Msc Nursing 1st year
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
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
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.
These persons regularly and habitually
sleep for more than 9 hours/night and this
pattern of sleep doesnot cause any symptoms
These persons regularly and habitually
sleep for less than 6 hours/night and this
pattern of sleep does not cause any
symptoms or dysfunctions.
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.
• Sleep can be regarded as a physiological
reversible reduction of conscious awareness.
• Sleep disorders are divided into subtypes:
Disorders of sleep-wake schedule
Stage iv disorders
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.
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)
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.
Any painful or uncomfortable illness.
Brain stem or hypothalamic lesions
Rheumatic and other musculoskeletal diseases
Periodic movements in sleep
ALCOHOL AND DRUG USE
A mphetamines or other stimulants
Mania(due to decreased need for sleep)
Major depression(early morning awakening or
Dysthymia or neurotic depression(difficulty in
initiating sleep or early insomnia)
Schizophrenia and other psychoses(due to
Anxiety disorder(difficulty in initiating sleep due to
Separation or divorce
Death of spouse or a close relative
Stressful life situations
Naps during the day
Irregular sleeping hours
Lack of physical exercise
Excessive intake of beverages in the
A thorough medical and psychiatric
assessment;polysomnography may be
needed in some cases.
Treatment of underlying physical or
Withdrawal of current medications,if any.
Stimulus control therapy:-do not use the bed
for reading or chatting-go to bed for sleep
Regular, daily physical exercises in the
Avoid fluid intake and heavy meals just
Aviod caffeine intake(for eg:tea,coffee,cola
drinks)before sleeping hours.
Avoid reading or watching television while in
Back rub,warm milk and relaxation exercises.
Sleep in a comfortable environment.
Hypersomnia means one or more of the
Excessive day time sleepiness.
Sleep attacks during day time(falling asleep
Sleep drunkenness(person needs much more
time to awaken and during this period is
confused or disoriented)
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
Narcolepsy(in about 25% of all patients with
Sleep apnea(in about 50% of all patients with
2)ALCOHOL AND DRUG USE
Use of CNS depressant medications
Consists of excessive daytime
sleepiness and abnormal manifestation of
REM sleep occuring daily for at least 3
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)
It occurs either at awakening in
morning or at sleep onset.The person is
conscious but unable to move his body.(least
The treatment consists of :-
some patients and/or
Antidepressants(particularly when cataplexy is
a prominent symptoms)
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-
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.
Avoidance of alcohol and depressant
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
Very severe obstructive sleep apnea may
necessitate tracheostomy(functional only at
night),CPAP through nasal mesh,or even
This is a rare syndrome characterized
Hypersomnia (always present),occuring
recurrently for long periods of time.
Hyperphagia(usually present),with a
times),consisting of sexual
A typical episode lasts for one to several
weeks followed usually by a complete
Common age of onset is the second decade
The disorder is almost always seen in males.
No specific treatment is available,although
lithium and occasionally carbamazepine have
been reported to be successful.
Through physical and psychiatric
Treatment of underlying cause.
Associated or underlying insomnia should be
looked for and treated.
Withdrawal of current medication causing
Stimulant drugs like amphetamine given in the
morning or the evening.
Nonsedative antidepressant drugs such as
serotonin specific reuptake inhibitors.
C)DISORDERS OF SLEEP-
These are characterised by a disturbance in
the timing of sleep.
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.
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.
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.
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.
A)STAGE 4 SLEEP DISORDERS
These are disorders occuring during deep
The common stage 4 parasomnias are:
2)sleep-terrors or night terrors(pavor
The patient carries out autonomic motor
activities that range from simple to complex.
He may leave the bed,walk about or leave the
Arousal is difficult and accidents may occur
2)SLEEP-TERRORS OR NIGHT
The patient suddenly gets up screaming,with
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
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 patient talks during the stage 3 and 4 of
sleep but doesnot remember anything about it
in the morning on awakening.
Since benzodiazepines suppress stage 4 of
NREM sleep,a single dose at bedtime usually
provides relief from stage 4 parasomnias.
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
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
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.
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
Reading non-professional materials may be
useful. Perform bedtime rituals.
Use stress management technique in
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.
FOR PATIENT WITH SLEEP
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.
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
-Bedtime routine and sleeping environment
-Use of any medication
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
Sleep Pattern Disturbance
1. Impaired oxygen transport
2. Impaired elimination
6. Lack of exercise
7. Anxiety response
8. Life-style disruptions
As evidenced by:
(Must be present )
Difficulty falling or remaining asleep
(May be present)
Fatigue on awakening or during the day
Dozing during the day
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
The client will attain optimal amounts of sleep as
statements of feeling well rested
usual mental status
absence of frequent yawning and dark circles
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.
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
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)
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
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
ensure good room ventilation
encourage client to avoid drinking alcohol in the evening
(alcohol interferes with REM sleep)
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
perform actions to reduce interruptions during sleep
(80 - 100 minutes of uninterrupted sleep is usually
needed to complete one sleep cycle)
group care (e.g. medications, treatments, physical care,
assessments) whenever possible.
Consult appropriate health care provider if
signs and symptoms of sleep deprivation persist
Effect of cognitive behaviour therapy on sleep
disorder in parkinson’s disease in China: A pilot
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.
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
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.
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