Insomnia is the disruption in the amount and quality of sleep to the extent that it impairs functioning. Inadequate sleep can have detrimental effects on a patient’s physical and mental well-being. Our bodies repair themselves when we sleep, and sleep restores our mental clarity.
Insomnia can be temporary and will resolve once the cause is removed, such as a change in a work schedule, and is usually alleviated by simple adjustments. Chronic insomnia requires deeper assessment and often the use of sleeping medications. Nurses can institute ways to support sleep, such as decreasing stimuli and blocking off time to ensure patient’s rest isn’t interrupted as well as educating patients on how they can enjoy better sleep at home.
Attention: This nursing diagnosis has been renamed.
Nursing diagnoses are revised, added, or retired by the NANDA International Diagnosis Development Committee (DDC) to coincide with shifts in language standardization. “Insomnia” has been replaced with “Ineffective Sleep Pattern”. Students and seasoned nurses alike may be unfamiliar with this change, and thus NurseTogether has chosen to continue to use the diagnostic label “Insomnia” in this article until the recent relabeling receives wider adoption.
In this article:
- Causes (Related to)
- Signs and Symptoms (As evidenced by)
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Causes (Related to)
The following are common causes of insomnia:
- Stress/depression/grief/anxiety
- Use of stimulants (caffeine, medications)
- Alcohol or substance abuse
- Disruption to normal routines that affects sleep patterns (travel, shift work)
- Poor sleep hygiene (use of electronic before bed or caffeine too close to bedtime)
- Physical discomfort (pain, gastrointestinal upset)
- Incontinence
- Environmental factors (room temperature, lighting, unfamiliar setting)
- Chronic health conditions (heart failure, hyperthyroidism)
Signs and Symptoms (As evidenced by)
The following are common signs and symptoms of insomnia. They are categorized into subjective and objective data based on patient reports and assessment by the nurse.
Subjective: (Patient reports)
- Difficulty falling or staying asleep
- Restless sleep
- Poor sleep leading to daytime sleepiness, fatigue, poor concentration, irritability
- Waking up too early
- Decreased health and quality of life
- Missing appointments, late for work or school
- Increase in errors or accidents
Objective: (Nurse assesses)
- Observed tiredness, mood changes, lack of energy
- Appearance changes (disheveled dress, dark circles under eyes)
Expected Outcomes
The following are common nursing care planning goals and expected outcomes for insomnia:
- Patient will identify factors contributing to poor sleep patterns.
- Patient will report averaging 7-9 hours of restful sleep per night.
- Patient will report feeling rested and energized upon waking.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to insomnia.
1. Identify health conditions contributing to insomnia.
Chronic pain, shortness of breath, dementia, pregnancy, menopause, psychiatric conditions, narcolepsy, and incontinence can interrupt sleep patterns. Acute and chronic diseases and conditions should first be identified, as these cannot always be adjusted.
2. Assess sleep patterns.
Assess when the patient normally goes to bed, what time they wake up, how long it takes them to fall asleep, and how many times they wake up during the night to provide baseline data.
3. Identify poor sleep hygiene behaviors.
The use of electronics before bed, napping during the day, irregular bedtimes, caffeine intake too late in the day, and sedentary lifestyles contribute to inadequate sleep.
4. Assess the use of stimulants or drug abuse.
Overuse of caffeine or the abuse of stimulants, whether prescribed or not affects sleep patterns. The abuse of nicotine, alcohol, or drugs can cause insomnia.
5. Review medications.
Some medications have insomnia as a side effect. These include steroids, some antidepressants (SSRIs), drugs to treat Parkinson’s disease, some blood pressure medications, amphetamines used to treat ADHD, bronchodilators, and even over-the-counter medications to treat colds like decongestants.
6. Assess changes in schedules or life events.
The transition into a new job that requires shift work or frequent travel can disrupt sleep patterns. Parenting an infant also negatively affects sleep. These may all be temporary causes and can be adjusted to. It is still worthwhile to have a conversation with the patient about ways that sleep can be improved.
7. Assess for emotional trauma.
Suffering from a recent loss or experiencing grief, attempting to manage depression, or feeling anxious or stressed can lead to sleep dysfunction.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with insomnia.
1. Educate on basic sleep hygiene behaviors.
Instruct to establish a bedtime routine and stick to it. Restrict napping during the day if possible. Get up at the same time each day. Make the bedroom a place of relaxation only for sleeping, not working or watching tv. Getting adequate exercise is important, just not within a few hours of bedtime. It is also important to avoid strenuous exercise before bed.
2. Suggest ways to improve the environment.
Room-darkening curtains can keep out bright light if needing to sleep during the day. Sleep occurs best when the room is kept cool; use a fan if needed. While quiet is usually recommended, if background noise is needed, a white noise machine or other soothing sounds can help.
3. Refer to a sleep specialist or discuss a sleep study.
Despite implementing proper sleep hygiene practices, if sleep is still elusive, a sleep study may be necessary. This can uncover issues such as obstructive sleep apnea which can cause insomnia and related symptoms even when receiving a full night’s sleep.
4. Discuss switching medications or regimens if appropriate.
The patient may not be aware that their medications cause insomnia. Educate first which medications carry this side effect. If discontinuing is not an option, consider taking the medication in the morning and not before bedtime.
5. Recommend keeping a sleep log or using a tracker.
Keeping a journal of the “lights off” time, wake time, number of hours slept, number of sleep interruptions, and the perceived quality of sleep can help identify patterns. There are also many digital sleep trackers and apps that can track these details.
6. Do not drink fluids right before bed or consume large meals.
If incontinence causes nocturia and sleep disruptions, limit fluids before bed. Consuming large meals too close to bedtime can impede digestion and lead to acid reflux, which can prevent falling and staying asleep. Studies show caffeine should not be consumed within six hours of bedtime.
7. Recommend relaxing activities.
Part of a healthy bedtime routine is signalling to the mind and body that it’s time to shut down. Help the patient decide what’s best for them. This can include easy yoga and meditation, drinking chamomile tea, reading a relaxing book, or taking a warm bath.
8. Educate on sleep aid medications.
Melatonin is a natural sleep aid as the body produces it in control of the sleep-wake cycle. It is usually safe for short-term use and causes fewer side effects than prescribed sleep aids can cause. Still, some patients require stronger medications such as Ambien or benzodiazepines. It is important to only take medications for sleep under the consultation of a doctor.
9. Ensure chronic conditions are effectively treated.
Patients who struggle with insomnia as a secondary result of a chronic condition may be more difficult to treat. Ensure their underlying condition is effectively managed either through a specialist, medications, or other treatment.
10. Refer to a mental health professional for mindful sleep techniques.
Emotional challenges affecting sleep may require counseling. The use of techniques such as biofeedback, hypnosis, and guided meditations can be effective in thought training.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for insomnia.
Care Plan #1
Diagnostic statement:
Insomnia related to the use of amphetamines, as evidenced by difficulty staying asleep and increased absenteeism.
Expected outcomes:
- Patient will report better sleeping patterns.
- Patient will verbalize understanding of the harm of amphetamine use.
Assessment:
1. Obtain a history of substance overuse/abuse, including prescription, over-the-counter, and illicit drugs. Check for amphetamine addiction.
Amphetamine is a stimulant that can disrupt the circadian rhythm. Chronic, illicit, or abusive use of amphetamine may lead to psychotic issues that alter an individual’s overall health.
2. Monitor the effects of amphetamines.
Aside from sleep disturbances, long-term use or high doses of amphetamines can cause heart attack, stroke, seizures, renal failure, and hepatotoxicity, which all could be fatal.
3. Assess for signs of depression or anxiety.
Anxiety and depression are associated with substance use disorders. People with severe anxiety and depression are more likely to engage in risky drug-related behaviors. It is important to address underlying or comorbid mental health issues that may be contributing to amphetamine use. Also, treating underlying mental health problems may help with sleep.
Interventions:
1. Assist the patient in performing relaxation techniques to promote sleep (e.g., biofeedback, self-hypnosis, visualization, progressive muscle relaxation).
Relaxation techniques reduce sympathetic response and decrease stress, promoting sleep in patients who experience sleep disturbances.
2. Encourage the patient to participate in a regular exercise program in the morning.
Exercise helps to control stress and provides an acceptable and safe outlet to release energy.
3. Develop a behavioral program for insomnia.
Starting to practice proper sleep hygiene will address insomnia.
- Establish and maintain a regular sleeping and waking time
- Think of relaxing thoughts when in bed
- Avoiding napping in the daytime
- Avoiding heavy meals at bedtime
- Avoiding reading or watching TV in bed
- Getting up at the same time each day—even on weekends and days off
- Do relaxation exercises
4. Collaborate with other experts (e.g., sleep specialist, psychiatrist, counselor) as needed.
Follow-up evaluation or intervention with other experts may be needed when insomnia seriously impacts the client’s quality of life, productivity, and safety.
5. Refer to treatment for amphetamine use if appropriate.
It may also be necessary to refer the patient to treatment for substance use. Ensure that the patient is aware of this referral and prepared to engage in treatment.
Care Plan #2
Diagnostic statement:
Insomnia related to parenting a newborn as evidenced by non-restorative sleep and lack of energy.
Expected outcomes:
- Patient will report improvement in the sleep-rest pattern.
- Patient will report an increased sense of well-being and feeling rested.
Assessment:
1. Assess parent-infant interaction and note the provision of emotional support. Note the mother’s sleep-wake pattern.
Lack of knowledge of infant cues or relationship issues may create tension interfering with sleep.
2. Note the sleep-wake pattern of the baby.
Aligning one’s sleep-wake pattern with the baby’s will help plan and synchronize sleep times.
3. Assess the degree and nature of insomnia.
Adults can be considered to have insomnia if their daytime tiredness and sleepiness are accompanied by the following several nights/week:
- Inability to initiate sleep
- Awakening during the night with the inability to reinitiate sleep
- Short nighttime sleep
Knowing the degree and nature of insomnia will help the nurse tailor suitable sleeping aid techniques for the patient.
Interventions:
1. Advise nonpharmacological sleep aids (e.g., warm bath, light protein snack before bedtime, soothing music, etc.).
Nonpharmaceutical aids may enhance falling asleep. Relaxation sets the body and mind to sleep.
2. Advise an environment conducive to sleep and rest (e.g., peaceful, comfortable temperature, ventilation, dim light, closed door)
Many people sleep better in cool, dark, quiet environments.
3. Advise to refrain from over-thinking or worrying too much about tomorrow’s activities (e.g., care duties, household chores, maintaining the house) or on one’s problems at bedtime.
Letting go of worries or thinking about what must be done tomorrow can cause stress and difficulty falling asleep.
4. Instruct strategies to promote well-rested sleep for parents with newborns.
- Try to sleep when the baby sleeps
- Exempt self from household chores
- Assign shifting baby duties at night
- Ask for some help from friends or family
New parents are still in the process of adjusting to new roles. Teaching these strategies will help them get some restorative sleep.
Care Plan #3
Diagnostic statement:
Insomnia related to working overnight shifts as evidenced by difficulty concentrating and decreased quality of life.
Expected outcomes:
- Patient will verbalize being refreshed upon waking up and have no feelings of fatigue during the day most of the time.
- Patient will verbalize a plan to implement sleep-promoting routines.
Assessment:
1. Obtain a sleep history.
A sleep history should include the time needed to initiate sleep, duration of awakenings after the first sleep onset, total nighttime sleep amounts, and satisfaction with sleep amounts. The nurse can explore bedtime routines, use of medications and stimulants, and use of complementary/alternative therapies for stress management (e.g., herbal agents) and relaxation before bedtime. Assessment of sleep behavior and patterns is a vital part of any health status examination.
2. Identify other presence of factors that can contribute to insomnia.
Other factors may include chronic pain, arthritis, dyspnea, movement disorders, dementia, obesity, pregnancy, menopause, psychiatric disorders, metabolic diseases (e.g., hyperthyroidism, diabetes); prescribed and over-the-counter (OTC) drugs; alcohol, stimulants, or other recreational drug use; circadian rhythm disorders; environmental factors (e.g., noise, no control over thermostat, uncomfortable bed); major life stressors (e.g., grief, loss, finances). Aside from working overnight shifts, check whether there are also behaviors or accompanying conditions that may worsen insomnia.
3. Evaluate the use of caffeine and alcoholic beverages.
People working with overnight shifts tend to consume more caffeine to stay awake. Ensure the patient knows to stop all caffeine ingestion at least 6 hours before sleeping time.
Interventions:
1. Recommend limiting the intake of chocolate and caffeinated or alcoholic beverages, especially before bedtime.
Caffeine and alcohol may interfere with falling asleep or the duration and quality of sleep.
2. Explore other sleep aids (e.g., warm bath, light protein snack before bedtime, soothing music, etc.).
Non-pharmaceutical aids may enhance falling asleep free of the concerns of medication side effects such as morning hangovers or drug dependence.
3. Instruct to keep a sleep–awake diary for one month.
The diary should include bedtime, arising time, difficulty getting sleep, number of awakenings (reason), and naps. Sleep diaries provide data to improve the validity of the assessment.
4. Refer to a sleep specialist as indicated or desired.
Follow-up evaluation or intervention may be needed when insomnia is seriously impacting the patient’s quality of life, productivity, and safety (e.g., on the job, at home, or on the road).
References
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