This chapter provides a comprehensive description of sleep-related breathing disorders, which include includes obstructive sleep apnea (OSA), central sleep apnea (CSA), and Cheyne-Stokes breathing (CSB). It also describes sleep-related hypoventilation/hypoxemic syndromes and sleep-related hypoventilation/hypoxemia due to other medical conditions. CSB and CSA are characterized by instability of the respiratory control system that leads to apneic periods without respiratory effort. Sleep-related breathing disorders are characterized by partial or complete cessation of respiration during sleep, oxyhemoglobin desaturation and sleep fragmentation. Sleep-disordered breathing is a chronic condition that has major implications for morbidity, mortality, and quality of life throughout the world. Nurses, in collaboration with other health care providers, have important roles to play in assessment, treatment, and supporting long-term management and evaluation of this chronic condition. The chapter addresses the characteristics, epidemiology, related factors and consequences, pathophysiology, assessment, diagnosis, and treatment of these disorders, and discusses implications for nursing.
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Sleep loss has tremendous societal implications associated with lost productivity, injuries, accidents, and excessive financial costs. This chapter discusses the nature of sleep loss and sleep disorders and their implications for human health and well-being. It reviews the epidemiological and societal consequences of sleep disorders and discusses diagnostic classification systems and their implications for nursing. Sleep loss results from obtaining less sleep than needed and/or fragmented sleep that leads to deprivation of specific sleep stages even in the presence of adequate total sleep. However, chronic sleep deprivation is endemic and contributes to pathophysiology, daytime dysfunction, fatigue, sleepiness, morbidity, injury, mortality, and poor quality of life. Sleep loss, its consequences, and strategies to prevent and/or treat it are important thematic underpinnings in these narratives. Proficiency in the use of relevant sleep diagnostic classification systems is necessary to interdisciplinary collaboration and sleep diagnosis and treatment.
This chapter reviews normal physiological and anatomical changes that occur during pregnancy and discusses common sleep disorders that can occur during pregnancy as well as postpartum. It also discusses the adverse effects of poor sleep on labor and delivery outcomes and reviews postpartum sleep patterns within the context of risk for postpartum depression. The chapter examines the nurses’ role in sleep promotion in relation to sleep hygiene behaviors that can be adapted for pregnant women and new mothers and their families during the first 6 months postpartum. It describes alternative strategies nurses can use to safely promote sleep during perinatal period. Restless legs syndrome (RLS) and sleep-disordered breathing (SDB) or obstructive sleep apnea (OSA) the most critical causes of disturbed sleep during pregnancy and require urgent assessment and referral for effective and non-pharmacologic interventions. The chapter explores sleep during the postpartum period, when women’s experience with sleep deprivation is expected.
This chapter discusses the characteristics of sleep, factors associated with sleep, and evidence-based strategies to promote sleep in acute and critical care settings. It discusses implications for nursing practice and research. Disordered sleep is common in patients hospitalized in demographical and clinically diverse acute and critical care settings. Careful assessment for factors that increase the risk for sleep disturbance and its consequences during hospitalization is needed. Although randomized clinical trials are sparse, the available evidence suggests the promise of multimodal interventions that reduce environmental stimuli or their impact. Given the high prevalence of obstructive sleep apnea (OSA) in the general population and its underdiagnosis, there is a compelling need for assessment and preventative interventions for this condition. Research is needed on the short- and longer-term outcomes of sleep-promoting interventions on patients’ function, quality of life, and morbidity.
This chapter provides practical strategies for nursing care related to sleep promotion and prevention and treatment of sleep disorders in pediatric primary care settings, acute care settings, and schools. In children with sleep disorders, inadequate sleep does not often result in excessive daytime sleepiness, but in behavioral difficulties such as inattention, hyperactivity, cognitive dysfunction, and/or scholastic problems. Nurses who see children in the primary care setting can take an active role in the evaluation and assessment of all children’s sleep health and provide follow-up care and ongoing treatment monitoring for children who have sleep disorders. In the acute care setting, nurses can incorporate regular treatment plans for a child’s sleep disorder during hospitalization and should be aware of potential for obstructive sleep apnea (OSA)-related perioperative complications for children undergoing adenotonsillectomy. School nurses have the opportunity to promote healthy sleep and improve behavior and school performance in children at risk.
This chapter discusses the roles, qualifications, and educational opportunities for advanced practice nurses (APRNs) in specialized sleep practice. It provides exemplars of practice models to illustrate available opportunities. APRNs are well-positioned to develop specialized sleep practices, based on their strong preparation in health assessment, health promotion, and management of episodic and chronic health care conditions in a wide variety of populations and the pressing societal need for an increase in sleep specialists. Their expertise in promoting lifestyle change is a particular strength. Possible roles for APRNS are multidimensional and encompass clinical practice, education, advocacy, and research. Creative models of practice are needed and continue to emerge. While there is a growing cadre of APRNs with specialized sleep practices in a variety of settings, there is a need for more systematic opportunities for education in sleep, chronobiology, and sleep disorders in basic nursing education, graduate school, and continuing education (CE).
Insomnia is a highly prevalent condition that is known to be associated with important pathophysiological, cognitive, and functional consequences. Adults of all ages and all states of health frequently suffer from insomnia. Therefore, nurses are likely to encounter patients with insomnia in many health care and home settings, including primary care, and acute and long-term care settings. Assessment for insomnia should routinely be incorporated into nursing practice in these settings. Although hypnotics are of some use, cognitive behavioral therapy for insomnia (CBT-I) offers the best long-term results in improving sleep and the daytime sequela resulting from poor sleep. Nurse at all levels play an important role in assessment of insomnia, education about the importance of insomnia, and offering strategies for prevention of chronic insomnia. Effective diagnosis, prevention, and treatment of insomnia are likely to have important effects on reducing its deleterious effects on pathophysiology, functional performance, and quality of life.
Narcolepsy is a potentially disabling hypersomnia of central origin that is associated with dysregulation of sleep and waking states. Although less prevalent than some other sleep disorders, such as sleep apnea and insomnia, narcolepsy is very important because studies of this condition have provided scientists with insight into basic mechanisms of sleep-wake regulation. Although the exact cause of narcolepsy is unknown, causes appear to be multifactorial, for example, genetics, infection, stress, and low levels of the brain neurochemical hypocretin. Effective treatments are available and can improve this chronic condition, as well as its negative consequences. This chapter describes the characteristics and consequences of narcolepsy and strategies for assessment and treatment of this sleep disorder, and discusses implications for nursing practice. Nurses and advanced practice nurses, as members of an interdisciplinary team, play important roles in assessment, diagnosis, treatment, and follow-up care.
Disturbed sleep is associated with increased health care utilization and costs, risks to public safety, reduced quality of life, and morbidity and mortality in the general population. This chapter reviews data related to racial and ethnic health disparities in sleep disorders and discusses the implications for nursing. It focuses on American populations for whom there is available data on sleep. Latino, African, and Asian-Americans may be at greater risk to have or to develop sleep disorders, including sleep-disordered breathing, insomnia, and short sleep duration than their Caucasian counterparts. Risk for developing sleep-related comorbidities may be compounded by cultural barriers, language, acculturation, stress, low income, low education, and lack of health insurance. Well-designed studies are needed to adequately and appropriately evaluate the prevalence of sleep disorders and their associations with morbidity, mortality, function, quality of life and to evaluate sleep disorders treatment outcome.
This chapter provides an overview of information related to some of the most prevalent medical disorders associated with sleep problems including the prevalence, consequences, pathophysiology, and treatment. Unfortunately, sleep problems in patients with cardiovascular disease often go unrecognized and untreated. Clinician factors for this problem include lack of awareness of classic symptoms, lack of mechanistic research, and the need for multicenter random clinical trials. Conversely, diabetes is often associated with a variety of symptoms, which may trigger the development of sleep problems. These include anxiety, depression, painful neuropathy, nocturia, and restless legs. Reducing the severity and impact of symptoms has long been an important priority in the management of individuals with cancer. The chapter describes the impact that sleep problems have on the clinical outcomes of human immunodeficiency virus (HIV) /AIDS patients. It discusses a summary of information related to assessment, diagnosis, and follow-up care.
This chapter describes the characteristics, epidemiology, pathophysiology, and treatment of movement disorders: periodic limb movement disorder (PLMD) and restless legs syndrome (RLS) and suggests implications for nursing practice. Parasomnias and movement disorders are associated with many behaviors that occur in proximity to the sleep period during sleep stage transitions, or during REM or NREM sleep. Movement disorders, in particular, are associated with significant impairment in quality of life and possibly negative cardiovascular consequences. Both groups of conditions occur in adults and children. Although some conditions are occasional, benign, and self-limiting, others are persistent and associated with significant sleep loss and/or the risk of injury to self and others. Nursing care for movement disorders and parasomnias is focused on patient education, providing appropriate reassurance regarding benign and self-limiting behaviors, a safe environment, and symptom control where necessary. Sleep hygiene, avoiding caffeine, and regularly scheduled sleep-wake cycle often reduces negative consequences.
Circadian rhythm disorders (CRD) result from a complex interplay of developmental and pathophysiological circadian processes, comorbid psychiatric and medical conditions, and environmental factors. The etiology ranges from internal and genetic to psychological to psychosocial and environmental. Treatments are likewise variable and include pharmacologic, environmental, behavioral, occupational, and public health interventions. Nurses’ roles in working with people who experience these disorders are multifaceted and focus on anticipatory guidance, assessment, patient and family teaching, and assisting patients to adopt behavioral strategies and environmental changes that support the regularization of circadian rhythms. It is important for nurses to have an integrative perspective that recognizes important contributions of circadian physiology and environmental factors to sleep disorders. Clinical supervision is a critical element in developing skill and expertise with the clinical management of these disorders and should be used to broaden the nurse’s comfort and competence in a new area of practice for the novice.
Sleep is a multidimensional, biobehavioral process that is essential to human health and function. This chapter explains the behavioral and physiological aspects of normal sleep and strategies used to measure them. This information is foundational to the understanding of sleep disorders and their pathological consequences and providing nursing care that focuses on sleep promotion and sleep disorders treatment. Behaviorally, sleep is defined as a temporary perceptual disengagement from and unresponsiveness to environmental surroundings. The chapter describes sleep stages and cycles, physiological changes associated with sleep stages, and the neurobiology of wake and sleep onset and maintenance. Sleep is divided into two distinct stages such as non-rapid eye movement (NREM) and rapid eye movement (REM) sleep. The chapter also describes a homeostatic and circadian rhythm model of sleep and wake regulation and methods to measure sleep in humans across the lifespan.
This chapter describes nursing care for sleep disorders in the primary care setting. The most prevalent sleep disorders in adults and older adults, and those most commonly seen in primary care settings are insomnia, sleep-disordered breathing, and restless legs syndrome. There is a compelling need for widespread access to sleep assessment and treatment among the large population of primary care clients who have sleep disorders-many of which are currently undetected. Primary care providers, especially nurses, are in an ideal position to assess, implement, and evaluate sleep promotion and sleep disorders treatment in primary care clients. The reach, adoption, implementation, and long-term maintenance of sleep promotion and sleep disorders treatment is most likely to be successful if implemented at the practice/organizational level. Nurses, especially advanced practice nurses play a pivotal role in implementing and evaluating policies and procedures to assure the translation and uptake of these important services.
Sex and gender differences occur during normal sleep and at sleep-wake transitions and may influence the prevalence and presentation of sleep disorders across the lifespan. This chapter describes sex and gender differences in normal sleep throughout the lifespan and hormonal changes that affect sleep in women and men that may underlie risk for the development of sleep disorders. Gender refers to gender identity within the context of relationships to the society and culture that may evolve over time. Research on gender and sleep has revealed physiologically based sex differences in sleep and important information on sleep as a behavior embedded in the social environment. Although over the course of the human lifespan gender differences are modest, differences in presentation and prevalence of sleep disorders and their potential impact suggest the importance of sex- and gender-related factors in sleep promotion and assessment and management of sleep disorders.
This book emphasizes the importance of sleep across states of health, health care settings, and at all stages of human development. It uses an evidence-based approach to synthesize and integrate nursing and interdisciplinary research on sleep to serve as a foundation for curriculum, teaching, practice, and researchactivities. The book is divided into four units. Unit I addresses aspects of normal sleep, including normal sleep physiology and behavior and developmental and gender aspects. In Unit II, the book provides an overview of the importance of sleep and its consequences from an epidemiological perspective, extant sleep-related nosologies, and a guide to sleep assessment. Unit II also discusses the epidemiology, consequences, assessment, and treatment of the sleep disorders such as insomnia, sleep-related breathing disorders including central sleep apnea (CSA), parasomnias, narcolepsy and circadian rhythm disorders (CRD), and psychaitric and pediatric disorders, the health disparities associated with sleep disorders, and provides an overview of complementary and alternative therapies for sleep. Unit III focuses on integration of the clinical research on sleep into specific settings where many nurses work (occupational health, primary care, acute care, long-term care, psychiatric settings, pediatric primary care, pediatric acute care, and maternal-child health). In Unit IV, the book presents suggestions about ways to integrate sleep and sleep disorders into pre-licensure and graduate nursing education, ideas about the future of nursing practice related to sleep, and proposed directions for future research.
Sleep disorders are common in both children and adults. Untreated sleep disturbances pose significant, adverse daytime consequences and place individuals at considerable risk for adverse health outcomes. Nurses are well positioned to assess and intervene with sleep disorders because they care for people across all cultures, age groups, and health conditions in community and clinical settings. There is widespread agreement among clinical and research experts that sleep assessment should be an integral component of all health assessment, with the specific focus and scope dependent on the situation. This chapter familiarizes nurses with evidence-based approaches to the assessment of sleep. It addresses the basic components of sleep assessment for children and adults, including obtaining sleep-related history, detailed sleep evaluation, and physical examination. The chapter includes information on self-report and objective sleep measurement and resources on sleep assessment for nurses, patients, and their families.
This chapter provides an overview of common sleep disorders that affect children and specific information on sleep assessment in pediatric patients. Sleep disorders are common among children and adolescence, with the prevalence varying according to developmental stage. The chapter examines that children often exhibit symptoms of sleep disorders in ways that differ from the presentation of similar disorders in adults. Snoring, the most common symptom of obstructive sleep apnea (OSA) in children from infancy through adolescence, results from turbulence in airflow through the narrowed oronasopharynx. The importance of incorporating a developmental approach to sleep assessment and treatment into nursing care is underscored by the profound effects of sleep and sleep disorders on children’s behavior, learning, and daily function. Many sleep disorders can be addressed by the nurse and members of the interdisciplinary team with behavioral treatments.
This chapter discusses the work-related impediments to sleep and interventions to improve sleep, with implications for health promotion and occupational health programs in the workplace. The work relatedness of sleep is clear, and responsibility to improve duration and quality of sleep must be shared by the worker, the employer, and clinicians who are informed about sleep. Workers themselves must make time for sleep, select a schedule that permits adequate sleep, seek treatment for sleep disorders, and adhere to treatment recommendations. Occupational health providers are in a prime position to improve health of a large swath of the population by employing population-based principles to ensure that work-related sleep deprivation is reduced or eliminated. For occupational health nurses, this will add a new emphasis area to their practice, and allow them to use their current skills in an area that will reap great reward towards improving the health of their worker population.
This chapter familiarizes the reader with interactions between sleep and sleep disorders and psychiatric disorders. It discusses implications for nurses who work with patients who have psychiatric disorders. Patients with psychiatric disorders are treated across many practice settings. The chapter also discusses some of the most clinically salient and well-documented linkages between sleep and psychiatric illness and includes common mood disorders, anxiety disorders, schizophrenia, alcoholism, and attention deficit hyperactivity disorder (ADHD). It discusses pharmacologic and behavioral interventions related to treatment of the particular disorder as it relates to sleep. The chapter focuses on care of adults and addresses childhood issues in the content related to ADHD. Finally, it highlights information on the diagnostic features of the disorders; changes seen in the polysomnographic changes in sleep across these illnesses; and the impact of pharmacologic treatment on sleep.
Developmental aspects of sleep are manifested in physiological, perceptual, and behavioral aspects of sleep across the human lifespan from birth to old-age. Healthy sleep is also a marker of neurological development, health, and well-being. Nurses can play a supportive-educative role with individual clients and their families in helping them to understand their sleep and in promoting normal sleep patterns in the community and across health care settings. Sleep promotion has an important place in health care settings, as well as schools and the workplace. A key nursing role is clarification of misconceptions about sleep and supporting families and individuals to engage in behaviors that facilitate healthy sleep behaviors. Although many of the observed developmental changes in sleep are physiological in origin, sociocultural factors play an important role and should be incorporated into nursing care. Therefore, incorporating knowledge of cultural variations is an important component of promoting normal sleep.
In psychiatric nursing practice, recognition of sleep dysregulation associated with the various mental illnesses has implications that transect all levels of the systems involved in the general health of the individual receiving treatment. Across all specialties and levels of nursing practice, nurses deal directly with patients who live with psychiatric illness. Sleep disorders are common within this population of patients and are a source of significant morbidity and mortality. Accurate symptom identification, thorough assessment, and evidence-based intervention strategies related to sleep in those with psychiatric illness will have a powerful impact on public health. In order to facilitate increasing awareness of sleep in psychiatric nursing practice, a multifaceted approach needs to be developed that involves professional nursing education as well as health care and community organizations. Broad-based education is an essential key to facilitating the culture shift within these groups to embrace sleep-related science to the benefit of public health.
There is abundant evidence of the importance of sleep and sleep disorders in nursing practice. This chapter provides a perspective on future directions in nursing research, practice, and education relative to sleep promotion and prevention and treatment of sleep disorders. It also provides an opportunity to examine some of the exciting possibilities and challenges for advancing sleep science and the implementation of this evidence in the discipline of nursing. While the contributions of nurses to sleep science are growing, the application of science to practice and pedagogy lags behind scientific progress. The chapter presents an overview of opportunities and possible directions for nursing scholarship related to sleep, and also presents an overview of current trends that intersect with the need for evidence-based practice in sleep promotion, and suggest implications for nursing curricula. The effort will require creativity, dedication, strategic planning and successful interdisciplinary collaboration, as well as collaborations within nursing.
This chapter reviews the evidence for the effects of complementary and alternative medicine (CAM) therapy for promoting sleep, and discusses implications for nursing practice. The term “complementary” refers to the use of therapies that are outside of the realm of conventional western medicine, while the term “alternative” refers to use of modalities in place of conventional western medicine. The chapter also reviews research on the effects of CAM modalities on sleep is organized according to four CAM domains: mind-body, biological based, manipulative and body-based, and energy. CAM whole medical systems cut across all domains. The chapter provides an overview of CAM domains, examples of modalities in each category, and the specific modalities selected because of their potential relevance to sleep and sleep disorders. Resources and products are available to support nurses and other health care providers in providing CAM treatments.
Older adults living in long-term care (LTC) settings suffer from extremely disturbed sleep associated with many negative consequences including agitation, excessive daytime sleepiness, and accelerated cognitive and functional decline. This chapter describes the nature of sleep disturbances in LTC, the scope of concerns relative to sleep disturbances, the consequences of sleep disturbances, sleep-promoting interventions, and implications for research and nursing practice. Sleep is critically important in LTC residents. Nurses play a key role in identifying and assessing for sleep disorders, devising interventions to improve sleep, and determining when referrals to sleep specialists are required. Because the nurse’s personal beliefs about the importance of sleep influence practice, educational programs about the importance of sleep, the consequences of poor sleep, and evidence-based practice to promote sleep in the LTC environment are critical in supporting the implementation and continuance of practice patterns to address sleep problems and promote positive sleep outcomes.
Wilhelm Einthoven contributed significantly to the study of the heart by inventing the electrocardiogram (EKG). Einthoven attached wires or electrodes to the right arm, left arm, and left leg forming a theoretical triangle. When the electrodes were connected to a galvanometer, they measured the electrical activity generated within the heart. The EKG is recorded on special standardized paper that scrolls out of the machine at a specific and controlled speed. The baseline on a 12-lead EKG is an imaginary-line that connects T wave and P wave. A waves that goes upward and downward from the baseline are said to be positive and negative respectively. The 12 leads are consistently arranged in a standard pattern. The first six leads represent the frontal plane of the heart and are called the limb leads. The next six leads represent the horizontal plane of the heart and are called precordial leads.
The heart has an intricate electrical system, made up of highly specialized cells, that is responsible for generating each heart beat. The heart’s electrical system consists of five structures: the sinoatrial (SA node), the atrioventricular (AV node), the bundle of His, the right and left bundle branches, and the Purkinje fibers. The electrical activation of the atria is represented on the EKG as a “P” wave. The atrioventricular node is located in the lower part of the right atrium. The AV node receives the impulse from the SA node and continues transmitting it to the bundle of His. Ventricular depolarization is represented on the EKG as the QRS complex. The QRS complex consists of a Q wave, an R wave, and/or an S wave, occurring either singly or in any combination. The T wave represents ventricular repolarization. The ventricles must repolarize or recharge themselves before next cardiac cycle can begin.
This chapter defines the pathophysiology of Right Bundle Branch Block (RBBB) and the two electrocardiogram (EKG) criteria for RBBB. The right and left bundles form an exquisitely capable communication system. They carefully navigate the impulse and depolarize every single one of the hundreds of millions of ventricular cells. This depolarization of the right and left ventricles forms the normal QRS with a normal interval of 0.08. The normal QRS complex represents combined depolarization of all the right and left ventricular cells. Both ventricles normally depolarize at the same time, and so the left ventricular component of the total electrical force overshadows the much smaller right ventricular force. The ventricles are not depolarized at the same time, but in sequence—first the left ventricle, then the right ventricle. The chapter presents case examples of RBBB with associated hemiblock and anterior infarction.
This chapter explains different types of hemiblock such as left anterior hemiblock and left posterior hemiblock. Hemiblock is the loss of function in one of the two parts of the left bundle. Left anterior hemiblock (LAHB) occurs when there is a loss of function in the anterior branch or fascicle of the left bundle branch. Left anterior hemiblock shifts the mean QRS axis upward and leftward. Left posterior hemiblock (LPHB) occurs when there is a loss of function in the posterior part or fascicle of the left bundle branch. Like LAHB, it is diagnosed by evaluating the mean QRS axis or direction in the frontal plane. Left posterior hemiblock shifts the mean QSR axis to the patient’s right side. hemiblock does not significantly increase the duration of the QRS interval because each side of the heart has one functioning fascicle.
This chapter presents the ways in which PR, QRS, and QT intervals are measured. They are measured only in the limb leads. The limb leads: I, II, III, AVR, AVL, and AVF, are also called the frontal plane leads. The PR interval measures the duration of time from the very beginning of atrial activation to the very beginning of ventricular depolarization. The next step after measuring and analyzing the PR interval is to evaluate the QRS interval. The QRS interval measures the time from the beginning of ventricular activation to the end of ventricular activation. The last interval to be measured on the EKG is the QT interval. The QT measures the distance from the beginning of the QRS to the end of the T wave. The normal QT interval depends on the heart rate. The faster the heart rate, the shorter the QT interval and vice-versa.