Learning Objectives
By the end of this section, you will be able to:
- Identify nursing assessment skills for sleep disturbances
- Describe education to encourage good sleep hygiene practices
- Understand medication administration for sleep and rest
Nurses play an important role in caring for patients with sleep disturbances. Through the data collection (assessment) phase, patient education to improve sleep, and medication administration and education, nurses are involved directly in engaging with patients. Nurses can gather vital information about a patient’s personal and family history, advise about keeping a sleep log, and provide information about sleep studies for those who are prescribed such diagnostic testing. The role of the nurse often includes educating patients about issues they are experiencing and ideally helping identify methods to improve problems.
Assessment for Sleep Disturbances
Nursing care begins with the assessment—gathering necessary and helpful information upon which to build care planning—and continues with prioritizing patient problems, identifying ways to approach them, implementing the identified actions, and evaluating the outcome(s). In the case of sleep disturbances, data collection begins with a detailed family and personal history focused on particular factors that may influence rest and sleep.
Patients who have been experiencing insufficient sleep are often asked to keep a sleep log, and the nurse is able to analyze this diary of events, providing important information to the prescriber. Some patients are prescribed a sleep study, and nurses can educate the patient prior to such a study and assist with poststudy follow-up with the patient and family, if indicated.
Nursing assessment should also include inquiry as to any changes the patient has noticed—psychologically or physiologically—that could be a result of the lack of sleep. The patient may have made the connection or may not have considered sleep as the root of the changes. The nurse may be the first to recognize the link, particularly if already familiar with disorders that are often related to sleep disturbances.
Collect a Detailed History
Family and patient history, including diagnoses, surgeries, and medications, is a starting point for assessment. The nurse should perform a focused assessment, exploring sleep patterns, hours of sleep, and whether the patient or significant other reports loud snoring, or apneic periods followed by episodes of gasping as the body works to recover from the apnea-related hypoxia. Note that for those who work nights, times for sleep may need to be adjusted or follow-up questions added about time at work versus time off. Table 28.6 offers some guiding questions and can be modified to fit the practice needs of individual nurses.
| Questions | Answers |
|---|---|
| On an average night, how many hours do you sleep? | Recommended: Infants (4–12 months) 12 to 16 hours/day (including naps) Children (1–2 years) 11 to 14 hours/day (including naps) Children (3–5 years) 10 to 13 hours/day (including naps) Children (6–12 years) 9 to 12 hours/day Teens (13–18 years) 8 to 10 hours/day Adults (18 years or older) 7 to 8 hours/day |
| How do you rate your overall sleep quality over the past month? | Excellent Very good Fairly good Good Poor |
| Do you go to bed and wake up at about the same time every day, even on days off? | Yes No |
| While you’re doing things during the day, how likely is it for you to fall asleep or to struggle to stay awake? | Very likely Likely Not likely Unlikely |
| How often do you have trouble going to sleep or staying asleep? | Never Rarely Occasionally Often |
| During the past two weeks, how many times was loud snoring reported by your sleep partner? | Never Any number |
Analyze the Patient’s Sleep Log
It is helpful to have patients keep track of their sleep by using a sleep log (Figure 28.7). This may also be referred to as a sleep diary or journal. There is often more information desired by the healthcare team than just hours slept. Examples of questions to consider including in a sleep diary in order to provide comprehensive data include the following:
- What medication(s) do you take? What time do you take it/each?
- Do you exercise? How often? What time?
- How long did it take to fall asleep?
- How well did you sleep?
- How many disruptions during sleep time? How long did the disruptions last?
- How many daytime naps? How long were the naps?
- Did you drink caffeine or alcohol? How much? What time?
- Did you use tobacco or other drug substances? At what time?
Such a log quantifies the amount of sleep normally achieved, as well as the frequency of sleep disturbances, severity, and the impact on the patient’s activities during normally active times. It can also help patients to consider their sleep patterns and learn more about their sleep hygiene practices, distractions, and interruptions. Upon completion of a sleep log for the requested period of time, the nurse can analyze the data for specific details and trends.
Link to Learning
The National Institute of Health’s National Heart, Lung, and Blood Institute offers a template for a much more comprehensive sleep log that incorporates most of the desired details listed. Add any items not included but important for particular patients.
Sleep Study
Polysomnography simultaneously records physiologic monitoring, including EEG for recording brain waves, ECG for the electrical cardiac cycle, EOG for recording eye movements, EMG for recording muscle movements, and SaO2 (Figure 28.8). Monitoring leads for this recording are placed at locations on the scalp, face, eyelids, chest, and limbs, and a pulse oximeter is placed on a finger. Results display on a hypnogram and contribute to diagnosis of insomnia, sleep apnea, narcolepsy, somnambulism, and RLS.
Depending on the complexity of the information desired, the sleep study may be done in a sleep center or with a portable system at home. Typically, the data are collected throughout a normal sleep session or at least over several hours. A sleep specialist, often a pulmonologist, reviews the results. The polysomnography carried out at the sleep center is considered the gold standard. Advantages for the home test include fewer wires, leads, and devices, as well as sleeping in one’s own bed; it is also more cost effective unless it ultimately leads to a follow-up inpatient sleep study.
Link to Learning
The various sleep data and their implications are explained in this video.
Education to Encourage Good Sleep Hygiene Practices
Sleep disorders can range from simple to complex and can be acute or chronic. Treatment can be straightforward or may require a multipronged approach. For some people, creating or supporting good sleep hygiene is sufficient. Others may need extensive diagnostics and some combination of medications, therapy, and lifestyle modifications in order to establish efficient sleep patterns. Several practices contribute to good sleep hygiene, often relieving insomnia and other sleep-related issues. Certain beverages, such as herbal teas or warm milk, may foster sleep, with the caveat that drinking near bedtime may cause early arousals in order to void (Cherry, 2023; Cleveland Clinic, 2024). Routines, such as a warm bath, toothbrushing, and selection of sleep clothing, often support the sleep schedule, as the mind and body associate the habits and feelings with bedtime, rest, and sleep.
Maintain a Consistent Schedule for Sleep
Sleep schedule consistency can be important for sleep promotion. When activity and sleep schedules vary, it is more difficult for the body to maneuver between the two cycles and promptly establish restful sleep. Some people tend to stay up and get up later on days off, but this is actually counterproductive. It is better to set and maintain a consistent sleep schedule—the same bedtime and wake-up time every day, or at least approximately (Cherry, 2023; Cleveland Clinic, 2024). Sleep routines are personal, and different times and techniques may work for different people. It may take some time, and trial and error, to identify the “right way” for an individual to best prepare for sleep.
Establishing consistent lifestyle choices that promote sleep can also be helpful. This includes eliminating food and beverages (e.g., caffeine, alcohol) that cause wakefulness, or minimizing them to some hours prior to bedtime (Cherry, 2023; Cleveland Clinic, 2024). Creating a regular exercise routine is also helpful, as it produces a physical tiredness contributing to the overall desire and need for sleep. Other health benefits of exercise may add indirectly to sleep promotion and quality.
Incorporate a Relaxation Routine
Recall that sleep is closely associated with cycles of light and dark and circadian rhythms. Within these natural patterns, the release of chemicals assists with sleep (e.g., melatonin) and waking (e.g., cortisol). Working with these natural tendencies by limiting light at bedtime can help promote sleep. This can be especially helpful for those who work night shifts; investing in room-darkening blinds can provide a daytime environment of darkness and subsequent sleep promotion.
Life-Stage Context
Let There Be Light!
Age-related changes to the brain can limit circadian rhythm function and disrupt an older adult’s response to light and dark, thereby potentially causing problems with the sleep-wake cycles. Also, melatonin production tends to decrease with age. Nurses should ask patients about their sleep environments, whether they receive adequate exposure to natural light during the day, and if they reduce their light exposure before bedtime and overnight. Nurses can recommend patients turn television and lights off an hour before bed, use room-darkening blinds overnight, and, shortly after rising, open curtains and blinds or go outside to expose themselves to natural light at the time melatonin production normally begins (Casiraghi et al., 2021; Viganò et al., 2023).
Incorporating a relaxation routine can prove helpful for many patients. This may include one or a combination of activities or techniques, including mellow sounds or music, reading, meditation, yoga, and intentional breathing (Nunez, 2020). Watching TV and using computers, cell phones, or tablets tends to stimulate rather than relax, and may even cause stress. The light from such devices is also counterproductive toward sleep. Again, the choice of method, and the amount of time needed, will be based on what works for a particular person, and it may change periodically over time.
Link to Learning
Although using an electronic device is not advised as part of a sleep routine, there are several applications and videos available. The video portion can be disregarded and the device placed with no light visible, with only the audio playing as part of a bedtime routine.
Sustain a Temperature-Controlled Environment
Comfort during sleep is important, and temperature is one of those comforts. A cool room tends to be more conducive to falling and staying asleep. Maintaining a comfortable temperature for sleep may involve adjusting the thermostat or number of blankets, using a fan, or opening a window. Avoid temperature fluctuations in the bedroom.
Avoid Electronics Prior to Sleep
Electronics tend to be stimulating and, depending on the device and what is being done, may be stress-inducing or aggravating as well. The light from electronic devices such as cell phones, tablets, and computers can be distracting and can also make it more difficult to fall asleep. Even TV can make it more difficult to fall asleep. Allow some time before bedtime to be electronics-free, to enhance the transition from wakefulness to sleep (Nunez, 2020; Suni, 2024). Although notifications on some electronic devices can be silenced, for some people that may not be possible based on employment or family obligations and expectations. When possible, turning off devices is best, but putting them away from the sleeping area may be a viable alternative. Nurses teaching patients and families about sleep schedules and relaxation routines can guide their audience to a healthful and helpful transition time from stimulation and activity to quiet and rest.
Medication Administration for Sleep
Safe medication administration is a critical goal for nurses. Nurses need to know the different types of drugs used to promote sleep and their classifications, which are typically based on their MoA, or how a particular drug works. Other necessary information includes the reason the patient has been prescribed the drug, dosages for different uses, routes for administration, potential positive and negative side effects, possible adverse effects, and potential drug-to-drug, and/or drug-to-herbal interactions.
Medications to promote falling asleep and/or staying asleep are available over-the-counter (OTC) and by prescription. Patients may also take herbal remedies to help sleep as well. The common OTC choice for sleep are antihistamines, because drowsiness is a side effect of first-generation antihistamines. Other drugs are categorized as sedatives and/or hypnotics.
Safe Medication Administration
Medication administration is a major part of nursing care, and its accurate implementation is a critical component of patient safety (MacDowell et al., 2021). Like any medications, those prescribed to help with rest and sleep are prone to adverse drug events (ADEs) at different steps in the administration process. As part of the larger medical system, nurses must be vigilant in avoiding interruptions while giving medications, using safety measures such as barcode scanning of patients and drugs, and having a high level of knowledge of the drugs being administered (MacDowell et al., 2021).
Safe dosage incorporates the original five rights: right patient, medication, dose, time, and route. A nurse’s understanding that medications prescribed for sleep-related issues work in various ways with the CNS, with the potential for interactions with certain other drugs (e.g., opioid pain medications), is critical to maintain safe patient care. Table 28.7 provides examples of drugs, a brief description of how they work, typical dosage for sleep, common side effects, and concerning potential adverse effects. Check a reliable, current nursing drug resource for new updates. Also, be aware of the individuality of patient responses, and do not underestimate the importance of assessment and evaluation in nursing care.
| Drug Class | Example Drug | MoA | Adult Dose & Route | Side Effects | Adverse Effects |
|---|---|---|---|---|---|
| Benzodiazepines | Lorazepam (Ativan) | Enhances GABA | 2–4 mg PO at bedtime |
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| Temazepam (Restoril) | 15–30 mg PO at bedtime | ||||
| Triazolam (Halcion) | 0.125–0.25 mg PO at bedtime | ||||
| Nonbenzodiazepines | Eszopiclone (Lunesta) | Interacts with GABA receptors | 1–3 mg PO at bedtime (start with small dose) |
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| Ramelteon (Rozerem) | Melatonin agonist | 8 mg PO at bedtime |
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| Suvorexant (Belsomra) | Orexin A & B antagonist | 10–20 mg PO at bedtime |
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| Zaleplon (Sonata) | Binds to GABA receptors | 10 mg PO at bedtime; 5 mg if > 65 or of a lighter weight |
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| Zolpidem (Ambien) | Binds to GABA receptors | Women: 5 mg PO, SL, or spray at bedtime (may increase to 10 mg if lower dose not effective) Men: 5–10 mg PO, SL, or spray at bedtime |
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| Antihistamines | Diphenhydramine (Benadryl) Note: Diphenhydramine is packaged alone or combined with OTC analgesics (acetaminophen, ibuprofen). |
Histamine antagonist at H1 receptors | 1 mg/kg PO 20–30 minutes before bedtime; not to exceed 50 mg |
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| Hydroxyzine (Atarax, Vistaril) Note: Hydroxyzine for insomnia is an off-label use. |
Subcortical CNS depression; competes with H1 receptor sites |
50–100 mg PO 30–60 minutes before bedtime 50 mg IM 30–60 minutes before bedtime |
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| Herbal | Kava kava | Alters emotions at limbic system; anxiolytic, sedation effects. |
Herbals are not FDA approved and dosages are not definitively determined |
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| Melatonin | Synthesized from tryptophan and serotonin to help induce sleep |
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| Valerian | May increase GABA |
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Examples of stimulant drugs used for treatment of hypersomnolence are shown in Table 28.8 with a brief description of how they work, typical dosage for sleep, common side effects, and concerning potential adverse effects.
| Drug Class | Example Drug | MoA | Adult Dose & Route | Side Effects | Adverse Effects |
|---|---|---|---|---|---|
| Stimulants | Caffeine | Stimulates the CNS | Do not exceed 400 mg/day |
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| Methylphenidate (Ritalin, Concerta) | 20-30 mg PO in 2-3 divided doses, 30-45 minutes before meals. |
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| Amphetamine (Evekeo) | 5–60 mg/day PO in divided doses (Start with lowest effective dose & adjust for individual.) |
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| Amphetamine/ dextroamphetamine (Adderall) | 10 mg/day PO in divided doses (May be increased weekly by 10 mg until desired effect is reached.) |
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| Armodafinil (Nuvigil) | 150–250 mg/day PO in a.m. |
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| Modafinil (Provigil) | 200 mg/day PO in a.m. |
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Clinical Safety and Procedures (QSEN)
QSEN Competency: Safety: Combining Compatible Drugs
Disclaimer: Always follow the agency’s specific policy and procedure for medication administration.
Definition: Reduces risk for harm to patients.
Knowledge: The nurse will use strategies to support safe medication administration through multiple means.
Skill: Use strategies, such as interdisciplinary collaboration, to maintain current best practice, accuracy, and safety. The nurse will:
- Not rely entirely on memory in preparation for medication administration (e.g., dose, route, time to onset).
- Consult with interdisciplinary partners’ written or electronic resources to review current practice regarding medication compatibility and administration.
Attitudes: Understand the limits of human memory and abilities.
Education on Risks
The effects of medications to induce or foster sleep can have significant effects on the central nervous system. Therefore, nurses need to perform frequent assessments and reassessments relative to effectiveness and results. Nurses can be key players in providing education for patients as they consider or begin a new drug. As indicated, CNS effects can be as serious as seizures, hallucinations, and parasomnias. Cardiovascular and respiratory problems also may accompany some of the drugs, and renal function may be affected. Nurses should anticipate laboratory tests for organ function. Allergic reactions, such as angioedema and anaphylaxis, can be life-threatening, and patients should be educated about these potential reactions, including signs and symptoms of their presentation. For more on patient education, see Chapter 17 Patient and Family Education.
Patient Conversations
Benadryl for Sleep
Scenario: A patient, Reginald Washington, age 78, has been having trouble sleeping and calls and asks the nurse, Melissa, about using Benadryl, since there is some in the medicine cabinet at home. The nurse is concerned about this medication for Mr. Washington because it has a high risk of causing undesired effects in those over 60.
Nurse: Mr. Washington, I guess you’ve been having some trouble sleeping?
Patient: Yes, Melissa. I haven’t slept well for a few weeks now. It makes me feel fuzzy during the day to be so tired.
Nurse: Feeling that way is pretty common if you’re not sleeping well. You asked about using Benadryl.
Patient: Yes, my wife used it about a year ago, and it really helped her. So I thought I’d check because I’m on a blood pressure medicine.
Nurse: I’m very glad you asked about it. I’m not so concerned about the blood pressure medicine, but diphenhydramine, which is the drug you know as Benadryl, is not recommended for people over 60 years old.
Patient: Oh, really? I guess my wife shouldn’t have taken it.
Nurse: True. I guess she didn’t have problems.
Patient: No, she was fine. And she slept well.
Nurse: Some people, even over 60, have no issues. But it is on a list of risky medications for older adults because it can make the side effects worse, leading to adverse outcomes. Some people experience delirium or become more confused. I think we should check with your doctor to see what is recommended for you.
Patient: Oh, okay.
Nurse: I’ll check and call you back to let you know what is safer to help you sleep.
Patient: That sounds like a good idea.