Rest and sleep are necessary for physiological and psychological well-being. Rest is a state of mental and physical relaxation and calmness. Sleep is a state of altered consciousness during which an individual experiences minimal physical activity and a slowing of the body’s physiological processes. Sleep occurs in periodic time cycles and usually lasts for several hours at a time. Sleep is necessary for physiological and psychological healing. Waking and sleeping cycles are controlled by sleep centers in the brain and influenced by routines, seasons, environmental factors, and a person’s biological clock.

The stages of sleep are classified in two categories: non-rapid eye movement (NREM) and rapid eye movement (REM) sleep. NREM is the first phase of sleep, consisting of four stages. In stage 1 sleep, EEG frequency slows and theta waves spike. During this stage, the eyes roll slowly from side to side and only the face and neck muscles are tense. Stage 1 NREM sleep lasts about 10 minutes and is considered to be “light,” in other words, the person is easily awakened. A person in stage 1 NREM sleep is in a hypnagogic state, a condition between sleep and wake.

Stage 2 sleep is characterized by a further slowing of EEG patterns and loss of slow rolling eye movements. After approximately 20 minutes in stage 2, a deeper form of sleep, stage 3 to 4, is entered. Stage 3 sleep is medium-depth sleep and Stage 4 is the deepest sleep. During stage 3 to 4 sleep, all cortical brain cells fire simultaneously, resulting in large, slow delta waves on the EEG. Sleep 3 to 4 is thought to be restorative, though this is a stage in which sleepwalking, sleeptalking, enuresis, and night terrors appear. Growth hormone, necessary for tissue repair as well as growth, is secreted during stage 3 to 4. Stage 3 to 4 sleep takes up 25% of sleep in young children, gradually declines during adulthood, and is often absent in older adults.

REM sleep (Stage 5 sleep) occurs after about 90 minutes of NREM sleep. During this time, rapid conjugate eye movements appear, the heart and respiratory rates are irregular and often higher than when awake, and muscles are flaccid. Dreams occur during REM sleep. REM sleep is essential to well-being and is especially needed after periods of stress and illness. REM sleep occurs four to six times during a night’s sleep and become gradually longer during the night, accounting for 50 % of the newborn’s sleep, declining to 20% to 25% of sleep by early childhood. The sleep cycle, approximately 70 to 100 minutes, includes the five stages of sleep and occurs four to six times during an average sleep period of 7 to 9 hours.

The biological clock (an endogenous mechanism that measures time) controls fluctuations in physiological processes, such as temperature, respiratory rate, performance and alertness, and hormone levels. Chronobiology is the branch of science that studies the rhythms that are controlled by biological clocks. Biological rhythms include the circadian rhythm, cycling on a daily basis, the ultradian, cycling on a time period shorter than a day, infradian, cycling for a month or more, and circannual, cycling for about one year. When sleep, time zones, and mealtimes are inconsistent, a desynchronization of the circadian biological rhythms occurs, resulting in chronic fatigue, disrupted sleep, decreased performance, and decreased coping abilities.

The factors that affect rest and sleep are comfort level, anxiety/stress, the environment, lifestyle, diet/nutrition, hormones (especially in women), drugs/medications, culture, and age. Examples of the affects of drugs include alcohol and nicotine. Alcohol helps a person get to sleep, but the effect doesn’t last long into the sleep period. Nicotine is a stimulant and can impair sleep. During hospitalization and illness, stress, physical or emotional pain; the loss of familiar surroundings; the loss of routine; fear of the unknown; disruption due to procedures or treatments; noise level; exposure to continuous light; and the loss of privacy negatively affect rest and sleep.

Several alterations in sleep patterns are possible. The nursing diagnosis covering these alterations is Altered Sleep Patterns. Alterations in sleep patterns are either primary (the sleep alteration is the fundamental problem) or secondary (caused by a medical problem). Chronic insomnia (inability to sleep or inadequate quality of sleep) is associated with decreased work productivity, increased utilization of health care services, greater risk of accidents, short-term memory problems, cognitive and motor performance, and irritability. The types of insomnia are psychophysiological, idiopathic, and sleep-state misinterpretation. Psychophysiological insomnia occurs when a physical problem disrupts sleep, leading to anxiety about sleep, which leads to a further lack of sleep. Idiopathic insomnia is sleeplessness with an unknown origin. Idiopathic insomnia is diagnosed by an abnormal EEG, indicating a possible disturbance of the sleep centers of the brain, treatable with pharmacological interventions rather than behavioral interventions. Sleep-state misinterpretation is a condition in which the client is in a dreamlike state but not a deeper level of sleep state. An EEG shows the person claims to be awake but is actually asleep. This condition is ill-understood and often not believed by health professionals.

Other alterations include hypersomnia (an alteration in sleep pattern characterized by excessive sleep), narcolepsy (sudden, uncontrollable urges to fall asleep during the day, accompanied by poor quality of sleep), sleep apnea (periods of sleep during which air-flow stops for 10 seconds or more) sleep deprivation and snoring (prolonged, inadequate quality and quantity of sleep, either REM or NREM), and parasomnia (sleep alterations resulting from activation of physical systems at inappropriate times while sleeping, such as somnambulism, or sleepwalking; sleeptalking; bed wetting; bruxism, or teeth grinding; restless leg syndrome; and periodic limb movement syndrome). Two problems accompany narcolepsy: hypnagognic hallucinations, vivid dreams and hallucinations that incorporate elements of the environment, and sleep paralysis, waking from sleep unable to move, speak, or cry out. Physically, sleep apnea occurs because the soft palate closes off the airway. The person snores loudly because the brain signals a forceful breath. Risk factors for sleep apnea include overweight, alcohol or tobacco use, and sleeping on the back.

Nursing assessment of the person with sleep problems begins with assessment of the nature and quality of sleep, the typical sleep environments, factors associated with sleep, and the client’s or family’s opinion of the client’s sleep. The nursing diagnosis for sleep problems is Disturbed Sleep Pattern. Other nursing diagnoses, such as Activity Intolerance, are possible. The nurse includes the client’s input when developing expected outcomes. The plan should be geared to eliminating any contributing factors for insomnia.

Interventions to promote rest and sleep include creating a relaxing environment, calming the mind, ensuring appropriate nutrition, and initiating pharmacologic interventions. A relaxing environment means making the environment cool, dark, and quiet, and avoiding bright, stimulating colors on the wall. Mind-calming interventions include positive affirmations, medications, music therapy, visualization, and decreasing activity 30 minutes before bed time. Meals less than 3 hours prior to going to bed, as well as foods loaded with additives, spicy foods, caffeine, and alcohol can interfere with sleep. An adequate amount of exercise, at least 3 times a week for 20 minutes, facilitates sleep. Stress management techniques, such as progressive muscle relaxation, breathing exercising, and warm baths, also facilitate sleep.

Medications for insomnia include tricyclic antidepressants, antihistamines, and short-acting benzodiazepines. An example of tricyclic antidepressants is amitriptyline, given in small doses to facilitate sleep. Antihistamines, such as hydroxyzine or diphenhydramine, have mild sedative effects. Benzodiazepines are not recommended for long-term use.