Running Head: DISTURBED SLEEP PATTERN

Disturbed Sleep Pattern

Andrew Becker

Saginaw Valley State University

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Definition

Disturbed sleep pattern is defined as “time-limited interruptions of sleep amount and

quality due to external factors” (Wilkinson & Barcus p. 802). In the most recent Nursing

Diagnosis Handbook, defining characteristics of disturbed sleep pattern include difficulty in

daily functioning and falling asleep, dissatisfaction with sleep, reports of feeling unrested, and

unintentional awakening. Related factors to, and possible causes of disturbed sleep pattern

consist of environmental factors, immobilization, lack of sleep privacy, a nonrestorative sleep

pattern, or a sleep partner causing disruptions in sleep quality (Wilkinson & Barcus, 2017).

Disturbed sleep pattern as a nursing diagnosis is delegated for use in temporary disruptions in

sleep, as may be common in an inpatient healthcare setting. The nursing diagnosis itself is only

useful as a definition of the concept, etiologic factors must be taken into consideration to provide

useful nursing interventions for the patient (e.g., Disturbed sleep pattern related to lack of sleep

privacy during the night). In NANDA, disturbed sleep pattern serves only as a temporary nursing

diagnosis towards impaired sleep, with prolonged amounts of impaired sleep that interfere with a

patient’s lifestyle being directed towards nursing diagnosis such as Insomnia or Sleep

deprivation (Wilkinson & Barcus, 2017). Although the patient I cared for on the mental health

clinical rotation did have impaired sleep quality outside of the facility at home, the focus will be

on his disturbed sleeping patterns within the mental health unit at MidMichigan Medical Center -

Midland.

Role of Nurses

Inpatient healthcare facilities are not exactly conducive to quality sleep. External factors

like IV pumps beeping, call lights going off, nursing staff entering and exiting rooms can
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seriously interfere with the quality of sleep one is able to obtain in an inpatient healthcare

facility. Internal factors make matters only worse, including pain, being in an unfamiliar setting,

and sleeping in an unfamiliar bed; writes Shefali Luthra in a PBS article dated 2015 - “Why

Won’t Hospitals Let Patients Sleep?” Although some measures may be out of patient or nurse

control, the registered nurse has an obligation to do everything within their scope of practice to

provide comfort measures to the patient which can decrease the likelihood of developing a

disturbed sleep pattern while staying overnight at a hospital or inpatient care facility. These are

according to an interpretation of Provision 4 in The Code of Ethics for Nurses with Interpretive

Statements - “the nurse has authority, accountability, and responsibility for nursing practice;

makes decisions; and takes action consistent with the obligation to promote health and to provide

optimal care” (ANA, 2015, p.37).

Patient Experience

RM was admitted to the Mid-Michigan Emergency Department following a suicide

attempt three days ago in which RM took insulin from his uncle and ingested various other

medications. RM was admitted to the psychiatric ward via a petition and certification, and

recently signed a deferment. RM's chief diagnosis is “severe episode of recurrent major

depressive disorder without psychotic features.” RM was experiencing severe anxiety and bouts

of depression over his legal troubles which include a likely jail or prison sentence in the near

future. His legal issues include criminal sexual conduct. Patient states that he has panic attacks

that last anywhere from 20 minutes to an hour which exacerbates further anxiety and depression

which leads to exhaustion and ultimately leading to impaired sleep patterns. The patient also

stated that he has trouble sleeping at night, which has worsened during his admission to the

psychiatric ward. During both days that I was able to interact with RM he stated during breakfast
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that he “stayed up until around 3:00am or 4:00am reading and could not fall asleep.” From 4am

until 8am RM states that he “was in and out of sleep and woke up several times.” On the second

day I was able to interact with RM he was so anxious, restless, and agitated around 4:00am that

he was given an oral ‘cocktail’ consisting of Haldol 10mg, Ativan 2mg, Benadryl 50mg and

placed into seclusion then taken out two hours later when it was deemed appropriate. These

events are according to nurse hand off and the patient chart as our clinical group arrived shortly

after at 6:30am.

RM’s vital signs during breakfast the first day were temperature 98.1°F, heart rate 77,

respiratory rate 14, and blood pressure 132/88. Elevated heart rate and blood pressure may

interfere with the ability to sleep (Lederbogen et al., 2003); however, I was unable to obtain

night time vital signs for my patient. Pertinent labs for a mental health patient experiencing

severe depression include TSH and T3 for hypo or hyperthyroidism, vitamin D level, and a

urinary drug screen for suspected substance abuse. Hypothyroidism and vitamin D insufficiency

can play a role in mood regulation, depression, and sleeping habits (Spedding, 2014). RM’s TSH

level was 4.1 µg/dL which is slightly elevated, and a T4 level of 1.22 ng/dL which is within

normal limits. RM’s vitamin D level was 16 ng/dL which is slightly decreased. RM’s urinary

drug screen returned negative. Making sense of the larger picture overall, RM has anxiety and

severe depression related to thoughts of going back to jail for the crimes he has committed.

These factors have led to RM’s disturbed sleep pattern while admitted to the mental health unit.

All patient data was gathered directly firsthand or found in the patient’s chart at MidMichigan

Medical Center – Midland.

Student Perspective
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All things considered, it was clear between the verbal information obtained from the

patient, the nursing hand off from night shift, and data in the patient chart that RM had been

experiencing issues with sleep. To what extent I was unsure but using verbatim patient story as

main evidence it was understandable that RM lost a sizeable portion of potential sleep during the

prior nights of each day that I was on the unit. Patient reported that he stayed up until 3:00am

reading a book Saturday morning, and until 4:00am Sunday morning when he was put into

seclusion after a panic attack that he experienced. The sleep log from the night nurse (shift

7:00pm to 7:00am) showed that Friday night and Saturday morning RM was “awake in his room

with the light on reading” from the hours of 11:00pm until 3:00am and “awake in his room

reading while occasionally attempting sleep” from the hours of 12:30am until 4:00am Sunday

morning.

Information obtained from RM, other nurses, and the patient chart demonstrated that he

met six defining characteristics of the nursing diagnosis disturbed sleep pattern according to

NANDA (2017). Subjectively, RM told me he had difficulty in daily functioning because he

would be able to get through breakfast, but soon after would find himself tired again but not tired

enough to sleep, only restless. According to RM this made it difficult for him to attend groups

throughout the late morning and early afternoon. RM reported a dissatisfaction with sleep

because during the hours he was able to sleep, he found the sleep non-restorative and still awoke

multiple times. Each of these defining characteristics lead to RM having reports of feeling

unrested. Other defining characteristics of disturbed sleep pattern that were evident in RM

included dark circles under the eyes, restlessness, and decreased attention span (Wilkinson

& Barcus, 2017, p.803). These last three characteristics I was able to observe through

conversation with RM during breakfast, in the hallway, and in the patient’s room.
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A major related factor belonging to disturbed sleep pattern that I suspected to play a role

in RM’s inability to sleep through the night were environmental factors. RM stated that “the

reason I stayed up reading at night is because I’m used to my own bed and there are nurses

checking in all the rooms throughout the night.” This is according to my notes from the first day

that I was able to meet RM. The statements that RM told me along with nursing report and the

patient chart lead to suspicion that he was experiencing a disturbed sleep pattern (NANDA,

2017, p. 803).

Qualitative Study

Gellerstedt, L., Medin, J., & Karlsson, M. R. (2014) conducted a qualitative study in

Sweden that explored and described patients’ experiences of sleeping in hospitals. This

qualitative study used semi-structured interviews to acquire patient view and experiences as their

study design and method. A university hospital in Sweden found ten patients to participate in the

study that met the study criteria, one being a hospital stay of at least three days. The patients

chose to be interviewed on the day they were being discharged from the hospital. The study

focused on four main areas of focus that have the potential to disrupt sleep pattern while in the

hospital; bedside manner, physical factors, being involved, and integrity. The areas of focus in

the qualitative study that coincide with RM from the mental health unit are physical factors and

being involved. Under physical factors, numerous patients in the study stated during their

interview that the beds in the hospital were uncomfortable and negatively influenced sleep

(Gellerstedt et al., 2014, p. 182). RM reported that the single sized bed with a slim blanket at the

mental health unit made sleeping on the unit “rough and uncomfortable.” Being involved was

another area of focus for Gellerstedt et al., meaning the level of influence patients had on the

hospital ward’s activity and schedule (2014). Patients in the study described how the ward’s
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routines had a negative effect on their sleep. “They understood that checks on vital signs had to

be made but questioned the choice of timing” (Gellerstedt et al., 2014, p.183). The mental health

unit at MidMichigan Medical Center – Midland conducts vitals rounding every morning at

8:00am. RM was asleep both Saturday and Sunday at 8:00am when I attempted to get his vital

signs and complained that he wanted to continue sleeping and told me to “come back at nine

o’clock.” RM met the same criteria for negatively impacted sleep as found in the study. The

qualitative study concluded that several factors have potential to impact the amount and quality

of sleep a patient can acquire at the hospital. “To experience some degree of influence, to feel

involved, and to be able to preserve one’s integrity are, according to the patients, important

factors affecting sleep during hospitalization” (Gellerstedt et al., 2014, p. 187).

Middle Range Theory

Nursing theories attempt to define the different aspects of nursing and conduct a meta-

analysis of the nursing discipline itself. This abstract analysis of nursing allows nurses to think

critically about every facet of the profession and patient care. Middle range nursing theories

attempt to provide a tangible framework for handling complex situations. Middle range nursing

theories are more narrow and slim in nature than grand nursing theories and span the width

between grand nursing theories and actual nursing practice. Katharine Y. Kolcaba developed A

Theory of Holistic Comfort in Nursing in 1994. Kolcaba’s goal was to “postulate relationships

between patients’ needs, nursing interventions, comfort, and subsequent outcomes” (Kolcaba,

1994, p.1178). Kolcaba’s focus on comfort parallels nursing activities that can be put into

practice to assist patients that are experiencing a disturbed sleep pattern; “initiate/implement

comfort measures of massage, positioning, and affective touch” (NANDA, 2017, p. 806).
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The theory focuses on that, (a) human beings have holistic responses to complex stimuli,

(b) comfort is a desirable holistic outcome that is vital to the nursing discipline, and (c) human

beings strive to meet, or to have met, their basic comfort needs (Kolcaba, 1994, p.1178). As an

interpretation, undisturbed sleep patterns can be considered a basic human being comfort need.

Kolcaba breaks her theory into two dimensions. Dimension one of comfort consists of

three states, relief, ease, and transcendence. Dimension two is the contextual explanation of

comfort and involves four contexts, physical, psychospiritual, social, and environmental. The

second-dimension environmental context brings home the exact same qualities that are needed

for comfort as well as undisturbed sleep - levels of light, noise, temperature, and room ambience

(Kolcaba, 1994, p.1178).

The theory further breaks down to explain that nursing situations consist of an alpha press

and beta press. Alpha press is the sum of negative (obstructing forces), positive (facilitating)

forces, and interacting forces. Beta press is a person’s perception of the total effect of the forces

in alpha press. This complicated feature is better explained in appendix A through a series of

arrows that lead to the outcome of patient comfort. With Kolcaba’s middle range nursing theory,

nurses can design interventions to enhance comfort and measure the effectiveness of their

interventions upon the outcome of comfort (Kolcaba, 1994, p.1182).

Search Terms and Databases

The databases that were used to identify the articles that support the nursing intervention

for disturbed sleep pattern were CINAHL, Medline, ProQuest, and Cochrane Library. Search

terms included "mental health," "sleep," "hospitalization," "trial," "disturbed sleep pattern,"

"nursing interventions," "sleep enhancement," "patient experience," and "psychiatric." Specific

articles detailing nursing interventions for patients admitted to a mental health unit, as was my
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patient, were difficult to find. Instead I found the most relevant articles possible and interpreted

the results to explain interventions that could be implemented for RM at MidMichigan Medical

Center – Midland. I found a total of five articles at a research level of IV or higher relevant to my

topic. Two of the articles showed little to no evidence for their specific intervention to improve

sleep quality for patients so I excluded them and chose to focus on the three articles that outlined

interventions showing a level of proven effectiveness. One article was specific to mental health

patients, one study only specified that it was conducted with "medical patients," and the final

study was done using coronary care patients. Although patients in each setting have differences,

the nursing interventions used to improve disturbed sleep patterns and sleep quality remain

relatively similar. "Sleep enhancement" was the specific NANDA nursing intervention (NIC) I

choose for disturbed sleep pattern because it envelopes a varying group of activities that can be

completed by the registered nurse to help improve the sleep quality of the patient. Each article

touched on a specific activity under "sleep enhancement" that could be completed by a nurse, or

generalized their effectiveness as a whole.

Evidence Based Guideline

Specific evidence based guidelines involving nursing interventions to help patients in an

inpatient medical care facility experience a normal sleep pattern were difficult to find. However,

evidenced based pharmacological interventions for patients experiencing insomnia was found.

Moderate quality evidence from Guidelines.gov through the AHRQ and U.S. department of

Health and Human Services shows that doxepin, zolpidem, and eszopiclone improved sleep

outcomes in patients diagnosed with insomnia (Qaseem et al., 2016). RM at the time was not

currently prescribed any of these medications. However, as a registered nurse it would be my

responsibility to either make a recommendation or seek a solution if it may be pharmacological

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or otherwise to RM's psychiatrist if my patient continued to experience disturbed sleep while

under my care.

Nursing Intervention

Sleep enhancement is a nursing intervention to assist patients experiencing a disturbed

sleep pattern. Sleep enhancement is defined as the facilitation of a regular sleep-wake cycle

(Wilkinson & Barcus, 2017). Sleep enhancement further is broken down into other areas

according to a level IIb quasi-experimental pretest-posttest type study without control group

conducted by Juan Laguna-Parras, Maria Jerez-Rojas, Francisco Garcia-Fernandez, Dolores

Carrasco-Rodriguez and Inmaculada Nogales-Vargas-Machuca in Spain during 2007 and 2008.

The study is titled "Effectiveness of sleep enhancement nursing intervention in hospitalized

mental health patients." Laguna-Parras et al. include a broad range of activities in the sleep

enhancement intervention.

The activities that fall under the intervention of sleep enhancement include determining

the patient's sleep/activity pattern, explaining the importance of adequate sleep during

psychosocial stress, monitoring patient's sleep patterns and hours slept, adjusting the patient's

environment to promote better sleeping patterns, group care activities, and promoting an increase

in amount of hours slept (Laguna-Parras et al., 2008). All of these activities falling under the

umbrella of sleep enhancement were listed in RM's medical chart at MidMichigan Medical

Center – Midland. The study in Spain included a sample size of 289 patients that had a hospital

stay of at least 8 days and met the other inclusion criteria. The effectiveness of the nursing

intervention "sleep enhancement" was measured by comparing mean Oviedo Sleep

Questionnaire subscale scores and NOC sleep scores between admission and discharge. A

statistically significant improvement (p <.005) was found in all scores. This lead to the
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conclusion that the nursing intervention 'sleep enhancement' was effective for patients admitted

to an inpatient mental health facility with disturbed sleep patterns (Laguna-Parras et al., 2008).

According to Laguna-Parras et al. (2008), an activity listed in the nursing intervention

'sleep enhancement' is to "instruct patient how to perform autogenic muscle relaxation or other

non-pharmacological forms of sleep inducement." A level IIa randomized control trial was used

to explore the effectiveness of progressive muscle relaxation (PMR) on quality of sleep for

hospitalized patients in Mangalore, India. The study was written and conducted by Neethu

Francis and Fatima D'silva in 2012. The study found a sample size of 60 hospitalized medical

patients who experienced poor sleep quality to test the effectiveness of Jacobson's Progressive

Muscle Relaxation technique on quality of sleep at the facility. The participants used progressive

muscle relaxation for 30 minutes daily over a total span of five days (Francis & D'silva, 2012).

Through analysis of the study results using ANOVA, a significant difference (p <.05) was found

in quality of sleep from day one to day five thus concluding that five days of progressive muscle

relaxation therapy was very effective for hospitalized patients with poor sleep quality (Laguna-

Parras et al., 2008). RM at MidMichigan Medical Center – Midland did not use progressive

muscle relaxation therapy to help improve sleep quality, however the idea could have been

passed on to him, other nurses, or even his psychiatrist and could have had a potential to assist in

the disturbed sleep pattern that he was experiencing.

A level IIa intervention study conducted in Iran during 2012-2013 aimed to analyze

nursing interventions as a whole and their effectiveness on quality of sleep in patients

hospitalized in a coronary care unit. A coronary care unit has differences compared to a mental

health unit, but many of the nursing interventions that assist patients to obtain better sleep quality
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are the same. The study was conducted by K. Zamanibabgohar, M. Khademol-Hoseyni, and A.

Ebadi.

The method of the study was to train the nurses working on the coronary care unit in

evidenced based nursing guidelines that assisted in patient sleep quality (Zamanibabgohar,

Khademol-Hoseyni, Ebadi, 2012). These evidence based guidelines were similar to the

guidelines outlined by NANDA, including sleep enhancement techniques listed in the first study.

45 patients were placed in the control group without the implantation of evidenced based

guidelines, and 45 patients were placed in the experimental group that were using evidenced

based guidelines. The Pittsburg sleep quality questionnaire was used to examine the results. The

total mean score of adequate sleep was 6.71 (SD = 3.54) in the intervention group and 5.26 (SD

= 2.58) in the control group. The results were a statistically significant difference (p = .003). This

concluded that the implantation of evidenced based nursing guidelines improved the quality of

sleep in coronary care unit patients (Zamanibabgohar, Khademol-Hoseyni, Ebadi, 2012).

According to the study conducted by Zamanibabgohar, Khademol-Hoseyni, Ebadi (2012), using

evidence based nursing guidelines is proven effective and the nursing interventions provided for

RM at MidMichigan Medical Center Midland all had a potential to improve the amount and

quality of his sleep he obtained while admitted to the mental health unit.
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References

Gellerstedt, L., Medin, J., & Karlsson, M. R. (2014). Patients’ experiences of sleep in hospital: a

qualitative interview study. Journal of Research in Nursing, 19(3), 176-188.

doi:10.1177/1744987113490415

Kolcaba, K. Y. (1994). A theory of holistic comfort for nursing. Journal of Advanced Nursing,

19(6), 1178-1184.

Lederbogen, F., Schredl, M., Weber-Hamann, B., Kniest, A., Heuser, I., & Deuschle, M. (2003).

Effect of ambulatory blood pressure measurement on sleep in patients with a major

depressive episode. Blood Pressure Monitoring, 8(5), 187-190.

Luthra, S. (2015, August 17). Why won't hospitals let patients sleep? Retrieved April 09, 2018,

from https://www.pbs.org/newshour/health/wont-hospitals-let-patients-sleep

Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD (2016). Clinical Guidelines

Committee of the American College of Physicians. Management of chronic insomnia

disorder in adults: a clinical practice guideline from the American College of Physicians.

Ann Intern Med.;165(2):125-33.

Spedding, S. (2014). Vitamin D and Depression: A Systematic Review and Meta-Analysis

Comparing Studies with and without Biological Flaws. Nutrients, 6(4), 1501–1518.

http://doi.org/10.3390/nu6041501

The Code of Ethics for Nurses with Interpretive Statements. (2015). ANA scope of standards

book. Provision 4, page 37.

Wilkinson, J. M., Barcus, L., & Wilkinson, J. M. (2017). Pearson nursing diagnosis handbook:

NANDA-I diagnoses, NIC interventions, NOC outcomes. Boston: Pearson. Luthra, S.

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Appendix A

Kolcaba, K. Y. (1994). A theory of holistic comfort for nursing.