Download Thelan`s Critical Care Nursing

Chapter Five
Sleep Alterations
Priorities in
CRITICAL CARE
NURSING
Fourth Edition
Linda D. Urden
Kathleen M. Stacy
Mary E. Lough
Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Chapter 5-1
Objectives

Define the stages of sleep.

Explain the three physiologic effects that occur during
rapid eye movement (REM) sleep.

Describe changes in sleep resulting from the
aging process.

Define dysfunctional sleep.

Name three commonly prescribed critical care
medications that decrease REM sleep.

Describe evidence-based practice methods for
promoting sleep in critical care.
Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 2
Sleep Physiology
Definition of Sleep
A reversible behavioral state of perceptual
disengagement from and unresponsiveness
to the environment
Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 3
Sleep Physiology

Research has involved simultaneous monitoring
− Electrooculography (EOG) – measures eye
movement activity. Helps determine when the
patient is in rapid eye movement. It can also
establish when sleep onset occurs as reflected
by slow rolling eye movements.
− Electromyography= involves leads placed over
various muscle groups. Chin placed lead
detects atonia associated with REM sleep.
− Intercostal leads detect respiratory effort.
− Leads over anterior tibialis detect leg
movements that may be causeing the patient
to wake up during sleep.
Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 4
Patient undergoing a sleep study
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Slide 5
−
−
−
−
Electroencephalography (EEG) measures brain
wave activity during sleep. Each stage of sleep is
characterized by differing waveforms.
Electrocardiography (ECG) – shows cardiac
abnormalities, oximetry monitors saturation levels
during sleep.
Pizeoelastic bands around the chest and
abdomen detect respiratory disorders suc as
apnea
Thermocouples are used to monitor airflow
through the nose and mouth.
Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 6
Demonstrated two distinct stages
of sleep

Nonrapid eye
movement (NREM)

Rapid eye movement
(REM)
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Slide 7
Sleep Stages: NREM
Stages of Nonrapid Eye Movement
(NREM) Sleep
Stage 1
2%-5%
Stage 2
45%-55%
Stage 3
3%-8%
Stage 4
10%-15%
Transitional lighter
sleep
Deeper sleep
Slow wave activity
20% of EEG
Slow wave activity
50% of EEG
(Continued)
Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 8
Sleep Stages: NREM (Continued)
Stages 3 and 4 are
referred to as slow-wave
sleep or delta sleep
•
Highest arousal threshold
•
Parasympathetic nervous
system predominates
•
Hormonal changes to
promote anabolism
•
Protein synthesis and
tissue repair
•
Restorative period
Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 9
Sleep Stages: REM
Rapid Eye Movement (REM) Sleep
•
20% to 25% in young adults
•
“Dream” stage
•
Sympathetic nervous system
predominates
– Increased oxygen
consumption
– Increased BP, pulse, resp.,
cardiac output
– Increased chance of plaque
rupture due to surges in
pressure and changes in
coronary artery tone
Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 10
Age-Related Sleep Changes




Excessive sleepiness or insomnia in elderly
Fewer episodes of stages 3 and 4 NREM and
REM sleep
Fragmented sleep patterns with frequent
awakening
 Cardiac disease, diabetes, nocturia, restless
legs, pain
 Respiratory disorders and sleep apnea
 Altered circadian rhythms
Social and physical changes
Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 11
Sleep and Disease

Failure to gain adequate sleep is linked to:

Impaired glucose tolerance
 Weight gain in women
 Hypertension
 Increased levels of C-reactive protein, which is
an increased risk factor for CHD (coronary
heart disease)
Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 12
Sleep Apnea Syndromes

Definition: sleep-disordered breathing

Obstructive apnea (>10 seconds or more)
• Obstructive: Complete obstruction (location is the
upper airway)
• Hypopnea: Partial obstruction


Central: Lack of ventilatory muscle effort

Mixed: Both types in one apneic event
Apnea-hypopnea index used to diagnose sleep apnea
syndrome
(Continued)
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Slide 13
Sleep Apnea Syndromes (Continued)
Consequences of Obstructive Sleep
ApneaHypopnea Syndrome
− Hypercapnia
− Hypoxemia
− Acidosis
− Systemic and pulmonary hypertension
− Cardiovascular changes

(Continued)
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Slide 14
Sleep Apnea Syndromes

Assessment and diagnosis





(Continued)
Careful monitoring
Identify patients at risk
• Short neck, obesity , CVD, HTN,
Medical management
Surgical management
Nursing management
(Continued)
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Slide 15
Central Sleep Apnea

Characteristics



Absence of airflow and respiratory effort for at
least 10 seconds.
Absence of emg activity is present
Breathing resumes when CO2 levels become
excessive
Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 16
Medical Management
Non-Invasive





Weight loss
Side sleeping
Avoid sedative medications
Avoid alcohol before bedtime
Sleep deprivation avoidance
Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 17
Surgical Management



UPPP – large tonsillectomy is performed
Success has been measured in 40% to 60%
of patients.
Complications



Speech impairment
Post-op bleeding
infection
Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 18
CPAP





Treatment of choice
Administered with a nasal mask
Effective if the patient is compliant
If the patient cannot tolerate or CPAP is not
successful BIPAP provides separate
pressures during inspiration and expiration
can be used.
Proper mask fitting must be ensured.
Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 19
Nursing Care of patients

In the critical care
unit who have a
diagnosis of sleep
apnea need CPAP
should bring their
own machine and
use it in the critical
care unit.
Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 20
Sleep Apnea Syndromes

(Continued)
Nursing management




Educating patient and family
Monitoring for apnea while in the ICU
Promote compliance with continuous positive
airway pressure (CPAP) or bimodal positive
airway pressure (BiPAP) devices
Postoperative monitoring for surgical
interventions
Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 21
Sleep Promotion in Critical Care





Massage
Relaxing sounds
Music therapy
Open visitation policies
Controlling noise and light
Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 22