12.3 Applying the Nursing Process
Open Resources for Nursing (Open RN)
Since the days of Florence Nightingale, sleep has been recognized as beneficial to health and of great importance during nursing care due to its restorative function. It is common for sleep disturbances and changes in sleep pattern to occur in connection with hospitalization, especially among surgical clients. Clients in medical and surgical units often report disrupted sleep, not feeling refreshed by sleep, wakeful periods during the night, and increased sleepiness during the day. Illness and the stress of being hospitalized are causative factors, but other reasons for insufficient sleep in hospitals may be due to an uncomfortable bed, being too warm or too cold, environmental noise such as IV pump alarms, disturbance from health care personnel and other clients, and pain. The presence of intravenous catheters, a urinary catheter, and drainage tubes can also impair sleep. Increased daytime sleepiness, a consequence of poor-quality sleep at night, can cause decreased mobility and slower recovery from surgery. Research indicates that postoperative sleep disturbances can last for months. Therefore, it is important to provide effective nursing interventions to promote sleep.[1]
Assessment
Begin a focused assessment on a client’s sleep patterns by asking an open-ended question such as, “Do you feel rested upon awakening?” From there, five key sleep characteristics should be assessed: sleep duration, sleep quality, sleep timing, daytime alertness, and the presence of a sleep disorder. Examples of focused interview questions are included in Table 12.3a. These questions have been selected from sleep health questionnaires from the National Sleep Foundation’s Sleep Health Index and the National Healthy Sleep Awareness Project.[2]
Table 12.3a Focused Interview Questions Regarding Sleep[3]
| Questions | Normal Findings |
|---|---|
| How many hours do you sleep on an average night? | 7-8 hours for adults (See Table 12.3b for recommended sleep by age range.) |
| During the past month, how would you rate your sleep quality overall? | Very good or fairly good |
| Do you go to bed and wake up at the same time every day, even on weekends? | Yes, they generally maintain a consistent sleep schedule |
| How likely is it for you to fall asleep during the daytime without intending to? Do you struggle to stay awake while you are doing things? | Unlikely |
| How often do you have trouble going to sleep or staying asleep? | Never, rarely, or sometimes |
| During the past two weeks, how many times did you have loud snoring while sleeping?
Note: It is helpful to ask the client’s sleep partner this question. |
Never |
It is also helpful to determine the effects of caffeine intake and medications on a client’s sleep pattern. If a client provides information causing a concern for impaired sleep patterns or a sleep disorder, it is helpful to encourage them to create a sleep diary to share with a health care provider. Use the following information to view a sample sleep diary.
Download a Sleep Diary from the National Heart, Lung, and Blood Institute.
Additional subjective assessment questions can be used to gather information about a clients typical sleep routine so that it can be mirrored during inpatient care, when feasible.
Nurses also perform objective assessments of a client’s sleep patterns during inpatient care. The number of hours slept, wakefulness during the night, and episodes of loud snoring or apnea should be documented. Note physical (e.g., sleep apnea, pain, and urinary frequency) or psychological (e.g., fear or anxiety) circumstances that interrupt sleep, as well as sleepiness and napping during the day.[4],[5]
Concerns about signs of sleep disorders should be communicated to the health care provider for follow-up.
Life Span Considerations
The amount of sleep needed changes over the course of a person’s lifetime. Although sleep needs vary from person to person, Table 12.3b shows general recommendations for different age groups based on recommendations from the American Academy of Sleep Medicine (AASM) and the American Academy of Pediatrics (AAP).[6]
Table 12.3b Recommended Amounts of Sleep by Age Group[7]
| Age | Recommended Amount of Sleep |
|---|---|
| Infants aged 4-12 months | 12-16 hours a day (including naps) |
| Children aged 1-2 years | 11-14 hours a day (including naps) |
| Children aged 3-5 years | 10-13 hours a day (including naps) |
| Children aged 6-12 years | 9-12 hours a day |
| Teens aged 13-18 years | 8-10 hours a day |
| Adults aged 18 years or older | 7–8 hours a day |
If an older adult has Alzheimer’s disease, it often changes their sleeping habits. Some people with Alzheimer’s disease sleep too much; others don’t sleep enough. Some people wake up many times during the night; others wander or yell at night. The person with Alzheimer’s disease isn’t the only one who loses sleep. Caregivers may have sleepless nights, leaving them tired for the challenges they face. Educate caregivers about these steps to promote safety for their loved one and help them and the client sleep better at night:
- Make sure the floor is clear of objects.
- Lock up any medications.
- Attach grab bars in the bathroom.
- Place a gate across the stairs.[8]
Diagnostic Tests
A sleep study may be ordered for a client suspected of having a sleep disorder. A sleep study monitors and records data during a client’s full night of sleep. A sleep study may be performed at a sleep center or at home with a portable diagnostic device. If done at a sleep center, the client will sleep in a bed at the sleep center for the duration of the study. Removable sensors are placed on the person’s scalp, face, eyelids, chest, limbs, and a finger to record brain waves, heart rate, breathing effort and rate, oxygen levels, and muscle movements before, during, and after sleep. There is a small risk of irritation from the sensors, but this will resolve after they are removed.[9] See Figure 12.10[10] of an image of a client with sensors in place for a sleep study.
Diagnoses
NANDA-I nursing diagnoses related to sleep include Disturbed Sleep Pattern, Insomnia, Readiness for Enhanced Sleep, and Sleep Deprivation.[11] When creating a nursing care plan for a client, review a nursing care planning source for current NANDA-I approved nursing diagnoses and interventions related to sleep. See Table 12.3c for the definition and selected defining characteristics of Sleep Deprivation.
Table 12.3c Sample NANDA-I Nursing Diagnosis Related to Sleep Deprivation[12]
| NANDA-I Diagnosis | Definition | Selected Defining Characteristics |
|---|---|---|
| Sleep Deprivation | Prolonged periods of time without sustained natural, periodic suspension of relative consciousness that provides rest. | Anxiety
Apathy Combativeness Confusion Decreased functional ability Prolonged reaction time Drowsiness Fatigue Hallucinations Heightened sensitivity to pain Irritable mood Transient paranoia |
A sample nursing diagnostic statement is, “Sleep Deprivation related to an overstimulating environment as evidenced by irritability, difficulty concentrating, and drowsiness.”
Outcome Identification
An overall goal related to sleep is, “The client will awaken refreshed once adequate time is spent sleeping.”[13]
A sample SMART outcome is, “The client will identify preferred actions to ensure adequate sleep by discharge.”[14]
Planning Interventions
Evidence-based nursing interventions to enhance sleep are summarized in the following box.
Sleep Enhancement Interventions[15],[16]
- Adjust the environment (e.g., light, noise, temperature, mattress, and bed) to promote sleep
- Encourage the client to establish a bedtime routine to facilitate wakefulness to sleep
- Facilitate maintenance of the client’s usual bedtime routines during inpatient care
- Encourage elimination of stressful situations before bedtime
- Instruct the client to avoid bedtime foods and beverages that interfere with sleep
- Encourage limitation of electronic devices before bedtime (e.g., phone, computer, television)
- Encourage the client to limit daytime sleep and participate in activity, as appropriate
- Bundle care activities to minimize the number of awakenings by staff to allow for sleep cycles of at least 90 minutes
- Consider sleep apnea as a possible cause and notify the provider for a possible referral for a sleep study when daytime drowsiness occurs despite adequate periods of undisturbed night sleep
- Educate the client regarding sleep-enhancing techniques
Transforming Hospitals Into Restful Environments to Promote Healing
Nurses nationwide have been researching innovative ways to transform hospitals into more restful environments that promote healing. As reported in the American Nurse, strategies include using red lights at night to reduce light exposure, reducing environmental noise, bundling care, offering sleep aids, and providing clienteducation[17]:
- Switching to Red Lights: Nurses can use red lights when providing care at night. Adult and pediatric clients were found to sleep better with reduced white lights.
- Reduce Environmental Noise: Clients were surveyed regarding factors that affected their ability to sleep, and results indicated bed noises, alarms, squeaking equipment, and sounds from other clients. Noise can be reduced by replacing the wheels on the trash cans and squeaky wheels on chairs, repairing malfunctioning motors on beds, switching automatic paper towel machines in the hallways with manual ones, and altering the times floors are buffed. Visitor rules can be implemented, such as no overnight stays in semiprivate rooms and overnight visitors in private rooms were asked to not use their cell phones, turn on the TV, or use bright lights at night.
- Bundling Care: Nurses reinforce bundling care by interdisciplinary team members to reduce sleep interruptions. For example, a “Quiet Time” policy can be set from midnight to 5 a.m. Quiet Time includes dimming lights, closing client room doors, and talking in lower voices.
- Offering Sleep Aids: Nurses can ask clients about what aids they use at home to help them sleep, such as extra pillows or listening to music. On admission, sleep kits can be provided with ear plugs and eye masks and at bedtime, warm washcloths can be offered to clients for comfort.
- Client Education: Clients and families can be provided with printed materials on the benefits of sleep and rest for optimal healing, participating in rehabilitative therapies, and prevention of delirium.
Pharmacological Interventions
See specific information about medications used to facilitate sleep in the previous “Sleep Disorders” section of this chapter.
Implementing Interventions
When implementing interventions to promote sleep, it is important to customize them according to the specific client’s needs and concerns. If medications are administered to promote sleep, fall precautions should be implemented, and the nurse should monitor for potential side effects, such as dizziness, drowsiness, worsening of depression or suicidal thoughts, or unintentionally walking or eating while asleep.
Evaluation
When evaluating the effectiveness of interventions, start by asking the client how rested they feel upon awakening. Determine the effectiveness of interventions based on the established SMART outcomes customized for each client situation.
- Hellström, A., Fagerström, C., & Willman, A. (2011). Promoting sleep by nursing interventions in health care settings: A systematic review. Worldviews on Evidence-Based Nursing, 8(3), 128–142. https://doi.org/10.1111/j.1741-6787.2010.00203.x ↵
- Chaput, J., & Shiau, J. (2019). Routinely assessing patients' sleep health is time well spent. Preventive Medicine Reports, 14. https://doi.org/10.1016/j.pmedr.2019.100851 ↵
- Chaput, J., & Shiau, J. (2019). Routinely assessing patients' sleep health is time well spent. Preventive Medicine Reports, 14. https://doi.org/10.1016/j.pmedr.2019.100851 ↵
- Wagner, C. M., Butcher, H. K., & Clarke, M. F. (2024). Nursing interventions classification (NIC) (8th ed.). Elsevier. ↵
- Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. pp. 843-846. ↵
- National Heart, Lung, and Blood Institute. (2022). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency ↵
- National Heart, Lung, and Blood Institute. (2022). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency ↵
- National Institute on Aging. (2016). A good night’s sleep. U.S. Department of Health & Human Services. https://www.nia.nih.gov/health/good-nights-sleep#safe ↵
- National Heart, Lung, and Blood Institute. (2022). Insomnia. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/insomnia ↵
- “Wired_up_for_a_sleep_study_02A.jpg” by Joe Mabel is licensed under CC BY-SA 3.0 ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. pp. 843-846. ↵
- Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. pp. 843-846. ↵
- Wagner, C. M., Butcher, H. K., & Clarke, M. F. (2024). Nursing interventions classification (NIC) (8th ed.). Elsevier. ↵
- Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. pp. 843-846. ↵
- Trossman, S. (2018). Nurses offer strategies to promote patients’ rest and sleep. American Nurse. https://www.myamericannurse.com/strategies-promote-patients-rest-sleep/ ↵