CHAPTER 45

SLEEP
Reference:
Berman, A. & Synder, S. (2016) Kozier & Erb’s Fundamentals of Nursing.
10th ed. Pearson Education, Inc. (pages 1092- 1111).

Prepared by:
Jacqueline D. Guerra - Polancos, RN, MSN, DrPH
Associate Professor, AUP College of Nursing
Second Semester, 2020
Sleep is a basic human need

Sleep is require for many reasons:

✓ To cope with daily stresses
✓To prevent fatigue
✓To conserve energy
✓To restore the mind and body
✓To enjoy life more fully
 Sleep is an important factor in a person’s
quality of life, yet sleep disorder and sleep
deprivation are an unmet public health
problem
Many member of the general public and
health professionals are unaware of the
consequences of chronic sleep loss (e.g.
increased risk of hypertension, diabetes,
obesity, depression, heart attack, and stroke)
Physiology of Sleep
• Sleep - altered state of consciousness;
perception
of and reaction to environment is decreased
• Cyclic nature of sleep controlled by lower part
of brain
• Neurons in reticular formation integrate
sensory information from PNS, relay it to
cerebral cortex
• Reticular activating system (RAS) involved
in sleep-wake cycle
Neurotransmitters

• Affect sleep-wake cycle

• Serotonin
• Thought to lessen response to sensory
stimulation
• Gamma-aminobutyric acid (GABA)
• Thought to shut off activity in neurons of RAS

• Acetylcholine, dopamine, noradrenalin

• Associated with cerebral cortical arousal
Exposure to Darkness

• Darkness and sleep rituals cause a decrease

in stimulation of RAS
• Pineal gland begins to secrete melatonin
and person feels less alert
• During sleep, growth hormone (GH)
secreted and cortisol inhibited
 Insomnia is not caused by melatonin deficiency, and
melatonin is not a sleep hormone. Actually, melatonin has
very little to do with falling asleep. Melatonin is produced
in the presence of darkness and it just happens to
correlate with sleep cycles.
https://empoweredsustenance.com/melatonin-is-bad-for-you/
Circadian Rhythm

• Circadian rhythm – 24-hour internal biological clock

• Circadian synchronization
• Biological clock coincides with sleep-wake cycle
• Person awake when body temp highest and asleep
when body temp lowest
• By 3-6 months of age, regular sleep-wake cycle usually
established
 Circadian Rhythms (cont.)

Controlled from within the body and synchronized with

environmental factors, such as light and darkness.
A new nursing graduate’s first job requires 12-hour night shifts.
Which strategy will make it easier for the graduate to sleep during the day
and remain awake at night?
A. Wear dark wrap-around sunglasses when driving home in the morning,
and sleep in a darkened bedroom
B. Exercise on the way home to avoid having to stand around waiting for
equipment at the gym.
C. Drink several cups of strong coffee or 16 oz of caffeinated soda when
beginning the shift.
D. Try to stay in a brightly lit area when working at nigh.
 Intensive Care Unit (ICU) Psychosis

Abstract
• Patients who become psychotic in intensive care units are usually
suffering from delirium. Underlying causes of delirium such as anxiety,
sleep deprivation, sensory deprivation and overload, immobilization,
an unfamiliar environment and pain, are often preventable or
correctable. Early detection, investigation and treatment may prevent
significant mortality and morbidity. The patient/physician relationship
is one of the keystones of therapy. More severe cases may require
psychopharmacological measures. The psychotic episode is quite
distressing to the patient and family; an educative and supportive
approach by the family physician may be quite helpful in patient
rehabilitation.
Can Fam Physician. 1984 Feb; 30: 383–388. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2154033/
Two types of Sleep alternate in cycles

1. NREM – non-rapid eye movement

2. REM – rapid eye movement

NREM
✓Occurs when activity in RAS is inhibited
✓Constitutes 75% - 80% of sleep
✓Consists of 4 stages
Physiologic Changes in NREM Sleep
• Arterial BP falls
• Pulse rate decreases
• Peripheral blood vessels dilate
• Cardiac output (CO) decreases
• Skeletal muscles relax
• Basal metabolic rate (BMR) decreases 10% - 30%
• Growth Hormone levels peak
• Intracranial pressure decreases
Page 1094 Box 45 - 1
REM Sleep
• Occurs every 90 minutes
• Lasts 5 - 30 minutes
• Acetylcholine and dopamine increase
• Most dreams take place in REM sleep
• Brain is highly active
• Brain metabolism increases as much as 20%
• Distinctive eye movements occur
• Voluntary muscle tone dramatically decreases
• Deep tendon reflexes absent
 REM Sleep (cont’d)

• May be difficult to arouse; may awaken

spontaneously
• Gastric secretions increase
• HR and RR are often irregular
• Regions of brain associated with learning,
thinking, organizing information stimulated
 Sleep Cycles

• Usually last 90 - 110 minutes in adults

• Usually four to six cycles during 7 - 8 hours of sleep
• If awakened from any stage, must restart at stage I
• As sleep progresses, less time in stages III and IV of
NREM and more in REM, dreams longer

• Regions of brain associated with

• Brain is highly active learning, thinking, organizing
• Gastric secretions increase information stimulated
Functions of Sleep

• Restores normal levels of activity

• Restores normal balance among parts
of nervous system
• Necessary for protein synthesis
• Psychological well-being
Physiologic Changes in NREM Sleep
• Arterial BP falls
• Pulse rate decreases
• Peripheral blood vessels dilate
• Cardiac output (CO) decreases
• Skeletal muscles relax
• Basal metabolic rate (BMR) decreases 10% - 30%
• Growth Hormone levels peak
• Intracranial pressure decreases
Page 1094 Box 45 - 1
Physiologic Changes in NREM Sleep

Pulse rate decreases

DEPOLARIZATION
C
R
O
E
N D
S L
T I
Y A
R A
S X
A
A S
C T
L T T D
T O
U I O U
I L
B O L B
O E N
N E

During repolarization the coronary

arteries receive blood by virtue
of gravity..
C
R
O
E
N D
S L
T I
Y A
R A
S X
A
A S
C T
L T T D
T O
U I O U
I L
B O L B
O E N
N E

During repolarization the coronary

arteries receive blood by virtue
of gravity..
C
R
O
E
N D
S L
T I
Y A
R A
S X
A
A S
C T
L T T D
T O
U I O U
I L
B O L B
O E N
N E

During repolarization the coronary

arteries receive blood by virtue
of gravity..
Coronary Artery Disease
A disorder in which
one of more of the
coronary arteries
become narrowed
by atherosclerosis or
vasospasm, and
obstruct necessary
blood flow to a
specific part of the
heart.
Vasospasm may lead to:
Nursing Outcomes (NOC): ACTIVITY TOLERANCE
Interventions Rationales
Assess baseline tolerance for • Promotes and protects circulatory
activity, ability to adapt to function and reduces cardiac
limitations and/ or restrictions workload.
on lifestyle

Assess pulse, respiration, and • Pulse increase more than 20/min

BP 5 min before, during and and increase in BP and respirations
after activity. indicate need for reduction in
activity.

If activity causes pain, • Controls pain during activity.

administer vasodilators
NOC: ACTIVITY TOLERANCE (cont.)

Interventions Rationales
Provide progressive activity
• Allows for activity program that
following bed rest to allow to
increases slowly as endurance
use commode, sit at side of
bed, sit in chair, ambulate as increases.
client is able.

Schedule activities around • Maintains activity below angina

rest periods. threshold.

Instruct patient to avoid

• Conserve energy and prevents
extending activities
angina.
beyond tolerance
 NOC: ACTIVITY TOLERANCE (cont.)
Interventions Rationales

Instruct patient to avoid activity • Requires additional oxygen for

after eating, bathing, or during activities.
stress periods.

Instruct patient to keep • Availability to administer when

medication nearby when needed.
performing activity.

Inform to cease activity when • Conserve energy and prevents

pain occurs and when taking angina.
medication, to sit on chair
and wait for pan to pass.
HYPERTENSION to STROKE
Many member of the general public and health
professionals are unaware of the
consequences of chronic sleep loss (e.g.
increased risk of hypertension, diabetes,
obesity, depression, heart attack, and stroke)
How much is too much?
The amount of
activity that you
have for today
is contingent
(will depend
upon) to the
amount of sleep
that you have
last night.
• The ratio of NREM to REM sleep varies with age.
Many factors can affect sleep:
▪ Illness
▪ Environment
▪ Lifestyle
▪ Emotional stress
▪ Stimulants and alcohol
▪ Diet
▪ Smoking
▪ Motivation
▪ Medications
Nursing responsibilities to help clients
sleep include:

a. Teaching clients ways to enhance sleep

b. Supporting bedtime rituals
c. Creating a restful environment
d. Promoting comfort and relaxation
e. Enhancing sleep with medications
 Review
Test Your Knowledge!
RULES for HEALTH
EllenHEALTH
RULES FOR G. White
1. SLEEPING rooms should be well ventilated.
2. No person should sleep on feathers.
3. Clothing worn in the day, should not be worn at night.
4. When taken off, it should be thoroughly aired.
5. Otherwise effete matters remain in it.
6. Sleep is the best restorer of the Nervous system.
7. One hour of sleep before midnight is worth two after it.
8. Never eat anything between meals.
9. Two meals a day is better than three.
https://m.egwwritings.org/en/book/1455.1728
RULES for HEALTH (cont.)
Ellen G. White

10. The drink which nature provides is cold water.

11. The use of salt may fairly be questioned.
12. It has no nutriment in it, and greatly provokes costiveness.
13. Persons of constipated bowels will find its disuse
advantageous.LES FOR HEALTH
13. Persons of constipated bowels will find its disuse
advantageous.
14. Daily exercise in the open air is an absolute pre-requisite to
Health.
15. Without Health of body, vigor of mind is not to be expected.
16. With feeble body and mind, large spirituality cannot be
enjoyed, https://m.egwwritings.org/en/book/1455.1728
 CHAPTER 45

SLEEP
Reference:
Berman, A. & Synder, S. (2016) Kozier & Erb’s Fundamentals of Nursing.
10th ed. Pearson Education, Inc. (pages 1092- 1111).

Prepared by:
Jacqueline D. Guerra - Polancos, RN, MSN, DrPH
Associate Professor, AUP College of Nursing
Second Semester, 2020