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)
- Substance or alcohol 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. //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 //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 //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 //www.sleepfoundation.org/sleep-diary
- Tsai, S. (2017, March 1). Medicines That Can Cause Insomnia. National Jewish Health. Retrieved December 2, 2021, from //www.nationaljewish.org/conditions/insomnia/causes/medicines-that-can-cause-insomnia
People with insomnia can’t fall asleep, stay asleep or get enough restful slumber. Insomnia is a common sleep disorder. Over time, lack of sleep can lead to health problems like diabetes, hypertension and weight gain. Behavioral and lifestyle changes can improve your rest. Cognitive behavioral therapy (CBT) and sleeping pills also help.
Insomnia is a common sleep disorder that is characterized by difficulty:
- Falling asleep initially.
- Waking up during the night.
- Waking earlier than desired.
What are the symptoms of insomnia?
Chronic insomnia may cause:
- Difficulty falling asleep and/or waking up in the middle of the night.
- Difficulty returning to sleep.
- Feeling tired/fatigued during the daytime.
- Irritability or depressed mood.
- Problems with concentration or memory.
What are the types of insomnia?
Insomnia can come and go, or it may be an ongoing, longstanding issue. There is short term insomnia and chronic insomnia:
- Short term insomnia tends to last for a few days or weeks and is often triggered by stress.
- Chronic insomnia is when the sleep difficulties occur at least three times a week for three months or longer.
How common is insomnia?
Sleep disorders are very common. They affect up to 70 million Americans every year.
Insomnia symptoms occur in approximately 33% to 50% of the adult population while Chronic Insomnia disorder that is associated with distress or impairment is estimated at 10% to 15%.
How much sleep do most people need?
Most adults need around seven to nine hours of sleep per night but the amount of sleep needed to function at your best varies between individuals. The quality of your rest matters just as much as the quantity. Tossing and turning and repeatedly awakening is as bad for your health as being unable to fall asleep.
Many things can contribute to the development of insomnia including environmental, physiological and psychological factors, including:
- Life stressors including your job, relationships, financial difficulties and more.
- Unhealthy lifestyle and sleep habits.
- Anxiety disorders, depression and/or other mental health problems.
- Chronic diseases like cancer.
- Chronic pain due to arthritis, fibromyalgia or other conditions.
- Gastrointestinal disorders, such as heartburn.
- Hormone fluctuations due to menstruation, menopause, thyroid disease or other issues.
- Medications and other substances.
- Neurological disorders, such as Alzheimer’s disease or Parkinson’s disease.
- Other sleep disorders, such as sleep apnea and restless legs syndrome.
What are the risk factors for insomnia?
Insomnia occurs more often in women than in men. Pregnancy and hormonal shifts can disturb sleep. Other hormonal changes, such as premenstrual syndrome (PMS) or menopause, can also can affect sleep. Insomnia becomes more common over the age of 60. Older people may be less likely to sleep soundly because of bodily changes related to aging and because they may have medical conditions or take medications that disturb sleep.
What are the consequences of insomnia?
When you can’t fall asleep or your rest is fitful, you may:
- Be irritable, anxious or depressed.
- Feel fatigued or low on energy throughout the day.
- Have memory problems or difficulty concentrating.
- Struggle at work, school or in relationships.
There is no specific test to diagnose insomnia. Your healthcare provider will perform a physical exam and ask questions to learn more about your sleep problems and symptoms. The key information for the diagnosis of insomnia is reviewing your sleep history with your doctor. Your provider will also review your medical history and medications you are taking to see if they may be affecting your ability to sleep. You may also:
- Get a blood test: Your doctor may want you do a blood test to rule out certain medical conditions such as thyroid problems or low iron levels that can negatively impact sleep.
- Keep a sleep diary: You may be asked to write down your sleep patterns for one to two weeks (bedtime, wake time, naps, caffeine use, etc.) This information can help your provider identify patterns or behaviors that interfere with rest.
- Complete a sleep study: Sleep studies (polysomnograms) are not necessary for diagnosing insomnia. If your doctor has concerns that your insomnia may be caused by sleep apnea or another sleep disorder, you may be referred. You may go to a sleep disorders center or do the study at home.
Over time, lack of sleep or poor quality sleep can negatively affect your physical and mental health. Insomnia can contribute to:
How is insomnia managed or treated?
Short-term insomnia often gets better on its own. For chronic insomnia, your healthcare provider may recommend:
- Cognitive Behavioral Therapy for Insomnia: Therapy (CBT-I): CBT-I is a brief, structured intervention for insomnia that helps you identify and replace thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep. Unlike sleeping pills, CBT-I helps you overcome the underlying causes of your sleep problems.
- Medications: Behavior and lifestyle changes can best help you improve your sleep over the long term. In some cases, though, taking sleeping pills for a short time can help you sleep. Doctors recommend taking sleep medicines only now and then or only for a short time. They are not the first choice for treating chronic insomnia.
Can melatonin help me sleep?
Your body produces a hormone called melatonin that promotes sleep. Some people take melatonin supplements as a sleep aid. But there’s no proof that these supplements work. Because the U.S. Food and Drug Administration (FDA) doesn’t regulate supplements the same as medications, you should talk to your healthcare provider before taking one.
Lifestyle changes and improvements to your bedtime routine and bedroom setup can often help you sleep better:
- Avoid large meals, caffeine and alcohol before bed.
- Be physically active during the day, outside if possible.
- Cut back on caffeine, including coffee, sodas and chocolate, throughout the day and especially at night.
- Go to bed and get up at the same time each day, including weekends.
- Put away smartphones, TVs, laptops or other screens at least 30 minutes before bedtime.
- Quit smoking.
- Turn your bedroom into a dark, quiet, cool sanctuary.
- Unwind with soothing music, a good book or meditation.
Some people with insomnia sleep better after changing daytime and nighttime behaviors. When these changes don’t help, therapy or medications can improve slumber.
You should call your healthcare provider if you experience:
- Difficulty concentrating or memory problems.
- Extreme fatigue.
- Mood problems, such as anxiety, depression or irritability.
- More than three months of sleep problems.
What should I ask my healthcare provider about insomnia?
If you have insomnia, you may want to ask your healthcare provider:
- Am I taking any medications keeping me awake?
- What changes can I make to sleep better?
- How does cognitive behavioral therapy improve sleep?
- How do I find a therapist?
- Could I have other sleep disorders like sleep apnea?
If you're suffering from insomnia, don't hesitate to reach out to your healthcare provider for help. They may offer tips for managing issues that interfere with your sleep. Many people with insomnia rest better after changing their diet, lifestyle and nighttime routines. Or they may also recommend medications or cognitive behavioral therapy.
Last reviewed by a Cleveland Clinic medical professional on 10/15/2020.
References
- American Academy of Sleep Medicine. Healthy Sleep Habits. (//sleepeducation.org/essentials-in-sleep/healthy-sleep-habits) Accessed 10/10/2020.
- American Academy of Family Physicians. Insomnia. (//familydoctor.org/condition/insomnia/) Accessed 10/10/2020.
- Centers for Disease Control and Prevention. Sleep and Sleep Disorders. (//www.cdc.gov/sleep/index.html) Accessed 10/10/2020.
- National Heart, Lung and Blood Institute. Insomnia. (//www.nhlbi.nih.gov/health-topics/insomnia) Accessed 10/10/2020.
- Sleep Foundation. Insomnia. (//www.sleepfoundation.org/insomnia) Accessed 10/10/2020.
- U.S. Department of Health and Human Services. Insomnia. (//www.womenshealth.gov/a-z-topics/insomnia) Accessed 10/10/2020.
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