All mammals including humans require sleep for survival. Sleep facilitates body restoration, innate protection and energy-conservation. There are two main types of sleep and these include the non-rapid eye move sleep and/or the rapid eye movement sleep (BaHammam, 2010). It has been established that non rapid eye movement sleep involves transitional and deeper sleep stages. Research further indicates that sleep involves a number of 90-minute NREM/REM cycles (Weber, 2013). Sufficient amounts of both of these are imperative in bringing about restoration one’s mental and/or physical functioning. Alterations in sleep through disturbances during night time interfere with both the quantity and the quality of sleep. It also brings about an individual’s impairment during day time. In the ED and ICU setting according to (Waller & Jennum, 2013). sleep pattern alterations leads to negative psychology outcomes such as low immunity, poor metabolism, lowered protein catabolism, poor nitrogen balance and thus longer hospital stays. Deprivation of sleep diminishes the patient’s quality of life (QOL), including their cognitive abilities (BaHammam, 2010). Alterations in sleeping patterns also bring about an increase in the patient’s pain intensity, anxiety and even depression. ICU patients and those in the ED usually have a nocturnal sleep that is fragmented, poor efficiency in sleep and sleep latency. There sleep periods are brief, frequently interrupted by arousals, marketing it evenly distributed across both day and night. These arousals usually by noise and strong lighting interfere with the patient’s sleeping patterns. This discussion will focus on highlighting the main environmental factors within the ED and ICU that a patient’s sleeping patterns(Waller & Jennum, 2013). The discussion will also outline the different roles of nurses in controlling the identified factors in order to minimize this problem.
How Environmental Factors in the ED/ICU Contribute To Alterations in Sleep Patterns of Patients
Noise is a major environmental factor that contributes to alteration in the sleep patterns of patients under care in the EDs and in the ICU. Noises within these areas are caused by telephone noise of bedside phones, noises caused by intravenous pump alarms, the ventilator alarms and from conversing caretakers contributed to arousal that alters the patient’s sleep patterns (Bosma & Ranieri, 2009). It is listed among environmental hazard universally as it brings about adverse physical, social, psychological, and spiritual ill-health. Noises from the above sources cause arousal among patients in ICU through its indirect activation of their sympathetic nervous system. This arousal results into awakening thus fragmenting their sleep the pattern (Bosma & Ranieri, 2009). Louder noises lead to hyper-arousal and this can be very detrimental to patients within these specialized care units especially when they are bound to have longer hospital stays.
Apart from the sources of noise mentioned, others include banging noises from windows and doors closing, water sounds and the bubbling of chest-tubes (Weber, 2013). Usually, nurses within the critical care units are never unaware of their conversations and its irritating effect on the part of the patients. Studies indicate that increasing by just a factor of 10 decibels leads to double the loudness of the noise. Recommended noise levels where both rapid and non-rapid eye movement sleep occurs are 35 decibels (Waller & Jennum, 2013). Noise within residential areas and hospitals should therefore be maintained at 45 decibels or lesser during the day. At night however, 35 decibels or lesser noise levels should be allowed. It has been established that some ICUs and EDs report noise levels of even beyond 80 decibels.
- Lights and Color
Strong disruptive light is listed among air pollutants as is the case for loud noise. Research indicates that light is a strong environmental synchronizer that usually entrains sleep by promoting a normal sleep and/or wakefulness cycle. The ICU and ED environment with strong lighting normally alter the patients’ sleeping patterns (Weber, 2013).. As a consequence, their healing process is slowed, pain intensity increases, they get depressed and anxious and even experience fatigue contributing to longer hospital stays. Windowless critical care units bring about impaired cognition while natural lighting promotes the patient’s mood easing anxiety and depression. The cognitive impairment that results due to windowless care units with bright lights which make the patient’s unable to figure out those within the room and the procedures being carried out(Waller & Jennum, 2013). This brings about anxiety, panic and worry. Bright fluorescent tubes bring about strong and harsh light leading to visual fatigue which also interrupts sleep. It also leads to repetitive headaches if patients are not shielded from them. Glares from glass, and polished surfaces affect the elderly patients within the ED and ICUs. Where strong lights are left on for long hours in these units some patients get depressed especially where they cannot control them (Rawding, 2016). The resultant headache, depression and anxiety impact on their healing process while at the same time interfering with their spiritual health. Unmuted bright colors in the critical care units and their reflection in bright light also lead to awakening thus altering a patient’s sleeping patterns.
Nurses Roles in the Provision of Holistic Person-Centered Care by Minimizing the Environmental Factors and Putting the Patient in the Possibly Best Condition for Self-Healing
- Non-pharmacologic Approaches in the Management of Sleep Disturbance
There are different categories of non-pharmacologic approaches towards improving patient’s sleep. These according to include cognitive-behavioral interventions, provision of complementary therapies and further, modification of the environment.
- Cognitive-Behavioral Interventions
The first intervention can thus be cognitive behavioral therapy for a patient’s insomnia. Nurses should use this approach in treating the patients in the ICU and ED who have for comorbid insomnia and where the patient develops primary chronic insomnia(Waller & Jennum, 2013). Specific components of this approach include the provision of behavioral strategies to the patient such as encouraging them to regularly sleep, controlling the stimulus for sleeping, cognitive therapy, provision of sleep hygiene education and further; relaxation each of which can be given as a mono-therapy (Ashworth et al, 2010). In other cases however, multi-component therapy is needed while ensuring that the interventions are appropriate to the social, psychological, emotional and cultural welfare of the patient. Cognitive Behavioral Therapy for Insomnia (CBTI) helps in reducing the perpetuating factors which are below a patient’s insomnia threshold. It also helps in de-conditioning the body’s hyper-arousal response which normally leads to fragmented sleep pattern. Cognitive therapy usually decreases the patient’s dysfunctional beliefs and/or attitudes which prevent the onset of sleep and its maintenance (Ashworth et al, 2010). As a mono-therapy on the other hand, sleep hygiene education to the patient helps in controlling several habits, practices and environmental factors which influence the length and quality of a patient’s sleep. The specifics in sleep hygiene education should include directions on effective promotion of both onset and/or maintenance of sleep. Sleep hygiene just like CBTI should be tailor-made for each critical care setting.
- Complementary Therapy
Complementary therapies that aim at improving a patient’s sleep should be used. These include, muscle relaxation, massaging and a healing touch which focus on enhancing positive health outcomes for the patient’s physical, psychological and spiritual well-being (BaHammam, 2010). Recent studies indicate that complementary therapies including massage, music therapy, relaxation of muscles and therapeutic touch are very beneficial interventions which promote sleep among critically ill patients. The nursing team can also facilitate the provision of early mobility for patients in the ED/ICU in order prevent and/or treat weakness in the muscles (Cheng & Yeung, 2012). It can also improve the patient’s long-term recovery where it is done step-wise, to boost the patient’s sleep outcomes. Music therapy can also be used in promoting a patient’s spiritual and/or psychological healing. Music is able to lull patients within critical care units to voluntarily sleep despite of the seething pain they might be having. Music therapy should thus be availed by the nursing team where available, to help in reducing the patient’s anxiety and depression. This is recommended especially for individuals who have survived acute myocardial infarction; patients who are currently on mechanical ventilators and; those that have undergone cardiac surgery (Weber, 2013). It should also be used as it lowers one’s heart rate their blood pressure and even enhances relaxation especially when it is not loud and disturbing or inappropriate.
The main environmental factors that contribute to alterations in a patient’s sleep patterns as discussed above include noise and excessive lighting. Proper control and management of these factors will extensively help in minimizing sleep interruptions in the ICU/ED setting(Waller & Jennum, 2013). In regard to noise, it is apparent that minimizing its effect on the patient promotes quicker healing physically, culturally, socially, psychologically and even spiritually (Busman & Ranieri, 2009). To minimize noise, there is need for nurses to provide patients with ear plugs and or earmuffs based on the consent of the patient or family member. It is also important for the interdisciplinary team attending to the patient to ensure that any nursing equipment which generates noise is switched off where it is not in use. In terms of lighting, it is important to provide the patient with natural lighting that is well controlled. The nursing team should facilitate the regulation of both natural and artificial lighting in the ED/ICU. The type of lighting tubes and bulbs should be appropriately chosen and maintained to prevent glares and flickering when under use(Waller & Jennum, 2013). The recommended maximum maximum light intensity needs to be set at 6.5 foot-candles for continuous lighting in the care unit but 19 foot-candles during short periods at night. Further, there is need for nurses to turn off lights that are not useful to enable the patient sleep.
Pharmacological treatment can be used along with other interventions in promoting sleep among patients in critical care units. Apparently, pharmacological treatment should be tailor-made for every patient and thus cannot be generalized. One of the approaches under this therapy includes the discontinuation of sleep-disrupting medication to allow patients have normal wake/sleep patterns (Weinhouse & Watson, 2011). For instance sedatives and/or analgesics should be reduced in dosage in order to promote sleep. This should however be done carefully to avoid cases of withdrawal symptoms like being restless, insomnia and fatigue (Chung & Youn, 2016). It is thus important that a systematic sedative taperi taperingng be done to minimize the risk of one developing sleep-linked withdrawal symptoms. Secondly, the patients can be put on medications for treating acute sleep disturbances to only be used for a short time along with continuous reassessment of the patient (Weinhouse & Watson, 2011). Administration of these medications needs to be done along with recommended non-pharmacologic interventions. Particularly, Benzodiazepines are used in treating sleep disorders. Even so, they alter these medications alter one’s sleep architecture by reducing deeper NREM and/or REM phased of sleep. Since REM sleep relates to respiratory dysfunction, reduction of benzodiazepine-induced REM can be an advantage among some patients (Sterniczuk et al, 2014). Even so, there are several limitations of benzodiazepines and these include dependence risks, among other adverse events like nightmares and restlessness. It is thus apparent that pharmacological approaches are imperative in managing sleep alterations just like the non-pharmacological approaches used.
In conclusion therefore, sleep pattern alteration in the ED/ICU are mainly caused by noise and lighting. The discussion above outlines how noise and lighting interrupt sleep patterns leading to delayed healing, longer hospital stay, development of mental and physical complications and poor body immunity. The discussion further focuses on the pharmacological and non-pharmacological approaches in minimizing the effect of the environmental factors while promoting sleep among patients in critical care units. The nursing interventions are holistic in nature and can enable the provision of person-centered in the ICU/ED.
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