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7/21/2014
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26th Annual Southwestern Regional NP Symposium
Susan Phillips MSN, RN, PMHCNS‐BC, PMHNP‐BC
Carol Moffett Ph.D, FNP‐BC, CDE, FAANP
Arizona Nurses Association
Chapter 9
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Learning Objectives1. Describe symptoms of fatigue
2. Identify self‐assessment strategies to monitor fatigue and tools for client assessment
E i f i d l
Fatigue
3. Examine fatigue and sleep management methodologies including countermeasures to promote health and safety
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Fatigue
Zhou et al., (2011). Mismatch subjective alertness objective performance, Sleep Research.3
Introduction Approximately 38% of the U.S. workforce is fatigued
40 million Americans suffer from a sleep disorder
Fatigue results in:
Fatigue
•insomnia •sleep apnea
•restless legs syndrome •circadian rhythm sleep‐wake disorders
•narcolepsy •shift work sleep disorders
Fatigue results in:
‐ slower reaction time
‐ trouble concentrating and remembering
‐ difficulty communicating with others
‐ falling asleep on the job or while driving
‐ risk for making a safety‐critical error
‐deterioration in health (increases in obesity, diabetes and cancer)
Fatigue leads to a variety of adverse medical outcomes, burnout, errors, and client dissatisfaction
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Fatigue
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Awareness is the first and most important step in fatigue management
Signs of Excessive Fatigue
Emotional More quiet or withdrawn than usual
Lack of energy
Fatigue
Lack of energy
Lacking the motivation to perform
tasks
www.eheandme.com6
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Signs of Excessive Fatigue
Physical Yawning
Drooping eyelids
Fatigue
p g y
Rubbing of eyes
Head dropping
Microsleep
Digestive problems
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Signs of Excessive Fatigue
Mental Difficulty concentrating on tasks
Lapses in attention
Fatigue
Difficulty remembering tasks being performed
Failing to communicate important information
Failing to anticipate events or actions
Accidentally doing the wrong thing
Accidentally not doing the right thing
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Lack of Sleep May Lead to Junk Food Binging
Fatigue
Food BingingA Swedish Study of 16 normal weight young men found:
Lack of sleep can lead to:
• eating larger portions of high‐calorie foods • increasing food intake regardless of whetherfeeling full
• increasing long‐term risk of weight gain
Uppsala University, news release, Feb. 20, 2013 http://consumer.healthday.com/Article.asp?AID=6737589
Individual Fatigue Likelihood AssessmentStep 4. Add all points together to determine your score.
INDIVIDUAL FATIGUE LIKELIHOOD ASSESSMENT
Individual Fatigue Likelihood AssessmentStep 1. Sleep in prior 24 hours
Sleep < 2h 3h 4h 5+hPoints 12 8 4 0
S Sl i i 8 h
FRONT BACK
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Step 2. Sleep in prior 48 hoursSleep <8h 9h 10h 12+hPoints 8 6 4 0
Step 3. Hours of wake since last sleepAdd one point per hour awake greater
than sleep in step 2.
http://www.tc.gc.ca/eng/civilaviation/standards/standards‐3922.htm
NP Fatigue SurveyDemographics
Respondents 134 93% Female
Age
20‐30 3%
31‐40 17%
41‐50 20%
51‐60 45%
61‐70 14%61 70 14%
71‐80 1%
Education
Masters 76%
DNP 10%
PhD 7%
Years
RN prior to NP 67% > 10 yrs
As NP 50% >10 yrs
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Work Schedule and Hours
Time of Day usually worked
Day 76%
Day & or Eve. 23%
Hrs/Day in clinical practice 8‐10 38%
10‐12 28%
12‐16 13%
>16 2%
# Days/wk in clinical practice# Days/wk in clinical practice
3 days/wk 13 %
4 days/wk 21%
5 days/wk 47%
7 days/wk 3%
Hrs/wk in clinical practice
<48 hrs 75%
>56 hrs 16%
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NP Survey Results
Client Load, Time per Client, and Positions
# Clients/day usually seen
<10 16%
10‐15 31%
16‐20 26%
21‐25 18%
>26 10%
# Minutes/ client /
No restrictions 25%
10‐20 min 38%
20‐30 min 24%
>30 min 13%
# Of Positions of Employment
1 position 65%
2 or more 35%
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Sleep
Hrs/night of sleep
<4 1.4%
4‐5 12%
6‐7 65.5%
8‐9 18%
>9 3%
Concern re: quality of sleep
NP Survey Results
Concern re: quality of sleep
Seriously 14%
Moderate 35%
Mildly 32%
Not at all 18%
How often Relaxed at HS
Not at all 8%
Some of time 41%
At least ½ of time 30%
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Sleep Pressure—Increases with time
•After ‐Awake for 24 hours‐‐sleep happens quickly with inactivity
Sleep Cycle
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Human Biological Clock
17http://upload.wikimedia.org/wikipedia/commons/thumb/3/30/Biological_clock_human.svg/2000px‐Biological clock human.svg.png
Eppworth Sleepiness ScaleScore of 8 Borderline 10 Abnormal
Situation Would Never Doze
Slight Chance of Dozing
Moderate Chanceof Dozing
High Chance of Dozing
Sitting & Reading 0 1 2 3
Watching TV 0 1 2 3
Sitting, inactive in public place (i th t ti )
0 1 2 3(ie, theater or meeting)
Passenger in car for an hour without break
0 1 2 3
Lying down to rest in afternoon
0 1 2 3
Sitting quietly after lunch without alcohol
0 1 2 3
In a car while stopped for a few minutes in traffic
0 1 2 3
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Other Sleep Questionnaires & Tools Children's Sleep Habits Questionnaire (abbreviated)
Book to assist parents
School Sleep Habits Survey
8 page survey for use with TEENS
Teens require 8½ hours—and on average 9¼ hours of uninterrupted sleep
National Sleep Foundation Sleepiness Test ( 6 items)
On line quiz found on National Sleep Foundation Site
National Sleep Foundation Site offers many tools
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Common Sleep Disorders
Obstructive Sleep Apnea Loud disruptive snoring
Idiopathic Daytime Hypersomnia
Excessive daytime sleepiness
Narcolepsy Excessive sleepiness, sleep paralysis (briefly unable to move when awakening), hypnogogic hallucinations, cataplexy (sudden loss of muscle strength triggered by emotion or laughter)
Insomnia Sleep onset difficulties, awakenings with trouble falling asleep
Delayed Sleep Phase Unconventional timing of sleep/wake schedule
Syndrome
Restless Leg Syndrome Uncomfortable leg sensations accompanied by urge to move or adjust legs or arms
Periodic Limb Movements of Sleep
Semi rhythmic contractions of the limb accompanied by limb jerks usually of the feet
REM Sleep Behavioral Disorder (RSBD)
Dream enacted behaviors– can include yelling, screaming, punching, running
Parasomnias Abnormal behaviors –such as night terrors, sleep walking, sleep talking
Nocturnal Eating Uncontrolled episodes of eating—person may not be aware of
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Sleep Hygiene1. Allow enough time for sleep.
‐‐‐‐Most people need 7‐9 hours of sleep each day
2. Avoid heavy meals and alcohol before sleep.
3. Reduce intake of caffeine and other stimulants several hours before bedtime
4. Arrange a sleep environment that is very dark, comfortable, quiet, &
Fatigue
cool to facilitate falling asleep quickly and staying asleep.
4. Avoid TV beds and other media‐furniture.
5. Follow an exercise routine (but not within 3 hours before bedtime).
‐‐‐Daily physical activity improves sleep‐helps with stress management, and promotes general health
6. Seek assistance from healthcare providers for continuing difficulties with sleep, since specific sleep disordersmay require special treatments.
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Food and Drink to Promote Sleep
1. No caffeine 4‐6 hours before bed2. No alcohol at least 3 hours before bed (affects REM
sleep)3 N h l b f b d
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3. No heavy meals before bed• Foods to eat:
• Oatmeal• Almonds• Whole grain bread• Hummus
Sleep Aids
Report using meds to help sleep
40%
Freq of med use for the 40% who reported use
5‐7 x/wk 50%%
NP Survey Results
Report using Alcohol to assist with sleep
17%
Freq of Alcohol use for the 17% who
reported use
5‐7x/wk 42%
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OTC Sleep Aids (Antihistamines)Medication Uses Adverse Effect
Diphenhydramine (Benadryl)
Allergy symptoms, Insomnia •Caution with CNS depressants (e.g. ETOH).due to additive sedative effect.•Common reactions : dizziness, drowsiness, impaired coordination, blurred i i h i
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vision, hypotension, photosensitivity
Nyquil Cold & Flu acetaminophen – decreases fever/painchlorphreniramine –antihistamine for relieving allergic rhinitis, sneezing, itchy/watery eyes, itchy nose/ throatdextromethorpan – antitussivefor suppressing cough
•Abuse potential•Caution with CNS depressants (e.g. ETOH).due to additive sedative effect•Common reactionsBlurred vision, diplopia, fatigue, hypotension, agranulocytosis
Melatonin OTC‐ & Prescriptive CousinsPromote Sleep Initiation
Medication Uses Adverse Effects
Melatonin (dietary supplement)3 mg/hsProlonged Release prescriptive version
•Insomnia,•treatment of jet lag, •some anti‐inflammatory affect,•circadian rhythm sleep disorders,
Use with caution with benzodiazepines (potentiates anxiolytic effect )and CNS depressants (increases the sedative effect)Avoid cerebral stimulants – work synergistically and exacerbate
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p papproved in Europe
2 Prescription
Melatonin Receptor Agonists approved by FDA
1. Tasimelteon2. Ramelteon
(Roserem) ‐8mg & 16mg doses
•Tasimelteon –only for use in blind adults tx 24hr sleep cycle disturbances•Ramelteon‐ tx. Delayed sleep onset (decreased time to fall asleep and duration of sleep by40min)
y g yinsomnia
•Ramelteon‐ (6% report) somnolence, dizziness, nausea, fatigue, headache, and insomnia
•Skidmore‐Roth, L. (2006). Mosby’s handbook of herbs& natural supplements (3rd ed.). St. Louis, MO: Elsevier. EpocratesOnline.•http://en.wikipedia.org/wiki/Melatonin
Prescription Sleep MedicationsPromote Sleep Initiation
Medication Benefit Adverse Effect
Zolpidem(Ambien)5 & 10 mg dosing
2013 FDA –advisedWomen‐ 5 mg dose
Short‐term use for insomnia (3 months)—sleep initiationShort acting hypnotic•Short half life 2‐3 hours
Serious Reactions ‐ depression exacerbation, SI, aggressive behavior, complex sleep‐related behavior, hallucinations, amnesia, withdrawal if abrupt d/cCaution in Elderly‐ fall riskCommon Reactions – drowsiness(extending more than 8 hours with
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gincreased MVA especially in women), dizziness, lightheadedness, lethargy, drugged feeling
Eszopiclone(Lunesta)
Schedule IV5/2014 FDA warning
starting dose decreased
to 1 mg‐ men and women
Insomnia – onset and maintenance•Half life 6 hours
Serious Reactions – similar to AmbienCommon Reactions – somnolence, depression, anxiety, confusion, hallucinations, abnormal dreamsImpairments–impaired driving noted 11 hours after dose (men =women), memory and coordination impairments
•Triazolam (Halcion) •Zaleplon (Sonata)
Insomnia Both can be habit forming—properties similar to benzodiazipines
Prescription Sleep MedicationsMedications Uses Adverse Effects
Hydroxyzine(Vistaril)Antihistamine25‐100 mg
Anxiety, pruritis, sedation, nausea and vomiting, insomnia½ life 3 hours
•Caution with CNS depressants (e.g. ETOH)due to additive sedative effect. May impair thinking and reactions, slurred speech, driving impairment
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5 g p g pcaution
Lorazepam (Ativan)Benzodiazepine2‐4 mg at bedtime (adult)1‐2 mg (elderly)
Anxiety, short‐term treatment of insomnia, pre‐op sedation
•Dependency/Addiction•Serious Reactions –respiratory depression, apnea, respiratory depression, dependency, abuse, SI, avoid abrupt withdrawal•Common Reactions –sedation, dizziness, fatigue, amnesia, confusion
Drug Use Adverse Effects
Doxepin (Silenor)***3mg‐6 mg
Insomnia (early morning awakening and returning to sleep), depression
Few side effects at low dose. Good safety and efficacy in elderly with low dose CNS depression at higher dose
Imipramine(Tofranil)
Depression, chronic pain, insomnia
Avoid sudden withdrawal, use caution with ETOH abuse, contraindication with
Prescription Sleep MedicationsSleep Initiation &Return to Sleep –Tricyclic Anti Depressants
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10‐20 mg
FDA Black Box Warning
– suicidality risk
St. John’s WortSerious Reactions ‐ QT prolongation, orthostatic hypotension, syncope, ventricular arrhythmias, hallucinations, psychosisCommon Reactions –drowsiness, dizziness, blurred vision , impaired coordination, confusion, anxiety, agitation
Amitriptyline (low dose) 10‐25 mg‐‐ 2 hrs prior to HS
See above See above
InsomniaCognitive Behavior Therapy to Treat InsomniaGoodnight Mind: Turn off Your Noisy Thoughts & Get a Good
Night’s Rest
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Cognitive Behavioral Therapy for Insomnia App– VA sponsored
CBT‐i Coach –collaborative ‐‐between VA’s National Center for PTSD, Stanford School of Medicine, and DoD’s National Center for Telehealth and
Technology.31
5 of 10 Best Insomnia Apps
Sleep Cycle alarm clockiPhone ‐ 4.5 stars $0.99
Insomnia Cure –Sleep Now –
with Max KirsteniPhone 4 stars $2 99
Fatigue
http://www.healthline.com/health‐slideshow/top‐insomnia‐iphone‐android‐apps
iPhone ‐ 4 stars ‐ $2.99
SleepiPhone ‐ 4.5 stars ‐ $0.99
Yoga for InsomniaiPhone ‐ 4.5 stars ‐ $2.99
Deep Sleep withAndrew Johnson
iPhone & Android –4 ‐4.4 stars ‐ $2.99
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Perceived Fatigue related Problems
Concern re : errors due to fatigue
Seriously 11%
Moderately 18%
Mildly 39%
Not at all 32%
Ability to concentrate affected
NP Survey Results
All or most of time 8%
Some of time 65%
Never 27%
Feel Drowsy Driving after work
Most of time 14%
Some of time 49%
Never 37%
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Commuting
One of the most dangerous activities is Driving While
Fatigue
gFatigued
Danger increases when driving at times your body wants to sleep
Nightshift workers are 4 to 7 times more likely to have an accident while driving home
DWF
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How often do you feel?–
not at all– some of the time–
a moderate amount of time–
at least half of the time–
a little more than half of the time–
most of the time–
–....distressed about work?
10.14%14
31.88%44
23.19%32
9.42%13
13.04%18
12.32%17
NP Survey Results
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–....dread about waking up to another day of work?
28.68%39
41.18%56
9.56%13
7.35%10
6.62%9
6.62%9
–....like quitting your job?
33.33%46
31.16%43
10.87%15
6.52%9
8.70%12
9.42%13
–....like your mind is foggy and inattentive at work?
31.65%44
46.76%65
10.79%15
4.32%6
2.88%4
3.60%5
–....exhausted at work?
20.86%29
45.32%63
13.67%19
6.47%9
7.19%10
6.47%9
–....that too h i
20.86% 29.50% 19.42% 4.32%6
11.51%6
14.39%
How often do you feel?–
not at all– some of the time–
a moderate amount of time–
at least half of the time–
a little more than half of the time–
most of the time–
NP Survey Results
much is expected of you at work?
29 41 27 6 16 20
–....that your work life takes all of your energy?
17.52%24
21.90%30
16.79%23
7.30%10
13.14%18
23.36%32
–....mentally or physically exhausted after work?
7.41%10
31.11%42
12.59%17
11.85%16
20.00%27
17.04%23
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....you have
difficulty recovering your energy between work
14.39%20
43.17%60
15.11%21
7.19%10
9.35%13
10.79%15
How often do you feel?–
not at all– some of the time–
a moderate amount of time–
at least half of the time–
a little more than half of the time–
most of the time–
NP Survey Results
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shifts?
....you do not get enough time between work shifts to recover your energy fully?
22.30%31
41.73%58
14.39%20
6.47%9
6.47%9
8.63%12
How often do you feel?– not at all–
some of the time–
a moderate amount of time–
at least half of the time–
a little more than half of the time–
most of the time
–....you have lots of energy to give family and friends?
16.18%22
53.68%73
13.24%18
6.62%9
7.35%10
2.94%4
–....you have f
22.46% 48.55% 15.22% 5.80% 5.07% 2.90%
NP Survey Results
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energy for your
hobbies/relaxingactivities in your spare time?
31 67 21 8 7 4
–....you have energy for physical exercise?
25.90%36
38.85%54
18.71%26
4.32%6
7.19%10
5.04%7
...fully rested at the start of each work day/shift?
15.11%21
43.17%60
17.99%25
4.32%6
8.63%12
10.79%15
Managing Fatigue Beasts
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CountermeasuresLighting the Work Environment
Stimulatory effects of 750‐1000 lux Illumination
Reverses normal fall in alertness related to night shift
Adverse health effects
Fatigue
Adverse health effects
Widespread neuroendocrine effects
Melatonin suppression
Elevation of cortisol
Increases heart rate
Hypertension
Hyperglycemia
Decrease in appetite regulating hormone leptin
Increased risk of cancer
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Interventions
Fatigue
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Sleep PressureWarm temperature Reduced social stimulation and interaction
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interaction Dim lightingMinimal physical activity Low noise levels Passive monitoring type work
Awake for 24 hours‐‐sleep happens quickly with inactivity
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Countering Sleep Pressure
– Cool temperature
– Increased social stimulation and interaction
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– Bright lighting
– Increased physical activity
– Loud noise levels
– Active work
Metro Nap Energy Pod1. Ergonomic2. Sound control3. Light control4. Timer
Rents for about
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Rents for about $700/month
Coffee: The Civil War Soldier’s Secret Weapon
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“The power of the soldiers to endure the fatigueof the march and keep their places in the ranks was greatly enhanced by an opportunity to brew a cup of coffee by the wayside.”Uncommon Grounds: The History of Coffee and How It Transformed Our World By Mark Pendergrast
CaffeinePositive Negative
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Strategic Use of Caffeine
1:30(am or
pm)
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7:30(am or
pm) 200 mg dose ‐ onset of action 15‐45 minutes
Hydrate
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7/21/2014
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Fatigue Management1. Symptoms of fatigue
• Emotional‐quiet, withdrawn, lack of energy and motivation• Physical‐ yawning, eye rub, head droop, digestive problems• Mental‐cognitive impairment, lapses in communication,
2. Self‐assessment strategies to monitor fatiguef
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• Awareness of symptoms• Fatigue assessment tool (Canadian), • Eppworth Sleepiness Scale
3. Fatigue and sleep management methodologies• Anticipate fatigue generating situations• Improve sleep quantity and quality (appropriately
diagnose and treat sleep problems)• Strategically use lighting, caffeine, and naps
Fatigue
Susan A. Phillipsanne1028@email.phoenix.edu
Carol Moffett cmoffett@mail.nih.gov
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