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Study Questions on Sleep and Rest

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1.Briefly describe the 4 stages of Non-rapid Eye Movement (NREM) sleep. 路Stage 1: NREM -Stage lasts a few minutes. It includes lightest level of sleep. Decreased physiological activity begins with gradual fall in vital signs and metabolism. Sensory stimuli such as noise easily arouses person. Awakened, person feels as though daydreaming has occurred. 路Stage 2: NREM-Stage lasts 10 to 20 minutes. It is a period of sound sleep. Relaxation progresses. Body functions continue to slow. Arousal remains relatively easy.

路Stage 3: NREM-Stage lasts 15 to 30 minutes. It involves initial stages of deep sleep. Muscles are completely relaxed. Vital signs decline but remain regular. Sleeper is difficult to arouse and rarely moves. 路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. Sleepwalking and enuresis (bed-wetting) sometimes occur. It is very difficult to arouse sleeper. 2.Describe REM sleep as related to respirations and eye movements. Eye movements are rapid and respirations are increased

REM Sleep-

路Stage usually begins about 90 minutes after sleep has begun. 路Duration increases with each sleep cycle and averages 20 minutes 路Vivid, full-color dreaming occurs; less vivid dreaming occurs in other stages. 路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. 路It is very difficult to arouse sleeper.

3.When does REM sleep occur?
It is the phase at the end of each sleep cycle. It lasts up to 60 minutes.(p&p, p.940) 4.Which stages represent 鈥渄eep鈥 sleep?
NREM Stage 4
5.What is the medical term for 鈥渟leepwalking鈥?
somnambulism
6.Define 鈥渆nuresis鈥.
Bed-wetting
7.Which stage of sleep resembles wakefulness?
NREM Stage 1
8.In which sleep stage(s) do the following occur?
a.release of growth hormone-NREM stage 4 (p&p. p.941)
b.protein synthesis/tissue renewal- rest and sleep (p&p. p.941) c.brain tissue/cognitive restoration-REM(P&P. P.941)
9.During which stage of sleep does somnambulism and enuresis occur? NREM Stage 4
10.During which stage of sleep is a person difficult to arouse? Stages 3 &4 (pp, p.940)
11.What is meant by the sleep rhythm or cycle?
P.941, (P&P) An adults normal sleep patterns

12.What major neurotransmitter is associated with sleep? What is its function? Gabba-aminobutyric acid (GABA). It pushes chloride ions into the neurons. This greatly decreases the fire action potentials of the neurons. (p.302, kee) 13.Which sleep stage is important for mental and emotional stability? REM sleep

14.Explain the relationship of exercise and sleep.
Exercise preferably in the afternoon but no more than 2 hours before going to sleep. 15.What neurotransmitter is released by the reticular activating system (RAS) to maintain alertness and wakefulness? Norepinephrine (p&p, p940)

16.By what age does an infant sleep through the night?
Usually develop a nighttime pattern of sleep by 3 months. (p&p 945) by the age of 2, children usually sleep through the night 17.What is the most common sleep problem for the
a.Toddler? Waking up in the middle of the night because there is less REM sleep (p&p 945) b.Preschooler? Usually has difficulty relaxing or quieting down after a long, active day and has bedtime fears, awakens during the night, or has nightmares (p&p 945) 18.How many hours does the toddler/preschooler usually sleep? 12 hours a night (p&p 945)

19.What about the sleep needs of the adolescent?
On average teenagers get about 7 1/2 hours of sleep per night. The typical adolescent is subject to a number of changes such as school demands, after-school social activities, and part-time jobs, which reduce the time spent sleeping . Shortened sleep time often results in EDS, which frequently leads to reduced performance in school, vulnerability to accidents, behavior and mood problems, and increased use of alcohol (N 20.Describe sleep changes for the elder adult.

Complaints of sleeping difficulties increase with age. More than 50% of older adults report sleep problems. Older adults experience weakening, desynchronized circadian rhythms that alter the sleep-wake cycle. Episodes of REM sleep tend to shorten. There is a progressive decrease in stages 3 and 4 NREM sleep; some older adults have almost no stage 4, or deep sleep. An older adult awakens more often during the night, and it takes more time for him or her to fall asleep.

The tendency to nap seems to increase progressively with age because of the frequent awakenings experienced at night. The presence of chronic illness often results in sleep disturbances for the older adult. For example, an older adult with arthritis frequently has difficulty sleeping because of painful joints. Changes in sleep pattern are often caused by changes in the CNS that affect the regulation of sleep. Sensory impairment reduces an older person’s sensitivity to time cues that maintain circadian rhythms. (945) 21.Dreams are more vivid during which sleep stage?

REM sleep (p&p p.942)

22.Describe the environmental factors affecting sleep.

Drugs and substances, lifestyle, usual sleep patterns, emotional stress, environment (he physical environment in which a person sleeps significantly influences the ability to fall and remain sleep. Good ventilation is essential for restful sleep. The size, firmness, and position of the bed affect the quality of sleep. If a person usually sleeps with another individual, sleeping alone often causes wakefulness. On the other hand, sleeping with a restless or snoring bed partner disrupts sleep.) (p&p 946) exercise and fatigue, food and calorie intake

23.Describe the effect each of the following has on sleep.
a.Body weight
b.Relationships
c.Shift work
d.Vigilance
e.Nutrition/metabolism
f.Elimination
g.Exercise
h.Alcohol
i.Bedtime routine
j.Bedtime environment
k.Lifestyle/habits
l.Illness
m.Medications
n.Moods

24.Identify the things clients have stated disturb their sleep while in the hospital. In hospitals and other inpatient facilities noise creates a problem for patients. Noise in hospitals is usually new or strange and often loud. Thus patients wake easily. This problem is greatest the first night of hospitalization, when patients often experience increased total wake time, increased awakenings, and decreased REM sleep and total sleep time. People-induced noises (e.g., nursing activities) are sources of increased sound levels. ICUs are sources of high noise levels because of staff, monitor alarms, and equipment.

Close proximity of patients, noise from confused and ill patients, ringing alarm systems and telephones, and disturbances caused by emergencies make the environment unpleasant. Noise causes increased agitation; delayed healing; impaired immune function; and increased blood pressure, heart rate, and stress. Light levels affect the ability to fall asleep. Some patients prefer a dark room, whereas others such as children or older adults prefer keeping a soft light on during sleep. Patients also have trouble sleeping because of the room temperature. A room that is too warm or too cold often causes a patient to become restless. (946) 25.Define 鈥渋nsomnia鈥.

The inability to fall asleep. (p. 294, Kee)

26.What are the signs/symptoms of sleep deprivation?
Confusion and suspicion. Various body functions (ex. Mood, motor performance, memory and equilibrium) are altered when prolonged sleep loss occurs. Changes in the natural and cellular immune sytstem also occur with moderate to severe sleep deprivation. (p&p, p.941) 27.List & compare the common sleep disorders.

Box 42-2 p.943, p&p
路Insomnias- Adjustment sleep disorder (acute insomnia), Inadequate sleep hygiene, Behavioral insomnia of childhood, Insomnia caused by medical condition 路Sleep-Related Breathing Disorder

路Central Sleep Apnea Syndromes- Primary central sleep apnea, Central sleep apnea caused by medical condition, Obstructive sleep apnea syndromes 路Hypersomnias Not Caused by a Sleep-Related Breathing Disorder- Narcolepsy (four specified types), Menstrual-related hypersomnia, Hypersomnia caused by a medical condition 路Parasomnias- Disorders of Arousal- Sleepwalking, Sleep terrors 路Parasomnias Usually Associated with REM Sleep- Nightmare disorder, REM sleep behavior disorder 路Other Parasomnias- Sleep-related hallucinations, Sleep-related eating disorder, Sleep-related enuresis (bed-wetting) 路Circadian Rhythm Sleep Disorders

路Primary Circadian Rhythm Sleep Disorders- Delayed sleep phase type, Advanced sleep phase type 路Behaviorally Induced Circadian Rhythm Sleep Disorders- Jet lag type, Shift work type, Drug or substance use 路Sleep-Related Movement Disorders- Restless legs syndrome, Periodic limb movements, Sleep-related bruxism (teeth grinding) 路Isolated Symptoms, Apparently Normal Variants, and Unresolved Issues- Long sleeper, Short sleeper, Sleep talking 路Other Sleep Disorders- Physiological (organic) sleep disorders, Environmental sleep disorder 28.Describe the assessment for a sleep disorder.

Assess the patients normal sleep patterns, sources (patient, bed partner, and children of patient), Epworth sleepiness scale (evaluates the severity of EDS) and the Pittsburgh sleep quality index (assesses the sleep quality and sleep patterns). Visual analogue scale, 0-10 sleep rating, sleep history (rituals, preferred environment, what time patient gets up in morning, usual bedtime), illnesses, emotional and mental status, current life events 29.Define obstructive sleep apnea (OSA).

Occurs when muscles or structures of the oral cavity or throat relax during sleep. The upper airway becomes partially or completely blocked, diminishing nasal airflow (hypopnea) or stopping it (apnea) for as long as 30 seconds. (p&p, 943) 30.Identify the signs of sleep apnea.

EDS, sleep attacks, fatigue, morning headaches, irritability, depression, difficulty concentrating, and decreased sex drive (p&p 943) 31.What are the dangers of sleep apnea?

Breathing stops, the sleep cycle is interrupted so the person doesn鈥檛 get enough sleep 32.What should the nurse teach the sleep apnea client about sleep position? To sleep on their sides vs. their backs

33.What is CPAP?
Continuous positive airway pressure

34.Why is CPAP necessary?
The mask delivers room air at a high pressure. The air pressure prevents airway collapse 35.Why should the nurse instruct clients to bring their CPAP to the hospital with them? Its effective and will help the patient sleep in the already noisy hospital 36.Define and describe narcolepsy.

A dysfunction of mechanisms that regulate sleep and wake states. During the day a person suddenly feels an overwhelming wave of sleepiness and falls asleep; REM occurs within 15 minutes of falling asleep. (p&p 944) 37.What is one thing a nurse can do to promote sleep for a client who is going to surgery in the morning? Provide information about the purpose of procedures and routines and answer questions which will give them peace of mind needed to rest or fall asleep. 38.How do hypnotics affect REM sleep?

The duration of REM sleep is decreased
39.What must the nurse remember about sedation and consent forms? Sedatives and ambulation? If a patient is under the influence of drugs they cannot sign consent forms for themselves. A family member must do it for them. And a patient needs to be watched carefully when walking while under the influence of sedatives. 40.Define 鈥減arasomnia鈥.

Sleep problems that are more common in children than adults. (SIDS) is thought to be related to apnea, hypoxia,and cardiac arrhythmias caused by abnormalities in the autonomic nervous system that are manifested during sleep. Parasomnias that occur in children include somnambulism (sleep walking), night terrors, nightmares, nocturnal enuresis (bed wetting), body walking, and bruxism (teeth grinding). (p&p 944)

41.Should you awaken people during parasomnia events?
no
42.Describe 鈥淚CU syndrome鈥 and its effect on sleep.
Hospitalization makes patients particularly vulnerable to the extrinsic and circadian sleep disorders. Constant environmental stimuli within the icu such as strange noises from equipment, the frequent monitoring and care given by nurses, and ever-present lights confuse patients. Repeated environmental stimuli and the patients poor physical status lead to sleep deprivation (p&p p.944) 43.What impact does sleep deprivation have on ADLs?

If a person is deprived from sleep they wont have enough energy to do their normal daily activities. 44.What questions should be asked during a sleep assessment? Box 42-5 p948 鈥escribe for me the type of sleep problem you are having. 鈥hy do you think you are not getting enough sleep?

鈥escribe a recent night’s sleep. How is this sleep different from your usual sleep? Signs and Symptoms
鈥o you have difficulty falling asleep, staying asleep, or waking up? 鈥ave you been told that you snore loudly?
鈥o you have headaches when awakening?
Onset and Duration of Signs and Symptoms
鈥hen did you notice the problem?
鈥hat do you do to relieve the symptom?
鈥ow long has this problem lasted?

Severity
鈥ow long does it take you to fall asleep?
鈥ow often during the week do you have trouble falling asleep? 鈥ow many hours of sleep a night did you get this week? 鈥ow does this compare to your usual amount of sleep? 鈥hat do you do when you awaken during the night or too early in the morning? Predisposing Factors

鈥hat do you do just before you go to bed?
鈥ave you recently had any changes at work or at home? 鈥ow is your mood? Have you noticed any changes recently? 鈥hich medications or recreational drugs do you take on a regular basis 鈥re you taking any new prescriptions or over-the-counter medications? 鈥o you eat food (spicy or greasy foods) or drink substances (alcohol or caffeinated beverages) that affect your sleep? 鈥o you have a physical illness that affects your sleep? 鈥oes anyone in your family have a history of sleep problems? Effect on Patient

鈥ow has the loss of sleep affected you?
鈥o you feel excessively sleepy or irritable or have trouble concentrating during waking hours? 鈥o you have trouble staying awake? Have you fallen asleep at the wrong times (e.g., while driving, sitting quietly in a meeting)? 45.How would the nurse determine a client鈥檚 usual sleep pattern? Sleep is a subjective experience. Only the patient is able to report whether it is sufficient and restful. (p&p 947) 46.Identify at least 3-4 nursing diagnoses appropriate for sleep problems. Anxiety, ineffective breathing pattern, acute confusion, compromised family coping, insomnia, fatigue, sleep deprivation, readiness for enhanced sleep

47.What kind of goals would be appropriate for sleep disorders? The patient will achieve a more normal sleep pattern within 4 weeks. The patient will achieve an improved sense of adequate sleep within 4 weeks. 48.What interventions would the nurse incorporate into the care plan? Encouraging short naps if possible, advise patient to contact heath care provider if fatigue persists after sleep improves, have the patient keep a sleep log for a week, teach the patient sleep hygiene measures, teach the patient relaxation measures that induce sleep, etc. (p&p 953) 49.Explain the non-pharmacological methods the nurse can use to promote sleep. 1.Arise at a specific time in the morning. 2. Take few or no daytime naps. 3. Avoid drinks that contain caffeine 6 hours before bedtime. 4. Avoid heavy meals or strenuous exercise before bedtime. 5. Take a warm bath, read, or listen to music before bedtime. 6. Decrease exposure to loud noises.

7. Avoid drinking copious amounts of fluids before bed. 8. Drink warm milk before bedtime. (p.295, kee) 50.Identify common herbal products used to promote sleep & the precautions for their use. Valerian is effective in mild insomnia and RLS. It effects the release of neurotransmitters and produces very mild sedation. Kava helps promote sleep in patients with anxiety. It needs to be used cautiously because of its potential toxic effects on the liver. Chamomile, an herbal tea, has a mild sedative effect that may be beneficial in promoting sleep. Caution patients about the dosage and use of herbal compounds because the us food and drug administration does not regulate them. Herbal compounds may interact with prescribed medication, and patients need to avoid using these together. 51.What discharge teaching may be used to promote sleep hygiene at home? Follow the same bedtime ritual every night

52.What is the difference between a sedative & a hypnotic?
Sedatives diminish physical and mental responses at lower dosages of certain CNS depressants but do not affect consciousness. Anesthesia may be achieved with hypnotics. (p.295, kee) 53.Common sedative-hypnotics are barbituates, benzodiazepines, and nonbenzodiazepines. (p.296, kee)

54.What is the drug classification for benzodiazepines?
Sedative-hypnotics
55.Common benzodiazepines are alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium) and lorazepam (Ativan)_. 56.What category of Schedule drugs do these controlled drugs belong in? a.Sedative-hypnotics-Schedule II (p.297, kee)

b.Benzodiazepines- Schedule IV (p.297, kee)
57.Which benzodiazepines are used for insomnia?
Estazolam (ProSom), flurazepam HCl (Dalmane), lorazepam (Ativan), quazepam (Doral), temazepam (Restoril), triazolam (halcoin) (p.301, kee) 58.What are the contraindications for benzodiazepines?
Paradoxical response (insomnia, excitation, euphoria, anxiety, rage) CNS depression, (sedation, light-headedness, ataxia, decreased cognitive function) Anterograde amnesia
Oral toxicity (drowsiness, lethargy, confusion)
IV toxicity (may lead to respiratory depression, severe hypotension, or cardiac/respiratory arrest)

*Pregnancy category risk D
*Use caution with liver disease
*Diazepam contraindication with respiratory disorders
59.Identify the common side effects/adverse reactions of sedative-hypnotics. 路Advise client to report adverse reactions such as hangover to health care provider. Drug selection or dosage might need to be changed. 路Instruct client that hypnotics such as secobarbital should be gradually withdrawn, especially if it has been taken for several weeks. Abrupt cessation of the hypnotic may result in withdrawl symptoms (e.g., tremors, muscle twitching) (p.298, kee) 60.Define:

a.Hangover- Residual drowsiness resulting in impaired reaction time. (p.296, Kee) b.Dependence- the result of chronic hypnotic use. Physical and psychological dependence can result. (p.296, Kee) c.Tolerance- results when there is a need to increase the dosage over time to obtain the desired effect. It is mostly caused by an increase in drug metabolism by live enzymes. The barbiturate drug category can cause tolerance after prolonged use. Tolerance is reversible when the drug is discontinued. (p.296, kee) 61.What assessment criteria must the nurse consider when caring for clients getting these medications? (sedative hypnotics) 路Obtain a drug history of current drugs and herbs client is taking 路Record baseline vital signs for future comparison

路Determine if there is a history of insomnia or sleep disorder 路Assess renal function. Urine output should be 600 mL/day. Renal impairment could prolong drug action by increasing half-life of the drug. 路Assess potential for fluid volume deficit, which would potentiate hypotensive effects. (p.298, kee) 62.What nursing diagnoses would be appropriate for these clients? (sedative hypnotics) 路Sleep deprivation r/t anxiety and stress

路Risk for injury r/t dizziness (p. 298, kee)

63.What goals would be appropriate?

路Patient will receive adequate sleep without hangover when taking hypnotic (p.298, kee) 64.What interventions are recommended? (sedative hypnotics) 路Recognize that continuous use of a barbiturate might result in drug abuse 路Monitor vital signs, especially blood pressure and respirations, 路Raise bedside rails of older adult and client receiving a hypnotic for the first time. Confusion may occur and injury may result 路Observe client, especially older adult or a debilitated client, for adverse reaction to secobarbital

路Check client鈥檚 skin for rashes. Skin eruptions may occur in clients taking barbiturates. 路Assess clients for withdrawal symptoms when barbiturates have been taken over a long period of time and abruptly discontinued. 路Administer IV pentobarbital at a rate of less than 50 mg/min. Do not mix pentobarbital with other medications. IM injection should be given deep in a large muscle such as the gluteus medius. (p.298, kee) 65.What are the evaluation criteria r/t these drugs? (sedative hypnotics) 路Assess the effectiveness of barbiturates.

路Evaluate respiratory status to ensure that respiratory distress has not occurred. (p.298, kee) 66.Make a list of the teaching points necessary for these clients. (sedative hypnotics) 路Teach the client to use nonpharmacologic ways to induce sleep (enjoying a bath, listening to music, drinking warm fluids, or avoiding drinks with caffeine 6 hours before bed). 路Instruct client to avoid alcohol and antidepressants, antipsychotics, and narcotic drugs while taking barbiturate. Respiratory distress may occur when these drugs are combined. 路Inform client that certain herbs may interact with CNS depressants such as barbiturates.

Herbal supplements may need to be discontinued or prescription drug dose may need to be modified. 路Advise client not to drive a motor vehicle or operate machinery. Caution is always encouragement. 路Instruct client to take hypnotic 30 minutes before bedtime. Short acting barbiturates take effect in 15 to 30 minutes. 路Encourage client to check with health care provider about OTC sleeping aids. Drowsiness may result from taking these drugs; therefore caution while driving is advised. (p.298, kee)

67.How long should clients be taking these drugs? Why? (sedative hypnotics) Clients should not be taking them for longer than 3 to 4 weeks because of dependency. 68.What are the signs of toxic effects? (sedative hypnotics) 路Benzodiazepines in acute overdose are considerably less dangerous than other anxiolytic/hypnotic drugs. The effect of an overdose is to cause prolonged sleep, without serious depression of respiration or cardiovascular function. However, in the presence of other CNS depressants, particularly alcohol, benzodiazepines can cause severe, even life-threatening, respiratory depression. The availability of an effective antag颅onist, flumazenil, means that the effects of an acute overdose can be counteracted, which is not possible for most CNS depressants. Acute Toxicity of Barbiturates:

路 Hypoxia, cyanosis, hypothermia.
路Respiratory, circulatory failure, coma, death.

69.What precautions are necessary when giving these drugs to elder adults? (sedative hypnotics) Nonpharmacologic methods should be used before sleep medications are prescribed. Because of physiologic changes in older adults, the use of hypnotics can cause a variety of side effects. Barbiturates increase CNS depression and confusion in the older adults and should not be taken for sleep. In most cases, older adults should be instructed to take the prescribed benzodiazepine no more than four times a week to avoid side effects and drug dependency. 70.What kinds of drugs would increase the effects of benzodiazepines?

Decrease? because barbiturates work on the central nervous system, they may add to the effects of alcohol and other drugs that slow the central nervous system, such as antihistamines, cold medicine, allergy medicine, sleep aids, medicine for seizures, tranquilizers, some pain relievers, and muscle relaxants. They may also add to the effects of anesthetics, including those used for dental procedures. The combined effects of barbiturates and alcohol or other CNS depressants (drugs that slow the central nervous system) can be very dangerous, leading to unconsciousness or even death. Anyone taking barbiturates should not drink alcohol and should check with his or her physician before taking any medicines classified as CNS depressants. 71.Which barbiturate classification is used for inducing sleep? Short-acting

72.What happens when Kava or Valerian are combined with alcohol, barbiturates, or narcotics? Kava kava may increase the sedative effect. Valerian may increase the sedative effect. (p. 297, kee) 73.Why should the nurse be concerned about a client with liver or kidney disease using barbiturates? It can have adverse effects

74.What monitoring precautions are necessary when giving sedative-hypnotics to elders? Signs of respiratory depression, next day sedation, amnesia, rebound insomnia, and impaired motor functioning and coordination which leads to increased risk for falls. (p&p, 958) 75.Why is the dosage of hypnotics tapered off before discontinuing use? To reduce the risk of drug dependency

76.The evaluation process should include assessment of _the sedative hypnotic in promoting sleep_ & _if side effects such as hang over have occurred after several days of taking the sedative hypnotic_. 77.What safety precautions are necessary after giving sedatives/hypnotics? Monitoring the vital signs for respiratory distress, put up the bed rails (older adults may be confused and could fall), observe for side effects such as hangover 78.What are 2 signs of sedative/hypnotic withdrawal?

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