A.

DEFINITION
Sleep is a state of rest accompanied by altered consciousness and relative
inactivity. It is a complex rhythmic state involving a progression of repeated cycles,
each representing different phases of body and brain activity. Although sensitivity to
external stimuli is diminished during sleep, this sensitivity can be readily reversed
(Carol, 2010). Rest connotes a condition in which the body is in a decreased state of
activity, with the consequent feeling of being refreshed. Rest and sleep are
fundamental components of well-being. All individuals require certain periods of
calm and lesser activity so that their bodies can regain energy and rebuild stamina.
The need for rest and sleep varies with age, developmental level, health status,
activity level, and cultural norms. Sleep disruption and/or deprivation can impair
one’s ability to think clearly and respond quickly; it can also compromise the
cardiovascular and immune systems ((D’Arcy, 2008).
Sleep refers to a state of altered consciousness during which an individual
experiences minimal physical activity and a general slowing of the body’s
physiological processes. Sleep generally occurs in a periodic cycle and usually lasts
for several hours at a time; disruptions in the usual sleep routine can be distressing to
clients and will most likely impair sleep further. As a restorative function, sleep is
necessary for physiological and psychological healing to occur. It is important for
clients, their significant others, and health care providers to understand the normal
sleep-wake cycle and how sleep affects mood and healing (fundamental).
B. PHYSIOLOGY OF SLEEP
According Carol (2010), two systems in the brainstem, the reticular activating
system (RAS) and the bulbar synchronizing region, are believed to work together to
control the cyclic nature of sleep. The RAS extends upward through the medulla, the
pons, the midbrain, and into the hypothalamus. It facilitates reflex and voluntary
movements as well as cortical activities related to a state of alertness. The RAS
comprises many nerve cells and fibers. The fibers have connections that relay
impulses into the cerebral cortex and spinal cord. During sleep, the RAS experiences
few stimuli from the cerebral cortex and the periphery of the body. Wakefulness
occurs when this system is activated with stimuli from the cerebral cortex and from
periphery sensory organs and cells. For example, an alarm clock awakens us from
sleep to a state of consciousness, in which we realize that we must prepare for the day.
Sensations such as pain, pressure, and noise produce wakefulness by means of
peripheral organs and cells. The hypothalamus has control centers for several
involuntary activities of the body, one of which concerns sleeping and waking. Injury
to the hypothalamus may cause a person to sleep for abnormally long periods. Various
neurotransmitters are involved with the sleeping process. Norepinephrine and
acetylcholine, in addition to dopamine, serotonin, and histamine, are involved with
excitation. Gamma-aminobutyric acid (GABA) appears to be necessary for inhibition.
However, research has yet to prove exactly how biochemical changes and hormones
function in sleep.
Circadian Rhythms
Rhythmic biologic clocks are known to exist in plants, animals, and humans.
Influenced by both internal and external factors, they regulate certain biologic and
behavioral functions in humans. Some cycles are monthly, such as a woman’s
menstrual cycle. Circadian rhythms complete a full cycle every 24 hours. “Circa” in
Latin means “approximately” and “diem” is the Latin word for “day”; circadian
represents approximately 1 day (Porth, 2007). Fluctuations in a person’s heart rate,
blood pressure, body temperature, hormone secretions, metabolism, and performance
and mood depend in part on circadian rhythms. Sleep is one of the body’s most
complex biologic rhythms. Circadian synchronization exists when an individual’s
sleep–wake patterns follow the inner biologic clock. When physiologic and
psychological rhythms are high or most active, the person is awake; when these
rhythms are low, the person is asleep. Although light and dark appear to be powerful
regulators of the sleep–wake circadian rhythm, they do not exert primary control. The
regulating mechanism is the person’s individual biologic clock, which is subject to
numerous influences, such as occupational demands and social pressures. For
example, nurses who work the night shift may routinely sleep from 2 p.m. to 8 p.m.,
and peak physiologic activity may occur between 10 p.m. and 6 a.m. during work.
Problems of desynchronization occur when sleep–wake patterns are frequently altered
and the person attempts to sleep during high-activity rhythms or to work when the
body is physiologically prepared to rest.

Stage of Sleep

Electroencephalograph (EEG) patterns, eye movements, and muscle activity are used
to identify stages of sleep. The stages of sleep are classified in two categories: non–
rapid eye movement (NREM) and rapid eye movement (REM) sleep.
1. NREM Sleep
With the onset of sleep, the heart rate and respiratory rate slow slightly and remain
regular. This first phase of sleep is referred to as NREM sleep. NREM sleep
consists of four different stages. As the client enters stage 1 sleep, there is a
general slowing of EEG frequency but an appearance of wave spikes; the eyes
tend to roll slowly from side to side, and muscle tension remains absent except in
the
facial and neck muscles. In adult clients with normal sleep patterns, stage 1 sleep
usually lasts only 10 minutes or so.
- Stage I
 The person is in a transitional stage between wakefulness and sleep.
 The person is in a relaxed state but still somewhat aware of the
surroundings.
 Involuntary muscle jerking may occur and waken the person.
 The stage normally lasts only minutes.
 The person can be aroused easily.
 This stage constitutes only about 5% of total sleep.
- Stage II
 The person falls into a stage of sleep.
 The person can be aroused with relative ease.
 This stage constitutes 50% to 55% of sleep.
- Stage III
 The depth of sleep increases, and arousal becomes increasingly
difficult.
 This stage composes about 10% of sleep
- Stage IV
 The person reaches the greatest depth of sleep, which is called delta
sleep.
 Arousal from sleep is difficult.
 Physiologic changes in the body include the following:
 Slow brain waves are recorded on an EEG.
 Pulse and respiratory rates decrease.
 Blood pressure decreases.
  Muscles are relaxed.

Metabolism slows and the body temperature is low. This constitutes about
10% of sleep.

2. REM Sleep
After the initial 90 minutes or so of NREM sleep in adults, the client enters REM
sleep. The EEG pattern resembles that of the awake state; there are rapid
conjugate eye movements; heart rate and respiratory rate are irregular and often
higher than when awake; and muscles, including those of the face and neck, are
flaccid, leaving the body immobilized. Dreams occur 80% of the time clients are
in REM sleep. Unlike stage 3 to 4 sleep, which is most abundant during the early
portion of a sleep period, REM sleep periods become longer as the night
progresses and the individual becomes more rested. An adult typically has four to
six REM sleep periods through the night, accounting for 20% to 25% of sleep.
REM sleep makes up 50% of sleep in the newborn, then gradually declines to 20%
to 25% of sleep by early childhood. It remains fairly constant throughout the
remainder of the life span.
 Eyes dart back and forth quickly
 Small muscle twitching, such as on the face.
 Large muscle immobility, resembling paralysis
 Respirations irregular; sometimes interspersed with apnea
 Rapid or irregular pulse
 Blood pressure increases or fluctuates.
 Increase in gastric secretion.
 Metabolism increases; body temperature increases
 Encephalogram tracings active
 REM sleep enters from stage II of NREM sleep and reenters
NREM sleep at stage II: arousal from sleep difficult
 Constitutes about 20% to 25% of sleep
C. VALUE / NORMAL
- Newborns and Infants
Sleep Pattern: Newborn: Sleeps an average of 16 hours/24 hours; averages
about 4 hours at a time. Each infant’s sleep pattern is unique. On average, infants
 sleep 10 to 12 hours at night with possibly several napsduring the day. Usually by
8 to 16 weeks of age, an infant sleeps through the night.
- Toddlers
Sleep Pattern: Need for sleep declines as this stage progresses. May initially sleep
12 hours at night with two naps during the day and end this stage sleeping 8 to 10
hours a night and napping once during the day.
- Preschoolers
Sleep Pattern: Children in this stage generally sleep 9 to 16 hours at night, with
12 hours being the average.
- School-Aged Children
Sleep Pattern: ounger school-aged children may require 10 to 12 hours nightly,
whereas older children in this stage may average 8 to 10 hours.
- Young Adults
Sleep Pattern: The average amount of sleep required is 8 hours, but in fact, many
young adults require less sleep.
- Older Adults
Sleep Pattern: An average of 5 to 7 hours of sleep is usually adequate for this age
group.
D. VARIETY OF DISTURBANCE
A nurse who interviews a patient to obtain a sleep history needs to understand
common sleep disturbances to recognize significant data. The most recent
classification of sleep disorders categorized by the International Classification of
Sleep Disorders includes four major categories of disturbances:
Dyssomnias, parasomnias, sleep disorders associated with medical or psychiatric
disorders, other proposed disorders. The more common sleep disorders are the
dyssomnias and parasomnias.
a. Dyssomnias are sleep disorders characterized by:
- Insomnia or excessive sleepiness: is characterized by difficulty falling asleep,
intermittent sleep, or early awakening from sleep.
- Sleep hygine refers to nonpharmacologic recommendations that help an
individual get a better night’s sleep.
- Hypersomnia is a condition characterized by excessive sleep, particularly
during the day.
 - Sleep apnea is a condition in which a person experiences the absence of
breathing (apnea) or diminished breathing efforts (hypopnea) during sleep
between snoring intervals.
- Narcolepsy is a condition characterized by an uncontrollable desire to sleep.
- Restless leg syndrome (RLS) cannot lie still and report unpleasant creeping,
crawling, or tingling sensations in the legs.
- Sleep deprivation refers to a decrease in the amount, consistency, or quality of
sleep.
b. Parasomnias are patterns of waking behavior that appear during REM or NREM
stages of sleep. A brief description of these disturbances follows. Parasomnias are
patterns of waking behavior that appear during REM or NREM stages of sleep.
E. PATHWAY

A single normal sleep cycle. In the normal nocturnal pattern, the shaded cycle is
repeated four or five times. Periods of REM sleep generally increase in duration, and
periods of deep sleep (stage IV) progressively decrease as morning approaches.
F. DIAGNOSTIC TEST
These stages have been studied and analyzed with the help of the
- Electroencephalograph (EEG), which receives and records electrical currents
from the brain.
- Electrooculogram (EOG), which records eye movements.
- Electromyograph (EMG), which records muscle tone.
G. COLLABORATIVE TREATMENT
- Using Medications to Produce Sleep
Medications for sleep are often ordered for patients. Sedativehypnotics induce sleep;
antianxiety drugs reduce anxiety and tension. However, the sleep produced by
sedative-hypnotics is an unnatural sleep. All these drugs disturb either REM or
NREM sleep to some degree. Although most sedativehypnotics provide several nights
of excellent sleep, the medication often loses its effect after 1 or 2 weeks. At this
point, many people increase the dosage of the medication or complement the drug
with alcohol. Vigorous nursing intervention is needed to prevent a patient from
developing a pattern of drug dependency and alcohol abuse. The most commonly
prescribed sleep aids belong to the sedative-hypnotic class of benzodiazepines. These
drugs include flurazepam (Dalmane) and temazepam (Restoril). When used to induce
sleep, both these drugs have the potential to produce daytime drowsiness, a morning
hangover effect, and physical and psychological dependence. Drugs in
a newer class of nonbenzodiazepines are less likely to cause adverse effects and have
a lower risk of abuse. These more commonly prescribed drugs include eszopiclone
(Lunesta) and zolpidem (Ambien). The most recently approved sleep medication is
ramelteon (Rozerem). This drug is classified as a melatonin receptor agonist and it
normalizes sleep cycles by enabling the body’s supply of melatonin to naturally
promote sleep (Goldsmith, 2007).
- Ensure Appropriate Nutrition
Certain foods can actually enhance sleep. Tryptophan, a substance in milk, promotes
sleep by stimulating the brain’s production of the neurotransmitter serotonin. The old
wives’ tale that drinking warm milk promotes sleep is supported by scientific data.
Other dietary considerations include avoiding large or heavy meals close to bedtime,
refraining from eating spicy or other foods that cause GI distress, and avoiding
caffeine after noon.
H. NURSING CARE
1. Assesment
Discussion of sleep and activity patterns is included as part of the regular health
history. Any client acknowledging a sleep disturbance should be thoroughly
assessed to determine sleep routines, sleep alterations, type of disturbances, and
impact of sleep problems. Typically the client is a reliable source for this
information, but a spouse or partner who shares sleeping arrangements may be
 able to add valuable information to the client’s report. Questions regarding the
client’s usual sleep patterns should include:
 Nature of sleep (restful, uninterrupted)
 Quality of sleep (usual sleep pattern, schedules, hours of sleep, feeling
upon awakening).
 Sleep environment (description of room, temperature, noise level).
 Associated factors (bedtime routines, use of sleep medications or any other
sleep inducers).
 Opinion of sleep (adequate, restores energy adequately, inadequate,
problematic)

Questions regarding altered sleep patterns are intended to reveal such information
as:

 Nature of the problem (inability to fall asleep, difficulty remaining asleep,

inability to fall asleep after awakening, restless sleep, daytime sleepiness).
 Quality of the problem (number of hours of sleep versus number of hours
spent trying to sleep, number of hours of sleep a night, duration and
frequency of naps or other compensatory measures, number of wakings
per sleep period).
 Environmental factors (lighting, bed, noise level, surrounding stimulation,
sleep partner).
 Associated factors (relation to meals eaten, activity before retiring, life
and work stressors, anxiety level, pain, recent illness or surgery).
 Alleviating factors (mild diet, warm drink before retiring, reading a book,
listening to quiet music, taking a hot bath, taking sleeping pills)..
 Effect of problem (fatigue, irritability, confusion)
2. Nursing Diagnose
The primary diagnosis for individuals experiencing sleep problems is insomnia.
According to Carpenito-Moyet (2008), insomnia is defined as ‘‘a state in which a
person experiences a change in the quantity or quality of his rest pattern that
causes discomfort or interferes with desired lifestyle’’ (p. 387). Alterations in
sleep can manifest through verbal complaints of the client, physical signs such as
yawning or dark circles under the eyes, or alterations in mood such as apathy or
 irritability. If the client presents with problems in addition to the sleep
disturbance, the nurse must be alert to the possibility that the sleep disturbance is
the cause (not the effect) of another problem. For example, a client may be
experiencing activity intolerance related to lack of sleep as evidenced by verbal
complaint, extreme fatigue, disorientation, confusion, and lack of energy.
3. Nursing Intervention
Rest and sleep are essential components of well-being. Planning for patient care,
especially in a health care facility, involves planning with the patient suitable
measures to promote rest and sleep. Whenever nurses care for a patient, nursing
measures support the following expected patient outcomes: The patient will:
 Maintain a sleep–wake pattern that provides sufficient energy for the day’s
tasks.
 Demonstrate self-care behaviors that provide a healthy balance between
rest and activity.
 Identify stress-relieving rituals that enable the patient to fall asleep more
easily.
 Demonstrate decreased signs of sleep deprivation
 Verbalize feeling less fatigued and more in control of life activities.
 Approximate patient’s regular sleep–wake cycle in planning care.
 Determine the effects of the patient’s medications on sleep pattern.
 Adjust environment (e.g., light, noise, temperature, mattress, bed) to
promote sleep.
 Encourage patient to establish a bedtime routine to facilitate transition
from wakefulness to sleep.
 Facilitate maintenance of patient’s usual bedtime routines, presleep
cues/props, and familiar objects (e.g., for children, a favorite blanket/toy,
rocking, pacifier, or story; for adults, a book to read, etc.) as appropriate.
 Instruct patient to avoid bedtime foods and beverages that interfere with
sleep.
 Instruct patient how to perform autogenic muscle relaxation or other
nonpharmacologic forms of sleep inducement.
 Initiate/implement comfort measures of massage, positioning, and
affective touch.
 Discuss with patient and family sleep-enhancing techniques.