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Emotional More quiet or withdrawn than usual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

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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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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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