Page 217 - Cardiac Nursing

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C HAPTER 8 / Sleep 193
caused by or may accentuate the underlying health problem. A Sleep Restriction Therapy
fourth goal is to assist patients to learn behavioral patterns that en- Sleep restriction therapy causes sleep deprivation, and conse-
hance the quality of their sleep. quently increases the sleep drive. Before beginning sleep restric-
tion therapy the individual maintains a sleep log for 2 weeks. This
log facilitates estimating the average sleep time versus time spent
in bed. The allowed sleep time is the average subjective sleep time,
SLEEP PROMOTING but is never less than 5 hours. The time in bed is adjusted by
INTERVENTIONS 15-minute increments or decrements, depending on the sleep ef-
ficiency. Sleep efficiency is defined as the average sleep time or
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Nonpharmacological Outpatient time in bed multiplied by 100%. If sleep efficiency is greater than
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Interventions for the Management of 90%, the time in bed is increased by 15 minutes, and if it is less
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Sleep Disturbances in Patients with than 85%, the time is decreased by 15 minutes. 282
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Cardiovascular Disease Sleep restriction has been shown in one study to increase total
sleep time, improve sleep latency, total wake time, sleep efficiency,
Nonpharmacological therapies for sleep problems are often effec-
tive but underutilized by health care providers. Treatment of sleep and subjective assessment of insomnia. Using this technique, im-
disturbances using nonpharmacological methods involves behav- provement continued to be significant for all sleep parameters at
ioral, cognitive, and physiological interventions. These therapies 36 weeks. The efficacy of sleep restriction alone or in combination
may be used alone or in combination and typically are more ef- with other modalities has also been shown in other controlled
162,284,285
fective for the long-term management of sleep disturbances than trials. However, the use of this technique with cardio-
medications alone. 281,282 vascular patients has not been fully tested and should be used with
caution given the vulnerability of the cardiac patient to sleep
deprivation.
Relaxation Therapy and Imagery
Anxiety and related thoughts are often detrimental to sleep and Sleep Education and Hygiene
may prevent or delay sleep onset. Relaxation training originally Sleep hygiene measures alone are not adequate for the treatment
designed to reduce anxiety has also been used successfully for the of sleep disturbances; however, they may be beneficial when used
treatment of sleep onset insomnia. Several relaxation techniques in conjunction with other therapies. Sleep hygiene includes health
are recommended for the treatment of sleep disturbances. These practices, habits, and environmental factors that influence sleep.
techniques include progressive muscle relaxation, autogenic train- Health care providers need to educate cardiac patients regarding
ing, and imagery. Autogenic training focuses on increasing blood sleep and its disorders. It is important to emphasize that simple
flow to the legs and arms. The sensations of warmth and heaviness lifestyle changes can help in the treatment of their sleep problems.
are used to promote somatic relaxation. Positive imagery may also Some of the sleep-related practices and habits that may impair
be used to promote sleep in conjunction with relaxation tech- sleep are listed in Display 8-3. Additionally, some patients with
niques. Once a selected technique is established, the patient must cardiovascular disease or HF may be taking over-the-counter or
practice it at least twice per day. Typically, it requires several weeks herbal medications with stimulant properties. Patients may not
of practice before the technique is acquired. Relaxation techniques volunteer this information unless specifically asked. Assessment of
may be best used as a method to extend sleep rather than used as these factors and education regarding behavior change may help
an initial therapy for sleep onset. 282,283 improve sleep.
Light Therapy
Stimulus Control
To cope with being awake during the night, many individuals The circadian cycle is responsible for the 24-hour sleep and wake
with chronic sleep disturbances engage in behaviors in the bed- rhythm. Circadian rhythm disorders can cause sleep disturbances
room that may further contribute to wakefulness. These may as a result of a dysfunctional relationship existing between one’s
include worrying, reading, and watching television among
other behaviors. One report of sleep onset insomniacs found
there was an improvement in sleep in 70% of the subjects when
they consistently followed the practice of having only 10 min- DISPLAY 8-3 Behaviors and Habits Nonconducive
utes to fall asleep (20 minutes in the elderly). 281 Stimulus con- to Sleep
trol is designed to break the relationship between maladaptive Spending too much time in bed
behaviors and arousal. 282 Patients using stimulus control are Frequent daytime napping
told to: Too few daytime activities
■ Go to bed only if you are sleepy Late evening exercise
Inadequate morning light exposure
■ Avoid activities in the bedroom that keep you awake, other
Excessive caffeine, especially in the later half of the day
than sex Evening alcohol consumption
■ Only sleep in the bedroom
Smoking in the evening
■ Leave the bedroom when awake Late heavy dinner
■ Return to the bedroom only when sleepy Anxiety in anticipation of poor sleep
■ Get up at the same time each morning, regardless of the Environmental factors, such as the room being too warm,
amount of sleep too noisy, or too bright
■ Avoid napping during the day