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SLEEPSLEEP
Kuswantoro Rusca Putra, S.Kp.,M.Kep
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WHAT IS SLEEP
Sleep: This is the state of unconsciousness from which a subject can be aroused by appropriatesensory or other stimuli.
Sleep may also be defined as a normal, periodic,inhibition of the reticular Activating system.
Awake: This is the state of readiness / alertnessand ability to react consciously to various stimuli.
Coma: This is the state of unconsciousness from which a person cannot be aroused by any externalstimuli
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FUNCTIONS OF SLEEPFUNCTIONS OF SLEEP
Restoration theory: Body wears out during
the day and sleep is necessary to put it back
in shape Preservation and protection theory: Sleep
emerged in evolution to preserve energy
and protect during the time of day when
there is little value and considerabledanger
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SLEEP CENTRE
Supra-chiasmatic Nucleus (SCN)
Normal sleep is under control of the reticular
activating system in the upper brain stem and
diencephalon
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VentroLateralVentroLateral PreopticPreoptic Nucleus (Hypothalamus)Nucleus (Hypothalamus)
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Fig. 9-12, p. 280
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SLEEP CENTRE
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SLEEP CENTRE
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SLEEP CENTRE
Sleep is promoted by a complex set of neural
and chemical mechanisms
Daily rhythm of sleep and arousalsuprachiasmatic nucleus of the
hypothalamuspineal glands secretion of
melatonin
Slow-wave sleep: Raphe nuclei of the medulla
and pons and the secretion of serotonin
REM sleep: Neurons of the pons
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NORMAL SLEEP REQUIREMENT
New born = 15 - 20 hours.
Children = 10 -15 hours.
Adults = 6-9 hours.
Old age = 5-6 hours.
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RETICULAR ACTIVATING SYSTEM
Thalamic part causes arousal that is
awakening from deep sleep [sensory input,
pain stimuli, Bright light].
The RAS and cerebral cortex continue to
activate each other through a feedback
system.
The RAS also has a feedback system with
the spinal cord.
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CIRCADIAN RHYTHM
Endogenous circadian rhythms
Rhythm that last about a day humans last around 24. h
Examples:
Activity
Temperature
waking and sleeping
secretion of hormones
eating and drinking
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RETICULAR ACTIVATING SYSTEM
Light:
Retinal ganglion cells send direct projections to the
SCN
this provides information about light to the SCN lightcan also alter blood-borne factors SCN is highly
vascularized
Melatonin:
secreted from the pineal gland increased levels of
melatonin make you sleepy melatonin can act on
receptors in the SCN to phase advance the biological
clock
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TYPES OF SLEEP
There are two types of sleep:
1) Non Rapid Eye Movement Sleep
[Slow Wave Sleep- Dreamless].2) Rapid eye movement sleep
[Dreamful].
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SLOWWAVE SLEEP
1. Slow-wave (non rapid eye movement sleep)
This stage of sleep consists of four stages.
Stage 1: This is an initial stage between
awakening and sleep.
It normally lasts from 1-7 minutes.
the person feels relaxed with eye closed.
If awakened, the person will frequently say that hehas not been sleeping.
E.E.G. findings: Alpha waves diminish and Theta
waves appear on EEG.
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SLOWWAVE SLEEP
Stage 2:
This is the first stage of true sleep.
T
he person experiences only light sleep.It is a little harder to awake the person.
Fragment of dream may be experienced.
Eyes may slowly roll from side to side.
E.EG-findings: Shows sleep spindles (sudden,
sharply, pointed waves 12-14-Hz (cycles/sec).
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SLOWWAVE SLEEP
Stage3:
This is the period of moderately deep sleep.
The person is very relaxed.
Body temperature begin to fall.
B.P decreases.
Difficult to awaken the person.
This stage occurs about 20-25 minutes after
falling asleep.
E.E.G.findings: Shows mixture of sleep spindles and
delta waves.
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SLOWWAVE SLEEP
Stage4: Deep sleep starts
Person become fully relaxed.
Respond slowly if awakened.
E.E.G.findings: Dominated by Delta Waves.
Note: Most sleep during each night is of a slow wave
Lasts for 80=90 minutes.
Dreams / night mare even occur.The difference is that the dreams in slow wave
sleep are not remembered but in REM, dreams
can be remembered.
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RAPID EYE MOVEMENT SLEEP
RAPID EYE MOVEMENT SLEEP [PARADOXICALSLEEP/DREAMFUL SLEEPS]
In normal sleep bouts of REM sleep lasting for 5-20
minutes usually appear on the average after every90 minutes.
The first such period occurring 80-100 minutes after theperson falls a sleep.
When the person is in extreme sleep, the duration ofeach bout of REM is very short.
It may even be absent.
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CHARACTERISTICS OF REMS
Active dreaming.
Difficult to arouse by sensory stimuli.
Decreased muscle tone through out the body. Heart rate and respiration usually become
irregularwhich is characteristic of a dream
state. Brain is highly active in REM sleep and
brain metabolism may be increased by 20%.
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CHARACTERISTICS OF REMS
E.E.G.findings: Shows pattern of brain wave
to those of wakefulness that is which it is
called Paradoxical.
In summary, REM sleep is a type of sleep in
which the brain is quite active.
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CHARACTERISTICS OF SWS AND REMS
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DREAMS AND REMS
What are true dreams for?
Although research has yet to answer this
question, a prevalent view today is that dreams
dont serve any purpose at all, but are sideeffects of REM
To exercise groups of neurons during sleep some
are in perceptual and motor areas REM occurs in other mammals and to a much
greater extent in fetuses and infants than adults
REM sleep may help consolidate memories
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DREAMS AND REMS
True dream - vivid, detailed dreams
consisting of sensory and motor sensations
experienced during REM sleep thought - lacks vivid sensory and
motor sensations, is more similar to daytime
thinking, and occurs during slow-wave sleep
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PHYSIOLOGICAL CHANGES IN SLEEP
Physiological changes during sleep:
CVS: Pulse Rate, cardiac output, blood pressure,
and vasomotortone are decreased but the blood
volume is increased.
Respiration: Tidal volume and rate of respiration
is decreased. BMR is decreased 10-15%.
Urine volume: Urine volume is decreased. Secretions: Salivary / lacrimal secretions are
reduced, gastric/sweet secretions are increased.
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PHYSIOLOGICAL CHANGES IN SLEEP
Muscles: Relaxed.
Superficial reflexes are unchanged except plantex
reflex.
Deep reflexes are reduced.
Effects produced by awakening after 60-100 hours:
Equilibrium disturbed.
Neuromuscular junction fatigue. Threshold for pain is lowered.
Some cells dead.
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DISORDERS OF SLEEP
Disorder of sleep:
Insomnia: Inability to sleep
Somnolence: Extreme sleepness
Disorder of slow wave sleep:Sleep talking / sleep walking
[common in children]
Night tremors: Are seen in III, IV stage of slow wave sleep
[common in children]. Disorder of REM sleep:
Night mare = Frightening dream.
Sleep Paralysis= Subject is awake but unable to speak or
move. Sleeping Sickness.
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DISORDERS OF SLEEP
Somnambulism - sleepwalking
Nightmares - frightening dreams that wake a sleeperfrom REM
Night terrors - sudden arousal from sleep andintense fear accompanied by physiological reactions(e.g., rapid heart rate, perspiration) that occur duringslow-wave sleep
Narcolepsy - overpowering urge to fall asleep thatmay occur while talking or standing up
Sleep apnea - failure to breathe when asleep
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DISORDERS OF SLEEP
Night Terrors
experience of intense anxiety from which a person
awakens screaming in terror occur during non REM sleep
more common in children
Sleep Walking
occurs mostly in children
runs in familiesexpressed early in the night during stage 3 and 4
sleep
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PainPain
Kuswantoro Rusca Putra, S.Kp.,M.Kep
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Definitions:
An unpleasant sensory and emotional
experience associated with actual orpotential tissue damage, or described in
terms of damage.
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Categories of Pain
Acute - Pain of short duration with known
cause
Trauma
Surgery
Chronic - prolonged pain with unknown
duration
Chronic benign - osteoarthritis, migraine
Chronic malignant - bone metastasis, pancreatic
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Signs andSymptoms
Acute Pain = Grimacing, sweating,
hypertension, tachycardia
Chronic Pain = Loss of appetite, lack
of sleep, depression, anxiety
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Transmission of Pain
Types of Nerves
Neurotransmitters
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PeripheralandCentralPathways for PainAscending TractsAscending Tracts Descending TractsDescending Tracts
Cortex
Midbrain
Medulla
Spinal Cord
Thalamus
Pons
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MECHANISMS OF PAIN TRANSMISSION
Nociceptors are receptors that are
preferentially sensitive to a noxious stimulus.
Nociceptors are free nerve endings in theskin that respond only to intense, potentially
damaging stimuli.
The joints, skeletal muscle, fascia, tendons,
and cornea also have nociceptors that have
the potential to transmit stimuli that produce
pain
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MECHANISMS OF PAIN TRANSMISSION
The large internal organs (viscera) do not
contain nerve endings that respond only to
painful stimuli.
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MECHANISMS OF PAIN TRANSMISSION
Prostaglandins are chemical substances
thought to increase the sensitivity of pain
receptors by enhancing the pain provokingeffect of bradykinin
These chemical mediators also cause
vasodilation and increased vascular
permeability, resulting in redness, warmth,and swelling of the injured area
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MECHANISMS OF PAIN TRANSMISSION
Chemicals that reduce or inhibit the
transmission or perception of pain include
endorphins and enkephalins.
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MECHANISMS OF PAIN TRANSMISSION
There are two main types of bers involved in
the transmission of nociception.
Smaller, myelinated A (A delta) berstransmit nociception rapidly, which produces
the initial fast pain. pain impulses due to
mechanical pressure
Type C bers are larger, unmyelinated bers
that transmit what is called second pain. pain
impulses due to chemicals or mechanical
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Nociceptive pain in the visceral organs may be
referred to other parts of the body
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FACTORS INFLUENCING
THE PAIN RESPONSE
Past Experience
Anxiety and Depression
Culture
Age
Gender Placebo Effect
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Principles of Pain Therapy
Assessment
Treatment
Reassessment and Evaluation
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Questions to Ask about Pain
P-Q-R-S-T format
Provocation How the injury occurred & what activities q othe pain
Quality - characteristics of painReferral/Radiation
Severity How bad is it? Pain scale
Timing When does it occur? p.m., a.m., before, during, afteractivity, all the time
Pattern: onset & duration
Area: location
Intensity: level
Nature: description
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Tools
for pain measurement
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Pain Intensity Rating
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From Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, SchwartzP: Wongs Essentials ofPediatricNursing, 6/e, St. Louis, 2001, P. 1301. Copyrighted by Mosby, Inc.
Pain Intensity Rating
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Sample of Childs FACES Pain Rating Scale
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Cries score
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Pain Assessment Techniques
In infants, behavior must beinterpreted by using physiological and
behavioral measures
CRIES is useful for neonates from 32
weeks to infants of up to 1 year
FLACC (full term neonate 7 years)
Preschool children (ages 3 to 7) are in
a transition group in which verbalabilities are developing.
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Frequency of re-assessment
Acute setting of pain
1) within 30 minutes of parenteral drug
administration,
2) within one hour of oral drugadministration,
3) with each report of new or changed
pain
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NON PHARMACOLOGIC INTERVENTIONS
Cutaneous Stimulation and Massage
Ice and Heat Therapies
Transcutaneous Electrical Nerve
Stimulation (TENS)
Distraction
Guided Imagery
Relaxation Techniques
Hypnosis
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59
WHO's three step ladder to
use of analgesic drugs
www.who.int/cancer/palliat
ive/painladder
3
1
2
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OPTIONS FOR TREATMENT OFPAIN
Nonopioids (NSAID, Achetaminofen)
Opioids (Morphine, Codeine, Hydromorphone,
Methadone, Meperidine)
Analgesic Adjuvants(steroids,benzodiazepines,antidepressants, andanticonvulsants)
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Thank you