7 Focused Assessment: Sleep Assessment
Learning Objectives
At the end of this chapter, the learner will:
- Assess sleep and rest patterns.
- Document the findings from sleep assessment.
I. Overview of Sleep
This chapter will introduce the assessment of sleep. Sleep is essential for human life. It provides healing and restoration to the body through lowering the metabolism that allows countervailing restorative processes. The amount of sleep varies in person and age groups. The National Sleep Foundation recommend sleep durations for newborn babies, up to 18 hours of sleep, and the amount of sleep is declining as the child ages. Toddlers may need 11 to 14 hours of sleep; school-age children need 9 to 11 hours per night; teenagers will need 8-10 hours of sleep; most healthy adults, aged 18 to 64 will require about 7 to 9 hours of sleep every night; over 65 years old may need 7-8 hours of sleep (Hirshkowitz et al., 2015). See illustration below (Raparound, 2021).
Environmental distracters and stimulants such as caffeine, nicotine can affect the ability to fall asleep.
Periodic shift work may interrupt the circadian rhythm, change the usual sleeping patterns and result in sleep disruption. Medical and psychiatric conditions such as pain, shortness of breath, sleep apnea, and depression could cause sleep disruptions. Inadequate sleep or sleep deprivation relates to impaired cognitive functions and links to poor memory, increased risk for depression and obesity. See illustration below (Häggström, 2014).
Knowledge Check
II. Stages of Sleep
Sleep is divided into 2 phases: non-rapid eye movement (NREM) and rapid eye movement (REM).
- NREM includes 3 stages.
Stage 1: beginning to fall asleep. During this period, heart rates and respiration rates are reducing, and muscles relax. It is easy to be awoken in this stage.
Stage 2: light sleep. Heart rates, respiration rates, and muscles are more relaxed. Body temperature is decreasing, and eye movements are stopped.
Stage 3: deep sleep. It is difficult to awake during this stage. Heart rates and respiration rates slow down to the lowest levels. If aroused in this stage, the individual may have temporary mental impairment. In this stage, the immune systems will be strengthened, and the body and tissues will be repaired and regrown. (Patel et al., 2021).
- REM stage: when entering this stage, eyes move rapidly from side to side under the closed eyelids. Heart rates, respiration rates, and blood pressure increase to levels similar to the waking state. During this stage, skeletal muscles are paralyzed, and high brain activity is observed. Most dreams occur during this time. With proper REM sleep, brain can perform better in mental concentration and mood regulation which in terms enhance work performance and quality of life (Dumper et al., n.d.).
NREM and REM sleep stages are alternating in the sleep cycles which occur about every 90 minutes and repeat 4-6 times throughout the sleep (Patel et al., 2021). Five full sleep cycles are equivalent to about 7.5 hours of sleep.
A more detailed overview of sleep stages is available at: https://opentext.wsu.edu/psych105/chapter/stages-of-sleep/
Knowledge Check
III. Medical Terminology
| circadian rhythm | natural cycle of physical, mental, and behavior changes that the body goes through in a 24-hour cycle |
| hypnotics | sleep-inducing drugs |
| insomnia | inability to sleep |
| narcolepsy | a neurological disorder characterized by overwhelming daytime drowsiness and sudden attacks of sleep |
| sedatives | drugs can calm down brain activity and may induce sleep |
| sleep apnea | a sleep disorder that occurs when breathing is interrupted during sleep |
| sleep deprivation | a condition caused by sleep deficiency which may affect cognitive and physical functions |
Knowledge Check
IV. Sleep Assessment
When assessing sleep, sleep history should be evaluated including total amount of sleep, usual sleep patterns, quality of sleep, use of sleeping aids like alcohol, sedatives, or hypnotics.
Sample interview questions are like:
What is your usual sleep habit?
Are you able to fall asleep and stay asleep without difficulty?
How many hours of sleep do you have?
Are you getting adequate sleep?
Do you need to use any aid to induce sleep?
Health problems that interfere with sleep should also be assessed.
- Mental: anxiety? Stress?
- HEENT: nasal congestion? Pain?
- Neuro: headache/migraine? sleep apnea?
- Respiratory: shortness of breath? Cough?
- CV: chest pain? Palpitation? Leg pain?
- GI: pain in abdomen? Gastroesophageal reflux? Constipation or diarrhea?
- GU: frequent urination? Pain?
- MS and skin: pain in joints? Itching?
V. Documentation of Assessment Findings
VI. Related Diagnostic Tests
To evaluate sleep, a sleep diary or a sleep study are commonly used.
A sleep diary or sleep log is a subjective, self-reported way to record an individual’s sleeping and waking related information. It is a useful tool to assist in evaluating sleep problems and it can help individuals to self-evaluate factors influencing their sleep (Mallinson et al., 2019).
The sleep study is a non-invasive test that records body activity during sleep. It can be used to diagnose sleep disorders such as sleep apnea, narcolepsy, and insomnia. It is usually conducted in a sleep lab. The patient will be observed REM and NREM sleep cycles with an EEG monitor. Other data such as eye movements, oxygen levels, heart rates, respiration rates, snoring and body movements will also be measured while the patient is asleep.
Polysomnography (PSG) is a type of sleep study which includes at least 3 independent tests (EEG, EOG, EMG) that monitor different body functions during sleep (Luyster et al., 2015).
∘ Electroencephalogram (EEG)—measures and records the brainwave activity to identify sleep stages and seizure activity.
∘ Electrooculogram (EOG)—records eye movements. These movements are important for identifying the various sleep stages, especially the REM stage.
∘ Electromyogram (EMG)—records muscle activity such as teeth grinding and face twitches.
A sample of polysomnogram that records several physical variables is shown below.
VII. Learning Exercises
VIII. Attribution and References
- Dumper, K., Jenkins, W., Lacombe, A., Lovett, M., & Perimutter, M. (n.d.). Introductory Psychology. Introductory Psychology. https://opentext.wsu.edu/psych105/ Accessed June 28, 2021.
- Häggström, Mikael (2014). "Medical gallery of Mikael Häggström 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.008. ISSN 2002-4436. Public Domainhttps://commons.wikimedia.org/w/index.php?curid=6892366
- Hirshkowitz, M., Whiton, K., Albert, S. M., Alessi, C., Bruni, O., DonCarlos, L, Hazen, N. Herman, J., Katz, E.S., Kheirandish-Gozal, L., Neubauer, D., O’Donnell, A, Ohayan, M., Peever, J., Rawding, R., Sachdeva, R., Setters, B., Vitiello, M., Ware, C., and Hillard, A. (2015). National Sleep Foundation’s sleep time duration recommendations: methodology and results summary. Sleep Health. 1(1), 40–43. https://doi.org/10.1016/j.sleh.2014.12.010 Accessed June 25, 2021.
- Luyster, F. S., Choi, J., Yeh, C., Imes, C. C., Johansson, A. E., & Chasens, E. R. (2015). Screening and evaluation tools for sleep disorders in older adults. Applied Nursing Research, 28(4), 334-340. doi: 10.1016/j.apnr.2014.12.007
- Mallinson, D., Kamenetsky, M., Hagen, E., & Peppard, P. (2019). Subjective sleep measurement: comparing sleep diary to questionnaire. Nature and Science of Sleep, 11, 197-206. doi: 10.2147/NSS.S217867 Accessed June 28, 2021.
- National Sleep Foundation: Sleep by the numbers. 2021. https://www.thensf.org/sleep-facts-and-statistics/ Accessed June 24, 2021.
- Patel, A., Reddy, V., % Araujo, J. (2021). Physiology, sleep stages. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526132/ Accessed June 30, 2021.
- Patient Safety Primer: Fatigue, Sleep Deprivation, and Patient Safety. 2019. https://psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety#Current-Context Accessed June 24, 2021.
- Polylerus, Public domain via Wikimedia Commons https://upload.wikimedia.org/wikipedia/commons/6/69/Man_sleeping_striped-sheets.JPG
- Raparound, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons, created Jan. 2021.
- Tonicthebrown, Public domain, via Wikimedia Commons https://upload.wikimedia.org/wikipedia/commons/5/5d/PLMD_Polysomnogram.png
