sleep & rest

SLEEP & REST

By:Mr. M. Shivanandha Reddy

Definition• Rest is a condition in which the body is in a

decreased state of activity without physical emotional stress and freedom from anxiety.

• Sleep is a state of rest accompanied by altered level of consciousness and relative inactivity, and perception to environment are decreased

PHYSIOLOGY OF SLEEP• The cyclic nature of sleep is thought to be

controlled by Centers located in the brain and by Circadian Rhythms.

• Reticular activating system (RAS) located at the brain stem and Cerebral Cortex plays an important role in sleep wake cycle.

…………….PHYSIOLOGY OF SLEEP

• Sleep begins with the activation of the pre optic area of the anterior hypothalamus.

• Sleep promoting neurons act over wake promoting neurons by releasing Gamma Amino Butyric Acid (GABA).

• The inhibition of wake promoting neurons results in intensifying sleep process.

…………….PHYSIOLOGY OF SLEEP• Another key factor to sleep is exposure to

darkness.• Darkness and preparing for sleep (e.g., lying

down, decreasing noise) cause a decrease in stimulation of the RAS.

• During this time, the Pineal gland in the brain begins to actively secrete the natural hormone Melatonin, and the person feels less alert.

…………….PHYSIOLOGY OF SLEEP

• With the beginning of daylight, Melatonin is at its lowest level in the body and the stimulating hormone, Cortisol , is at its highest causing wakefulness.

Circadian Rhythms• It is a sort of 24-hour internal biological clock.

The term circadian is from the Latin “circa dies”, meaning “about a day.”

• Biological rhythms exist in plants, animals, and humans.

• In humans, these are controlled from within the body and synchronized with environmental factors, such as light and darkness.

Types/ Stages/ Phases Of Sleep• Electroencephalogram (EEG) patterns, eye movements

and muscle activity are used to identify stages of sleep. The stages of sleep are classified into two stages:

• Non Rapid Eye Movement (NREM) Sleepo Stage 1o Stage 2o Stage 3o Stage 4• Rapid Eye Movement Stage(rem) Sleep. During sleep, NREM and REM sleep alternate in cycles

Non Rapid Eye Movement (NREM) Sleep

• First stage of sleep is known as NREM sleep.• About 75% to 80% of sleep during a night is

NREM sleep.• It consists of four stages:o Stage 1o Stage 2o Stage 3o Stage 4

NREM Sleep• Stage 1: NREM• Stage lasts a few minutes.• It includes lightest level of sleep.• Gradual fall in vital signs and metabolism.• General slowing of EEG frequency• Eyes tend to roll slowly from side to side• Sensory stimuli such as noise easily arouses

person.• Sleeper may deny he is sleeping.

NREM Sleep• Stage 2: NREM• Stage lasts 10 to 20 minutes.• It is a period of sound sleep.• Relaxation progresses.• Further slowing of EEG• Absent eye ball movements• Body functions continue to slow.• Arousal remains relatively easy

NREM Sleep• Stage 3: NREM• Stage lasts 15 to 30 minutes.• It involves initial stages of deep sleep.• Muscles are completely relaxed.• Large slow waves in EEG• Vital signs decline but remain regular.• Sleeper is difficult to arouse and rarely moves

NREM Sleep

• Stage 4: NREM• Stage lasts approximately 15 to 30 minutes.• It is the deepest stage of sleep.• If sleep loss has occurred, sleeper spends considerable

portion of night in this stage.• Vital signs are significantly lower than during waking

hours.• Further slowing of EEG• Sleepwalking and enuresis (bed-wetting) sometimes occur.• It is very difficult to arouse sleeper

REM Sleep• Stage usually begins about 90 minutes after

sleep has begun.• Dreaming occurs in this stage• Stage is typified by rapidly moving eyes,

fluctuating heart and respiratory rates, increased or fluctuating blood pressure, loss of skeletal muscle tone, and increase of gastric secretions.

• EEG pattern resembles that of awake state.• It is very difficult to arouse sleeper.

SLEEP CYCLE

FUNCTIONS OF SLEEP• Conservation of energy• Restoration of tissues and growth• Thermoregulation• Regulation of emotions- sleep deprivation

causes emotional disorders like irritability, anxiety, depression etc.

• Neural maturation• Memory and learning- there will be information

transfer between cerebral cortex and hippocampus during sleep

Normal Sleep Requirements• Newborn: 16-18 hours /day• Infants: 12-14 hours• Toddlers: 10-12 hours• Preschool: 11-12 hours• School-Age: 8- 12 hours• Adolescents: 8-10 hours• Adult: 6-8 hours• Elders: 6 hours

FACTORS AFFECTING SLEEP

• Both the quality and the quantity of sleep are affected by a number of factors.

• Sleep quality is a subjective characteristic• Quantity of sleep is the total time the individual

sleeps.• 1. AGE• 2. Illness• Illness that causes pain or physical distress (e.g.,

arthritis, backpain) can result in sleep problems

…….FACTORS AFFECTING SLEEP

• Examples: Respiratory conditions• Pain• need to urinate during the night


• 3. Environment• Environment can promote or hinder sleep• Any change—for example, noise in the environment

—can inhibit sleep.• The absence of usual stimuli or the presence of

unfamiliar stimuli can prevent people from sleeping• Discomfort from environmental temperature (e.g.,

too hot or cold) and lack of ventilation can affect sleep


• Light levels can be another factor• Another influence includes the comfort and

size of the bed. • A person’s partner who has different sleep

habits, snores, or has other sleep difficulties may become a problem for the person also.


• 4. Lifestyle• Following an irregular morning and night time

schedule can affect sleep.• Night shift workers frequently obtain less

sleep than other workers and have difficulty falling asleep.


• 5. Emotional Stress• Stress is considered to be the major cause of

short-term sleeping difficulties . • A person preoccupied with personal problems

(e.g., school- or job-related pressures, family or marriage problems) may be unable to relax sufficiently to get to sleep.

…….FACTORS AFFECTING SLEEP• 6. Stimulants and Alcohol• Caffeine-containing beverages act as

stimulants of the central nervous system (CNS).

• Drinking beverages containing Caffeine in the afternoon or evening may interfere with sleep.

• Even though alcohol induces sleep, it disturbs REM sleep causing irritability.


• 7. Diet• Certain foods induces sleep • Ex: the L- tryptophan present in the milk

induces sleep

• 8. Smoking• Nicotine has a stimulating effect on the body,

and smokers often have more difficulty falling asleep than non smokers.

• Smokers can be easily aroused


• 9. Motivation• Motivation can increase alertness in some

situations• Ex: During the time of examination Browsing internet in the late night


• 10. Medications:• Beta-blockers have been known to cause

insomnia.• Narcotics, such as morphine, are known to

suppress REM sleep and to cause frequent awakenings and drowsiness.

• Most Hypnotics suppresses REM sleep

SLEEP DISORDERS

• Sleep disorders are mainly classified into 3 categories

SLEEP DISORDERS

DYSOMNIAS PARASOMNIAS

DISORDERS DUE TO OTHER MEDICAL

CONDITIONS

DYSOMNIAS• The sleep itself is pretty normal.• But the client sleeps too little, too much, or at

the wrong time.• So, the problem is with the amount (quantity),

or with its timing, and sometimes with the quality of sleep.

DYSOMNIAS

• Common Dysomnias are:• Insomnia• Hypersomnia• Narcolepsy• Sleep Apnea• Insufficient Sleep/ Sleep Deprivation

Insomnia• Insomnia is described as the inability to fall

asleep or remain asleep. • Persons with insomnia awaken not feeling

rested.• Insomnia is the most common sleep

complaint.• Acute insomnia lasts one to several nights and

is often caused by personal stressors or worry.• If the insomnia persists for longer than a

month, it is considered Chronic insomnia

……..Insomnia

• Insomnia can result from physicl discomfort and more often from mental tension or anxiety.

• People who are habituated to drugs or who takes large amounts of alcohol are at high risk for insomnia.

InsomniaClinical manifestations:

■ Difficulty falling asleep ■ Waking up frequently during the night ■ Difficulty returning to sleep ■ Waking up too early in the morning ■ Unrefreshing sleep ■ Daytime sleepiness ■ Difficulty concentrating ■ Irritability

Insomnia

• Treatment is development of new behavioral patterns that induces sleep

• Create a sleeping environment that induces sleep

• Create positive sleep thoughts

Hypersomnia• Hypersomnia refers to conditions where the

affected individual obtains sufficient sleep at night but still cannot stay awake during the day.

• Hypersomnia can be caused by medical conditions, for example, CNS damage and certain kidney, liver, or metabolic disorders, such as diabetic acidosis and hypothyroidism.

Hypersomnia

• Treatment of hypersomnias include treating the underlying disease conditions

Narcolepsy

• Narcolepsy is a disorder of excessive daytime sleepiness caused by the lack of the chemical hypocretin in the area of the CNS that regulates sleep.

• Clients with narcolepsy have sleep attacks or excessive daytime sleepiness, and their sleep at night usually begins with a sleep-onset REM period (dreaming sleep occurs within the first 15 minutes of falling asleep).

Narcolepsy

• People sleeps several times a day even when they are conversing with people or while driving.

• CNS stimulants and Antidepressants are the drugs used to treat narcolepsy.

Sleep Apnea

• Sleep Apnea is characterized by frequent short breathing pauses during sleep.

• Although all individuals have occasional periods of apnea during sleep, more than five apneic episodes longer than 10 seconds in an hour is considered abnormal and should be evaluated by a sleep medicine specialist.

…….Sleep Apnea

• Sleep Apnea is most frequently diagnosed in men and postmenopausal women, it may occur during childhood.

• Three types of apnoea based on the cause• 1. Obstructive Apnoea • 2. Central Apnea• 3. Mixed Apnea

…….Sleep Apnea

• 1. OBSTRUCTIVE APNOEA:• Obstructive apnea occurs when the structures of

the pharynx or oral cavity block the flow of air.• Enlarged tonsils and adenoids, a deviated nasal

septum, nasal polyps, and obesity predispose the client to obstructive apnea

• Treatment includes surgical removal of tonsills, correcting nasal septum, weight loss may be helpful.

…….Sleep Apnea

• 2. CENTRAL APNEA:• Due to defect in the respiratory centre of the

brain.• Clients who have brainstem injuries and often

have central sleep apnea.• 3.MIXED APNOEA• Mixed apnoea is combination of obstructive

and central apnea

Insufficient Sleep/ Sleep Deprivation

• A prolonged disturbance in quality and quantity of sleep can lead to a syndrome called as sleep deprivation.

• It is not a sleep disorder but result of prolonged sleep disturbance.

• It produces various physiological and behavioural symptoms based on the severity of deprivation.

Insufficient Sleep/ Sleep Deprivation

Individuals may develop:• Attention and concentration deficits• Reduced vigilance• Distractibility• Reduced motivation• Fatigue• Diplopia and dry mouth.

PARASOMNIAS• Something abnormal occurs during sleep itself, or

during the times when the client is falling asleep or waking up

• The quality, quantity, and timing of the sleep are essentially normal.

Most common DISORDERS are:• Bruxism• Enuresis• Periodic limb movement disorder• Sleep talking• Sleep walking

…….PARASOMNIAS ■ Bruxism. Usually occurring during stage II NREM sleep, characterized by clenching and grinding of the teeth.

• This clenching and grinding of the teeth can eventually erode dental crowns, cause teeth to come loose, and lead to deterioration of the temporomandibular (TMJ) joint, called TMJ syndrome

…….PARASOMNIAS

■ Enuresis. Bed-wetting during sleep occuring in children over 3 years old.

• More males than females are affected.• It often occurs 1 to 2 hours after falling asleep.

…….PARASOMNIAS

• Periodic limb movement disorder (PLMD). In this condition, the legs jerk twice or three times per minute during sleep.

• It is most common among older adults.• Respond well to medications such as

levodopa, pramipexole , ropinirole, and gabapentin

…….PARASOMNIAS

• Sleeptalking. Talking during sleep occurs during NREM sleep before REM sleep.

• It rarely presents a problem to the person unless it becomes troublesome to others

…….PARASOMNIAS

• Sleepwalking. Sleepwalking (somnambulism) occurs during stages III and IV of NREM sleep. It is episodic and usually occurs 1 to 2 hours after falling asleep.

• Sleepwalkers tend not to notice dangers (e.g., stairs) and often need to be protected from injury

Disorders due to other medical conditions

• These disorders are associated with Medical or Psychiatric or other illness

• Usually the disorders that cause sleep disturbance includes:

• Depression• Alcolism• Thyroid dysfunction• Peptic ulcer• COPD- chronic obstructive pulmonary disease

Nursing Interventions To Promote Sleep

• 1. Sleep-Wake Pattern• Maintain a regular bedtime and wake-up

schedule• Eliminate day time naps. If naps are taken,

limit to 20 minutes or less twice a day• Instruct the client to go to bed when sleepy.• Use warm bath and relaxation techniques• If unable to sleep in 15 to 30 minutes, get out

of bed and persue some relaxation activity.

…..Nursing Interventions To Promote Sleep

• Establish a regular, relaxing bedtime routine before sleep such as reading, listening to soft music, taking a warm bath, or doing some other quiet activity.

• Avoid dealing with office work or family problems before bedtime

• Get adequate exercise during the day to reduce stress, but avoid excessive physical exertion at least 3 hours before bedtime.

…….Nursing Interventions To Promote Sleep

• 2. Environment:• Create a sleep-conducive environment that is

dark, quiet, comfortable, and cool.• Keep noise to a minimum; block out extraneous

noise as necessary with white noise from a fan, air conditioner.

• Sleep on a comfortable mattress and pillows.• Listen to relaxing music• Increase exposure to bright light during the day

……..Nursing Interventions To Promote Sleep

• 3. Diet:• Limit alcohol, caffeine, and nicotine in late

afternoon and evening• Consume carbohydrates or milk as a light snack

before bedtime.• Avoid heavy and spicy foods. Heavy or spicy

foods can cause gastrointestinal upsets that disturb sleep

• Decrease fluids 2 to 4 hours before sleep

……Nursing Interventions To Promote Sleep• 4.Medications:• Use sleeping medications only as a last resort• Minimize the usage of medicines as much as

possible because many contain antihistamines that cause daytime drowsiness.

• Take analgesics 30 mins before bedtime to relieve aches and pains.

• Consult the health care provider about adjusting other medications that may cause insomnia.

sleep & rest

Health & Medicine