Many factors can contribute to disturbed sleep patterns. Some common factors follow.
Pathophysiologic
Related to excessive hyperactivity secondary to:
Bipolar disorder
Attention-deficit disorder
Panic anxiety
Illicit drug use
Related to frequent awakenings secondary to:
Impaired oxygen transport
Angina
Respiratory disorders
Peripheral arteriosclerosis
Circulatory disorders
Impaired elimination: bowel or bladder
Diarrhea
Retention
Constipation
Dysuria
Incontinence
Frequency
Impaired metabolism
Hepatic disorders
Gastric ulcers
Hyperthyroidism
Treatment Related
Related to interruptions (e.g., for therapeutic monitoring, laboratory tests)
Related to difficulty assuming usual position secondary to (specify)
Related to excessive daytime sleeping or hyperactivity secondary to (specify medication):
Tranquilizers
Sedatives
Amphetamines
Monoamine oxidase inhibitors
Hypnotics
Barbiturates
Antidepressants
Corticosteroids
Antihypertensives
Situational (Personal, Environmental)
NANDA-I approved*
Related to disruption caused by sleep partner*
Related to environmental disturbances*
Related to insufficient privacy*
Related to immobilization
Related to insufficient privacy
Related to nonrestorative sleep pattern
Related to lighting, noise, noxious odors
Related to unfamiliar sleep furnishings
Related to ambient temperature, humidity
Related to caregiving responsibilities
Related to change in daylight-darkness exposure
Related to excessive daytime sleeping
Related to depression
Related to inadequate daytime activity
Related to pain
Related to anxiety response
Related to discomfort secondary to pregnancy
Related to lifestyle disruptions
Occupational
Emotional
Sexual
Financial
Social
Related to environmental changes (specify)
Hospitalization (noise, disturbing roommate, fear)
Travel
Related to fears
Related to circadian rhythm changes
Maturational
Children
Related to fear of dark
Related to fear
Related to enuresis
Related to inconsistent parental responses
Related to inconsistent sleep rituals
Adult Women
Related to hormonal changes (e.g., perimenopausal)
Immobilization
AUTHOR'S NOTESleep disturbances can have many causes or contributing factors. Some examples are asthma, tobacco use, stress, marital problems, and traveling. Disturbed Sleep Pattern describes a situation that is probably transient due to a change in the individual or environment (e.g., acute pain, travel, hospitalization). Risk for Disturbed Sleep Pattern can be used when an individual is at risk due to travel or shift work. Insomnia describes an individual with a persistent problem falling asleep or staying asleep because of chronic pain and multiple chronic stressors. It may be clinically useful to view sleep problems as a sign or symptom of another nursing diagnosis, such as Stress Overload, Chronic Pain, Ineffective Coping, Disabled Family Coping, or Risk-Prone Health Behavior.
CLINICAL ALERTThe National Sleep Foundation recommends the sleep needed according to age follows (2015, 2021):
- Newborns (0 to 3 months): Sleep range narrowed to 14 to 17 hours each day (previously, it was 12 to 18)
- Infants (4 to 11 months): Sleep range widened 2 hours to 12 to 15 hours (previously, it was 14 to 15)
- Toddlers (1 to 2 years): Sleep range widened by 1 hour to 11 to 14 hours (previously, it was 12 to 14)
- Preschoolers (3 to 5): Sleep range widened by 1 hour to 10 to 13 hours (previously, it was 11 to 13)
- School-age children (6 to 13): Sleep range widened by 1 hour to 9 to 11 hours (previously, it was 10 to 11)
- Teenagers (14 to 17): Sleep range widened by 1 hour to 8 to 10 hours (previously, it was 8.5 to 9.5)
- Younger adults (18 to 25): Sleep range is 7 to 9 hours (new age category)
- Adults (26 to 64): Sleep range did not change and remains 7 to 9 hours
- Older adults (65+): Sleep range is 7 to 8 hours (new age category)
Level 1 Fundamental Focused Assessment (all settings)
Sleep Patterns (Present, Past)
Subjective
Rate sleep on a scale of 1 to 10 (10 = rested, refreshed)
Usual bedtime and arising time
Difficulty getting to sleep, staying asleep, or awakening (number)
Naps
History of Symptoms
Complaints of:
Sleeplessness
Fear (nightmares, dark, maturational situations)
Depression
Anxiety
Irritability
Objective Data
Drawn appearance (pale, dark circles under eyes, puffy eyes)
Yawning
Dozing during the day
Decreased attention span
Irritability
Inquire of night staff if the individual has been snoring, experiences apneas and/or excessive leg movements during sleep, and difficulty staying awake during normal daytime activities.
NOCRest, Sleep, Well-Being, Parenting Performance
The individual will report an optimal balance of rest and activity, as evidenced by the following indicators:
- Describes factors that prevent or inhibit sleep.
- Identifies techniques to induce sleep.
CLINICAL ALERTChronic sleep insufficiency is common in modern society and may result from a variety of factors, including work demands, social and family responsibilities, medical conditions, and sleep disorders. As sleep deficiency accumulates, individuals may experience reduced performance, increased risk for accidents and death, and detrimental effects on both psychological and physical health (Cirelli, 2015).
Sleep has 2 dimensions: duration (quantity) and depth (quality). When individuals fail to obtain adequate duration or quality of sleep, daytime alertness and function suffer. In response to sleep deprivation, sleep is often both longer and deeper. In many cases, however, sleep intensity can change without major changes in sleep duration. Sleep duration alone is therefore not a good indicator of how much sleep is needed to feel refreshed in the morning and function properly. Sleep involves 2 distinct stages: rapid eye movement (REM) and nonrapid eye movement (NREM). NREM sleep constitutes about 75% of total sleep time; REM sleep accounts for the remaining 25% (2014). The entire sleep cycle is completed in 70 to 100 minutes; this cycle repeats itself 4 or 5 times during the course of the sleep period (Norris, 2019). Sleep deprivation results in impaired cognitive functioning (e.g., memory, concentration, and judgment) and perception, reduced emotional control, increased suspicion, irritability, fatigue, sleepiness, confusion, tension, anxiety, and depression and disorientation (Bonnet & Arand, 2021). It also lowers the pain threshold and decreases production of catecholamines, corticosteroids, and hormones (Ibid).
Level 1 Basic Focused Interventions (all settings, community)
NICEnergy Management, Sleep Enhancement, Relaxation Therapy, Exercise Promotion, Environmental Management, Parent Education: Child-rearing Family
Because various factors can disrupt sleep patterns, the nurse should consult the index for specific interventions to reduce certain factors (e.g., pain, anxiety, fear). The following suggests general interventions for promoting sleep and specific interventions for selected clinical situations.
Discuss the Reasons for Differing Individual Sleep Requirements, Including Age, Lifestyle, Activity Level, and Other Possible Factors
R:Although many believe that a person needs 8 hours of sleep each night, no scientific evidence supports this. Individual sleep requirements vary greatly. Generally, a person who can relax and rest easily requires less sleep to feel refreshed. With aging, less time is spent in the sleep cycle stages 3 and 4, which are the most restorative stages of sleep. The results are difficulty falling asleep and staying asleep (*Cole & Richards, 2007).
Explain Sleep Insufficiency May Be a Consequence of a Reduced Amount of Duration and/or Sleep Quality (Bonnet & Arand, 2021)
R:Sleep quality is determined by the number of arousals (or awakenings) from sleep during the night, as well as the percentage, duration, and type of sleep stages. It is possible for an individual to sleep 8 or more hours and still be sleep deprived. In such cases, the sleep deprivation is usually due to disturbances in the quality of sleep (Bonnet & Arand, 2021).
Explain the Need for Sleep Cycle
R:Sleep cycle. An individual typically goes through 4 or 5 complete sleep cycles each night. Awakening during a cycle may cause him or her to feel poorly rested in the morning (Norris, 2019).
Encourage or Provide Evening Care:
- Bathroom or bedpan
- Personal hygiene (mouth care, bath, shower, partial bath)
- Clean linen and bedclothes (freshly made bed, sufficient blankets)
R:A familiar bedtime ritual may promote relaxation and sleep. Sleep is difficult without relaxation, which the unfamiliar hospital environment can hinder.
Increase Daytime Activities in Residential Facilities or at Home, as Indicated
- Establish with the individual a schedule for a daytime program of activity (walking, physical therapy).
- Encourage naps in the morning.
- Limit the amount and length of daytime sleeping if excessive (i.e., more than 1 hour).
- Encourage others to communicate with the individual and stimulate wakefulness.
R:Early-morning naps produce more REM sleep than do afternoon naps. Naps that are longer than 90 minutes decrease the stimulus for longer sleep cycles in which REM sleep is obtained.
Ask About Their Usual Bedtime Routine—Time, Hygiene Practices, Rituals Such as Reading—and Adhere to It as Closely as Possible
R:Sleep rituals prepare the mind, body, and spirit for rest and decrease cortical responses.
- Consume a desired bedtime snack (avoid highly seasoned and high-roughage foods) and warm milk.
R:Warm milk contains L-tryptophan, which is a sleep inducer.
- Avoid alcohol, caffeine, and tobacco at least 4 hours before retiring.
R:Caffeine and nicotine are CNS stimulants that lengthen sleep latency and increase nighttime wakening (Miller, 2019). Alcohol induces drowsiness but suppresses REM sleep and increases the number of awakenings (Miller, 2019).
Use Pillows for Support
R:Pillows can support a painful limb, pregnant or obese abdomen, or the back.
Explain the Need to Avoid Sedative and Hypnotic Drugs
R:Sleep medications can increase awakenings and fewer total sleep hours (LaReau et al., 2008). These medications begin to lose their effectiveness after a week of use, requiring increased dosages and leading to the risk of dependence.
Cluster Procedures to Minimize the Times You Need to Wake the Individual at Night. If Possible, Plan for at Least 4 Periods of 90 Minutes of Uninterrupted Sleep
R:To feel rested, a person usually must complete an entire sleep cycle (70 to 90 minutes) 4 or 5 times a night.
If the individual is being awoken for monitoring, use SBAR with a prescribing professional.
SBAR
Situation: Mr. Nelo has only slept _ hours in the last 24 hours.
Background: He is not sleeping because. . . .
Assessment: He is c/o of more pain and wants a sleeping pill.
Recommendation: It would be useful to . . . e.g., stop vital signs from 10
PM
to 6
AM
unless needed, change the times for medication administration.
Provide treatments before 10
PM
and after 6
AM
when possible.
Discuss with physician/nurse practitioner (NP)/physician assistant (PA) the use of a "sleep protocol." This will allow the nursing staff the authority not to wake a person for blood draws or vital signs if appropriate (Bartick, 2009).
R:Implementation of the sleep hygiene protocol permitted acutely injured or ill patients in our intensive care unit to fall asleep more quickly and to experience fewer sleep disruptions (Faraklas et al., 2013).
- Close the door to the room or pull the curtains.
- Designate "quiet time" between 10
PM
and 6
AM
. - Play lullabies over the public address system.
- Have a timer switch off overhead hallway lights at 10
PM
. - Mute phones close to individual rooms; avoid intercom use except in emergencies.
- Take vital signs at 10
PM
and start again at 6
AM
unless otherwise indicated. - Medications are ordered b.i.d., t.i.d., q.i.d., not "q" certain hours when possible.
- No administering a diuretic after 4
PM
. - Avoiding blood transfusions during "quiet time" due to frequent monitoring.
R:A small study reported that a "sleep protocol" can reduce the number of individuals reporting disturbed sleep by 38% and generate a 49% reduction in individuals needing sedatives (*Bartick, 2009). A quality improvement effort on a medical-surgical unit minimized sleep interruptions to allow patients 6 or more hours of uninterrupted sleep (Lampron & Copeland, 2019).
Advise Ancillary Staff/Students to Report the Amount of Time Spent Sleeping, Including Naps and Nighttime
R:The quality and amount of sleep time with at least 4 periods of 90 minutes of uninterrupted sleep is the goal.
Initiate Health Teaching as Indicated
Explain that hypnotics contribute to sleep disturbances through the following mechanisms (Miller, 2019):
- Requiring increasing dosage as a result of tolerance
- Depressing central nervous system function
- Producing paradoxic effects (nightmares, agitation)
- Interfering with REM and deep sleep stages
- Causing daytime somnolence because of a long half-life
Advise if poor sleep is contributing to daytime fatigue and pain, try the following tips to improve sleep at home (Arthritis Foundation, 2012):
- Maintain a regular daily schedule of activities, including a regular sleep schedule.
- Exercise, but not late in the evening.
- Set aside an hour before bedtime for relaxation.
- Eat a light snack before bedtime. You should not go to bed hungry, nor should you feel too full.
- Make your bedroom as quiet and as comfortable as possible. Maintain a comfortable room temperature. Invest in a comfortable mattress and/or try a body-length pillow to provide more support.
- Use your bedroom only for sleeping and for being physically close to your partner.
- Arise at the same time every day, even on weekends and holidays.
- Avoid long naps. If a nap is needed to get you through the day, keep it short, and schedule it well in advance of your bedtime. Try exercising in the afternoon rather than napping.
- Avoid sleeping pills.
- Avoid drinking alcohol near bedtime and caffeine-containing foods/drinks, coffee, tea, and chocolate.
- Do not smoke. If you must smoke, do not smoke before bedtime.
- Use a clock radio with an automatic shutoff to play soft music at bedtime. If you are not a heavy sleeper, wake up to music rather than a clanging alarm.
- Take a warm bath before going to bed.
- Listen to soothing music or a relaxation tape.
- Read before bedtime if you like, but avoid suspenseful, action-filled novels or work-related material that can preoccupy your thoughts and cause a poor night's sleep.
- Use earplugs or white noise to block distracting noises.
- Before going to bed, write down your worries and make a "things to do" list. Then put it away for tomorrow so you can stop thinking about them.
- If you do not go to sleep within 30 minutes after going to bed, or if you wake up in the middle of the night and cannot get back to sleep, get up and go to a different room. Try a relaxation technique, read, or listen to soothing music.
Refer to the CWS: Getting Started to Sleep Better.
Level 2 Specialty Focused Interventions (pediatrics)
Explain the Sleep Differences of Infants and Toddlers (Hockenberry, Rodgers, & Wilson, 2018)
R:There are age-related sleep requirements and behavior.
- Explain night to the child (stars and moon).
- Discuss how some people (nurses, factory workers) work at night.
- Explain that when night comes for them, day is coming for other people elsewhere in the world.
- If a nightmare occurs, encourage the child to talk about it, if possible. Reassure the child that it is a dream, even though it seems very real. Share with the child that you have dreams too.
R:Children need to understand nighttime and be assisted to prepare for it. Preparation for bedtime involves switching the child from activity to bedtime gradually. It is a time for calmness, reassurance, and closeness.
Stress the Importance of Establishing a Sleep Routine (*Murray, Zentner, & Yakimo, 2009)
- Set a definite time and bedtime routine. Begin 30 minutes before bedtime. Try to prevent the child from becoming overtired and agitated.
- Establish a bedtime ritual with bath, reading a story, and soft music.
- Ensure that the child has his or her favorite bedtime object/toy, pillow, blanket, and so forth.
- Quietly talk and hold the child.
- Avoid TV and videos.
- If the child cries, go back in for a few minutes and reassure for less than a minute. Do not pick up the child. If crying continues, return in 5 minutes and repeat the procedure.
- "If extended crying continues, lengthen the time to return to the child to 10 minutes" (*Murray, Zentner, & Yakimo, 2009). Eventually the child will fatigue and fall asleep.
- "The child should remain in his or her bed rather than co-sleep for part or all of the night with parents" (*Murray, Zentner, & Yakimo, 2009). Occasional exceptions can be made for family crises, trauma, and illness.
R:"Bedtime rituals become a precedent for other separations and help the child strengthen a sense of trust and build autonomy" (*Murray, Zentner, & Yakimo, 2009). Co-sleeping with parents interferes with parental restorative sleep and promotes the child as in charge.
- Provide a night-light or a flashlight to give the child control over the dark.
- Reassure the child that you will be nearby all night.
R:Children can be helped to learn that their beds are safe places. Bedtime is often difficult with sleep problems commonly related to resistance to separation and normal fears.
Level 2 Specialty Focused Interventions (older adults all settings)
CLINICAL ALERTExcessive sleepiness may be caused by difficulty initiating sleep, impaired sleep maintenance, waking prematurely, sleep disorders, or sleep fragmentation (Chasens & Umlauf, 2012). Older adults report obstructive sleep apnea (OSA), insomnia, and restless legs syndrome (Ibid).
Older adults report excessive sleepiness as a common symptom; unfortunately, this is often ignored. A focused assessment on this reported symptom is indicated to determine contributing factors and treatment (Chasens & Umlauf, 2012).
Refer also to the Basic Focused Interventions under Disturbed Sleep Pattern.
Explain the Effects of Aging on Sleep Efficiency. Younger People Have 80 to 90% Sleep Efficiency versus Older Adults Who Have 50 to 70% (Miller, 2019)
R:Sleep efficiency is the percentage of time asleep during the time in bed (Miller, 2019).
Explain the Age-Related Effects on Sleep
R:Older adults have more difficulty falling asleep, are more easily awakened, and spend more time in the drowsiness stage and less time in the dream stages than do younger people (Miller, 2019).
Consult with Primary Care Provider for Treatment on Medical Complaints That Interfere with Sleep
R:Management of medical conditions, psychological disorders, and symptoms that interfere with sleep, such as depression, pain, hot flashes, anemia, or uremia (Chasens & Umlauf, 2012).
Explain That Some Medications (Prescribed, Over the Counter) Should Be Avoided Because of Their Risk for Dependence and the Risks of Drowsiness
If the individual needs sleeping pills occasionally, advise him or her to consult their primary care provider for a type with a short half-life.
R:Over-the-counter sleep aids contain antihistamines, which can cause dizziness and risk for falls.
Recommend Sleep Aids That Are Safe, Such as:
Herbal teas, such as chamomile, Bedtime tea, and lemon balm.
Melatonin can be effective in some individuals and is safe.