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.
Causes of Insomnia (Related to)
- 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
- 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)
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
- 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 for 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.
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 for 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.
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 signaling 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 most people to take and does not cause drowsiness and other side effects prescribed sleep aids can cause. Still, some patients require stronger medications such as Ambien or benzodiazepines.
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.
References and Sources
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
- Drake, C., Roehrs, T., Shambroom, J., & Roth, T. (2013). Caffeine effects on sleep taken 0, 3, or 6 hours before going to bed. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 9(11), 1195–1200. https://doi.org/10.5664/jcsm.3170
- Robinson, L., Smith, M., Segal, R., & Segal, J. (2021, June). Therapy for Sleep Disorders. HelpGuide.org. Retrieved December 2, 2021, from https://www.helpguide.org/articles/sleep/therapy-for-sleep-disorders.htm
- Sleep Advisor. (2021, June 7). Sleep and Digestion – How to Improve Your Gut Health. Sleep Advisor. Retrieved December 2, 2021, from https://www.sleepadvisor.org/sleep-and-digestion/
- Suni, E. (2021, February 25). Sleep Diary: How and Why You Should Keep One. Sleep Foundation. Retrieved December 2, 2021, from https://www.sleepfoundation.org/sleep-diary
- Tsai, S. (2017, March 1). Medicines That Can Cause Insomnia. National Jewish Health. Retrieved December 2, 2021, from https://www.nationaljewish.org/conditions/insomnia/causes/medicines-that-can-cause-insomnia
