Many patients on the step-down unit where I work complain that they cannot get a good night's sleep. I realize this is a common problem for hospitalized patients. How should nurses address it?-L.R., GA.

Jennifer N. Kain, BSN, RN, and Tara J. Sharpp, PhD, RN, reply: Sleep is essential for recovery from illness, injury, or surgery, but many patients report poor sleep quality in hospital settings.1-3 According to studies that used polysomnography (PSG), which is considered the gold standard for sleep monitoring, patients in healthcare facilities may experience as little as 2 hours of sleep per night, as many as eight awakenings in an hour, and decreased time in deep and/or rapid eye movement (REM) sleep.1,4 (See Sleep monitoring devices.)

These effects can have significant clinical consequences. For example, within 24 to 48 hours, patients deprived of sleep may experience decreased respiratory function, changes in perception, anxiety, irritability, depersonalization, and temporal disorientation.1,5 Short-term sleep loss leads to increases in BP, heart rate, neutrophils, blood glucose levels, and markers of inflammation.1 Within 48 to 90 hours, patients may experience delusions, hallucinations, and disordered thinking. Patients who are highly sleep-deprived are at risk for delirium and conversely, delirium shows a measurable decrease in sleep quality.5,6

Factors disrupting sleep

Excess noise is a common cause of sleep disruption in hospitals. In one study, about 20% of reported sleep disruptions were related to noise levels ranging from 49.65 to 103.3 decibels (dB).1 This figure is well over the guidelines established by the World Health Organization, which recommends noise levels lower than 30 dB in hospitals.2

Bright lighting typical of hospital settings is another factor that disrupts sleep. Research has demonstrated that light levels varied from 5 to 1400 lux (lx) in the ICU; just 100 lx is enough to decrease melatonin, a key hormone that influences sleep cycles and circadian rhythms.7,8

Medications can also interfere with sleep. Surgical patients who receive opioids may experience an absence of REM sleep in their first post-op day.3 Vasopressors, beta-blockers, and antidepressants can also decrease REM sleep.1 In addition, diuretics can disrupt sleep by increasing the frequency of urination and corticosteroids may cause nightmares.1 Ironically, even medications prescribed to promote sleep can disrupt sleep cycles; for example, benzodiazepines and barbiturates may interfere with REM and deep sleep stages.3

Nursing interventions

Lowering unnecessary levels of noise and light is one of the best ways to foster adequate sleep hygiene. In units where a noise volume below 30 dB and light level below 100 lx is unattainable, nurses can promote patient sleep by recommending earplugs and eye masks. In one systematic review, patients who wore both earplugs and eye masks experienced 2.19 more hours of sleep on average.3 In another study, patients who wore earplugs alone more than doubled their average duration of restorative deep sleep with an increase from 31 to 74 minutes.9

By masking external sounds, white noise may help minimize noise disruption in patients who cannot tolerate earplugs.1 Alternatively, some hospitals have instituted quiet hours to improve patient sleep by setting times to limit noise and intrusive light.1,10 In addition, providing calming music prior to sleep fosters a relaxing environment that can improve the quality of sleep.10

Minimizing sleep disruptions for nursing care is another strategy that promotes sleep. Many sleep disruptions occur when patient care is performed during the night shift, so bundling nursing interventions can minimize sleep disruptions and increase the quality and quantity of sleep.2

Low-tech interventions, such as noise and light reduction and clustered nursing care, can be initiated in any setting. In the future, healthcare facilities may consider investing in more advanced sleep monitoring technology, such as a noninvasive textile-based ECG.11 Hospitals with a patient population with an increased length of stay or high rates of delirium may consider devices that measure sleep deprivation, such as pupil tracking systems because pupillary reflexes decline with sleep deprivation.12

Sleep monitoring devices1,3,4,11-13

PSG is the current gold standard measurement for sleep, measuring brain waves, oxygenation, heart rate, respiratory rate, and eye and leg movements. However, PSG involves monitoring devices that may be disruptive to sleep as well. Alternatively, actigraphy involves the use of wristwatch devices that track gross motor activity during a normal sleep cycle, but these devices cannot track the same amount of information as PSG.

REFERENCES