Chapter 8: Sleep & Sleep Disorders Nursing Care

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Welcome to the Deep Dive.

Today we're getting into something absolutely fundamental sleep.

I mean, think about it.

In an 80 -year life, that's something like 24 years spent sleeping, a huge part of our lives, and it affects, well, everything, mood, memory, physical health.

So today we're diving deep into Lewis's Medical Surgical Nursing, specifically the chapter on sleep and sleep disorders, really essential stuff for all you future nurses.

Our mission here is simple, break down this dense critical nursing content into something clear, structured, and genuinely useful.

We'll cover the basics of sleep, look at common disorders, insomnia, sleep apnea, you know ones, and really focus on your role as a nurse.

Assessment, interventions, patient teaching, we'll explain the tricky terms, focus on that nursing process, and use examples you might actually see.

And to help us navigate all this, we have our expert guide with us.

Great to be here.

Yeah, sleep.

It's fascinating.

Let's start with the basics.

What is sleep?

It's not just being unconscious, right?

It's a state where you're not consciously aware of your surroundings, but you can be easily woken up.

That's the key difference from, say, a coma.

It's dynamic, organized, incredibly complex, and totally essential for health, for survival even.

And when we don't get enough, we call that sleep insufficiency.

It doesn't support optimal functioning.

This could be sleep deprivation, just not enough hours, or sleep fragmentation, you know, waking up constantly.

Poor quality, either way.

Then there's the broader idea of sleep disturbance.

That's poor sleep from anything, really.

Noise, pain, or actual sleep disorders like insomnia, obstructive sleep apnea, narcolepsy.

There's a whole list.

Wow.

Okay.

And the scale of this.

Lewis's says 35 % of Americans get less than seven hours, and 50 to 70 million have a sleep disorder, maybe without even knowing it.

That's huge.

So what are the knock -on effects if these things aren't addressed, beyond just feeling grobby?

Oh, the effects are massive.

Health, safety, the economy, severe daytime sleepiness messes with work, social life, and it's a factor in,

like 90 ,000 car accidents a year, almost 800 deaths, billions of dollars lost.

And here's something critical for you as nurses.

Patients with chronic illnesses,

they're at the highest risk.

But here's the kicker.

We often don't ask, and patients often don't mention sleep problems.

It just gets missed.

That's a really important point for practice.

Okay, so we know what it is and why it matters, but how does our body actually do sleep?

How does the brain manage all this?

It's honestly incredible.

The brain has these complex networks, wakefulness,

that's largely driven by the ascending reticular activating system, the ARRA, and the brainstem.

It uses neurotransmitters like acetylcholine, dopamine, keeps the cortex active, which is why, you know, in Alzheimer's, where you lose those cholinergic neurons or Parkinson's affecting dopamine, you see major sleep problems.

Makes sense, right?

Yeah, it connects the dots.

And conversely, different brain areas, like the hypothalamus, promote sleep using things like GABA melatonin.

Even inflammation during an infection releases cytokines that make you feel sleepy.

Your body's literally telling you to rest.

And a really key player here is orexin, sometimes called a hypocretin.

It's a neuropeptide made in the hypothalamus, and it's vital for keeping us awake, like a stay awake signal.

Okay.

So some newer sleep meds actually work by blocking orexin.

And on the other side, low levels of orexin that's strongly linked to narcolepsy, where people have those sudden, irresistible urges to sleep.

Interesting.

And melatonin.

Everyone talks about melatonin.

Right.

Melatonin is a hormone from the pineal gland.

Its release is tied to the light -dark cycle.

Basically, as light fades, melatonin ramps up, telling your brain it's time to wind down, to turn off wakefulness.

That's why looking at bright screens late at night can mess things up.

It suppresses melatonin.

All this is managed by circadian rhythms, our internal 24 -hour clocks.

The master clock is the suprachasmatic nucleus, the SCN, in the hypothalamus.

And light is the main thing that synchronizes it.

So things like light therapy can actually be used to shift those rhythms if they're off.

It's amazing how finely tuned it all is.

And we can actually measure this, right?

What does that sleep architecture look like?

What do nurses need to know about that?

Yeah.

Sleep architecture is just the pattern of sleep stages across the night.

We measure it with polysemography PSG that involves an EEG for brainwaves, EOG for eye movements, EMG for muscle tone.

During sleep, we cycle between two main states,

NREM, non -rapid eye movement sleep, and REM, rapid eye movement sleep.

We go through maybe four to six of these cycles a night, each lasting roughly 60 to 110 minutes.

NREM is about 75, 80 % of sleep.

It has three stages.

N1 is that light, drowsy state, easy to wake up from.

N2 is most of night.

Heart rate slows, temperature drops.

Then there's N3.

This is the really important one for nurses to understand.

It's the deepest stage, slow -wave sleep, super restorative.

But here's the thing, N3 declines a lot with age.

Most older adults get very little N3.

So that explains why maybe older patients often feel less refreshed, wake more easily.

Exactly.

It helps you understand their experience.

Protecting what little N3 they get becomes really important in care.

And then REM sleep follows NREM about 20, 25 % of the night.

Brain activity looks almost like being awake, but your major muscles are essentially paralyzed.

You can't move.

This is when most vivid dreaming happens.

Got it.

So with sleep being so crucial,

what are the real -world health consequences when patients don't get enough?

What impacts do they often underestimate?

People really underestimate the cumulative damage.

It's not just feeling tired.

Insufficient sleep hits almost every system.

Neurologically.

Impaired thinking, irritability, mood swings, cardiovascular, increased risk for high blood pressure, arrhythmias, heart disease.

It can actually raise BP in people who already have hypertension.

Endocrine system.

Higher risk for type 2 diabetes, think insulin resistance and obesity.

Immune system gets suppressed long -term, inflammation goes up, contributing to things like heart disease, metabolic syndrome,

and mental health is huge.

Poor sleep is a symptom of these aren't just minor things.

They genuinely impact recovery, quality of life, everything.

Okay.

So given all that, the hospital has got to be one of the worst places to try and get good sleep, right?

Yeah.

What does this mean for us as nurses trying to create a better environment?

You hit the nail on the head.

Hospitals, especially ICUs, are notoriously bad for sleep.

Constant noise alarms, staff talking, bright lights messing with melatonin, then all the care activities, vital signs, meds, procedures, often around the clock.

Yeah, it's relentless.

Plus the patient's own symptoms, pain, trouble breathing, nausea, and many common meds, especially opioids, can make sleep worse or increase the risk of breathing problems during sleep.

The consequences.

Delirium delayed recovery.

Less sleep makes patients more sensitive to pain too.

So your role as a nurse is just critical here.

You can't make an ICU silent, but you can make a difference.

How so?

What practical things do we do?

Small things add up.

Try to cluster care activities to allow for uninterrupted sleep periods.

Be mindful of noise.

Maybe talk quieter at the nurse's station at night.

Respond to alarms quickly.

Dim the lights.

Offer comfort measures.

Back rub.

Repositioning.

Maybe an eye mask or earplugs if appropriate.

Advocate for rest periods.

And if a patient is really struggling, maybe talk with the healthcare provider about potentially using a hypnotic sleep aid short -term.

It's about being proactive and protective of sleep.

That makes sense.

Small actions, big impact.

Okay, let's dive into some specific disorders.

Where should we start?

Probably the most common one.

Yeah, let's start with insomnia.

Affects about one in three adults.

It's basically difficulty falling asleep, staying asleep, waking up too early, or just feeling like your sleep wasn't refreshing.

We talk about short -term insomnia less than three months and chronic insomnia, which goes on for three months or more and usually causes daytime problems.

Chronic effects about 10 % Americans, more often women, and those with lower socioeconomic status.

And what usually causes insomnia?

Is it just stress?

Stress is a big one for sure.

But behaviors play a huge role too.

Things like having a really erratic sleep schedule, taking long naps late in the day, spending ages in bed awake trying to force sleep.

Lifestyle choices too.

Alcohol might make you drowsy initially, but a fragment sleep later.

Stimulants like nicotine, caffeine.

Remember caffeine half -life is long, maybe six, nine hours in older adults.

So that afternoon coffee can definitely impact sleep.

Right, good reminder.

Lots of medications have insomnia as a side effect.

Antidepressants, blood pressure meds, steroids, and then underlying psychiatric issues, medical conditions,

pain.

It's often multifactorial.

Clinically, you'll hear patients talk about taking forever to fall asleep, waking up a lot, or waking up way too early.

And during the day, it's fatigue, trouble concentrating, irritability, poor performance.

It sounds so subjective though.

How do we actually diagnose insomnia properly?

You're right.

Self -report is key.

A one to two week sleep diary is really helpful tracking bedtimes, wake times, how long it took to fall asleep, awakenings, sleep quality.

A thorough sleep history is crucial too.

There are questionnaires like the insomnia severity index and sometimes actigraphy that wrist device tracking movement can help confirm the patient's report or see if treatment is working, but it's not usually needed just for diagnosis.

Okay, so once we have a handle on it, what's the approach?

What's the most important thing a nurse can teach someone struggling with insomnia?

The absolute cornerstone is sleep hygiene.

This is critical teaching.

Simple things, but powerful.

Only go to bed when you actually feel sleepy.

If you're not asleep after about 20 minutes, get out of bed, do something quiet, then try again later.

Okay.

Keep a consistent sleep wake schedule even on weekends as much as possible.

Make sure the bedroom is dark, quiet, cool, no stimulating activities in bed, no tv, no scrolling on your phone.

Avoid caffeine, nicotine, alcohol for at least four, six hours before bed.

Don't exercise vigorously too close to bedtime.

Sounds like common sense, but easy to let slip.

Exactly.

For chronic insomnia, the gold standard is actually cognitive behavioral therapy for insomnia or CBTI.

It's a structured therapy that tackles the thoughts of behaviors that perpetuate insomnia, stress management, challenging unhelpful beliefs about sleep, stimulus control, sleep restriction.

It really works.

Drug therapy should generally be short term.

The risks are dependence and rebound insomnia if stopped abruptly.

First line are often drugs like zolpidem, those benzodiazepine receptor agonists, but here's a huge drug alert nurses need to know.

These can cause complex sleep behaviors like sleepwalking, even sleep driving.

If a patient reports anything like that, they need to stop the drug immediately.

Newer drugs block orexin, that wakefulness signal we talked about, but really for any sleep med, especially in older adults, start low, go slow.

Avoid those older PM antihistamines like diphenhydramine.

The anticholinergic side effects are problematic.

So the strategy is really non -drug first and meds as a short -term bridge used cautiously.

Precisely.

CBTI and sleep hygiene address the root causes.

Meds just manage symptoms, often temporarily.

Okay, let's make this real.

Think about GP, 49,

postmenopausal, always tired, using OTC diphenhydramine.

Partner says she snores loudly, sometimes stops breathing.

BMI is high, BP is up.

How do we approach her nursing care?

GP is a classic complex case.

Your nursing assessment is key.

Ask detailed sleep questions.

What time trouble falling asleep?

How many awakenings?

Sleepy during the day?

But critically, you must ask.

As your partner say, you snore loudly, gasp, or stop breathing.

Because that points towards.

Obstructive sleep apnea, host snoring, witness pauses and breathing, daytime sleepiness, high BMI, postmenopausal status, red flags for OSA.

We need to assess her caffeine, tea, cola, and that diphenhydramine used educator.

It's not helping and has side effects.

A sleep diary is we teach sleep hygiene, especially about caffeine timing.

But given the OSA suspicion, she needs more investigation.

Definitely.

Her PSG results, AHA of 24, low oxygen, confirm moderate OSA.

So now our plan has to address both the insomnia symptoms and the underlying OSA.

It likely involves CPAP therapy, weight management advice, and ongoing sleep hygiene.

It shows how these things often overlap.

And that brings us neatly to extractive sleep apnea or OSA.

The most common sleep disorder breathing issue, maybe 25 % of where the upper airway gets partially or fully blocked during sleep.

Apnea is a near complete blockage over 10 seconds.

Hypopnea is a partial blockage.

Basically, throat muscles relax, tongue falls back, airway narrows or closes,

airflow stops or reduces, oxygen drops, hypoxemia, CO2 rises, hypercapnia.

This triggers a brief arousal to restore breathing, often so quick the person doesn't remember it.

He's most at risk for developing OSA.

Obesity is a major one.

BMI over 30, age over 65, neck size 16 inches plus, being male and being post -menopausal for women are also key risk factors.

Clinically, loud snoring, witnessed apneas, daytime sleekiness are the big three, morning headaches can happen too from the CO2 buildup, and untreated OSA.

It's serious.

Linked to high blood pressure, diabetes, heart rhythm problems, heart disease, heart failure really takes a toll.

Plus, the chronic sleep loss affects concentration, memory, mood, and increases accident risk.

How do we nail down the diagnosis?

History is important, screening tools like StopBang help assess risk.

But the gold standard is polysomnography, PSG, the sleep study.

It measures breathing effort, airflow, oxygen levels, brain activity, etc.

We look at the apnea hypopony index, AHI, the average number of apneas or hypoponies per hour.

An AHI over 5 with oxygen dips confirms OSA, over 30 is considered severe.

So once diagnosed, what are the main treatments and what's our role as nurses?

For mild OSA, we start with behavioral changes.

Positional therapy, sleeping on the side, maybe elevating the head of the bed.

Weight loss, if needed.

Avoiding alcohol and sedatives before bed is crucial, they relax airway muscles further.

And safety education about driving while sleepy is vital.

For moderate to severe OSA, the mainstay is continuous positive airway pressure CPAP.

It's a mask connected to a machine that delivers pressurized air, essentially splinting the airway open.

Right, the air splint.

Exactly.

CPAP works wonders, reduces apnea, improves daytime function, quality of life.

But adherence is the big challenge.

Masks can be uncomfortable, cause nasal stuffiness.

Your role as a nurse is huge here.

Education, support, helping patients find the right mask, setting realistic goals.

And in the hospital.

Big caution with opioids and sedatives.

They can worsen OSA significantly.

Ensure patients bring their home CPAP if possible and use it.

Collaborate with the team.

There are also oral appliances like mouth guards that reposition the jaw for milder cases.

And surgery is an option if nothing else works, aiming to remove obstructing tissue.

Post -op, your main concerns are airway monitoring and bleeding.

Okay, that covers the big two.

What about other sleep disorders we might see?

Just briefly.

Sure.

Periodic limb movement disorder, PLMD, repetitive leg jerks during sleep.

Causes fragmented sleep, daytime tiredness, often needs medication.

Ask about restless legs too, often go together.

Circadian rhythm disorders, the body clock is out of sync.

Think jet lag, or shift work sleep disorder.

Melatonin or light therapy can help reset the clock.

Narcolepsy,

trouble regulating sleep wake.

Uncontrollable sleep attack, sometimes going straight into REM.

Cataplexy, sudden muscle weakness with emotion can occur in type 1.

Management involves scheduled naps, stimulants, and huge emphasis on safety.

Especially driving.

And parasomnias, weird behaviors during sleep.

Sleep walking, sleep terrors, often in NREM.

Nightmares, usually REM.

These can be triggered or worsened by sleep disruption, medications, stress things common in hospital settings, especially ICU.

Got it.

Now, thinking about specific groups, older adults, what are the key nursing considerations there?

Sleep definitely changes with age.

Total sleep time often decreases.

More wakenings, less deep sleep than N3.

But here's a common misconception.

Older adults do not need less sleep.

Their need stays about the same, they just struggle more to get consolidated quality sleep.

They're also more prone to other sleep disorders, like sleep apnea, which might show up looking like insomnia.

Chronic conditions, pain, multiple medications all interfere with sleep.

And safety is huge.

Nighttime awakenings mean increased fall risk, especially if they use alcohol.

Poor sleep can worsen confusion or delirium.

And often, they just accept poor sleep as part of getting old and don't report it.

So you need to ask specifically using assessment tools.

Be super cautious with sleep med star low, avoid long acting benzos and those OTCPM meds with defenhydramine.

That's really important.

Now for our listeners, nurses themselves, what are the special considerations for our own sleep?

Oh, this is critical.

Nurses, especially those on rotating or night shifts, are at high risk for shift work sleep disorder.

Insomnia, when trying to sleep,

sleepiness when needing to be awake.

It leads to fatigue, lower job satisfaction, more stress.

And that chronic fatigue isn't just bad for us, it's a patient safety issue.

It impairs judgment, decision making, reaction time, increases error risk.

Constantly fighting your body clock disrupts circadian rhythms linked to long term health issues like heart problems, mood disorders.

So what can nurses do?

It feels unavoidable sometimes.

It's tough, no doubt.

Strategies that help include strategic napping, even short ones on breaks if possible.

Trying to maintain a consistent anchor sleep schedule, even on days off, helps stabilize the rhythm somewhat.

For night shift, trying to sleep just before the shift can boost alertness.

Good sleep hygiene is non -negotiable.

And having some control over your schedule, if possible, makes a difference.

We have to prioritize our own rest to provide safe care.

Absolutely.

Wow, we've covered a huge amount of ground from neurotransmitters to CPAP masks.

Thinking about everything we've discussed, what are the absolute key clinical takeaways for nurses listening?

I think number one is recognizing that sleep is not a luxury.

It's a fundamental pillar of health with impacts across every body system.

Don't underestimate it in your patients.

Number two,

your role in assessment is critical.

Ask about sleep.

Use diaries, questionnaires.

Listen to bed partners if possible.

You might be the first person to pick up on a significant sleep disorder.

And number three, embrace the nursing process.

Teach sleep hygiene consistently.

Understand the rationale behind treatments like CVTI and CPAP.

Be cautious and knowledgeable about sleep medications.

Collaborate with the whole team.

Your interventions really do matter for patient safety, recovery, and their overall well -being.

Excellent summary.

So here's a final thought to leave you with.

Considering how deeply sleep loss affects everything, our patient's health, our own ability to function as providers, how can we as nurses start advocating for sleep to be treated less like an afterthought and more like a vital sign integrated into every patient assessment?

Something to think about.

Thank you so much for joining us for this deep dive.

We hope this helps you connect the dots from the textbook to your clinical practice.