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Sleep disorders
Sleep disorders
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Sleep disorders

  1. 1. NEELU ARYAL Msc Nursing 1st year SLEEP DISORDER
  2. 2. SLEEP  Nearly one third of our life is spent in sleep.  EEG recording show typical features of sleep.  It is known that sleep is divided into two different phases. 1)D-sleep(desynchronized or dreaming sleep) or REM sleep(rapid eye movement sleep) or active sleep or paradoxical sleep) 2)S-sleep(synchronized sleep) or NREM- sleep(non-REM sleep) or quiet sleep or orthodox sleep.S-sleep or NREM-sleep is further divided into 4 stages,from stage 1 to stage 4.
  3. 3. CONTINUE…  As the person falls asleep,the person first passes through these stages of NREM-sleep. Depending on the duration of total sleep,two extremes of normal sleeping patterns have been described. 1)long-sleepers These persons regularly and habitually sleep for more than 9 hours/night and this pattern of sleep doesnot cause any symptoms or dysfunctions.
  4. 4. CONTINUE… 2)Short-sleepers These persons regularly and habitually sleep for less than 6 hours/night and this pattern of sleep does not cause any symptoms or dysfunctions.
  5. 5. DSM-IV Classification 1) Primary Sleep Disorder 2) Sleep disorder related to another mental disorder 3) Other sleep disorder, most notably those due to a general medical condition or substance-induced.
  6. 6. SLEEP DISORDERS(TYPES) • Sleep can be regarded as a physiological reversible reduction of conscious awareness. • Sleep disorders are divided into subtypes: 1)DYSSOMNIAS Insomnia Hypersomnia Disorders of sleep-wake schedule
  7. 7. CONTINUE… 2)PARASOMNIAS Stage iv disorders Other disorders
  8. 8. DYSSOMNIAS  Dyssomnias are those sleep disorders which are characterized by disturbances in the amount,quality or timing of sleep.These are the commonest disorders of sleep.
  9. 9. INSOMNIA  Insomnia means one or more of the following: 1)Difficulty in initiating sleep. 2)Difficulty in maintaining sleep This includes both: -frequent awakenings during the night,and -early morning awakening. 3)Non-restorative sleep,i.e.despite adequate duration of sleep,feeling of not having rested present(poor quality sleep)
  10. 10. DIAGNOSIS  Sleep disturbances should be at least : 3 times a week For at least 1 month and It causes marked distress or interference with social and occupational functioning.
  11. 11. CAUSES MEDICAL ILLNESS  Any painful or uncomfortable illness.  Heart disease  Respiratory diseases  Brain stem or hypothalamic lesions  Delirium  Rheumatic and other musculoskeletal diseases  Periodic movements in sleep  Old age
  12. 12. CONTINUE… ALCOHOL AND DRUG USE  Delirium tremens  A mphetamines or other stimulants  Chronic alcoholism
  13. 13. CONTINUE… CURRENT MEDICATION  Fluoxetine  Steroids  Theophylline  Propranolol
  14. 14. CONTINUE… PSYCHIATRIC DISORDERS  Mania(due to decreased need for sleep)  Major depression(early morning awakening or late insomnia)  Dysthymia or neurotic depression(difficulty in initiating sleep or early insomnia)  Schizophrenia and other psychoses(due to psychotic symptoms)  Anxiety disorder(difficulty in initiating sleep due to worrying thoughts)
  15. 15. CONTINUE… SOCIAL CAUSES  Financial loss  Separation or divorce  Death of spouse or a close relative  Retirement  Stressful life situations
  16. 16. CONTINUE… BEHAVIOURAL CAUSES  Naps during the day  Irregular sleeping hours  Lack of physical exercise  Excessive intake of beverages in the evening,for eg:coffee  Disturbing environment(heat,cold,noise)
  17. 17. TREATMENT  A thorough medical and psychiatric assessment;polysomnography may be needed in some cases.  Treatment of underlying physical or psychiatric disorder.  Withdrawal of current medications,if any.
  18. 18. CONTINUE… NON-DRUG TREATMENT  Progressive relaxation  Autosuggestion  Meditation,yoga  Stimulus control therapy:-do not use the bed for reading or chatting-go to bed for sleep only.
  19. 19. CONTINUE… SLEEP HYGIENE  Regular, daily physical exercises in the evening.  Avoid fluid intake and heavy meals just before bedtime.  Aviod caffeine intake(for eg:tea,coffee,cola drinks)before sleeping hours.  Avoid reading or watching television while in bed.  Back rub,warm milk and relaxation exercises.  Sleep in a comfortable environment.
  20. 20. B)HYPERSOMNIA Hypersomnia means one or more of the following:  Excessive day time sleepiness.  Sleep attacks during day time(falling asleep unintentionally)  Sleep drunkenness(person needs much more time to awaken and during this period is confused or disoriented)
  21. 21. DIAGNOSIS  Sleep disturbance occurs daily for at least 1 month or for recurrent periods of shorter duration,and that it causes either marked disterss or interferes with social and occupational functioning.
  22. 22. CAUSES 1)MEDICAL ILLNESS  Narcolepsy(in about 25% of all patients with hypersomnia)  Sleep apnea(in about 50% of all patients with hypersomnia)  Kleine-Levine syndrome 2)ALCOHOL AND DRUG USE  Stimulant withdrawal  Alcohol intoxication  Use of CNS depressant medications
  23. 23. CONTINUE… 3)PHYCHIATRIC DISORDERS  Dysthymia  Atypical depression  Avoidance reaction 4)IDIOPATHIC HYPERSOMNIA
  24. 24. MEDICAL ILLNESS 1)NARCOLEPSY Consists of excessive daytime sleepiness and abnormal manifestation of REM sleep occuring daily for at least 3 months.
  25. 25. SYMPTOMS  Sleep attacks(most common)  Cataplexy-sudden decrease or loss of (sleep paralysis)muscle tone,often generalized and may lead on to sleep.  Hypnagogic hallucinations(dream like vivid perceptions associated with fearfulness)  Sleep paralysis: It occurs either at awakening in morning or at sleep onset.The person is conscious but unable to move his body.(least common)
  26. 26. TREATMENT The treatment consists of :-  Stimulant medication(eg:amphetamines)in some patients and/or  Antidepressants(particularly when cataplexy is a prominent symptoms)
  27. 27. CONTINUE… 2)SLEEP APNEA  It is characterized by repeated episodes of apnea during sleep.  Apnea is defined as cessation of airflow at the nostrils(and mouth)for 10 seconds or longer.  The apnea can be of central type,obstructive type or mixed type.  It is common in elderly and obese(pick- wickian syndrome)
  28. 28. CONTINUE…  Typically,there are 5 or more apneic episodes per hour of sleep and the total number of apneic episodes exceed 30 during one night sleep.In severe cases,the number of episodes may be in hundreds.
  29. 29. TREATMENT  Avoidance of alcohol and depressant medications.  Use of stimulants like caffeine,regular exercises and losing excess weight,teaching correct sleep posture.  Corrective procedures for obstructive sleep apnea.(eg:mechanical tongue retaining device)  Very severe obstructive sleep apnea may necessitate tracheostomy(functional only at night),CPAP through nasal mesh,or even pharyngoplasty.
  30. 30. CONTINUE… 3)KLEINE-LEVIN SYNDROME This is a rare syndrome characterized by:-  Hypersomnia (always present),occuring recurrently for long periods of time.  Hyperphagia(usually present),with a varacious appetite.  Hypersexuality(associated at times),consisting of sexual disinhibition,masturbatory activity,exhibitionism,and/or inappropriate sexual advances.
  31. 31. CONTINUE…  A typical episode lasts for one to several weeks followed usually by a complete remission.  Common age of onset is the second decade of life.  The disorder is almost always seen in males. TREATMENT  No specific treatment is available,although lithium and occasionally carbamazepine have been reported to be successful.
  32. 32. TREATMENT OF HYPERSOMNIA  Through physical and psychiatric assessment.  Treatment of underlying cause.  Associated or underlying insomnia should be looked for and treated.  Withdrawal of current medication causing hypersomnia  Stimulant drugs like amphetamine given in the morning or the evening.  Nonsedative antidepressant drugs such as serotonin specific reuptake inhibitors.
  33. 33. C)DISORDERS OF SLEEP- WAKE SCHEDULE  These are characterised by a disturbance in the timing of sleep. CAUSES 1)Jet lag type: Sleepiness and alertness occurs at an inappropriate time of day relative to local time. Occuring after repeated travel across more than one time zone.
  34. 34. CONTINUE… 2)Shift work type:  Insomnia during major sleeping period or excessive sleepiness during major wake period associated with night shift work. 3)Delayed sleep phase type:  A persistent pattern of late sleep onset and late awakening time.
  35. 35. TREATMENT  No specific treatment needed.  Benzodiazepines may be needed for short- term correction of insomnia.  Changes in’work-shifts’ may be needed for persons with unusual sleep phases.  Exposure to sunlight during outdoor activity(instead of staying indoors) and adopting the local(new)hours for sleeping (and working)can help in combacting jet lag.
  36. 36. PARASOMNIAS  Parasomnias are dysfunctions or episodic nocturnal events occuring with sleep,sleep stages or partial arousal.  Most parasomnias are common in childhood though they may persist into adulthood.
  37. 37. TYPES A)STAGE 4 SLEEP DISORDERS  These are disorders occuring during deep sleep.  The common stage 4 parasomnias are: 1)sleep-walking(somnambulism) 2)sleep-terrors or night terrors(pavor nocturnus) 3)sleep-related enuresis 4)bruxism 5)sleep-talking(somniloquy)
  38. 38. CONTINUE… 1)SLEEP-WALKING(SOMNAMBULISM)  The patient carries out autonomic motor activities that range from simple to complex.  He may leave the bed,walk about or leave the house.  Arousal is difficult and accidents may occur during sleep-walking 2)SLEEP-TERRORS OR NIGHT TERRORS(PAVOR NOCTURNUS)  The patient suddenly gets up screaming,with autonomic arousal(tachycardia,sweating,and hyperventilation).
  39. 39. CONTINUE…  He may be difficult to arouse and rarely recalls the episode on awakening.  In contrast,nightmares(which occur during REM sleep) are clearly remembered in the morning. 3)SLEEP-RELATED(BED WETTING) 4)BRUXISM  The patient has involuntary,and forceful grinding of teeth during sleep.  It causes the destruction of the tooth enamel.  The patient remains completely unaware of the episode.
  40. 40. CONTINUE… 5)SLEEP-TALKING(SOMNILOQUY)  The patient talks during the stage 3 and 4 of sleep but doesnot remember anything about it in the morning on awakening. TREATMENT  Since benzodiazepines suppress stage 4 of NREM sleep,a single dose at bedtime usually provides relief from stage 4 parasomnias.
  41. 41. CONTINUE… B)OTHER SLEEP DISORDERS  Nocturnal angina  Nocturnal asthma  Nocturnal seizures  Sleep paralysis
  42. 42. SLEEP HYGIENE  Avoid naps except for a brief 10-15 min nap 8 hrs after rising but check with the physician first because in some sleep disorders naps can be beneficial.  Get regular exercise at least 40 min each day that causes sweating  Take a warm bath or warm shower about 2 hrs before bedtime.  Don’t use bright light even you have to remain awake for long during nighttime
  43. 43. CONTINUE…  Expose to half an hour of sunlight during 30 min of rising should be useful to prevent drowsiness in the morning  Take regular time out of bed for 7 days a week  Don’t smoke to get sleep  Give up smoking entirely or don’t smoke after 7 p.m.  Avoid caffeine entirely or limit no more than 3 cups per day and not after 10 a.m.  Too much time in bed is not good Remember that quality of sleep is important.
  44. 44. CONTINUE…  Keep the clock face turned away. Don’t see what time of night you are awake.  Don’t eat heavily or drink 3 hrs before bedtime. A light bedtime snacks is o.k.  Incase of problem of regurgitation, elevate the head of bed and prevent spicy as well as oily meal before bedtime  Keep your room well ventilated, dark and quiet during nighttime.  Reading non-professional materials may be useful. Perform bedtime rituals.
  45. 45. CONTINUE…  Use stress management technique in daytime.  Make sure that mattress isn’t too firm or too soft. Ensure that the pillow is of appropriate height and firmness.  An occasional sleeping pill is alright but use only after consultation with doctor.  Use bedroom only for sleep. Avoid activities that lead to prolonged arousal.
  46. 46. FOR PATIENT WITH SLEEP DISORDER Assessment  To promote the restful sleep for clients, nurse can assess the sleep pattern.  Usually patients are the best resources for describing their sleep problem. Some time we can take history from the partner.  In case of children, older children or mother can best describe the pattern of sleep and its problem.
  47. 47. CONTINUE… The tools for sleep assessments are:  Sleep history including -Description of client’s sleep problem; nature, sign/symptoms, onset, duration, predisposing factors, severity, effects on client. -Usual sleep pattern prior to sleep problem -Recent changes in sleep pattern -Physical illness -Bedtime routine and sleeping environment -Use of any medication
  48. 48. CONTINUE…  Pattern of dietary intake or any substance -symptoms experienced during waking hours -recent life event - Current emotional and mental status  Sleep diary including -times when patient tries to fall asleep -approximate time that patient fall asleep -time of awakening during night -record of food, physical activity, worries, mental activity
  49. 49. NURSING DIAGNOSIS Sleep Pattern Disturbance Related To: 1. Impaired oxygen transport 2. Impaired elimination 3. Immobility 4. Medication 5. Hospitalization 6. Lack of exercise 7. Anxiety response 8. Life-style disruptions
  50. 50. CONTINUE… As evidenced by: Major: (Must be present )  Difficulty falling or remaining asleep Minor: (May be present)  Fatigue on awakening or during the day  Dozing during the day  Agitation  Mood alterations
  51. 51. NURSING DIAGNOSIS  Sleep pattern disturbance related to decreased physical activity, fear, anxiety, inability to assume usual sleep position, frequent assessments or treatments, unfamiliar environment, and discomfort resulting from current illness/injury.
  52. 52. EXPECTED OUTCOME  The client will attain optimal amounts of sleep as evidenced by:  statements of feeling well rested  usual mental status  absence of frequent yawning and dark circles under eyes
  53. 53. INTERVENTION  Assess for signs and symptoms of a sleep pattern disturbance. (e.g. statements of difficulty falling asleep, not feeling well rested, or interrupted sleep; irritability; disorientation; lethargy; frequent yawning; dark circles under eyes).  Determine the client's usual sleep habits.
  54. 54. CONTINUE…  Implement measures to promote sleep: perform actions to reduce fear and anxiety.  Discourage long periods of sleep during the day unless signs and symptoms of sleep deprivation exist or daytime sleep is usual for client Perform actions to relieve discomfort if present (e.g. reposition client; administer prescribed analgesics, antiemetics, or muscle relaxants
  55. 55. CONTINUE…  discourage intake of foods and fluids high in caffeine (e.g. chocolate, coffee, tea, colas) in the evening.  offer client an evening snack that includes milk or cheese unless contraindicated (the L-tryptophan in milk and cheese helps induce and maintain sleep)
  56. 56. CONTINUE…  allow client to continue usual sleep practices (e.g. position; time; presleep routines such as reading, watching television, listening to music, and meditating) whenever possible.  satisfy basic needs such as comfort and warmth before sleep.  encourage client to urinate just before bedtime.
  57. 57. CONTINUE…  reduce environmental distractions (e.g. close door to client's room; use night light rather than overhead light whenever possible; lower volume of paging system; keep staff conversations at a low level and away from client's room; keep beepers and alarms on low volume; provide client with "white noise" such as a fan, soft music, or tape-recorded sounds of the ocean or rain; have sleep mask and earplugs available for client if needed)  ensure good room ventilation  encourage client to avoid drinking alcohol in the evening (alcohol interferes with REM sleep)
  58. 58. CONTINUE…  if possible, administer medications that can interfere with sleep (e.g. steroids, diuretics) early in the day rather than late afternoon or evening  administer prescribed sedative-hypnotics if indicated.  perform actions to reduce interruptions during sleep (80 - 100 minutes of uninterrupted sleep is usually needed to complete one sleep cycle)  restrict visitors  group care (e.g. medications, treatments, physical care, assessments) whenever possible.
  59. 59. CONTINUE…  Consult appropriate health care provider if signs and symptoms of sleep deprivation persist or worsen.
  60. 60. CONTINUE…  Evaluation  Reassessment
  61. 61. RESEARCH RESEARCH ARTICLE  Effect of cognitive behaviour therapy on sleep disorder in parkinson’s disease in China: A pilot study  By:Hualu Yang RN1  Article first publish on 27 nov 2012  In this study they evaluated the effect of cognitive behaviour therapy provided to individual with parkinson’s disease.  A single group interupted time series design was used in this pilot study.
  62. 62. CONTINUE…  Analysis were conducted on 22 participants who provided data on pretest posttest and 3 months follow up.  At each time point, participants completed a sleep diary and parkinson’s disease sleep scale.  There was a significant difference between pre-test and post-test.  The result suggests that cognitive behaviour therapy facilitates improvement of sleep disorders in patient with parkinson’s disease and provides important information necessary to design more definitive studies in the future.
  63. 63. THAN K YOU