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Psychiatric / Mental Health Nursing

Psychiatric / Mental Health Nursing. Sleep Disorders Chapter 20. Sleep Disorders. Sleep deprivation – discrepancy between hours of sleep obtained and hours of sleep required for optimal functioning Implications for Health Safety Quality of life .

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Psychiatric / Mental Health Nursing

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  1. Psychiatric / Mental Health Nursing Sleep Disorders Chapter 20

  2. Sleep Disorders • Sleep deprivation – discrepancy between hours of sleep obtained and hours of sleep required for optimal functioning • Implications for • Health • Safety • Quality of life

  3. Theories of Sleep Disorders - continued • Studies show those with chronic insomnia have physiological differences. • Studies suggest that gene variations are involved in human circadian activity. • There is predisposition to sleep disorders based on genetic susceptibility and familial pattern.

  4. Theories of Sleep Disorders - continued • Any emotional or cognitive arousal can precipitate or perpetuate insomnia. • Environmental conditions, including associating the sleeping room with lying awake, cause distress and are a powerful perpetuating factor to sleep problems.

  5. Normal Sleep Cycle Complex interaction between CNS and environment • Non-REM (NREM) sleep • Composed of four stages • REM sleep • Reduction and absence of skeletal muscle tone • Bursts of rapid eye movement • Myoclonic twitches of facial and limb muscles • Dreaming • Autonomic nervous system variability

  6. Regulation of Sleep • Complex interaction between two processes • Homeostatic process or sleep drive – promotes sleep • Circadian process or circadian drive – promotes wakefulness • Influenced by • Endogenous factors • Exogenous factors

  7. Sleep Requirements • Varies from individual to individual • Long sleepers • Require more than 10 hours of sleep each night • Short sleepers • Can function effectively on fewer than 5 hours of sleep per night

  8. Primary Sleep Disorders • Dyssomnias • Primary insomnia • Primary hypersomnia • Narcolepsy • Breathing-related sleep disorders • Circadian rhythm disorders • Dyssomnias not otherwise specified • Restless legs syndrome • (Box 20-1)

  9. Primary Insomnia • Most common sleep complaint • Difficulty with sleep initiation • Sleep maintenance • Early awakening • Non-refreshing, nonrestorative sleep

  10. Interventions for Primary Insomnia • Sleep hygiene – conditions and practices that promote continuous and effective sleep • Behavioral therapies • Educational components • Behavioral components • Cognitive components • Some instances – hypnotic medication (Table 20-1)

  11. Parasomnias • Unusual or undesirable behaviors or events • Occur during • Sleep/wake transitions • Certain stages of sleep • Arousal from sleep

  12. Sleep Disorders Related to Other Mental Disorders • Insomnia related to another mental disorder • Hypersomnia related to another mental disorder • Major depressive disorder • Anxiety disorders • Schizophrenia

  13. Sleep Patterns in Major Depressive Disorder • Insomnia of maintenance or early wakening type most common • Insomnia is the most commonly reported residual symptom after remission • Sleep pattern disturbance may respond to antidepressant treatment sooner than other symptoms

  14. Sleep Patterns in Schizophrenia • Exacerbation of illness causes significant sleep disruption • Extreme sleep difficulty can accompany severe anxiety • Heightened concern of delusions and hallucinations • Circadian cycle disrupted

  15. Sleep Patterns in Schizophrenia - continued • Reduction in REM sleep • Do not experience REM rebound • Deficits in slow-wave sleep found in clients with acute and chronic schizophrenia

  16. Sleep Patterns in Manic Episodes of Bipolar Disorder • Sleep time significantly reduced • Clients don’t complain of insomnia and can go without sleep • Reduced slow-wave sleep • Reduced REM latency

  17. Other Sleep Disorders • Sleep disorders due to a general medical condition • Substance-induced sleep disorders • In both sleep disorders, sleep disturbance may be • Insomnia • Hypersomnia • Parasomnia • Combination

  18. Sleep Patterns in Substance Abuse • Severe sleep disorder during intoxication or withdrawal periods • Persists even after prolonged abstinence of some substances

  19. Sleep Patterns in Substance Abuse - continued • Substance-induced mood disorder characterized by sustained use of stimulants to stay awake or alcohol to induce sleep • Examples of substances

  20. Key Assessments • Assessment • General assessment – sleep patterns • Identifying sleep disorders • Functioning and safety

  21. Key Assessments - continued • Self-defined - say they get enough sleep to feel refreshed, have energy, fall asleep quickly

  22. Key Assessments - continued • Behaviorally defined - observe alertness during sedentary, repetitive activity; note ability to fall asleep and final wakening at habitual rising time; utilize photographic serializing of movement during sleep

  23. Key Assessments - continued • Comprehensive sleep studies are conducted in sleep labs: - polysomnogram - multiple sleep latency test

  24. Nursing Diagnosis • Nursing Diagnosis • Sleep deprivation related to inadequate quality and quantity of sleep • Insomnia related to medical, psychiatric, or sleep disorder, substance use/abuse, or inadequate sleep hygiene • Readiness for enhanced sleep • Risk for injury related to inadequate sleep

  25. Nursing Outcome Identification • Outcomes Identification • Sleep • Rest • Risk control • Personal well-being • (Table 20-2) • Planning

  26. Implementation Basic Level Interventions • Counseling • Health teaching and health promotion • Pharmacological interventions Advanced Practice Interventions • Cognitive-behavioral therapy

  27. Guidelines for Good Sleep Hygiene • Maintain regular sleep–wake schedule • Rise at the same time each day • Go to bed when sleepy and relaxed • Maintain rituals in preparation for sleep • Control for temperature, lighting, noise • Avoid stimulants before bed • Focus on enjoying sleep that is achieved

  28. Guidelines for Insomnia • Treatment for sleep disorders is complex • Follow guidelines for good sleep hygiene • Utilize good sleep hygiene before taking sedative hypnotic medications • Instill a sense of hope that insomnia will improve, client can manage it effectively

  29. Guidelines for Insomnia - continued • Facilitate setting realistic goals. • Teach normal developmental changes in sleep patterns. • See treatment provider for continued insomnia. • Differentiate between myths and evidence-based practice.

  30. Evaluation • Based on whether or not patient experiences improved sleep quality as evidenced by • Decreased sleep latency • Fewer nighttime awakenings • Shorter time to get back to sleep after awakening

  31. Pharmacology

  32. Sleep and Wakefulness • Goal: Improve quantity and quality of sleep • May prevent worsening of mood, anxiety and pain if sleep improves • Many choices: evaluate lifestyle • Do not underestimate the POWER of sleep

  33. Sleep Agents: NT • Nearly all hypnotics work on at least one of these neurotransmitters: • GABA • Histamine

  34. Rx Sleep agents • Barbiturates • Benzodiazepines • Non-benzos • Melatonin Receptors Agonists

  35. Sleep agents • Barbituturates – first used in 1860s named after St Barbara • Nembutal (pentobarbital) • Seconal (secobarbital)

  36. Sleep agents • Benzodiazepines • Short Acting • Halcion (triazolam) • Intermediate • Restoril (temazepam) • Prosom (estazolam) • Long Acting • Dalmane (flurazepam)

  37. Sleep Agents • Non-Benzos • Zolpidem - Ambien (5 - 10 mg/night) • Ambien CR • Zaleplon - Sonata (10 mg/night) • Eszopiclone -Lunesta (1-3 mg/night) • Cholral Hydrate – Noctec, AquachloralSupprettes, Somnote(500 - 2000 mg/d) • Diphenhydramine - Benadryl, Sominex, Nytol (25 - 100 mg/d)

  38. Sleep Agents • Melatonin Receptor Agonist • Rameltoeon - Rozerem (8mg/d) • Valdoxan (agomelatine) also works on 5-HT2c so is antidepressant

  39. Sleep Agents • Over the Counter OTC • Benadryl (diphenhydramine) • Atarax/Vistaril (hydroxyzine Kava Kava Caution: may cause liver toxicity Valerian

  40. Side Effects • Hangover • Amnesia • Headache

  41. When Starting on Sleepers • Sleep hygiene first – remember caffeine • Cool, quiet, dark room without dogs and kids • Don’t mix with Alcohol • Go straight to bed and lay down

  42. Wake Agents: NT • Nearly all wake promoting agents work on at least one of these neurotransmitters: • Norepinephrine • Dopamine

  43. Wake Agents • Provigil = Nuvigil • FDA Indication • Excessive sleepiness due to narcolepsy • Obstructive sleep apnea • Shift work sleep disorder Treat fatigue and sleepiness due to other conditions – depression and MS

  44. Wake Agents • Stimulants • Provigil (modafinil) • Nuvigil (armodafinil)

  45. When Starting on Wakers • Sleep hygiene first – not a replacement for sleep

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