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Sleep Deprivation

Sleep Deprivation. Dr. Abdul- Monim Batiha Assistant Professor Critical Care Nursing Philadelphia University . Outlines:. DEFINITION. STAGES OF SLEEP. CIRCADIAN RHYTHM. CIRCADIAN DESYNCHRONIZATION. DYSFUNCTIONAL SLEEP. SLEEP DEPRIVATION IN CRITICAL CARE UNITS.

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Sleep Deprivation

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  1. Sleep Deprivation • Dr. Abdul-MonimBatiha • Assistant Professor • Critical Care Nursing • Philadelphia University

  2. Outlines: • DEFINITION. • STAGES OF SLEEP. • CIRCADIAN RHYTHM. • CIRCADIAN DESYNCHRONIZATION. • DYSFUNCTIONAL SLEEP. • SLEEP DEPRIVATION IN CRITICAL CARE UNITS.

  3. EFFECTS OF SLEEP DEPRIVATION IN CRITICAL CARE UNITS • SIGNS AND SYMPTOMS OF SLEEP DEPRIVATION. • NURSING ROUTINES AND INTERVENTIONS. • PHARMACOLOGY AND SLEEP. • NURSING’S CHALLENGE. • PREPARING THE PATIENT FOR SLEEP.

  4. Definition • Sleep is a state of unconsciousness from which a person can be aroused by appropriate sensory or other stimuli. (Guyton 1991( • It is a reversible behavioral state of perceptual disengagement from and unresponsiveness to the environment. (William 2004)

  5. Sleepis the state of natural rest observed in most mammals. It is characterized by a reduction in voluntary body movement, decreased reaction to externalstimuli, an increased rate ofanabolism the synthesis of cell structures, and a decreased rate of catabolism( the breakdown of cell structures(. regular sleep is necessary for survival. (Free encyclopedia 2007)

  6. Adults normally spend Approximately one third of their lives asleep .

  7. Researchinvolving the simultaneous monitoring of the • Electroencephalogram (EEG) • Electrooculogram (EOG) • Electromyogram (EMG)

  8. STAGES OF SLEEP • Non-rapid eye movement (NREM) • Consists of four stages • Stage I and II — 50% to 60 % of sleep, light sleep • Stage III and IV — 20% of sleep, deep-sleep states (delta sleep) • Rapid eye movement (REM) • 20-25% of total sleep

  9. In Stage 1 • The individual may not even be aware that he has begun to sleep. • Still aware of his surroundings, • The individual is relaxed and drowsy, • His thoughts are aimless and begin to drift • Thinking is less reality-oriented. • Amplitude of brain waves low.

  10. The individual is less reactive to outside stimuli, but can still be aroused easily. • Body temperature and vital signs start to drop as metabolism slows. • Stage 1 is a brief stage, lasting no more than 7 minutes. • Lasts 2% to 5% of total sleep time.

  11. Stage 2 of NREM sleep • Is a slightly deeper sleep and is a transition or “door” stage to deeper NREM stages or to REM sleep. • The individual is no longer aware of his surroundings, • Amplitude of brain waves higher.

  12. and is a little harder to awaken. • Fragments of dreams may occur, • Eyes slowly roll from side to side. • Metabolism and vital signs continue to decrease. • Sleep spinder. • Lasts 5-15 minutes. • This is the most stable and predominant NREM sleep stage in adults.

  13. NREM Stage 3 sleep • Is much deeper than that of Stage 2, and the individual is now more difficult to arouse. • Snoring may begin to occur • Because of decreased muscle tone. Vital signs, body temperature, and metabolism are decreased. • Roughly 15 to 20 minutes after falling asleep.

  14. Stage 4 NREM sleep • Deepest sleep stage, and the individual is very difficult to awaken. • Sometimes referred to as “weary sleep," it is at this time that sleep walking and bed-wetting can occur. • The individual rarely moves at this time

  15. vital signs and metabolism are at their lowest, with the parasympathetic system dominant. • Elevated GH and other anabolic hormones, such as prolactin and testosterone, imply that anabolism is taking place, particularly in tissues with a high protein content. • Thus activities include protein synthesis and tissue repair.

  16. When people speak of having had a good night’s sleep, it is likely primarily Stage 4 sleep that they are referring to. • NREM Stages 3 and 4 are the deepest stages of sleep and are often reported together as delta-wave sleep, for the amplitude of waves seen on the EEG during these stages. • 20% to 25% of sleep for the adult, but this percentage decreases with age.

  17. REM sleep • REM sleep is sometimes referred to as paradoxical sleep. • REM sleep is a very active stage with a high degree of cerebral and physiologic activity. • REM sleep continues to facilitate protein anabolism, but during this same time there is great fluctuation in autonomic nervous system activity, causing heart rate variability.

  18. Increases in parasympathetic tone. • Sympathetic stimulation.

  19. There is increased cerebral blood flow during REM sleep . • Evidence suggests that the adrenalin surge that more than doubles during REM sleep may be responsible for episodes of ischemia, sudden cardiac death, and strokes in the early morning hours. • Most dreams occur during REM sleep • REM sleep can last from 5 to 35 minutes

  20. REM sleep is of great importance to nurses because as the patient is entering this stage of sleep, the nurse may notice a change in vital signs and become concerned that the patient's condition is worsening.

  21. Walking ↓ NREM (Stage 1) NREM (Stage 2) NREM ( Stage 3)REM NREM ( Stage 4) NREM (Stage 2) NREM ( Stage 3) The cyclic Nature of sleep

  22. The cyclic nature of sleep and wakefulness is thought to be regulated by complex neurochemical reactions arising in the tissues of the brain stem known as the reticular formation.

  23. The sleep-wakefulness cycles, as well as the REM/nonREM cycle, are throughout be mediated by the neurotransmitters serotonin, dopamine, norepinephrine, and epinephrine. Current research suggests that the control of sleep is a very complex process not confined to one localized part of the brain.

  24. Circadian rhythm • The sleep-wake cycle follows the circadian rhythm in a 24-hour cycle synchronized with other biologic rhythms. Nighttime sleep is the normal pattern for most adults.

  25. When sleep occurs during the low phase of the circadian rhythm, circadian synchronization is present . Sleep that occurs during normal waking hours is out of phase or desynchronized

  26. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - • 8AM 2PM 8PM 2AM 8AM

  27. Desynchronized sleep is rated as poor-quality sleep and causes a decreased arousal threshold; therefore frequent awakenings are more likely. Irritability, restlessness, depression, anxiety, and decreased accuracy in task performance are characteristic effects of desynchronized sleep.

  28. Resynchronization with the circadian rhythm must occur whenever sleep has become desynchronized for the individual to establish a normal sleep-activity pattern. Although variable among individuals, the resynchronization process is thought to require a minimum of 3 days with a consistent sleep-wake schedule.

  29. During resynchronization, the individual often feels fatigued and unable to perform all of his or her activities of daily living.

  30. CIRCADIAN DESYNCHRONIZATION • The loss of rhythmicity may result from external stressors, which then alters the timing relationships of neural, hormonal, and cellular systems. • Humans respond to stressors, such as surgery, immobilization, and pain, with increased levels and altered timing of adrenal and other hormones.

  31. Farr and other reported that circadian levels; the timing of temperature, blood pressure, and heart rate; and urinary excretion of catecholamines, sodium, and potassium were altered after surgery in hospitalized patients.

  32. Nursing interventions that maintain normal rhythmicity of the day-night cycle.

  33. SLEEP DEPRIVATION INCRITICAL CARE UNITS • Patients in critical care units often experience a lack of sleep or frequent disruptions to their sleep, further compounding their illness. • Psychological stress alone can temporarily affect an individual’s sleep patterns. • More time is spent trying to initiate sleep, and when sleep occurs, it mainly consists of lighter sleep in Stages 1 and 2

  34. Research has shown that patients in critical care units may spend 40% to 50% of their sleep time awake, and of the remaining sleep time only 3% to 4% in REM sleep. • Psychological stressors may cause an individual to need more REM sleep and may cause the individual to feel that they dreamed more than usual and had less restful sleep.

  35. Illness and hospitalization certainly increase psychological stress, but unfortunately hospitalization makes it less possible for the individual to obtain adequate REM sleep.

  36. Novaes and colleagues (1997)conducted a study to evaluate physical and psychological stressors in the intensive care unit (ICU) patients. Fifty patients were asked to complete the Intensive Care Unit Environmental Stressor Scale, ranking the 40 items from not stressful to very stressful. Of these 40 items, not being able to sleep was ranked as the second most important stressor, second only to pain.

  37. Using EEGs, Hilton documented quantity and quality of sleep of nine patients in a respiratory critical care unit. Total sleep time ranged from 6 minutes to 13.3 hours. Only 50% to 60% of the sleep occurred at night, and no patients had complete sleep cycles. NREM stage 1 sleep predominated, to the deprivation of all other stages. Significant deprivation of restorative sleep (NREM stages 3 and 4) was demonstrated with only 4.7% to 10.5% of sleep time being spent in these stages (normally 30% to 35%).

  38. Shaver, in a review of sleep research, notes that sleep deprivation is considered to be a contributing factor in postoperative psychosis.

  39. There is substantial evidence to support the fact that 4 days of sleep deprivation results in a decreased production of ATP, the critical energy substance.

  40. EFFECTS OF SLEEP DEPRIVATION IN CRITICAL CARE UNITS • Sleep deprivation has been shown to induce a catabolic state and negatively affect the immune system and healing. • There is decreased ability to resist and fight infection, further impacting the healing process and hospitalization. • Immunosuppression • and decreased tissue repair

  41. studies report decreased pain tolerance and profound fatigue of the sympathetic nerve centers. • Cortisol secretions are normally diminished during sleep and rise in the morning following circadian rhythms. • Sleep deprivation in critical care patients prolongs cortisol secretion and results in decreased healing, making patients more susceptible to infection and a prolonged recovery process.

  42. Lack of sleep has also been shown to contribute to upper airway musculature dysfunction and hypoxic ventilatory responsiveness, adversely affecting gas exchange. This could have a significant impact on patients with respiratory problems, particularly those who are being weaned from the ventilator or those who have just been extubated

  43. Signs and symptoms of sleepdeprivation • The signs and symptoms of sleep deprivation may not be so apparent, at least initially. • Behavioral changes such as restlessness and irritability may occur within 48 hours. • Disorientation • slurred speech may precede psychotic behavior, which can occur within 96 hours

  44. If a patient is deprived primarily of NREM sleep • He may experience: - fatigue, apathy, speech deterioration, poor judgment, and lack of energy. - ptosis and lack of facial expression.

  45. Deprivation of REM sleep • May cause the patient to feel continually tired and have difficulty concentrating. When deprived of REM sleep for greater than 24 to 48 hours, the patient may experience irritability, confusion, poor impulse control, paranoia, and hallucination, or exhibit aggressive behavior

  46. If an individual does not obtain enough sleep to meet his biological needs, this sleep deprivation will accumulate over time until the brain signals the body to obtain sleep. • If sleep deprivation is prolonged, when the patient finally enters sleep, it consists of predominantly Stage 2 and the deep recovery sleep of Stage 4. REM sleep usually does not occur until the second or third night

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