pump can administer a preset dose per time period, or patient-

controlled administration of drug (or both). Nurse needs to assess every two hours:

O₂ saturation, BP., respirations, LOC

2. Epidural analgesia postop, labor & delivery, or chronic pain. catheter placed in

epidural space (not spinal cord) between the vertebra & spinal cord covering. Can

be one time administration ie. back pain, or continuous (stays in place) & removed

at a later time. check blood pressure - tends to be higher with a rapid dose.

some drugs used: Delotid, Morphine, Demerol (can cause nausea), with all

check BP, respirations, GI, assess LOC.

See table 1398 (41-1) Care of Patients receiving epidural opoiods.

Keep Narcan (Naloxone) at bedside as an antidote for narcotics

3. Local Anesthesia block nerves directly

ie. dentist office

no systemic effect

"Emla cream" (lidocaine cream)- placed 30 minutes to 1hr prior is a local topical

anesthetic used for IV insertion for children or sutures

I. Numeric Sedation Scale

1. awake & alert no action needed

2. occasionally drowsy but easy to arouse no action

3. frequently drowsy, drifts off to sleep during conversation: reduce dose or just

monitor patient

4. somnolent with minimal or no response to stimuli, discontinue opioid, consider use

of naloxone (Narcan), check respirations

III. Nursing Diagnoses pg 1394 analgesic ladder know

1. pain noted - give nonopioid adjuvent + - (NSAIDs ↓need for narcotics)

2. pain persisting or ↑, give opioid for mild to mod. pain. nonopioid +, adj. + -

3. pain persisting or ↑, give opioid for mod. to severe pain, nonopioid +, adj. + -

4. freedom from cancer pain

Three types of pain scales

Three types of pain scales

1. simple descriptive

2. numeric intensity (1-10)

3. Wong-Baker faces (good for children)

I. Pain perception - 5^th vital sign interpretation of pain

1. threshold the least amount of stimuli that is needed for a person to identify it as pain

2. tolerance the maximum amount of painful stimuli a person is willing to withstand

without seeking avoidance of the pain (can change with circumstances)

J. Physiology of pain

1. transduction

2. transmission

3. modulation

4. perception

K. Transduction activation of pain receptors

Pain receptors, known as nociceptors, are sensory neurons on skin that travel via peripheral nervous system. These are excited by mechanical, thermal, or chemical stimuli.

*During transduction, stimuli trigger the release of biochemical mediators related to pain that sensitize these receptors.

*Some pain medications are effective during transduction in blocking portions of this process.

L. Transmission from site of injury to brain (afferent impulses)

1. pain impulse travels form the peripheral nerve fibers to the spinal cord

2. then from the spinal cord to the brain,pain control can take place at this step. ie. Opioids

block the release of neurotransmitters and stops the pain at the spinal level

3. A delta fibers are large nerve fibers that conduct organ pain that can be described as

aching or burning. (visceral pain)

4. reflex arc protective reflex response to protect the body from danger, such as touching a

hot iron. *substance "P" - neurotransmitter that enhances transmission in reflex pathway




M. Modulation pg 1374 (41-13)

1. The process where the pain sensation is inhibited or modified

2. regulation probably due to neuromodulators. these are endogenous opioids, morphine-like

substances that bind to opioid receptor sites in the brain. These are endorphins &

enkephalins

3. other neurotransmitters that have a "blocking" effect are" serotonin & norepinephrine




N. Gate Control Theory of Pain

1. describes the transmission of pain and describes a relationship between pain & emotions

2. smaller peripheral nerve fibers conduct pain stimuli to the brain, and large diameter

nerve fibers inhibit the transmission of pain from the spinal cord to the brain.

3. a gating mechanism located in the spinal cord exhibit exciting & inhibiting signals that

affect the impulses are attempting to reach the brain at the same time.

4. past experiences and learned behavior can alter the gating mechanism, thus altering the

responses to pain.

5. attempts to explain why pain is interpreted differently by different people

6. also explains why heat,cold, and pressure are effective for some pain relief

TENS unit gate control theory

O. Responses to pain

1. physiologic involuntary

2. behavioral

3. affective




P. Physiologic responses: pg 1372 box 41-1

1. increase in blood pressure and heart rate as part of the fight or flight response. These

values return to normal after a number of minutes or hours, in spite of the continuation of

the pain

2. reflexive withdrawal away from pain

3. the person may hold their breath or the respirations may become short & shallow or

rapid

4. pallor

5.increase in glucose output and adrenalin also due to the fight or flight response

6. nausea & vomiting

7. fainting

8. alters immune system if last long enough, can increase the risk of infection & disease

9. the pain threshold is lowered if the pain is persistent

10. increases cardiac workload




Q. Behavioral responses

1. crying

2. moaning

3. grimacing

4. restlessness

5. decrease in movement can lead to other complications




R. Affective responses

1. depression

2. anxiety

3. fatigue

4. hopelessness

5. restlessness

6. sleeplessness

7. ↓appetite

8. decreased quality of life




S. Psychogenic Pain

1. a physical reason for pain cannot be identified

2. all other diagnoses should be thoroughly reviewed &n exhausted

3. documentation is the same as physical pain (many times pt has seen multiple Drs.)




T. Cultural considerations

1. influence reaction to & expression of pain

2. there is little variation in pain threshold, but culture influences the amount of pain one

tolerates

3. in some cultures, tolerance of pain signifies strength & endurance

4. family, gender, age, anxiety, past experiences, & religion also affect pain expression

Oriental not display/verbalize pain encourage to take pain meds

Comfort and Pain Management

Pain

A. defined: "an unpleasant sensory and emotional experience associated with actual or potential

tissue damage or described in terms of such damage" (American Pain Society, 2003).

B. Origin pg 1371

1. physical cause of pain can be identified

2. psychogenic cause of pain cannot be identified

3. Referred pain is perceived in an area distant from its point of origin (nerve-related)

ie. gall bladder pain mid back, kidney pain front of abdomen, appendicitis umbilicus,

liver right scapula

C. Classification Ch 41 Taylor

1. duration

2. location (source)

3. etiology

4. intensity

D. Acute pain

1. rapid onset

2. varies in intensity from mild to severe

3. warms of problem

4. is protective in nature

5. disappears after cause is resolved or recovery occurred

E. Chronic pain

1. last beyond normal period of healing

2. may involve periods of remissions & exacerbations

3. interfere with functioning

4. may lead to withdrawal, anger, frustration, dependency& depression

F. Location of pain

1. cutaneous skin or subcutaneous tissue (ie. superficial paper cuts)

2. somatic originates in tendons, ligaments, bones, blood vessels & nerves (ie. bone

fracture or sprain of foot)

3. visceral poorly localized & originates in body organs can be referred ie. pain from MI

heart attack) felt in jaw and left arm (men)

G. Etiology

1. Physiological occurs as a result of an intact, properly functioning nervous system

sending messages that tissue is damaged & in need of repair

2. Neuropathic results from injury to nerves of PNS or CNS, typically chronic (source can

be undetermined ie. burning, aching, shocking, dull, tingling)

H. Intensity Taylor 1384

1. mild 1-3 on a 1-10 scale

2. moderate 4-6

3. severe 7-10