Hey, what's up everyone, Doctor Zishan here.
I really wanted to take a moment to thank everyone that listens
to our podcast, that subscribes to the podcast, that even shares
it amongst other people and your peers.
Thank you so much from myself and the team at NCLEX High
Yield. It's because of the audience
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education. Why not?
And then also right after that, we started doing trivia.
It helps the neurons fire. So on on test day, you get that
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have the on demand going. If you like the podcast, if you
like our YouTube channel, imagine having 70 hours of
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every topic and seeing all these people get 85 and out.
So again, thank you all so much and good luck.
All right, so today's podcast we're going to focus on sleep.
Now you may ask me, well, Doctor Z sleep really for the boards.
What can they possibly ask me that's so pertinent for the
boards that we have to talk about sleep?
There's a lot of different things that affect sleep and
that's something that we talk about when we talk about my
pneumonic needs, right? Always teach your patients about
their needs, nutrition, exercise, ETOH to avoid that,
don't smoke and we added in sleep.
So Doctor Z Shanz needs sleep is so important because there's so
many different parts of sleep and it may be something that we
deal with with patients outpatient or even inpatient.
So some of the topics that we're going to get into today are
sleep hygiene, super important when you're educating your
patients. We're going to talk about
circadian rhythm, especially when we're talking about
patients in the ICU or hospitalizations.
We're going to talk about restless leg syndrome.
We're going to talk about narcolepsy.
We're going to talk about obstructive sleep apnea as well.
So a lot of these topics get overlooked along with the stages
of sleep. And then we're going to try and
get into some practice questions and see how the boards are going
to ask them, whether it be pharmacological, whether it be
education, whether it be just teaching our patients and doing
that basic care and comfort in these situations and what they
pertain to. So as there's a lot of different
things that we can talk about here and we're definitely going
to get into them in depth. So let's get started.
A good starting point is understanding our circadian
rhythm. So what is our circadian rhythm?
It is in fact our body's internal 24 hour biological
clock. So for 24 hours, what's
happening? What's regulating our sleep,
wake cycles, our temperature, our hormones, bodily functions,
things of that nature. Because in a 24 hour period,
that rhythm needs to be as consistent as possible.
So we don't have any type of sleep disruptions and things
like hospitalizations, things like ICU, these are going to
disrupt our circadian rhythm. So as nurses, it is very
important for us to do interventions well.
What type of a question is that? Which of the following should
the nurse provide? It's education.
It's a select all that applied. So we want to maintain a
consistent schedule for sleeping.
Wake up at the same time, go to sleep at the same time, dim
lights in the evening, bright lights during the day,
activities during the day. Don't schedule anything at night
time and encourage that relaxation or techniques for
relaxation, things like reading, things like meditation, things
like breathing. And again, we want to minimize
any type of interruptions at night time, especially when
these patients are in for an extended period of time.
It's very easy to mess with that circadian rhythm.
But some of this is not in our control.
There are things like sleep disorders that actually are hard
for us to control. We may have more interventions
that need to be done. So what are sleep disorders at
the board's like? And the type of question that I
would ask here is 100% a case study with the matrix or grid.
And I'm going to compare because as you know, it's a differential
diagnosis or comparison of different types of diagnosis
that have similar or overlapping types of signs and symptoms.
So what sleep disorders would I throw into a case study?
Well, how about insomnia? How about sleep apnea?
How about narcolepsy? And the last one, restless leg
syndrome? I think this would be an
amazing, amazing case study or a matrix type grid type question.
But before we get into those sleep disorders, let's just talk
about regular sleep hygiene. Super important that we educate,
educate, educate our patients on sleep hygiene.
Well, it's it comes back to one of those things that I'm so
repetitive and so annoying about and it is Doctor Zeeshan's
needs. Always take care of your
patients needs N EE DS and we added in that last S.
So what is the needs as a refresher nutrition.
When do we say the opposite? We don't exercise.
Give me what you can. We don't say the opposite ETOH,
which is alcohol avoid, avoid, avoid DS is don't smoke in the
last S is sleep. These things are so important in
our day-to-day health and in any situation that we talk about, we
talk about basic care and comfort all the time.
Well, if I'm going to think about if I'm going to think
about somebody's basic care in any situation, I'm always going
to take care of their needs. So the last one, sleep and sleep
hygiene is super important. So what are some types of things
that I'm going to talk about with sleep hygiene when I'm
trying to educate my patients? So when I talk about education,
it's going to be a select all that apply question and or
further teaching further intervention.
So the first one, our sleep environment, we want to try to
keep it as dark as possible. So can we encourage blackout
curtains or eye masks or things to block out light?
Absolutely, absolutely. We want to, again, like we're
talking about our circadian rhythm in our patients that are
hospitalized or in the ICU. We want to keep it dim or dark
at night and we want to make it bright or open up the the
curtains or the blinds during the daytime, get that natural
light. That natural light is so
important for our patients, especially when they're
hospitalized, if we have the ability to do so.
Noise control, minimize, or some people even like white noise,
something in the background like a fan.
These things tend to soothe people as well, too comfortable
bed, pillows, blankets, things of that nature and temperature
control. So keeping the room at a decent
temperature, at a cool temperature where patients feel
comfortable. Again, basic care and comfort
when it comes to their environment.
But when we're educating our patient, especially outpatient,
we're looking at their pre sleep routine.
So again, things like relaxation techniques, meditation, deep
breathing, reading, limiting screen time.
I know a lot of us love either watching TV, maybe sitting on
our phones, on our tablet, on our computer, but that is actual
stimulation. So read a book or just meditate
or breathe. close your eyes. You'll be surprised how quickly
this can change your sleep habits.
Things like supplementation. Now my caveat with
supplementation is always going to be consult your primary care
physician, your nutritionist, whoever it is that takes care of
your health before you do anything.
But in a personal sense, I'm going to talk about my
experience with supplementation. As studies progressed, we
learned that magnesium and if we talk about hypomagnesemia, think
about that. When do we lose magnesium?
Well, we lose magnesium with diuretics, we lose magnesium
with alcohol intake. But what is the side effect of
hypomagnesemia? We get tremors, we get that
nerve instability. If we supplement magnesium, then
we're going to get that nerve or neurological stability.
Do you think that helps us with maybe anxiety or going to sleep?
Studies have shown so. So I've been taking magnesium
personally and that's been helping me.
So again, supplementation in our pre sleep routine is very
important if your primary care and or whoever takes care of
your health deems necessary. Another thing that I take is a
product called Magic Mind. Now Magic Mind I take two times
a day. One is in the morning and one of
the sleep hygiene rules is caffeine, caffeine, caffeine,
right? We don't want to overtake
caffeine. We don't want to take caffeine
into the late afternoon or into the evening.
But the thing about Magic Mind is it gives me that start in the
daytime, that caffeine that's time released.
So that way I'm not getting that surge of caffeine and then
crashing hard where it's ruining my entire day.
And I'm getting that excessive daytime sleepiness, which we'll
talk about in some of these sleep disorders here later.
So the active ingredients in Magic Mind are going to help me,
lion's mane, ashwagandha throughout the daytime.
But now I'm starting to take their nighttime formula, Their
Magic Minds sleep right before bed, along with about 30 minutes
before bed, along with my magnesium, something that's been
studied by doctors. Again, for me, it's all about
studies and validation, Something that's been studied
over 10 years and has scientific advisory by a board of doctors.
I'm going to trust it a lot more than somebody that claims
things. So my magic minds for sleep, my
magic mind for the daytime is way more important to me than
getting a cup of coffee or tea throughout the day or taking one
of those energy drinks. I like things that are natural.
I like things that are more sustained.
And the cool thing with Magic Mind is that they're giving our
students 45% off. If you buy the two combination,
all you have to do is go to magicmind.com/high Yield Jan,
like January and get started. So again, that's
www.magicmind.com/high Yield Jan and they're giving 45% off to
our students. The last thing in our pre sleep
routine is avoid heavy meals or alcohol prior to bedtime.
We don't want to take a type of stimulants.
So these are things that we want to do as a pre sleep routine,
consistent sleep schedule when it comes to sleep hygiene,
daytime nighttime, when you wake up, when you go to sleep, it
doesn't matter what day of the week it is, keep it consistent.
And then again, exercising regularly and that daylight
exposure. So just common things that we're
going to educate our patients on when it comes to a sleep cycle.
Now we've got to talk about these different types of sleep
disorders because the boards are going to love to compare the
four aforementioned sleep disorders, insomnia, obstructive
sleep apnea, narcolepsy, and restless leg syndrome.
So let's start with one that I think comes up more frequently
than not, and that is insomnia. It's one of those things that we
have a hard time falling asleep, staying asleep, or we're waking
up too early or we're not able to go back to sleep.
And it's not because we have things to do or we have to wake
up. It's the fact that we actually
have the opportunity to rest, but we just can't.
And it is associated with these following risk factors, anxiety,
depression, chronic pain, select all that apply.
So the risk factors are very important to understand.
Ultimately, risk factors are what type of question they are.
In fact, select all that apply. What are the signs and symptoms
of insomnia that excessive daytime sleepiness or EDS,
excessive daytime sleepiness? We're going to have difficulty
concentrating, we're going to have memory issues, we can have
irritability, we can have anxiety, we can have increased
risk for accidents because we have that excess daytime
sleepiness. So signs and symptoms select all
that apply. And as I go through each one of
these signs and symptoms, you're going to notice that there are
things that overlap. This is why I said this is a
perfect matrix or a grid type question.
So what are we going to do about it?
Well, let's talk about our nursing interventions and or
treatment, basic care and comfort, pharmacological or non
pharmacological interventions. Obviously we go from least
invasive to most invasive. And when we're talking about
insomnia, if we're talking about the underlying cause being
something, something like anxiety or depression, well,
let's go back to mental health. With mental health, if we have
anxiety or we have a depression in general with mental health,
unless it's something like bipolar or something like
psychosis or things that need medication in that moment, what
is our first go to cognitive behavioral therapy?
So how does that change here? It doesn't.
So again, now we're tying in mental health again, teaching
them about sleep hygiene, cognitive behavioral therapy.
This is going to be our gold standard when we're talking
about non pharmacological nursing interventions for
insomnia. We can use pharmacological
interventions. So let's do a little bit of
farm. We can give them a sedative,
hypnotic, something like zolpidem.
If they were to ask anything about any type of farm with
zolpidem, what would they ask? Well, I would probably ask
identification. Remember, farm drugs are going
to be freebie questions. So identification, the fact that
we don't want to use this for an extended period of time because
we can develop tolerance, we can develop dependency.
We also want to educate them about things that we don't want
to mix it with, IE other types of sedatives, things like
benzodiazepines, things like alcohol.
And we want to talk about a side effect that can develop if we
use it too long, which is rebound insomnia.
Meaning we use it for insomnia, we take it away and then boom,
our insomnia actually gets worse.
Rebound insomnia. And also educating to not use it
in elderly patients. So with zolpidem and again, the
brand name, we're not going to worry about, but those that
don't know the brand name or can tie the brand name to it, it is
in fact Ambien. The next one is narcolepsy.
Not necessarily something I think is super, super high
yield, but I think it would be a great way to throw in a matrix
or grid. So what is narcolepsy?
Well, it's actually a neurological disorder.
It's excessive daytime sleepiness and sudden attacks of
sleep. There may be some certain signs
and symptoms, so here goes that matrix or grid where I'm going
to compare it to these other sleep disorders, signs and
symptoms. Excessive daytime sleepiness.
Cataplexy. What is cataplexy?
It's a sudden or brief loss of muscle tone.
You just kind of like become limp and it can be triggered by
emotions. You become toneless and limp.
Sleep paralysis, meaning you have this temporary inability to
move, like you're kind of stuck in a dream and you're, you're,
you're trying to move, you're trying to scream, but you can't.
And that can happen right before waking up or falling asleep.
And the last one is a term that we should know, hypnagogic
hallucinations. So what are hypnagogic
hallucinations? It's this vivid dreamlike
hallucination when you're about to fall asleep.
It almost feels like you're right there and it's happening
and it's real life, but it's not.
It's actually a hallucination, but it feels super real and
super vivid. So the signs and symptoms of
narcolepsy, how do we diagnose it?
Well, here's a freebie question. How do we diagnose it with the
polysomnography? A sleep study catch them going
into that hypnagogic hallucination.
Check out their sleep paralysis, see if they're having any type
of cataplexy, and then during the daytime, that excessive
daytime sleepiness. So what can we do about
narcolepsy? Well, we try to treat it
pharmacologically. This is one of those things that
we cannot use cognitive behavioral therapy for.
We use a medication called Modafinil and it is a stimulant.
So with Modafinil, what are we concerned about?
If it's a stimulant, We're worried about our vital signs.
We're worried about our blood pressure.
We're worried about our heart rate, we're worried about when
we're going to take it. Are we going to take it towards
the end of the night or we can take it towards the daytime.
So of course QAM or upon awakening.
We're also going to be worried about their appetite because
stimulants are going to be appetite suppressant.
So we have to worry about weight, BMI, electrolyte
disturbances, education, education, education Modafinil
educate them about safety precautions.
Well, doctor Z you narcolepsy safety precautions, I told you
they can develop cataplexy, meaning they go toneless.
Fall precautions, fall precautions.
The next one is our OSA obstructive sleep apnea.
Obstructive sleep apnea, meaning there's some sort of an
obstruction during my sleep that's causing me not to
breathe. Obstructive sleep apnea with
obstructive sleep apnea are risk factors can be non modifiable or
modifiable. What are the non modifiable risk
factors? Things like gender, male sex,
age greater than 40, postmenopausal women or family
history of obstructive sleep apnea or any type of anatomical
obstruction. But modifiable risk factors,
things that we can actually work on and change are obesity, which
is probably the major risk factor ABMI over 30 next
circumference because that pressure from an enlarged next
circumference can close our upper airway, causing that
obstruction. A next circumference of greater
than 17 inches in men and greater than 16 inches in women.
Smoking, alcohol use, especially before bed, sedatives, these are
all things that we can modify prior to.
What are some signs and symptoms that we're going to see when
we're talking about obstructive sleep apnea?
Loud intermittent snoring. Loud intermittent snoring.
You're going to typically see this by the partner.
The partner is going to be like they snore so loud, they snore
so loud, and then sometimes I think they stop breathing.
So witnessed apnea by the partner gasping or choking or
snorting sounds. So they're falling asleep,
falling asleep, falling asleep, and they stop breathing.
Then all of a sudden the respiratory system in our brain
kicks in and it says, wake up, wake up, wake up, you're not
breathing. And they do one of those and
then they wake up and you're like, whoa, what just happened?
How do we diagnose this? Again, polysomnography.
So again, a sleep study gold standard.
How are we going to treat this? Well, things that are
modifiable, we teach them about their needs, right?
Again, it comes back to the same concept, but things that are non
modifiable, what are we going to do about it?
And this is when we get into a continuous positive airway
pressure, we continuously give them this positive pressure
through their airway or what's called a CPAP continuous
positive airway pressure. We'll be surprised at how many
different things can be affected by obstructive sleep apnea.
Well, let's just think about this.
Let's go from head to toe. You know, I like to do
progression. Let's start with the brain.
If I don't have enough oxygen, do you think I can develop
anxiety, depression, fogginess, fatigue?
Yeah. Let's move down to the heart.
Increase blood pressure, Tachycardia.
Yeah. Let's go down to the pancreas.
Insulin resistance, increased blood sugar levels.
Yeah. So we talk about GI.
Can we start to develop weight gain?
Can we develop GERD? Yeah, We're talking about system
by system, the fact that we're not getting enough sleep, that
our body is being affected from head to toe.
And you'll see these signs and symptoms start to resolve when
this patient starts on AC PAP. They'll be like, whoa, I can't
believe I was not sleeping properly.
They get used to it. So educate, educate, educate
them. The last one is restless leg
syndrome. With restless leg syndrome, it
is a neurological disorder with this uncontrollable urge to move
the legs. And it's because we've got this
like tingling, numbness, crawling, burning, itching on
the legs. It's so uncomfortable that we
continuously have to move our legs, and it typically happens
when we're getting ready to sleep, while we're sleeping, or
when we're inactive. Moving or stretching or walking
alleviates the symptoms, but that's very inconvenient when
we're trying to sleep. Daytime fatigue and irritability
because I'm not sleeping properly.
I've got this restless leg syndrome.
The causes or the risk factors? Typically, we're worried about
genetics. Here it is, family history and
age, if it starts before the age of 45.
But there are some other things that can cause it, one being
iron deficiency. So what type of lab values am I
going to look at? Well, let's look at ferritin
levels less than 50. That is something I can
supplement. Remember if it is iron
deficiency that's causing restless leg syndrome, here goes
one of my concepts. Give them what they don't have,
give them iron. It could be chronic conditions,
things like end stage renal disease, diabetes or peripheral
neuropathy. Things like antihistamines,
antipsychotics, antidepressants may make the situation worse.
And another one that comes up that we were talking about
earlier in maternity is pregnancy typically seen in the
third trimester in pregnancy. If we start to see this, what
are we going to do about it? Well, we're going to educate
them that this typically resolves postpartum.
So alleviate it by walking around, by getting up, as
uncomfortable as it sounds, especially when we're trying to
sleep, especially when we're pregnant, especially when we're
fatigued. But because it resolves
typically after birth, we're not going to do any type of
pharmacological intervention here.
So clinical diagnosis, again, clinically we're going to
diagnose it by the signs and symptoms, but again, we can rule
out an actual lab value by getting ferritin levels, give
them what they don't have with any type of neuropathy.
Here's a drug that you must know, a little bit of farm here,
the drug pregabalin or gabapentin, super high yield.
Why with any type of neuropathy, with restless leg syndrome, we
can use a commonly prescribed drug.
So identify pregabalin, identify gabapentin for any type of
neuropathy. Well, where do we see
neuropathy, diabetic neuropathy, peripheral neuropathy and PAD.
These drugs are going to help stabilize those, stabilize those
nerves and get rid of that neurological pain that
neuropathy. So again, super high yield drug
with pregabalin. Little recap.
Well, we talked about circadian rhythm, how our sleep wake
cycles work. We moved on to sleep hygiene,
very important to educate our patients, great way to ask,
select all that apply and real life.
We talked about sleep disorders. We talked about narcolepsy,
insomnia, obstructive sleep apnea and restless leg syndrome.
We talked about the signs and symptoms because it makes a
perfect case study or matrix grid type question risk factors.
Another one of those six questions, nursing
interventions, another one of those matrix grid questions in
your case study, treatment freebie questions,
pharmacological non pharmacological interventions
and education, education education, nursing interventions
that basic care and comfort. So again with sleep, very
important to take a look at these and I hope you enjoy it.
Thank you for joining.