CHAPTER 42  Sleep 957
of uncertainty about the state of their health. Giving patients
FIG. 42-7  Mask suitable for continuous positive airway pressure
(CPAP).
For example, if a patient needs frequent dressing changes, is receiv-
ing intravenous therapy, and has drainage tubes from several sites,
do not make a separate trip into the room to check each problem.
Instead use a single visit to perform all three tasks. Become the
patient’s advocate for promoting optimal sleep. This means becom-
ing a gatekeeper by postponing or rescheduling visits by family,
asking consultants to reschedule visits, or questioning the fre-
quency of certain procedures.
Promoting Safety.  Patients with OSA are at risk for complica-
tions while in the hospital. Surgery and anesthesia disrupt normal
sleep patterns. After surgery patients reach deep levels of REM
sleep. This deep sleep causes muscle relaxation that leads to OSA
(Hwang et al., 2008). Patients with OSA who are given opioid
analgesics after surgery have an increased risk of developing airway
obstruction because the medications suppress normal arousal
mechanisms (Hwang et al., 2008). These patients often need ven-
tilator support in the postoperative period because of the increased
risk of respiratory complications. Monitor the patient’s airway,
respiratory rate, depth, and breath sounds frequently after surgery.
Recommend lifestyle changes to patients with OSA that include
sleep hygiene, alcohol moderation, smoking cessation, and a
weight-loss program (Freedman, 2010). Teach the patient to elevate
the head of the bed and use a side or prone position for sleep. Use
pillows to prevent a supine position (Lamm et al., 2008; Pinto and
Caple, 2010).
One of the most effective therapies is use of a nasal continuous
positive airway pressure (CPAP) device at night, which requires a
patient to wear a mask over the nose. A mask delivers room air at
a high pressure (Fig. 42-7). The air pressure prevents airway col-
lapse. The CPAP device is portable and effective particularly for
obstructive apnea. Another treatment option is the use of an oral
appliance. These appliances advance the mandible or tongue to
relieve pharyngeal obstruction (Wickwire and Collop, 2010). In
cases of severe sleep apnea the tonsils, uvula, or portions of the soft
palate are surgically removed. The success of surgical procedures
to correct OSA varies.
Stress Reduction.  Patients who are hospitalized for extensive
diagnostic testing often have difficulty resting or sleeping because
control over their health care minimizes uncertainty and anxiety.
Providing information about the purpose of procedures and rou-
tines and answering questions give patients the peace of mind
needed to rest or fall asleep. A nurse on the night shift needs to take
time to sit and talk with patients unable to sleep. This helps to
determine the factors keeping patients awake. Back rubs also help
patients relax more thoroughly. If a sedative is indicated, confer
with the patient’s health care provider to be sure that the lowest
dose is used initially. Discontinuing a sedative as soon as possible
prevents a dependence that seriously disrupts the normal sleep
cycle. Older adults’ metabolism of drugs is slow, making them more
vulnerable to the side effects of sedatives, hypnotics, antianxiety
drugs, or analgesics.
Restorative or Continuing Care.  The nursing interventions
implemented in the acute care setting are also used in the restor-
ative or continuing care environment. Controlling the environ-
ment, especially noise; establishing periods of rest and sleep; and
promoting comfort are important considerations. Nursing inter-
ventions related to stress reduction and controlling physiological
disturbances are also implemented in these settings. Helping a
patient achieve restful sleep in this environment sometimes
takes time.
Promoting Comfort.  Providing for personal hygiene improves a
patient’s sense of comfort. A warm bath or shower before bedtime
is relaxing. Offer patients restricted to bed the opportunity to void
and wash their face and hands. Toothbrushing and care of dentures
also help to prepare patients for sleep. Position patients to support
their dependent body parts and protect pressure points. Offer a
back or hand massage to aid in muscle relaxation just before a
patient goes to sleep (Harris and Richards, 2010) (see Chapter 43).
Controlling Physiological Disturbances.  As a nurse you will learn
to control symptoms of physical illness that disrupt sleep. For
example, a patient with respiratory abnormalities sleeps with two
pillows or in a semi-sitting position to ease the effort to breathe.
He or she benefits from taking prescribed bronchodilators before
sleep to prevent airway obstruction. A patient with a hiatal hernia
also needs special care. After meals he or she often experiences a
burning sensation as a result of gastric reflux. To prevent sleep
disturbances have the patient eat a small meal several hours before
bedtime and sleep in a semi-sitting position. Patients with pain,
nausea, or other recurrent symptoms receive any symptom-
relieving medication timed so the drug takes effect at bedtime.
Remove or change any irritants against the patient’s skin such as
moist dressings or drainage tubes.
Pharmacological Approaches.  The liberal use of drugs to
manage insomnia is quite common in American culture. CNS
stimulants such as amphetamines, caffeine, nicotine, terbutaline,
theophylline, and modafinil need to be used sparingly and under
medical management (Lehne, 2010). In addition, withdrawal from
CNS depressants such as alcohol, barbiturates, tricyclic antidepres-
sants (amitriptyline, imipramine, and doxepin), and triazolam
causes insomnia. You need to manage these carefully.
Medications that induce sleep are called hypnotics. Sedatives
are medications that produce a calming or soothing effect (Lehne,
2010). A patient who takes sleep medications needs to know about
their proper use and their risks and possible side effects. Long-term
use of antianxiety, sedative, or hypnotic agents disrupts sleep and
leads to more serious problems. The FDA requires that the product
labels of all sleep medications contain safety information related
to the potential adverse effects of severe allergic reactions; severe
facial swelling; and complex sleep behaviors such as sleep-driving,
954 UNIT 7  Physiological Basis for Nursing Practice
BOX 42-8  FOCUS ON OLDER ADULTS
Promoting Sleep
Sleep-Wake Pattern
• Maintain a regular bedtime and wake-up schedule (Townsend-Roccichelli
et al., 2010).
• Eliminate naps unless they are a routine part of the schedule.
• If naps are taken, limit to 20 minutes or less twice a day (Touhy and Jett,
2010).
• Go to bed when sleepy.
• Use warm bath and relaxation techniques (Ebersole et al., 2008).
• If unable to sleep in 15 to 30 minutes, get out of bed.
• Avoid stimulating activities before bedtime such as exercise or watching
television (Townsend-Roccichelli et al., 2010).
Environment
• Sleep where you sleep best.
• Keep noise to minimum; use soft music to mask it if necessary.
• Use night-light and keep path to bathroom free of obstacles.
• Set room temperature to preference; use socks to promote warmth.
• Listen to relaxing music (Touhy and Jett, 2010).
• Increase exposure to bright light during the day (Neubauer, 2009).
Medications
• Use sedatives and hypnotics with caution as last resort and then only short
term if absolutely necessary (Neubauer, 2009).
• Adjust medications being taken for other conditions and assess for drug
interactions that may cause insomnia or excessive daytime sleepiness.
Diet
• Limit alcohol, caffeine, and nicotine in late afternoon and evening (Touhy
and Jett, 2010).
• Consume carbohydrates or milk as a light snack before bedtime (Ebersole
et al., 2008).
• Decrease fluids 2 to 4 hours before sleep (Ebersole et al., 2008).
Physiological/Illness Factors
• Elevate head of bed and provide extra pillows as preferred (Townsend-
Roccichelli et al., 2010).
• Use analgesics 30 minutes before bed to ease aches and pains.
• Use therapeutics to control symptoms of chronic conditions as prescribed
(Chasens et al., 2008).
program, or listening to music helps a person relax. Relaxation
exercises such as slow, deep breathing for 1 or 2 minutes relieve
tension and prepare the body for rest (see Chapter 43). Guided
imagery and praying also promote sleep for some patients.
At home discourage patients from trying to finish office work
or resolve family problems before bedtime. The bedroom is not a
place to work, and patients need to always associate it with sleep.
Working toward a consistent time for sleep and awakening helps
most patients gain a healthy sleep pattern and strengthens the
rhythm of the sleep-wake cycle.
Promoting Safety.  For any patient prone to confusion or falls,
safety is critical. A small night-light helps a patient orient to the
room environment before going to the bathroom. Beds set lower
to the floor lessen the chance of a person falling when first standing.
Instruct patients to remove clutter and throw rugs from the path
used to walk from the bed to the bathroom. If a patient needs
assistance in ambulating from a bed to the bathroom, place a small
bell at the bedside to call family members. Sleepwalkers are unaware
BOX 42-9  PATIENT TEACHING
Sleep Hygiene Habits
Objective
• Patient will follow proper sleep hygiene habits at home.
Teaching Strategies
• Instruct patient to try to exercise daily, preferably in the morning or after-
noon, and to avoid vigorous exercise in the evening within 2 hours of
bedtime.
• Caution patient against sleeping long hours during weekends or holidays
to prevent disturbance of normal sleep-wake cycle.
• Explain that, if possible, patients should not use the bedroom for intensive
studying, snacking, television watching, or other nonsleep activity besides
sex.
• Encourage patients to try to avoid worrisome thinking when going to bed
and to use relaxation exercises.
• If patient does not fall asleep within 30 minutes of going to bed, advise
him or her to get out of bed and do some quiet activity until feeling sleepy
enough to go back to bed.
• Recommend that patient limit caffeine to morning coffee and limit alcohol
intake (more than 1 to 2 drinks a day interrupts sleep cycle).
• Ask patient to examine environment. Instruct that use of earplugs and
eyeshades may be helpful.
• Instruct patient to avoid heavy meals for 3 hours before bedtime; a light
snack may help.
Evaluation
• Have patient complete sleep-wake log for 1 week and compare it with
previous sleep-wake log.
• Ask patient to periodically complete visual analogue or sleep-rating scale
for perceptions of quality of sleep.
of their surroundings and are slow to react, increasing the risk of
falls. Do not startle sleepwalkers but instead gently awaken them
and lead them back to bed.
Infants’ beds need to be safe. To reduce the chance of suffoca-
tion, do not place pillows, stuffed toys, or the ends of loose blankets
in cribs. Loose-fitting plastic mattress covers are dangerous because
infants pull them over their faces and suffocate. Parents need to
place an infant on his or her back to prevent suffocation.
Promoting Comfort.  People fall asleep only after feeling comfort-
able and relaxed (Bulechek, Butcher, and Dochterman, 2008).
Minor irritants often keep patients awake. Soft cotton nightclothes
keep infants or small children warm and comfortable. Instruct
patients to wear loose-fitting nightwear. An extra blanket is some-
times all that is necessary to prevent a person from feeling chilled
and being unable to fall asleep. Patients need to void before retiring
so they are not kept awake by a full bladder.
Establishing Periods of Rest and Sleep.  In the home it helps to
encourage patients to stay physically active during the day so they
are more likely to sleep at night. Increasing daytime activity lessens
problems with falling asleep. In a home setting you will frequently
care for patients with chronic debilitating disease. The nursing care
plan includes having patients set aside afternoons for rest to
promote optimal health. Help adjust medication schedules, instruct
patients to regularly void before rest periods, and suggest silencing
the telephone ringer so rest periods are uninterrupted.
Stress Reduction.  The inability to sleep because of emotional
stress also makes a person feel irritable and tense. When patients
are emotionally upset, encourage them to try not to force sleep.

Otherwise insomnia frequently develops, and soon bedtime is
associated with the inability to relax. Encourage a patient who
has difficulty falling asleep to get up and pursue a relaxing activity
such as sewing or reading rather than staying in bed and thinking
about sleep.
Preschoolers have bedtime fears (fear of the dark or strange
noises), awaken during the night, or have nightmares. After night-
mares the parent enters the child’s room immediately and talks to
him or her briefly about fears to provide a cooling-down period.
One approach is to comfort children and leave them in their own
beds so their fears are not used as excuses to delay bedtime.
Keeping a light on in the room also helps some children. Cultural
tradition causes families to approach sleep practices differently
(Box 42-10). Always respect those that differ from traditional
recommendations.
Bedtime Snacks.  Some people enjoy bedtime snacks, whereas
others cannot sleep after eating. A dairy product such as warm milk
or cocoa that contains L-tryptophan is often helpful in promoting
sleep. A full meal before bedtime often causes gastrointestinal upset
and interferes with the ability to fall asleep.
Warn patients against drinking or eating foods with caffeine
before bedtime. Coffee, tea, colas, and chocolate act as stimulants,
causing a person to stay awake or to awaken throughout the night.
Caffeinated foods and liquids and alcohol act as diuretics and cause
a person to awaken in the night to void (National Heart, Lung, &
Blood Institute, 2009).
Infants require special measures to minimize nighttime awaken-
ings for feeding. It is common for children to need middle-of-the-
night bottle-feeding or breastfeeding. Hockenberry and Wilson
(2011) recommend offering the last feeding as late as possible. Tell
parents not to give infants bottles in bed.
Pharmacological Approaches.  Melatonin is a neurohormone
produced in the brain that helps control circadian rhythms and
promote sleep (Kryger et al., 2011). It is a popular nutritional
supplement that is found to be helpful in improving sleep efficiency
and decreasing nighttime awakenings (Pandi-Perumal et al., 2007).
The recommended dose is 0.3 to 1 mg taken 2 hours before bedtime.
Older adults who have decreased levels of melatonin find it benefi-
cial as a sleep aid (Kryger et al., 2011). Short-term use of melatonin
has been found to be safe, with mild side effects of nausea, headache,
and dizziness being infrequent (Larzelere et al., 2010). Ramelton
(Rozerem), a melatonin receptor agonist, is well tolerated and
appears to be effective in improving sleep (Morin et al., 2007).
Several other herbal products assist in sleep. Valerian is effective
in mild insomnia and RLS. It effects release of neurotransmitters
and produces very mild sedation (Cuellar and Ratcliffe, 2009). Kava
helps promote sleep in patients with anxiety. It needs to be
used cautiously because of its potential toxic effects on the liver
(Larzelere et al., 2010). Chamomile, an herbal tea, has a mild seda-
tive effect that may be beneficial in promoting sleep (Moquin
et al., 2009). Caution patients about the dosage and use of herbal
compounds because the U.S. Food and Drug Administration
(FDA) does not regulate them. Herbal compounds may interact
with prescribed medication, and patients need to avoid using these
together (Meiner, 2011).
Building Competency in Evidence-Based Practice  Julie Arnold
tells you that her mother used melatonin to help her sleep before her fall at
home. She asks you if she should start taking melatonin to help her sleep.
Based on the evidence, what is your best response to Julie?
Answers to questions can be found on the Evolve website.
CHAPTER 42  Sleep 955
  BOX 42-10  CULTURAL ASPECTS OF CARE
Co-sleeping
Practices and patterns of sleep and rest vary among cultures. Culture and
biology influence the development of sleep problems in children. Sleep pat-
terns, bedtime routines, sleep aids, and sleep arrangements are components
of cultural practices related to the use of space and interaction distances
(Giger and Davidhizer, 2008). Traditionally experts recommend having infants
and children sleep in their own beds. Co-sleeping, in which infants and chil-
dren sleep with their parents, is a culturally preferred habit; and the practice
of co-sleeping varies between cultures (AABMPC, 2008). It is more common
in nonindustrialized countries. In some parts of the world co-sleeping practices
are seen as part of the bonding process and warmth and protection for an
infant (i.e., against the cold) (Sobralske and Gruber, 2009). This practice is
also common in the United States with Asian, Hispanic, and African American
families (AABMPC, 2008; Lahr et al., 2007). Health care providers in the United
States discourage this practice because of safety issues, even though research
does not show that the practice is unsafe. American culture promotes inde-
pendence in childhood. One belief is that co-sleeping does not promote this
independence; thus health care providers discourage it (Getter and McKenna,
2010). Research results related to co-sleeping and the incidence of sudden
infant death syndrome (SIDS) are mixed (Getter and McKenna, 2010). As a
nurse, be culturally sensitive when discussing co-sleeping practices with
parents and developing sleeping plans for children. The type of bed for a child
also varies. Some Native American tribes use a cradle board for infants,
whereas American Samoan infants sleep on a pandanus mat covered with a
blanket. These approaches lessen the child’s anxiety and create a strong
sense of security (Andrews and Boyle, 2008).
Implications for Practice
• Complete a thorough sleep assessment of the child and family.
• Discuss the risks of co-sleeping with parents. During the discussion remain
culturally sensitive and respectful of the parents’ views (Sobralske and
Gruber, 2009).
• Co-sleeping has been linked to increased risk of SIDS under certain condi-
tions such as parental smoking and alcohol or drug use (Getter and
McKenna, 2010).
• Instruct parents that practice co-sleeping to avoid using alcohol or drugs
that impair arousal. Decreased arousal prevents the parents from awaken-
ing if the child is having problems (Sobralske and Gruber, 2009).
• Co-sleeping should occur only with parents and not another adult or child
(AABMPC, 2008).
• Co-sleeping should occur on a firm mattress (never on a water bed, sofa
or couch) (AABMPC, 2008; Sobralske and Gruber, 2009).
• Encourage parents to use light sleeping clothes, keep room temperature
comfortable, and not bundle the child tightly or in too many clothes.
• Avoid using heavy quilts, comforters, pillows, and stuffed animals in the
bed (AABMPC, 2008).
The use of nonprescription sleeping medications is not advis-
able. Patients need to learn the risks of such drugs. Over the long
term these drugs lead to further sleep disruption, even when they
initially seemed to be effective. Caution older adults about using
over-the-counter antihistamines because of their long duration of
action, which can cause confusion, constipation, urinary retention,
and increased risk of falls (Passarella and Duong, 2008). Help
patients use behavioral and proper sleep hygiene measures to estab-
lish sleep patterns that do not require the use of drugs.
Acute Care.  Patients in acute care settings have their normal
rest and sleep routine disrupted, which generally leads to sleep
956 UNIT 7  Physiological Basis for Nursing Practice

BOX 42-11  EVIDENCE-BASED PRACTICE

Creating a Sleep Environment in the Hospital
PICO Question: What are best practices for a sleep hygiene protocol to
create an environment conducive to sleep for adult patients in a hospital?

Evidence Summary
Hospitalization causes a disruption in normal sleep habits for patients. Sleep
in hospitalized patients is disrupted by noise, lighting, and patient-care activi-
ties. Sleep is needed for healing and recovery (Richardson et al., 2009).
Implementing a specific sleep protocol that includes sleep hygiene measures
is an effective strategy to improve sleep quality and ability to stay asleep in
hospitalized patients (LaReau et al., 2008). A specified daytime quiet-time
intervention that includes limiting treatment activities, use of positioning and
pain-relief methods, and reduction of environmental stressors such as lighting
and noise significantly improves patient sleep. There is a direct relationship
between noise levels and number of patients sleeping (Gardner et al., 2009;
Richardson et al., 2009). Raising staff awareness of noise levels and harmful
effects of noise and providing education about strategies to reduce noise are
effective in removing barriers to patient sleep (Richardson et al., 2009).

Application to Nursing Practice FIG. 42-6  Positioning patient for sleep.

• Cluster nursing activities to provide uninterrupted periods of sleep (LaReau
et al., 2008).
• Provide programs for staff on the effects of noise and noise-reduction
strategies (Richardson et al., 2009).
• Develop a designated quiet time period during the day that incorporates
rest and reduction of noise on the unit (Gardner et al., 2009).
• Reduce lighting, telephone volumes, and staff conversations in the halls
during quiet time and nighttime (Gardner et al., 2009)
• Use sleep hygiene measures with patients such as personal hygiene,
adjusting room temperature, and relaxation methods (LaReau et al., 2008).
problems. In this setting nursing interventions focus on controlling
factors in the environment that disrupt sleep, relieving physiologi-
cal or psychological disruptions to sleep, and providing for un­
interrupted rest and sleep periods for the patient. “Excessive
Sleepiness” in the Evidence-based Geriatric Nursing Protocols for
Best Practice is based on the principle that nurses need to individu-
alize an effective strategy based on patient needs and that sleep
medications are a last-resort intervention (Chasens et al., 2008).
Environmental Controls.  In a hospital the nurse controls the
environment in several ways (Box 42-11). Close the curtains
between patients in semiprivate rooms. Dim lights on a hospital
nursing unit at night. One of the biggest problems for patients in
the hospital is noise. Important ways to reduce noise are to conduct
conversations and reports in a private area away from patient
rooms and keep necessary conversations to a minimum, especially
at night (Gardner et al., 2009). Additional ways to control noise in
the hospital are listed in Box 42-12.
Promoting Comfort.  Compared with beds at home, hospital beds
are often harder and of a different height, length, or width. Keeping
them clean and dry and in a comfortable position helps patients
relax. Some patients suffer painful illnesses requiring special
comfort measures such as application of dry or moist heat, use of
supportive dressings or splints, and proper positioning before retir-
ing (Fig. 42-6).
Establishing Periods of Rest and Sleep.  In a hospital or extended
care setting it is difficult to provide patients with the time
needed to rest and sleep. The most effective treatment for sleep
BOX 42-12  CONTROL OF NOISE IN THE HOSPITAL
• Close doors to patients’ room when possible.
• Keep doors to work areas on unit closed when in use.
• Reduce volume of nearby telephone and paging equipment.
• Wear rubber-soled shoes. Avoid clogs.
• Turn off bedside oxygen and other equipment that is not in use.
• Turn down alarms and beeps on bedside monitoring equipment.
• Turn off room television and radio unless patient prefers soft music.
• Avoid abrupt loud noise such as flushing a toilet or moving a bed.
• Keep necessary conversations at low levels, particularly at night.
• Conduct conversations and reports in a private area away from patient
rooms.
disturbances is elimination or correction of factors that disrupt the
sleep pattern. You need to plan care to avoid awakening patients
for nonessential tasks. Do this by scheduling assessments, treat-
ments, procedures, and routines for times when patients are awake.
For example, if a patient’s physical condition has been stable, avoid
awakening him or her to check vital signs. Allowing patients
to determine the timing and methods of delivery of basic care
measures promotes rest. Do not give baths and routine hygiene
measures during the night for nursing convenience. Draw blood
samples at a time when the patient is awake. Unless maintaining
the therapeutic blood level of a drug is essential, give medications
during waking hours. Work with the radiology department and
other support services to schedule diagnostic studies and therapies
at intervals that allow patients time for rest. Always try to provide
the patient with 2 to 3 hours of uninterrupted sleep during the
night.
When the patient’s condition demands more frequent monitor-
ing, plan activities to allow extended rest periods. A nurse instructs
assistive personnel in the coordination of patient care to reduce
patient disturbances. This means planning activities so the patient
has as long as an hour or more to rest quietly rather than having a
nurse or other personnel return to the room every few minutes.
958 UNIT 7  Physiological Basis for Nursing Practice

making phone calls, and preparing and eating food while asleep
(USFDA, 2010). Knowledge Experience
Benzodiazepines and nonbenzodiazepines are common classifi- • Characteristics of desirable • Previous patient responses
cations of drugs used to treat sleep problems. The nonbenzodiaz- sleep pattern to planned nursing
epines have become the treatment of choice for insomnia because • Behaviors reflecting interventions for promoting
adequate sleep sleep
of improved efficacy and safety of use (Neubauer, 2009). Experts
• Previous experience in
recommend a low dose of a short-acting medication such as zolpi-
adapting sleep therapies
dem (Ambien) for short-term use (no longer than 2 to 3 weeks)
to personal needs
(Cramwell-Bruce, 2007). These drugs cause fewer problems with
dependence and abuse and fewer rebound insomnia and hangover
effects than benzodiazepines (Passarella and Duong, 2008).
The benzodiazepines cause relaxation, antianxiety, and hyp-
EVALUATION
notic effects by facilitating the action of neurons in the CNS that
• Evaluate signs and symptoms of the
suppress responsiveness to stimulation, thereby decreasing levels patient’s sleep disturbance
of arousal (Lehne, 2010). Short-acting benzodiazepines (e.g. oxaz- • Review the patient’s sleep pattern
epam, lorazepam, or temazepam) at the lowest possible dose are • Ask the patient’s sleep partner to report
recommended. Initial doses are small; and increments are added the patient’s response to sleep therapies
gradually, based on patient response, for a limited time. Warn • Ask patient if expectations of care are
patients not to take more than the prescribed dose, especially if being met
the medication seems to become less effective after initial use. The
use of benzodiazepines in older adults is potentially dangerous
because of the tendency of the drugs to remain active in the
Standards Attitudes
• Use established expected • Demonstrate humility if an
body for a longer time. As a result, they also cause respiratory
outcomes to evaluate the intervention is unsuccess-
depression; next-day sedation; amnesia; rebound insomnia; and patient’s response to care ful; rethink your approach
impaired motor functioning and coordination, which leads to (e.g., improved duration of • Display perseverance in
increased risk of falls (Cramwell-Bruce, 2007; Neubauer, 2009). If sleep, fewer awakenings) staying with a plan or in
older patients who were recently continent, ambulatory, and alert trying new approaches
become incontinent or confused and/or demonstrate impaired in the case of chronic
mobility, the use of benzodiazepines needs to be considered as a sleep problems
possible cause.
Use benzodiazepines cautiously with children under 12 years of FIG. 42-8  Critical thinking model for sleep evaluation.
age. These medications are contraindicated in infants less than 6
months. Pregnant patients need to avoid them because their use is
associated with risk of congenital anomalies. Nursing mothers do
not receive the drugs because they are excreted in breast milk. Patient Outcomes.  Determine whether expected outcomes
Regular use of any sleep medication often leads to tolerance have been met. Use evaluative measures shortly after a therapy has
and withdrawal. Rebound insomnia is a problem after stopping been tried (e.g., observing whether a patient falls asleep after reduc-
the medication. Immediately administering a sleeping medication ing noise and darkening a room). Use other evaluative measures
when a hospitalized patient complains of being unable to sleep after a patient awakens from sleep (e.g., asking a patient to describe
does the patient more harm than good. Consider alternative the number of awakenings during the previous night). The patient
approaches to promote sleep. Routine monitoring of patient and bed partner usually provide accurate evaluative information.
response to sleeping medications is important. Over longer periods use assessment tools such as the visual ana-
logue or sleep-rating scale to determine whether sleep has progres-
sively improved or changed.
n n n EVALUATION
Also evaluate the level of understanding that patients or family
Through the Patient’s Eyes.  With regard to problems with members gain after receiving instruction in sleep habits. You
sleep, the patient is the source for evaluating outcomes. Each measure compliance with these practices during a home visit, when
patient has a unique need for sleep and rest. The patient is the you are able to observe the environment. When expected outcomes
only one who knows if sleep problems are improved and which are not met, revise the nursing measures or expected outcomes
interventions or therapies are most successful in promoting sleep based on the patient’s needs or preferences. When outcomes are
(Fig. 42-8). To evaluate the effectiveness of nursing interventions, not met, ask questions such as:
make comparisons with baseline assessment data to evaluate if • Are you able to fall asleep within 20 minutes of getting
sleep has improved. It is important to ask the patient if his or her in bed?
sleep needs have been met. For example, ask the patient, “Are you • Describe how well you sleep when you exercise.
feeling more rested?”; “Can you tell me if you feel we have done all • Does the use of quiet music at bedtime help you to relax?
we can to help improve your sleep?”; or “What interventions have • Do you feel rested when you wake up?
been most effective in helping you sleep?” If expectations have not If a nurse has successfully developed a good relationship with a
been met, you need to spend more time trying to understand the patient and a therapeutic plan of care, subtle behaviors often indi-
patient’s needs and preferences. Working closely with the patient cate the level of the patient’s satisfaction. Note the absence of signs
and bed partner enables you to redefine expectations that can be of sleep problems such as lethargy or frequent yawning or position
met realistically within the limits of the patient’s condition and changes in the patient. You are effective in promoting rest and sleep
treatment. if the patient’s goals and expectations are met.

KEY POINTS
• Sleep provides physiological and psychological restoration.
• The 24-hour sleep-wake cycle is a circadian rhythm that influ-
ences physiological function and behavior.
• The control and regulation of sleep depends on a balance
among regulators within the CNS.
• During a typical night’s sleep a person passes through four to
five complete sleep cycles. Each sleep cycle contains three NREM
stages of sleep and a period of REM sleep.
• The most common type of sleep disorder is insomnia.
• The hectic pace of a person’s lifestyle, emotional and psycho-
logical stress, and alcohol ingestion frequently disrupt the sleep
pattern.
• If a patient’s sleep is adequate, assess his or her usual bedtime,
normal bedtime ritual, preferred environment for sleeping, and
usual preferred rising time.
• When a patient has a sleep problem, conduct a complete sleep
history. Diagnosing sleep problems depends on identifying
factors that impair sleep.
• When planning interventions to promote sleep, considers the
usual characteristics of the patient’s home environment and
normal lifestyle.
• A regular bedtime routine of relaxing activities prepares a
person physically and mentally for sleep.
• An environment with a darkened room, reduced noise, com-
fortable bed, and good ventilation promotes sleep.
• Important nursing interventions for promoting sleep in the
hospitalized patient are establishing periods for uninterrupted
sleep and rest and controlling noise levels.
• Pain or other disease symptom control is essential to promoting
the ability to sleep.
• Long-term use of sleeping pills often leads to difficulty initiating
and maintaining sleep.
CLINICAL APPLICATION QUESTIONS
Preparing for Clinical Practice
Julie returns to the neighborhood health clinic with her husband,
David, for a follow-up visit. She tells you that since she started
her sleep hygiene plan she feels more rested but is still having
some problems sleeping because of her husband’s loud snoring.
Besides Julie’s report of David’s snoring, you note that he is
overweight.
1. Based on Julie’s report of David’s snoring, which additional
assessment data should you gather from David?
2. Based on David’s reported symptoms, what problem do you
suspect he might have? What recommendations do you give
David to improve his sleeping?
3. Julie and David tell you that they are concerned about their
6-year-old daughter. She just started school and is having sleep
problems. List at least four interventions for Julie and David to
use to improve their daughter’s sleep patterns.
  Answers to Clinical Application Questions can be found
on the Evolve website.
REVIEW QUESTIONS
Are You Ready to Test Your Nursing Knowledge?
1. The nurse is gathering a sleep history from a patient who is
being evaluated for obstructive sleep apnea. Which common
CHAPTER 42  Sleep 959
symptoms does the patient most likely report? (Select all
that apply.)
1. Headache
2. Early wakening
3. Excessive daytime sleepiness
4. Difficulty falling asleep
5. Snoring
2. The nurse incorporates which priority nursing intervention
into a plan of care to promote sleep for a hospitalized patient?
1. Have patient follow hospital routines
2. Avoid awakening patient for nonessential tasks
3. Give prescribed sleeping medications at dinner
4. Turn television on low to late-night programming.
3. Older adults are cautioned about the long-term use of seda-
tives and hypnotics because these medications can:
1. Cause headaches and nausea.
2. Be expensive and difficult to obtain.
3. Cause severe depression and anxiety.
4. Lead to sleep disruption.
4. The nurse is providing health teaching for a patient using
herbal compounds such as melatonin for sleep. Which points
need to be included? (Select all that apply.)
1. Can cause urinary retention
2. Should not be used indefinitely
3. May cause diarrhea and anxiety
4. May interfere with prescribed medications
5. Can lead to further sleep problems over time
6. Are not regulated by the U.S. Food and Drug Administra-
tion (FDA)
5. The patient reports vivid dreaming to the nurse. Through
understanding of the sleep cycle, the nurse recognizes that
vivid dreaming occurs during which sleep phase?
1. REM sleep
2. Stage 1 NREM sleep
3. Stage 4 NREM sleep
4. Transition period from NREM to REM sleep
6. The nurse teaches a patient taking a benzodiazepine that this
group of medications causes which symptom of a sleep
problem?
1. Nocturia
2. Hyperactivity
3. Grogginess and feeling hung over
4. Increased sleep time
7. Which intervention is appropriate to include on a care plan for
improving sleep in the older adult?
1. Decrease fluids 2 to 4 hours before sleep
2. Exercise in the evening to increase fatigue
3. Allow the patient to sleep as late as possible
4. Take a nap during the day to make up for lost sleep
8. Which statement made by a mother being discharged to
home with her newborn infant indicates a need for further
teaching?
1. “I won’t put the baby to bed with a bottle.”
2. “For the first few weeks we’re putting the cradle in our
room.”
3. “My grandmother told me that babies sleep better on their
stomachs.”
4. “I know I’ll have to get up during the night to feed the baby
when he wakes up.”
9. The nurse is developing a plan of care for a patient experienc-
ing narcolepsy. Which intervention is appropriate to include
on the plan?