4.5 Rest, Sleep, Comfort, Pain, and the Resident's Environment
Key Takeaways
Older adults normally sleep more lightly and wake more often, but a sudden change in sleep or a resident who is distressed most of the night should be reported.
Promote rest by following the resident's own bedtime routine, offering toileting and a back rub, lowering noise and light at night, and grouping care to limit interruptions.
Pain is whatever the resident says it is; report its location, intensity on a 0 to 10 scale, type, and timing, and watch for nonverbal signs in residents who cannot describe it.
Apply warm or cold treatments only when the nurse directs, with a cover between the pack and the skin, and remove them and report any very red, pale, blistered, numb, or painful skin.
Nursing facilities certified after October 1, 1990 must keep a comfortable temperature range of 71°F to 81°F, and air mattresses work only when they are inflated and not piled with extra pads.
4.5 Rest, Sleep, Comfort, Pain, and the Resident's Environment
Credentia's 2024 NNAAP outline lists Rest/Sleep/Comfort as one of the five Activities of Daily Living topics, and Prometric's Alabama outline lists sleep and rest needs and promoting circulation and skin integrity (specialized mattresses, chair cushions, positioning) under Promotion of Function and Health. The federal training curriculum also requires instruction in caring for the residents' environment. Comfort is not a luxury in a nursing home: poor sleep and unrelieved pain lead to falls, confusion, poor appetite, and behavior changes.
Sleep and Rest in Older Adults
Normal aging changes sleep. Older adults usually sleep more lightly, wake more often during the night, and wake earlier in the morning. They may nap during the day. These changes are normal; a sudden change in sleep, or a resident who is awake and distressed most of the night, is not, and should be reported.
What Disrupts Sleep in a Facility
| Cause | Examples | What the nurse aide can do |
|---|---|---|
| Physical discomfort | Pain, a full bladder, being too hot or cold, wet linens, hunger | Offer toileting before bed, reposition, check that linens are dry and wrinkle-free, adjust blankets, report pain |
| Environment | Hallway noise, staff conversations, bright lights, a roommate's television | Lower voices at night, dim lights, close the door if the resident wishes, use a night-light for safety |
| Emotions | Worry, grief, loneliness, fear in a new place | Listen, reassure, and report persistent anxiety or sadness |
| Routines | Caffeine late in the day, long daytime naps, little daytime activity | Offer decaffeinated drinks in the evening, encourage daytime activity as the care plan allows |
| Care interruptions | Waking a resident for vital signs, turning, or brief changes | Group care so the resident is disturbed as few times as possible |
Promoting Rest
- Follow the resident's routine. OBRA gives residents the right to choose when they go to bed and get up. Ask about bedtime habits: a shower, a snack, reading, prayer, or a particular blanket.
- Offer toileting, mouth care, and a back rub before sleep.
- Keep the room at a comfortable temperature. Federal rules require nursing facilities certified after October 1, 1990 to keep a temperature range of 71°F to 81°F (42 CFR 483.10(i)(6)).
- Leave the call light within reach, the bed in its lowest position, and a night-light on so the resident can see if they get up.
- Never use sedation or restraint to make a resident sleep, and never wake a resident only because it is convenient for staff.
Comfort and Pain
Pain is whatever the resident says it is. A nurse aide does not judge whether pain is "real"; the aide observes, reports, and uses comfort measures.
How Pain Shows
- What residents say: the location, the intensity (often on a 0 to 10 scale, where 0 is no pain and 10 is the worst pain imaginable), and the type (sharp, dull, burning, aching).
- What you see: grimacing, frowning, moaning, guarding or rubbing a body part, restlessness, refusing to move, sweating, and changes in breathing or pulse.
- In residents who cannot explain pain (for example, residents with advanced dementia): new agitation, striking out, crying, withdrawal, refusing food, or resisting care. Facilities often use a pain scale built on these behaviors.
What the Nurse Aide Does
- Ask about pain during care and report it to the nurse with details: where, how bad, what it feels like, when it started, and what makes it better or worse.
- Use comfort measures from the care plan: repositioning with pillows, supporting painful joints, a quiet and dim room, a back rub, and diversion such as music or conversation.
- Never give or offer any medication. After the nurse gives pain medication, report whether the resident seems more comfortable.
- Report pain that is new, severe, or not relieved, and chest pain immediately.
Warm and Cold Applications
Some care plans include warm compresses or packs (to relax muscles and increase circulation) or cold packs (to reduce swelling and numb pain). Older skin burns and freezes easily, and residents with diabetes or poor circulation may not feel damage. Apply warm or cold treatments only when the nurse directs, use a cover between the pack and the skin, follow the ordered time (commonly no more than 15 to 20 minutes), check the skin often, and remove the application and report if the skin is very red, pale, blistered, numb, or painful.
Caring for the Resident's Environment
The resident's room is their home. Under OBRA, residents have the right to a safe, clean, comfortable, and homelike environment, including the use of their own belongings when possible.
- Personal belongings: Handle them with respect, do not move them without permission, and label items according to facility policy. Report missing property, because misappropriation must be investigated.
- Safety and reach: Keep the call light, water, glasses, hearing aids, and phone within reach; keep pathways clear; and leave the bed low with wheels locked.
- Cleanliness: Remove meal trays and soiled items promptly, empty wastebaskets, and keep the overbed table clean, especially before meals.
- Pressure-redistribution equipment: Air or alternating-pressure mattresses and gel or foam chair cushions protect the skin only when they work as designed. Check that an air mattress is inflated and the pump is on, avoid piling extra pads or folded linens under the resident, and report equipment that is flat or alarming. Avoid ring or donut cushions, which press on the surrounding tissue.
Bedmaking
Clean, dry, wrinkle-free linen protects the skin and helps the resident sleep.
| Bed type | When it is used |
|---|---|
| Closed bed | Bed made with top linens pulled up, ready for a new admission or a resident who is up for the day |
| Open bed | Top linens fanfolded to the foot so a resident can get in easily |
| Occupied bed | Linens changed while the resident stays in bed because the resident cannot get up |
| Surgical (post-op) bed | Top linens folded to one side so a resident returning on a stretcher can be moved in |
Basic rules: wash your hands and gather linens in the order you will use them; carry linens away from your uniform; never shake linens or put them on the floor; wear gloves if linens are wet or soiled; keep the bottom sheet tight and wrinkle-free; leave the top sheet loose over the feet (a toe pleat); and change linens whenever they are wet or soiled, not only on bath days. The occupied bed steps that Prometric scores are in Section 7.3.
A resident with advanced dementia cannot describe pain. Today the resident is grimacing, guarding the left hip, and pushing staff away during care. What should the nurse aide do?
Report the behaviors to the nurse as possible signs of pain
Give the resident an over-the-counter pain reliever from the supply room
Document that the resident was uncooperative and finish care quickly
Wait to see whether the behavior continues into the next shift
Which nurse aide action best promotes sleep for a resident who wakes often at night?
Turning on all the overhead lights during night rounds
Serving a caffeinated cola with the evening snack
Waking the resident separately for each task during the night
Offering toileting and a back rub at the resident's usual bedtime
The nurse asks an aide to apply an ordered warm pack to a resident's shoulder. Ten minutes later the skin under the pack is very red and the resident says it burns. What should the aide do?
Rub lotion into the area and replace the pack
Remove the warm pack and report the skin change to the nurse
Leave the pack in place for the full ordered time, since redness is expected
Add a second warm pack so the treatment works faster
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