The Wizards of Nod
Nurses help sleep disorder patients reclaim their good mornings through therapy and education

By Heather Stringer
May 3, 2004

Lee Myers, RN, FNP, APRN, is an expert in an area of medicine that often is overlooked, although most people spend almost a third of their lives engaged in this activity. Myers is a nurse practitioner at the Sleep Disorders Center of Central Texas in Austin.

Myers admits that he stumbled onto this area of nursing when other jobs were unavailable, and never expected sleep medicine to have such radical impact on patients. His patients include people like a woman in her 70s who became limp in her legs when she played with her grandchildren because they made her laugh. She was suffering from cataplexy, a condition common in narcoleptic patients. Then there was the 36-year-old man who was falling asleep while driving and during work meetings because he had sleep apnea. The treatments for these two patients were relatively simple, and Myers watched their lives flip from unbearable to normal in a matter of weeks.

Even though dramatic improvements are common with sleep disorder patients, many sleep conditions remain undiagnosed. According to a 2003 poll of more than 1,500 adults conducted by the National Sleep Foundation, two-thirds of adults reported sleep problems, but only one in eight said their problems had been diagnosed.

Nurses agree that in many cases, patients consider their other health problems more important than their issues with sleep. Yet sleep disorders such as sleep apnea, restless legs syndrome, and insomnia left untreated can aggravate other health problems.

Poor sleep can affect the immune system and blood pressure levels and increase susceptibility to headaches and depression. Most nurses who work in sleep centers said that sleep apnea is the most common condition they treat and also the most rewarding.

Return to normalcy

“The patients come to you in such misery, and getting them started on treatment can be life-changing,” Myers said. People with sleep apnea usually have something obstructing their airflow in the nose or mouth and, as a result, may experience heavy snoring and periods where they don’t breathe momentarily. The inability to breathe usually causes someone to wake up, which can interrupt deep sleep, and is why these people can be excessively tired during the day.

With most sleep apnea cases, physicians ask their patients to spend a night in a sleep lab where technicians run tests to monitor electrical activity in the brain, eye movement, muscle activity, heart rate, and other things while the patient sleeps. If lab results reveal that the patient has sleep apnea, then the patients usually are prescribed nasal CPAP, or continuous positive airway pressure. The patient wears a mask over the nose during sleep to maintain this higher air pressure.

In the case of the sleep apnea patient in his 30s, Myers learned that the man had such severe apnea that he would wake up several times a night and couldn’t get back to sleep. “We started him on CPAP therapy a month ago, and now he’s raving about how his life has changed,” Myers said. “He had spent the last 10 years operating at 50%.”

The National Sleep Foundation estimates that about 18 million Americans have sleep apnea, and people who are most likely to have it include those who snore loudly and are also overweight, have high blood pressure, or who have a physical abnormality in the nose, throat, or other part of the upper airway.

For Myers, one of the most rewarding parts of his job is educating patients about their conditions and treatments.

Another problem Myers treats is restless legs syndrome, a condition in which people have the urge to move their legs to relieve discomfort, which can manifest in the form of a tingling, cramping, or burning sensation in the legs. People usually feel RLS when they are sitting down late in the day or at night or trying to fall asleep at night.

Myers has treated many older patients who have had this condition for 40 to 50 years, and in severe cases, RLS is debilitating if it prevents patients from sleeping at night. The treatment, Myers said, is usually simple and effective: a small dose of a drug used to treat Parkinson’s disease.

Although the sleep disorder may vary from patient to patient, nurses in this field usually spend time educating patients about the basic sleep cycles people go through during the night. The two main phases of sleep are non-REM (rapid eye movement) and REM, said Wendy Moore, RN, the lead nurse in the Mayo Sleep Disorders Center in Rochester, Minn. The deepest and most restorative sleep happens during the later phases of non-REM sleep. Moore believes nurses in particular need to guard their sleep hours because many do irregular shift work that can threaten sleeping routines.

“America is not a society that values people getting enough sleep,” Moore said. “When we wonder why we don’t feel well, it may be because we are sleep deprived. Many nurses have to work challenging shifts for years, and they need to be disciplined about getting enough sleep.”

Marcia Hill, RN, a certified clinical research coordinator at Baylor College of Medicine in Houston, said it is interesting to see how many people do not practice good sleep habits. Some guidelines for getting enough rest include:

> Keep to a regular time of going to bed and waking, even on weekends.
> Do not exercise less than five hours before bedtime.
> Don’t drink coffee or smoke three hours before bedtime.
> Turn the clock away if you struggle with watching the clock.
> Get up at the same time even if you have a poor night of sleep.

Even though these basic tips may work for many people, some of the most difficult cases in sleep medicine include insomnia patients who continue to struggle with getting enough rest.

“The majority of the time, insomnia has to do with a life stressor, and then the problem gets worse because of the stress of not being able to sleep,” Myers said. “The brain forms associations and bed becomes a place where someone can’t fall asleep.”

To treat these patients, Myers tells people to leave their bedroom if they can’t fall asleep after about 15 minutes. If that doesn’t work, he may suggest sleep restriction, or staying awake until 1 or 2 AM. This way the patient is so tired that sleep comes more easily. If this works and sleep becomes less frustrating, then he can help the patient work back to an earlier bedtime.

Shh! Patients sleeping

While most nurses who are interested in sleep medicine work with patients who have disorders, one nurse in Minnesota took a different tack on the subject. Cheryl Cmiel, RN, BAN, a staff nurse at Saint Marys Hospital in Rochester, Minn., had heard patients express discontent with the level of noise and interruptions during sleeping hours at her hospital. To investigate the problem, she decided to conduct a study in 1999. Cmiel and a team of other nurses placed noise dosimeters in three empty patient rooms during a night shift. They found peak dosimeter readings as high as 113 decibels — the equivalent of the noise from a jackhammer — during the shift change around 7 AM.

Cmiel and another nurse also spent a night in the thoracic surgery unit, and she was surprised at what she found. “It was very difficult to sleep,” she said. “I am a light sleeper, and I could hear the noise in the hallway from people talking and moving equipment.” She also was wakened by the sounds of different monitor alarms that sounded, for example, when the monitor couldn’t measure a reading if she moved.

Once Cmiel had identified the reasons for patient sleeping problems, she tackled the problem. She educated fellow nurses about the need to be quiet with equipment and their voices, and she also lowered the volume on the monitor alarms that patients wore.

“The most rewarding part is just getting the information out and hearing other areas are doing the same thing,” Cmiel said. “It was such simple things we did, and it didn’t take a lot of effort.”

Whether nurses are changing hospital routines or teaching patients about how to wear their new CPAP masks, nurses in sleep medicine agree that their work is rewarding.

“It’s very gratifying to talk to the patients when they come back after a month on CPAP, and so many will say, ‘I got my life back,’ ” said Brenda Ball, RN, a staff nurse in the outpatient treatment unit at Lima (Ohio) Memorial Hospital. “So many will say they feel rested, and wonder why it took so long for them to get here. It’s gratifying to know these people have had it make such a difference.”

Ball has become such a believer in what she teaches her patients that she’s changed her own sleeping habits. She used to get four to five hours of sleep per night.

Then she started to get seven to eight hours, and noticed that she felt better.

“Now when I get up, I am not as tired and I can go longer in the day without getting that dragging feeling,” Ball said. “I used to stay up until 11:30 and get up at 5 AM. Now I know those TV programs just aren’t worth it. There are portions of sleep we need or we can’t regenerate to prepare for the next day.”

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