Need Help Stat

CONSIDER: SLEEP

Definitions
Excessive daytime sleepiness: sleepiness that interferes with normal daily activities. A change from baseline (ask patient, family, or caregiver).

Insomnia: difficulty with falling asleep. Normal sleep latency is about 10 minutes.

Sleep apnea: cessation of respiration during sleep due to (1) airway obstruction caused by collapse of upper airway structures and/or (2) neurological dysfunction.

Restless leg syndrome: a condition where patients report uncomfortable crawly sensations in their legs when at rest that is often associated with motor hyperactivity and only relieved with activity. These patients find relief in getting up and walking around frequently at night.

Sleep changes with age: an increase in number of awakenings and arousals, decreased REM sleep, increased number of shifts in sleep stages, reduced sleep efficiency (percentage of time asleep compared to time spent in bed), and a tendency to go to bed earlier and awaken earlier.

Atypical Presentation
Daytime sleepiness is not normal-always assess for underlying causes. Restless leg syndrome may present with the patient observed walking in place next to the bed or wanting to climb out of bed or with leg thrashing at night. For many patients, the discomfort is only relieved by walking.

Assessment/Screening Tools

Sleep History

Screening questions for patient or family members

  • Usual bedtime and time of awakening
  • Napping (when and where)
  • Difficulty falling asleep
  • Difficulty staying asleep or frequent awakenings
  • Difficulty returning to sleep after waking during the night
  • Waking too early
  • Witnessed apneas
  • Sleep walking or night time wandering, falling at night (when and where)
  • Snoring
  • Nocturia
  • Obesity (BMI>30, neck size > 17/16)
  • Uncomfortable sensations in the legs or frequent kicking during sleep
  • Cognitive dysfunction
  • Depression
  • Recent history of car crashes or accidents due to sleepiness
  • Current diagnosis of sleep disorder or Sleep Apnea and use of CPAP

 

Excessive Sleepiness: Nursing Assessment and Interventions
Presenting Complaint

Difficulty in: 		Common Causes Nursing Interventions
Going to sleep and returning to sleep after being awakened Insomnia


Depression
  • Psychological distress can interfere with sleep onset.
  • Conversely, sleep deprivation can lead to depression and can also trigger exacerbation of other conditions (bipolar illness).
 Primary prevention and treatment with morning bright light exposure and sleep hygiene techniques such as avoiding: caffeine, daytime napping, and exercise prior to bedtime; consistency in sleep schedule; and managing environmental factors in patient care setting: noise (quiet); temperature (cool); motion/vibration (avoid); light (complete darkness); and comfort/bedding (patient preference).

Evaluate for sleep deprivation as a source of recent onset insomnia and early awakenings.

Screen for depression: When other measures have not been effective for insomnia provide appropriate medications short term only (<2 weeks). See Medication topic.
Staying asleep Sleep apnea (by medical diagnosis or by nursing observation).
  • Obtain baseline sleep information from patient and family, past medical history of sleep apnea or witnessed apneas, gasping, choking during sleep along with O2 desaturations. If apneas are witnessed during care of patient with no current diagnosis of sleep apnea, recommend consultation with sleep specialist for sleep study.
  • Most common treatment: continuous positive airway pressure (CPAP). Other treatments: weight loss or surgical techniques to reduce tonsils and/or soft palate.
  • Avoid sedating medications or provide CPAP anytime the patient is sleeping while on sedating medications.
  • Always be sure patients who use CPAP at home bring/use it every night at the hospital.
  • Sleep apnea patients will require extra airway support during anesthesia and recovery.
Staying asleep Restless leg syndrome
  • May be caused by iron deficiency anemia, floate/B12 deficiency, diabetes, hypothyroidism, medications (tricyclics, SSRIs, caffeine) and chronic renal failure.
  • Diagnosis based on symptom report, does not require a specialist referral or a sleep study.
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  • Evaluate labs: Ferritin, TIBC, folate, B12, fasting blood sugar, TSH, BUN, creatinine, Ca, Mg.
  • Initiate pharmacologic treatment as appropriate.
  • Consider discontinuing potential causative medications: tricyclics, SSRI's.
  • Avoidance of caffeinated beverages.
  • Validate and support recognition of condition and encourage daytime exercise.
  • Evaluate and modify the environmental factors in patient care settings (noise, temperature, motion/movement, light, comfort/bedding).
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    Awakening too early Aging changes


    Depression
    • Early awakening is sign of depression.
    • Sleep deprivation can lead to depression and can also trigger exacerbation of other conditions (bipolar illness).
  • Reinforce sleep hygiene practices.
  • Avoid daytime naps.
  • Maintain a regular sleep schedule.
  • Aggressively screen and treat reversible conditions: hypothyroidism; iron or folate deficiency; poor sleep hygiene, environmental factors.
  • Consider sleep deprivation as a source of recent onset insomnia and early awakenings.
  • Screen for depression:

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    Last updated - February 2005