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The nurse should inquire if the client feels he is getting enough sleep and rest.
Questions should focus on specific sleep patterns, such as how many hours a night the
person sleeps, interruptions, whether the client feels rested, any problems sleeping
(e.g., insomnia), what ritual the client uses to promote sleep, and any concerns the
client may have regarding sleep habits. Some of this information may have already
been presented by the client, but it is useful to gather data in a more systematic and
thorough manner at this time. Inquiries about sleep can bring out problems, such as
anxiety, which manifests as sleeplessness, or inadequate sleep time, which can
predispose the client to accidents. Compare the client’s answers with the normal sleep
requirement for adults, which is usually between 5 and 8 hours a night. However,
sleep requirements vary depending on age, health, and stress levels.
Objective Data
A. Assess Characteristic Limitation
1. Physical characteristic
Appearance (pale, dark around eyes circle, concave eyes)
Menguap
Feels sleepy all day long
Decrease of vision range
Sensitivity
Assessing
Assessment relative to a client’s sleep includes a sleep history, a sleep diary, a
physical examination, and a review of diagnostic studies.
Sleep history
Usual sleeping pattern, specifically sleeping and waking times; hours or
undisturbed sleep; quality of or satisfaction with sleep (e.g., effect on energy
level for daily functioning); and time and duration of naps.
Bedtime rituals performed to help the person fall asleep (e.g., a glass of hot
fluid, reading or other method of relaxing, and special equipment or
positioning aids).
Use of sleep medication and other drugs. Sleep can be disturbed by a variety
of drugs, such as stimulants or steroids, if they are taken close to bedtime.
Hypnotics and sedating antidepressants may cause excessive daytime
sleepiness.
Sleep environment (e.g., dark room, cool or warm temperature, noise level,
night-light).
Recent changes in sleep patterns or difficulties in sleeping.
If the client indicates a recent pattern change or difficulties in sleeping, a more
detailed history is required. This detailed history should explore the exact nature of
the problem and its cause, when it first began and its frequency, how it affects daily
living, what the client is doing to cope with the problem, and whether these methods
have been effective.
Sleep Diary
Sometimes clients with a sleeping problem can provide more precise
information if they keep a written record of their sleep pattern and the habits
associated with it. Such a sleep diary or log can be kept by clients who are sleeping at
home and should b maintained for at least 1 week. A sleep diary may include all or
selected aspects of the following information that pertain to the client’s specific
problem:
Total number of sleep hours per day
Activities performed 2 to 3 hours before bedtime (type, duration, and time)
Bedtime rituals (e.g., ingestion of food, fluid, or medication) before going to
bed
Time of (a) going to bed, (b) trying to fall asleep, (c) falling asleep
(approximate), (d) any instances of waking up and duration of these periods,
and (e) waking up in the morning
Any worries that the client believes have a positive or negative effect on sleep
Keeping such a diary may become stressful for some clients and further affect
their sleep. The nurse needs to advise the client to obtain the assistance of a bed
partner in keeping the diary or to discontinue the diary if it presents a problem. When
a diary is completed, the nurse and client can develop flowcharts or graphs that will
assist in organizing the data and identifying the specific problem.
Physical Examination
Examination of the client includes observation of the client’s facial
appearance, behavior, and energy level. Darkened areas around the eyes, puffy
eyelids, reddened conjunctiva, glazed or dull-appearing eyes, and limited facial
expression are indicative of sleep insufficiency. Behaviors such as irritability,
restlessness, inattentiveness, slowed speech, slumped posture, hand tremor, yawning,
rubbing the eyes, withdrawal, confusion, and incoordination are also suggestive of
sleep problems. Lack of energy may be noted by observing whether the client appears
physically weak, lethargic, or fatigued.
In addition, the nurse assesses whether the client has a deviated nasal septum,
enlarged neck, or is obese. These findings may be associated with obstructive sleep
apnea or snoring.
Diagnostic Studies
Sleep is measured objectively in a sleep disorder laboratory by
polysomnography: an electroencephalogram (EEG), electromyogram (EMG), and
electro-oculogram (EOG) are recorded simultaneously. Electrodes are placed on the
center of the scalp to record brain waves (EEG), on the outer canthus of each eye to
record eye movement (EOG), and on the chin muscles to record the structural
electromyogram (EMG). The following may also be monitored, depending on
findings of the initial interview; respiratory effect and airflow, ECG, leg movements,
and oxygen saturarin. Oxygen saturation is determined by monitoring with a pulse
oximeter, a light-sensitive electric cell that attaches to the ear or a finger. Oxygen
saturation and ECG assessments are of particular importance if sleep apnea is
suspected. Through polysomnography, the client’s activity (movements, struggling,
noisy respirations) during sleep can be assessed. Such activity of which the client is
unaware may be the cause of arousal during sleep.