Sleep Disturbances in Critical Care

This assignment explores the impact of environmental factors like noise and lighting on sleep quality in patients within critical care units (ICU/ED). It highlights how these disruptions can hinder healing, prolong hospital stays, and contribute to mental and physical complications. The discussion delves into pharmacological and non-pharmacological strategies for mitigating these effects and promoting restful sleep in critically ill patients. Nursing interventions are emphasized as being holistic and patient-centered.

Introduction to Specialty Practice: Critical Care Nursing 1
INTRODUCTION TO SPECIALTY PRACTICE: CRITICAL CARE NURSING
Name of Student:
Course Code + Name
Instructor:
Institution:
City, State:
Submission Date:

Introduction to Specialty Practice: Critical Care Nursing 2
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 physiological 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, making 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.

Introduction to Specialty Practice: Critical Care Nursing 3
How Environmental Factors in the ED/ICU Contribute To Alterations in Sleep Patterns of
Patients
a. Noise
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.

Introduction to Specialty Practice: Critical Care Nursing 4
b. 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.

Introduction to Specialty Practice: Critical Care Nursing 5
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
A. 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.
i. 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

Introduction to Specialty Practice: Critical Care Nursing 6
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.
ii. 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.

Introduction to Specialty Practice: Critical Care Nursing 7
iii. Environmental Modification
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.
B. Pharmacological Considerations
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

Introduction to Specialty Practice: Critical Care Nursing 8
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 tapering 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.

Introduction to Specialty Practice: Critical Care Nursing 9
References
Ashworth, P., Davidson, K. and Espie, C. (2010). Cognitive–Behavioral Factors Associated With
Sleep Quality in Chronic Pain Patients. Behavioral Sleep Medicine, 8(1), pp.28-39.
BaHammam, A. (2010). Sleep quality in CCU patients after controlling for environmental
factors. Sleep Medicine, 11(8), pp.804-805.
Bosma, K. and Ranieri, V. (2009). Filtering out the noise: evaluating the impact of noise and
sound reduction strategies on sleep quality for ICU patients. Critical Care, 13(3), p.151.
CHENG, K. and YEUNG, R. (2012). Impact of mood disturbance, sleep disturbance, fatigue and
pain among patients receiving cancer therapy. European Journal of Cancer Care, 22(1), pp.70-
78.
Chung, S. and Youn, S. (2016). Optimizing the Pharmacological Treatment for
Insomnia. Journal of Sleep Medicine, 13(1), pp.1-7.
Heussler, H., Chan, P., Price, A., Waters, K., Davey, M. and Hiscock, H. (2013).
Pharmacological and non-pharmacological management of sleep disturbance in children: An
Australian Paediatric Research Network survey. Sleep Medicine, 14(2), pp.189-194.
Rawding, R. (2016). Sleep: I Need How Much??. HAPS Educator, 20(4), pp.48-53.
Rj, I. and R, G. (2016). Role of environmental factors on sleep patterns of different age
groups. Asian Journal of Pharmaceutical and Clinical Research, 9(6), p.124.
Savard, M., Savard, J., Caplette-Gingras, A. and Ivers, H. (2011). W-D-030 WHAT TYPES OF
HOT FLASHES ARE ASSOCIATED WITH SLEEP DISTURBANCES IN BREAST CANCER
PATIENTS?. Sleep Medicine, 12, pp.S102-S103.
Sterniczuk, R., Rusak, B. and Rockwood, K. (2014). Sleep disturbance in older ICU
patients. Clinical Interventions in Aging, p.969.

Introduction to Specialty Practice: Critical Care Nursing 10
Waller, L. and Jennum, P. (2013). Age-related changes in sleep pattern and sleep structure and
the association to cognitive performance: the metropolit 1953 danish male birth cohort. Sleep
Medicine, 14, p.e24.
Weber, M. (2013). A Brief and Selective Review of Treatment Approaches for Sleep
Disturbance following Traumatic Brain Injury. Journal of Sleep Disorders & Therapy, 02(02).
Weinhouse, G. and Watson, P. (2011). Sedation and Sleep Disturbances in the
ICU. Anesthesiology Clinics, 29(4), pp.675-685.