Sleep Deprivation

Dr. Abdul-Monim Dr. Abdul-Monim BatihaBatiha

Assistant ProfessorAssistant ProfessorCritical Care NursingCritical Care Nursing

Philadelphia Philadelphia University University

Outlines:

DEFINITION. STAGES OF SLEEP. CIRCADIAN RHYTHM. CIRCADIAN DESYNCHRONIZATION. DYSFUNCTIONAL SLEEP. SLEEP DEPRIVATION IN CRITICAL CARE

UNITS.

EFFECTS OF SLEEP DEPRIVATION IN CRITICAL CARE UNITS

SIGNS AND SYMPTOMS OF SLEEP DEPRIVATION.

NURSING ROUTINES AND INTERVENTIONS.

PHARMACOLOGY AND SLEEP. NURSING’S CHALLENGE. PREPARING THE PATIENT FOR SLEEP.

Definition

Sleep is a state of unconsciousness from which a person can be aroused by appropriate sensory or other stimuli.

(Guyton 1991( It is a reversible behavioral state of

perceptual disengagement from and unresponsiveness to the environment.

(William 2004)

Sleep is the state of natural rest observed in most mammals. It is characterized by a reduction in voluntary body movement, decreased reaction to external stimuli, an increased rate of anabolism the synthesis of cell structures, and a decreased rate of catabolism( the breakdown of cell structures(. regular sleep is necessary for survival.

(Free encyclopedia 2007)

Adults normally spend Approximately one third of their lives asleep .

Research involving the simultaneous monitoring of the

Electroencephalogram (EEG) Electrooculogram (EOG) Electromyogram (EMG)

STAGES OF SLEEP

Non-rapid eye movement (NREM) Consists of four stages

Stage I and II — 50% to 60 % of sleep, light sleep Stage III and IV — 20% of sleep, deep-sleep states

(delta sleep)

Rapid eye movement (REM) 20-25% of total sleep

In Stage 1

The individual may not even be aware that he has begun to sleep.

Still aware of his surroundings, The individual is relaxed and drowsy, His thoughts are aimless and begin to drift Thinking is less reality-oriented. Amplitude of brain waves low.

The individual is less reactive to outside stimuli, but can still be aroused easily.

Body temperature and vital signs start to drop as metabolism slows.

Stage 1 is a brief stage, lasting no more than 7 minutes.

Lasts 2% to 5% of total sleep time.

Stage 2 of NREM sleep

Is a slightly deeper sleep and is a transition or “door” stage to deeper NREM stages or to REM sleep.

The individual is no longer aware of his surroundings,

Amplitude of brain waves higher.

and is a little harder to awaken. Fragments of dreams may occur, Eyes slowly roll from side to side. Metabolism and vital signs continue to

decrease. Sleep spinder. Lasts 5-15 minutes. This is the most stable and predominant

NREM sleep stage in adults.

NREM Stage 3 sleep

Is much deeper than that of Stage 2, and the individual is now more difficult to arouse.

Snoring may begin to occur Because of decreased muscle tone. Vital

signs, body temperature, and metabolism are

decreased. Roughly 15 to 20 minutes after falling asleep.

Stage 4 NREM sleep

Deepest sleep stage, and the individual is very difficult to awaken.

Sometimes referred to as “weary sleep," it is at this time that sleep walking and bed-wetting can occur.

The individual rarely moves at this time

vital signs and metabolism are at their lowest, with the parasympathetic system dominant.

Elevated GH and other anabolic hormones, such as prolactin and testosterone, imply that anabolism is taking place, particularly in tissues with a high protein content.

Thus activities include protein synthesis and tissue repair.

When people speak of having had a good night’s sleep, it is likely primarily Stage 4 sleep that they are referring to.

NREM Stages 3 and 4 are the deepest stages of sleep and are often reported together as

delta-wave sleep, for the amplitude of waves seen on the EEG during these stages.

20% to 25% of sleep for the adult, but this percentage decreases with age.

REM sleep

REM sleep is sometimes referred to as paradoxical sleep.

REM sleep is a very active stage with a high degree of cerebral and physiologic activity.

REM sleep continues to facilitate protein anabolism, but during this same time there is great fluctuation in autonomic nervous system activity, causing heart rate variability.

Increases in parasympathetic tone.

Sympathetic stimulation.

There is increased cerebral blood flow during REM sleep .

Evidence suggests that the adrenalin surge that more than doubles during REM sleep may be responsible for episodes of ischemia, sudden cardiac death, and strokes in the early morning hours.

Most dreams occur during REM sleep REM sleep can last from 5 to 35 minutes

REM sleep is of great importance to nurses

because as the patient is entering this stage

of sleep, the nurse may notice a change in

vital signs and become concerned that the

patient's condition is worsening.

Walking↓

NREM(Stage 1)

NREM )Stage 2(

NREM ) Stage 3( REM

NREM ) Stage 4( NREM )Stage 2(

NREM ) Stage 3(

The cyclic Nature of sleep

The cyclic nature of sleep and wakefulness is thought to be regulated by complex neurochemical reactions arising in the tissues of the brain stem known as the reticular formation.

The sleep-wakefulness cycles, as well as the REM/nonREM cycle, are throughout be mediated by the neurotransmitters serotonin, dopamine, norepinephrine, and epinephrine. Current research suggests that the control of sleep is a very complex process not confined to one localized part of the brain.

Circadian rhythm

The sleep-wake cycle follows the circadian

rhythm in a 24-hour cycle synchronized with

other biologic rhythms. Nighttime sleep is

the normal pattern for most adults.

When sleep occurs during the low phase of

the circadian rhythm, circadian

synchronization is present . Sleep that occurs

during normal waking hours is out of phase or

desynchronized

Sleep desynchronization

Fig. 10-8 Sleep synchronization and desynchronization with circadian rhythm.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --8AM 2PM 8PM 2AM 8AM

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me8 am i I

j

Desynchronized sleep is rated as poor-quality

sleep and causes a decreased arousal

threshold; therefore frequent awakenings are

more likely. Irritability, restlessness,

depression, anxiety, and decreased accuracy

in task performance are characteristic effects

of desynchronized sleep.

Resynchronization with the circadian

rhythm must occur whenever sleep has

become desynchronized for the individual to

establish a normal sleep-activity pattern.

Although variable among individuals, the

resynchronization process is thought to

require a minimum of 3 days with a consistent

sleep-wake schedule.

During resynchronization, the individual often

feels fatigued and unable to perform all of his

or her activities of daily living.

CIRCADIAN DESYNCHRONIZATION

The loss of rhythmicity may result from external stressors, which then alters the timing relationships of neural, hormonal, and cellular systems.

Humans respond to stressors, such as surgery, immobilization, and pain, with increased levels and altered timing of adrenal and other hormones.

Farr and other reported that circadian levels; the timing of temperature, blood pressure, and heart rate; and urinary excretion of catecholamines, sodium, and potassium were altered after surgery in hospitalized patients.

Nursing interventions that maintain normal

rhythmicity of the day-night cycle.

SLEEP DEPRIVATION INCRITICAL CARE UNITS

Patients in critical care units often experience

a lack of sleep or frequent disruptions to their sleep, further compounding their illness.

Psychological stress alone can temporarily

affect an individual’s sleep patterns. More time is spent trying to initiate sleep, and

when sleep occurs, it mainly consists of lighter sleep in Stages 1 and 2

Research has shown that patients in critical care units may spend 40% to 50% of their sleep time awake, and of the remaining sleep time only 3% to 4% in REM sleep.

Psychological stressors may cause an individual to need more REM sleep and may cause the individual to feel that they dreamed more than usual and had less restful sleep.

Illness and hospitalization certainly increase psychological stress, but unfortunately hospitalization makes it less possible for the individual to obtain adequate REM sleep.

Novaes and colleagues (1997)conducted a study to evaluate physical and psychological stressors in the intensive care unit (ICU) patients. Fifty patients were asked to complete the Intensive Care Unit Environmental Stressor Scale, ranking the 40 items from not stressful to very stressful. Of these 40 items, not being able to sleep was ranked as the second most important stressor, second only to pain.

Using EEGs, Hilton documented quantity and quality of sleep of nine patients in a respiratory critical care unit. Total sleep time ranged from 6 minutes to 13.3 hours. Only 50% to 60% of the sleep occurred at night, and no patients had complete sleep cycles. NREM stage 1 sleep predominated, to the deprivation of all other stages. Significant deprivation of restorative sleep (NREM stages 3 and 4) was demonstrated with only 4.7% to 10.5% of sleep time being spent in these stages (normally 30% to 35%).

Shaver, in a review of sleep research, notes that sleep deprivation is considered to be a contributing factor in postoperative psychosis.

There is substantial evidence to support the fact that 4 days of sleep deprivation results in a decreased production of ATP, the critical energy substance.

EFFECTS OF SLEEP DEPRIVATION IN CRITICAL CARE UNITS Sleep deprivation has been shown to induce

a catabolic state and negatively affect the immune system and healing.

There is decreased ability to resist and fight infection, further impacting the healing process and hospitalization.

Immunosuppression and decreased tissue repair

studies report decreased pain tolerance and profound fatigue of the sympathetic nerve centers.

Cortisol secretions are normally diminished during sleep and rise in the morning following circadian rhythms.

Sleep deprivation in critical care patients prolongs cortisol secretion and results in decreased healing, making patients more susceptible to infection and a prolonged recovery process.

Lack of sleep has also been shown to contribute to upper airway musculature dysfunction and hypoxic ventilatory responsiveness, adversely affecting gas exchange. This could have a significant impact on patients with respiratory problems, particularly those who are being weaned from the ventilator or those who have just been extubated

Signs and symptoms of sleepdeprivation

The signs and symptoms of sleep deprivation

may not be so apparent, at least initially.- Behavioral changes such as restlessness

and irritability may occur within 48 hours.- Disorientation- slurred speech may precede psychotic

behavior, which can occur within 96 hours

If a patient is deprived primarily of NREM sleep

He may experience:

- fatigue, apathy, speech deterioration, poor judgment, and lack of energy.

- ptosis and lack of facial expression.

Deprivation of REM sleep

May cause the patient to feel continually tired and have difficulty concentrating. When deprived of REM sleep for greater than 24 to 48 hours, the patient may experience irritability, confusion, poor impulse control, paranoia, and hallucination, or exhibit aggressive behavior

If an individual does not obtain enough

sleep to meet his biological needs, this sleep

deprivation will accumulate over time until the brain signals the body to obtain sleep.

If sleep deprivation is prolonged, when the patient finally enters sleep, it consists of predominantly Stage 2 and the deep recovery sleep of Stage 4. REM sleep usually does not occur until the second or third night

CAUSES OF SLEEP DEPRIVATION IN CRITICAL CARE UNITS

Related to patient: 1- Age. 2- physical condition (underlying disease). 3- Pain. 4- Anxiety, and stress. Related to staff: 1- Procedures are interrupting the sleep time. Related to the environment 1- Noisy, 2- Unfamiliar environment, 3- Lighting,

Dlin and others showed that the chief deterrents to sleep in the critical care unit in order of importance were (1) activity and noise, (2) pain and physical condition, (3) nursing procedures, (4) lights, (5) vapor tents, and (6) hypothermia.

Woods and Falk20 found that 10% to 17% of noises in the critical care unit were of a level capable of arousing patients from sleep (greater than 70 decibels).

Sleep-disturbing events validated by EEG were mainly staff and environmental noise, which occurred on the average of every 20 minutes. Quality and quantity of sleep were reported as poor in all subjects. Nightmares, hallucinations, restlessness, or other behavioral changes were observed in 60% of the patients in the sample.

ASSESSMENT OF SLEEP PATTERN DISTURBANCE

Description of the normal sleep pattern ِ�Any recent changes in the patient's normal

pattern resulting from the acute illness. Recent and more distant history of sleep

disturbances. The severity, duration, and frequency of the

problem.

History of chronic illnesses and physical conditions that may disturb sleep.

The critical care nurse should elicit history of snoring because of its relationship to sleep apnea and sleep disturbances.

The scientific standard for the measurement of sleep is the polysomnogram (PSG).

Sleep efficiency is an important sleep

variable defined as the proportion of actual sleep time in the total sleep period.(95% versus 65%)

Nursing routines and interventions

-In order to have early morning laboratory work

and test results available when physicians

make rounds, most critical care units wake

Patients at 5 AM or 6 AM to draw blood and do

electrocardiograms.

In a study of 203 patients from 4 ICU’s, patients were given a questionnaire on the day of discharge to evaluate their sleep during their stay in the ICU. The questions assessed perceived sleep quality and daytime sleepiness, perceived sleep disruption caused by environmental activities, and perceived sleep disruption caused by specific environmental noises. They that nursing interventions such as checking of vital signs were more disruptive to sleep than were other factors such as noise and light. (Friedman,1999)

One study reported that nurses generally

agreed that sleep was important to their

patients, but found it difficult to organize their

assessment routines and tasks to even

Accommodate 2-hour periods of quiet time.

(Olson,2001)

PHARMACOLOGY AND SLEEP Hypnotic drugs have been found to promote

the lighter stages of sleep (i.e., NREM stage 2) and may, paradoxically, be the cause of night terrors, hallucinations, and agitation in the elderly.

If hypnotics are indicated, it is wise to first

evaluate the medications that the patient is

receiving, to make certain that none of them

are contributing to the patient’s inability to

sleep. Consulting with the pharmacist may

help identify these medications so that

discussion can be initiated with the physician.

Barbiturates e.g amobarbital they increases NREM2, and suppress REM

Benzodiazepines e.g. Diazepam increases NREM stage 1 and reduces both NREM stages 3 and 4 and REM.

Morphine increases spontaneous arousals during sleep and shortens the sleep time by reducing both REM and NREM stages 3 and 4, resulting in overall lighter sleep.

It is the responsibility of the critical care nurse to assess the need for sedative and analgesic medications, to administer them in the most effective manner to promote sleep, and to monitor their effectiveness

NURSING’S CHALLENGE

The sleep process and effects of deprivation need to be incorporated into critical care education programs and continuing education programs, and encouraged as nursing research topics.

Sleep requirements need to become part of the written multidisciplinary plan of care, to allow for care and assessment of patients, but incorporating blocks of uninterrupted sleep.

It needs to be discussed in shift to shift report, and may need to be discussed in Health Team Conference. Nursing activities should be organized to make sleep a priority for patients in critical care units.

Nursing interventions for promoting and preparing the patient for sleep

If the patient has a pulmonary artery

and/or arterial line, make sure the transducer

is leveled to right atrium with the patient’s

head of the bed in the desired position.

Leveling the transducer at the phlebostatic

axis, with the patient in position for sleep, will

assure that the assessment readings taken

throughout the night are accurate to guide

decision-making. Assess the patient and the

intravenous lines for patency.

The proper location of the phlebostatic axis

Assess the patient for any pain or discomfort.

If pain medication is required, try to give it early enough so that it takes effect before bedtime and the patient will be pain-free and more relaxed. If sleep medication is ordered, offer it only after pain is relieved, so that the hypnotic will be more effective.

Offering a bedtime snack or a glass of warm milk may encourage sleep. Nursing activities such as freshening the bed linen and allowing the patient to brush his teeth, wash his face, and void before sleep are helpful.

Providing an extra pillow or blanket, arranging the pillows in a certain way, and assisting the patient to a comfortable position for sleeping may be helpful. A back massage can be very relaxing and therapeutic, and provides the patient with his nurse’s undivided attention for the moment.

For many patients, privacy or private room and providing the patient with his covering, pillows, and pajamas are all traditionally promote sleep.

Touch can be very therapeutic, and may provide an opportunity for the patient to ask questions or share concerns that might not otherwise have been verbalized.

If the patient has a tendency to nap during the

day, morning naps should be encouraged rather

than afternoon naps because afternoon naps

consist mostly of deep sleep (Stage 4) and short

periods generally leave the patient feeling tired.

(Hayter J, 2003)

(Richards, 2002) tested the effect of a back

massage and combination of muscle

relaxation, mental imagery, and music on the

sleep of 69 older men with a cardiovascular

illness who were hospitalized in a critical care

unit. Her study showed significant differences

between the back-massage and the control

group, in the percentage of Stage 2 and REM

sleep, with the back-massage group sleeping

longer than the control group.

When giving a hypnotic, make that the final

trip to the patient’s room for the shift. Before

leaving, make sure the patient has fresh

water, and that the call light is within reach.

Titrate environmental stimuli: turn down light, alarms, and decrease noise from TV and talking.

Activity during day time should be increased . Limiting caffeine intake after early afternoon

will promote sleep in the evening.

Make sure the intermittent suction machine

is turned off, the oxygen tubing is free of water,

faucets are not dripping, and the urinal is

empty and within reach. Pull the patient’s

curtain closed to help block out light from the

unit. If there is a door to the room, close it.

During the night, take note of any patient who

appears not to be sleeping. Turning and

wakefulness can often be detected on the

monitor by movement. By checking on the

patient, you may find that he is having pain, is

anxious, or in some distress that need further

assessment.

If it is necessary to assess the patient, perform

procedures during the night, or bathe the

patient, do so as quietly as possible. Since

critically ill patients sometimes cannot tolerate

a lot of activity at one time, try to space

procedures to allow a minimum of 2 hours of

uninterrupted sleep at a time.

Noise and interruptions should be kept to a

minimum, to allow the patient to obtain the

much needed NREM Stages 3 and 4 sleep and

REM sleep.

Have the patients use earplugs.

At bet time , provide information to lower anxiety. Do review of the day and remind patient of the progress made toward recovery, then add what to expect for the next day.

Institute “PM” care back to basics, brushing teeth, washing face, before “ bedtime”.

Allow family to be with the patient.

Post sign at designated times” patient sleeping”.

Document amount of uninterrupted sleep per shift, especially sleep episodes lasting longer than 2 hours.