Sleep Pattern Disturbance - Insomnia
Galanes, RN, MS, CCRN
Meg Gulanick, RN, PhD
NANDA: Disruption of sleep time causes discomfort or interferes
with desired lifestyle
Sleep is required to provide energy for physical and mental
activities. The sleep-wake cycle is complex, consisting of different stages of
consciousness: rapid eye movement (REM) sleep, non-rapid eye movement (NREM)
sleep, and wakefulness. As persons age the amount of time spent in REM sleep
diminishes. The amount of sleep that individuals require varies with age and
personal characteristics. In general the demands for sleep decrease with age.
The elderly sleep less during the night, but may take more naps during the day
to feel rested. Disruption in the individual's usual diurnal pattern of sleep
and wakefulness may be temporary or chronic. Such disruptions may result in
both subjective distress and apparent impairment in functional abilities. Sleep
patterns can be affected by environment, especially in hospital critical care
units. These patients experience sleep disturbance secondary to the noisy,
bright environment, and frequent monitoring and treatments. Such sleep
disturbance is a significant stressor in the intensive care unit (ICU) and can
affect recovery. Other factors that can affect sleep patterns include temporary
changes in routines such as in traveling, jet lag, sharing a room with another,
use of medications (especially hypnotic and antianxiety drugs), alcohol
ingestion, night-shift rotations that change one's circadian rhythms, acute
illness, or emotional problems such as depression or anxiety. This care plan
focuses on general disturbances in sleep patterns and does not address organic
problems such as narcolepsy or sleep apnea.
- Environmental changes
- Excessive or inadequate stimulation
- Abnormal physiological status or symptoms (dyspnea, hypoxia,
neurological dysfunction, and others)
- Normal changes associated with aging
- Verbal complaints of difficulty falling asleep
- Awakening earlier or later than desired
- Interrupted sleep
- Verbal complaints of not feeling rested
- Altered mental status
- Difficulty in arousal
- Change in activity level
- Altered facial expression (e.g., blank look, fatigued
Patient achieves optimal amounts of sleep as evidenced by rested
appearance, verbalization of feeling rested, and improvement in sleep
- (i) independent
- (i) Assess past patterns of sleep in normal
environment: amount, bedtime rituals, depth, length, positions, aids, and
- Sleep patterns are unique to each individual.
- (i) Assess patient's perception of cause of
sleep difficulty and possible relief measures to facilitate treatment.
- For short-term problems, patients may have insight into the
etiologic factors of the problem: fear over results of a diagnostic test,
concern over a daughter getting divorced, depression over the loss of a loved
one, and other events. Knowing the specific etiologic factor will guide
- (i) Document nursing or caregiver observations
of sleeping and wakeful behaviors. Record number of sleep hours. Note physical
(e.g., noise, pain or discomfort, urinary frequency) and/or psychological
(e.g., fear, anxiety) circumstances that interrupt sleep.
- Often, the patient's perception of the problem may differ
from objective evaluation.
- (i) Identify factors that may facilitate or
interfere with "normal patterns."
- Considerable confusion and myths about sleep exist.
Knowledge of its role in health/wellness and the wide variation among
individuals may allay anxiety, thereby promoting rest and sleep.
- (i) Evaluate timing or effects of medications
that can disrupt sleep.
- In both the hospital and home care setting, patients may be
following medication schedules that require awakening in the early morning
hours. Attention to changes in the schedule or changes to once a day medication
may solve the problem.
- (i) independent
- (i) Instruct patient to follow as consistent a
daily schedule for retiring and arising as possible.
- This promotes regulation of the circadian rhythm, and
reduces the energy required for adaptation to changes.
- (i) Instruct to avoid heavy meals, alcohol,
caffeine, or smoking before retiring.
- Though hunger can also keep one awake, gastric digestion
and stimulation from caffeine and nicotine can disturb sleep.
- (i) Instruct to avoid large fluid intake
- For patients may need to void during the night.
- (i) Increase daytime physical activities as
- To reduce stress and promote sleep.
- Instruct to avoid strenuous activity before bedtime.
- Overfatigue may cause insomnia.
- (i) Discourage pattern of daytime naps unless
deemed necessary to meet sleep requirements or if part of one's usual
- Napping can disrupt normal sleep patterns. However the
elderly do better with frequent naps during the day to counter their shorter
nighttime sleep schedule.
- (i) Suggest use of soporifics such as
- Which contains L-tryptophan that facilitates
- (i) Recommend an environment conducive to
sleep or rest (e.g., quiet, comfortable temperature, ventilation, darkness,
closed door). Suggest use of earplugs or eye shades as appropriate.
- (i) Suggest engaging in a relaxing activity
before retiring, such as warm bath, calm music, reading an enjoyable book,
- (i) Explain the need to avoid concentrating on
the next day's activities or on one's problems at bedtime.
- Obviously, this will interfere with inducing a restful
state. Planning a designated time during the next day to address these concerns
may provide permission to "let go" of the worries at bedtime.
- (c) Suggest using hypnotics or sedatives as
ordered; evaluate effectiveness.
- Use of hypnotic medications should be thoughtfully
considered and avoided if less aggressive means are effective because of their
potential for cumulative effects and generally limited period of benefit.
Different drugs are prescribed depending on whether the patient has trouble
falling asleep or staying asleep. Medications that suppress REM sleep should be
- (i) If unable to fall asleep after about 30 to
45 minutes, suggest getting out of bed and engaging in a relaxing
- The bed should not be associated with
- For patients who are hospitalized:
(i) Provide nursing aids (e.g., back rub, bedtime care,
pain relief, comfortable position, relaxation techniques).
- To promote rest.
- (i) Organize nursing care.
- To promote minimal interruption in sleep or rest.
- Eliminate nonessential nursing activities.
- Prepare patient for necessary anticipated
- (i) Attempt to allow for sleep cycles of at
least 90 minutes.
- Experimental studies have indicated that 60 to 90 minutes
are needed to complete one sleep cycle, and the completion of an entire cycle
is necessary to benefit from sleep.
- (i) Move patient to room farther from the
nursing station if noise is a contributing factor.
- (i) Post a "Do not disturb" sign on the
Education/Continuity of Care
- (i) independent
- (i) Teach about possible causes of sleeping
difficulties and optimal ways to treat them.
- (i) Instruct on nonpharmacological sleep
~ Care Plan Index ~
Outcomes Index ~
~ Care Plan Constructor Home ~