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Friday, November 26, 2010

Disturbed Sleep Pattern

Disturbed Sleep Pattern

NANDA Definition
Sleep pattern disturbance means time-limited disruption of sleep (natural, periodic suspension of consciousness) amount and quality.


Discussion of the Problem
Sleep is a basic human need. It is a universal biological process common to all human being. It is required for reasons such as to cope with the every day stresses, to avoid fatigue, to conserve energy, to refurbish the mind and body, and to enjoy life more fully. The sleep-wake is composed of different complex stages of consciousness namely: rapid eye movement (REM) sleep, nonrapid eye movement (NREM) sleep, and wakefulness. Amount of time spent during the REM sleep diminishes as person’s age increases. Age and personal characteristics affects the amount of sleep that individuals require. Generally, the demands for sleep decrease with age. Disturbance in the patient’s sleep pattern and wakefulness may be temporary or chronic. Sleep pattern may be disturbed by the following factors: bright environment, frequent monitoring and treatments, traveling, jet lag, sharing a room with another, use of medications (especially alcohol, antihistamines, antidepressants, beta-blockers, bronchodilators, caffeine, decongestants, narcotics, steroids, hypnotics, and anti-anxiety drugs), changes in routines such as in, night-shift rotations that change one’s circadian rhythms, acute illness, or emotional problems such as depression or anxiety. The major goal for clients with sleep disturbances is to maintain or develop a sleeping pattern that provides sufficient energy for daily activities. Other goals may relate to enhancing the client’s feeling of well-being or improving the quality and quantity of the client’s sleep.

Nursing Interventions Classification (NIC)
  • Sleep Enhancement

Nursing Outcomes Classification (NOC)
  • Anxiety Control
  • Sleep

Goal and Objectives
  • Patient will achieve maximum quantity of sleep as manifested by rested appearance, articulation of feeling rested, and enhancement in sleep pattern.

Subjective and Objective Data
  • Altered facial expression (e.g., blank look, fatigued appearance)
  • Altered mental status
  • Awakening earlier or later than desired
  • Change in activity level
  • Changes in behavior, e.g., listlessness/lethargy
  • Difficulty in arousal
  • Dozing
  • Interrupted sleep
  • Irritability
  • Restlessness
  • Verbal complaints of difficulty falling asleep
  • Verbal complaints of not feeling rested
  • Verbalizations of interrupted sleep
  • Yawning

Related Factors
  • Abnormal physiological status or symptoms (e.g., dyspnea, hypoxia, or neurological dysfunction)
  • Anxiety/fear
  • Depression
  • Environmental changes
  • Excessive or inadequate stimulation
  • External factors: necessity of ostomy care, excessive flatus/ostomy effluent
  • Internal factors: psychological stress, fear of leakage of pouch/injury to stoma
  • Medications
  • Normal changes associated with aging
  • Pain/discomfort

Assessment (Dx)
  • Establish sleep pattern in normal environment such as amount, bedtime rituals, depth, length, positions, aids, and interfering agents. Each individual has a unique sleep pattern.

GORDON’S FUNCTIONAL HEALTH PATTERN ASSESSMENT TOOL
SLEEP REST PATTERN
SUBJECTIVE
1.         Usual sleep habits: Hours per night ___; Naps: No__ Yes__ a.m.__ p.m.__ Feel rested?             Yes__ No__ Describe: ________________________
2.         Any problems:
a.         Difficulty going to sleep? No__ Yes__
b.         Awakening during night? No__ Yes__
c.         Early awakening? No__ Yes__
d.         Insomnia? No__ Yes__ Describe: _____________________________
3.         Methods used to promote sleep: Medication: No__ Yes__ Name: _______
            Warm fluids: No__ Yes__ What? __________________; Relaxation techniques: No__             Yes__ Describe: _______________________________


  • Assess timing or effects of medications that may disrupt sleep. In both the hospital and home care settings, patients may need to follow medication schedules that require awakening in the early morning hours. Clustering of nursing care is important.

  • Discover factors that may facilitate or interfere with normal sleep patterns. Knowledge about myths and its role in health/wellness and the wide variation among individuals may lessen anxiety, thereby promoting rest and sleep.

  • Document nursing observations of sleeping pattern and wakeful behaviors. Record the number of sleep hours. Assess physical (e.g., noise, pain or discomfort, urinary frequency) and/or psychological (e.g., fear, anxiety) conditions that interrupt sleep. Often, the patient’s perception of the problem may be different from objective evaluation.

  • Explore patient’s perception of reason of sleep difficulty and probable relief measures to assist treatment. Patients who experienced short term problems may have insight into the etiological factors of the problem (e.g., fear caused by results of a diagnostic test, concern over a son getting divorced, depression over the loss of a loved one). Knowing the specific etiological factor will give appropriate nursing interventions.

Therapeutic Interventions (Tx)
  • Discourage pattern of daytime naps unless considered necessary to meet sleep requirements or if part of one’s usual pattern. Napping can disrupt normal sleep patterns at night; however, elderly patients do better with frequent naps during the day to counter their shorter nighttime sleep schedules.

  • Maintain continuation of usual bedtime rituals. This promotes relaxation and readiness for sleep.

  • Recommend engaging in a relaxing activity before resting (e.g., calm music, warm bath, relaxation exercises, reading an enjoyable book). This will promote the feeling of fulfillment and allay anxiety before sleeping.

  • Recommend use of soporifics substances such as milk. Milk has lot of L-tryptophan, which facilitates sleep.

  • Recommend using hypnotics or sedatives as ordered by the physician; assess effectiveness. Use of hypnotic medications should be thoughtfully considered and avoided if less aggressive means are effective with the health care provider.

  • Stress the importance of the need to avoid concentrating on the next day’s activities or on one’s problems at bedtime. Obviously, this will hinder the patient to experience a restful state. Planning a selected time during the next day to address these concerns/problems may offer permission to "let go" of the worries at bedtime.

  • Suggest an environment conducive for sleeping or resting (e.g., quiet, comfortable temperature, sufficient ventilation, darkness, closed door). This will promote a better environment for resting or sleeping.

  • For hospitalized patients:
    1. Provide nursing aids or teach significant others to provide certain activities to promote sleep. (e.g., back rub, bedtime care, pain relief, comfortable position, relaxation techniques). These promote rest and sleep.

  • Organize and cluster nursing interventions: This promotes minimal interruption in sleep and rest.
    1. Remove nonessential nursing activities, especially during sleeping/resting hours.
    2. Prepare patient for necessary anticipated interruptions/disruptions.

·         Assist in administering analgesics or sedatives at bedtime as indicated or as ordered by the physician. Pain can interfere with patient’s ability to fall/remain asleep. Timely medication can enhance rest/sleep when patient experiences pain.

  • Move patient to room farther from the nursing station if noise is a contributing factor. The nurses’ station is a place where the physician and the nurses are interacting and it may caused noise which is not conducive for patients who are trying to sleep.

  • Try to allow for sleep cycles of at least 90 minutes. Experimental studies have shown that 60 to 90 minutes (1 hour to 1 and ½ hour) are needed to complete one sleep cycle, and the completion of a whole cycle is necessary to benefit from sleep.

Educative (Edx)
  • Encourage patient to follow a consistent daily schedule for sleeping and awakening as possible. This will encourage the regulation of the circadian rhythm, and lessens the energy required for familiarization to changes.

  • Encourage patient to increase daytime physical activities id not contraindicated. This lessens stress and promotes sleep.

  • Instruct on nonpharmacological sleep enhancement techniques. This is a cost effective measure with lesser side effects.

  • Instruct patient to avoid strenuous activity before bedtime. Over fatigue may cause insomnia.

  • Instruct to minimize drinking large fluid before bedtime. This lessens the patients chances to void at night.

  • Stress the importance of avoiding heavy meals, alcohol, caffeine, or smoking before resting. Though hunger may also keep an individual awake, gastric digestion and stimulation from caffeine and nicotine can alter sleep.

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