There are many types of disturbances that can prevent a tired patient from relaxing into sleep. Some of these are practical and may prevent sleep on one isolated occasion: this type of disturbance should be relatively easy for you and the patient to identify and resolve between you.

Other problems may prevent the patient from getting enough sleep night after night without there being any obvious or simple solutions. In these cases, identification of the cause is still the first step, even if this does not necessarily mean that a permanent answer to the problem is any easier to find immediately.

Environment

Consider the patient's environment. Is he in his own bedroom? A change of surroundings can be very disturbing and it is not only the patient in a hospital who suffers but the patient at home who is being nursed in a different room for convenience. If unfamiliarity of surroundings is keeping the patient awake, all you can do is try and leave the rest of his routine as unchanged as possible.

The patient may not be happy with the temperature of his room at night, especially if he is feverish. Is the room well ventilated without draughts and are the bedclothes warm enough for the time of year without being too heavy? One blanket more or less may make a surprising difference in the patient's comfort.

Is the room free from smells? The sense of smell is heightened in illness and the patient may be nauseated by cooking smells, stale flower water too near the bed or bedpans not removed immediately after use. The patient may even be disturbed by the smell of his own body. Discharges from a wound or stale sweat (particularly if the patient has a limb in plaster) can be extremely distressing.

You can do a lot to eliminate most disturbing smells. Try not to let cooking smells linger in the kitchen or passageways. Remember to use an air freshener in the bedroom after the patient has had a bowel action. Wash his skin often, using a deodorant where appropriate, and leave a pleasant-smelling aerosol within the patient's reach so that he can use it whenever he wishes to do so.

The amount of light may disturb the patient's sleep. If his condition warrants a night nurse or night sitter, there must be a light so that she can see the patient but it should be carefully shaded to avoid disturbing him. Conversely, the child used to a small nightlight may be afraid of the darkness if he is left without one.

Discomfort

People normally differentiate between night and day by wearing different clothes. It may help an ill person to feel more normal if he can also change into clean pajamas or a fresh nightdress to sleep. Wrinkled sheets, crumbs in the bed and untucked bedclothes all contribute to restlessness. Because of this, always see that the sheets are pulled taut and smooth when you are settling the patient to sleep and that he is comfortably settled on pillows.

This is especially important if the patient is totally confined to bed. The lack of any change of scenery and the consequent feelings of frustration and boredom serve to intensify even the slightest discomfort. Check also that the bedclothes are not too heavy although some patients are used to weight and miss it if it is removed - if blankets are replaced by a continental quilt for instance.

Make sure that a patient with breathing difficulties is comfortably supported with pillows. If something is irritating his skin or there is undue pressure on any part of it, this needs special attention. A swollen limb may be more comfortable raised on a pillow, while painful joints are often eased if the bedclothes are supported by a bed-cradle.

A full bladder is a common cause of sleeplessness, especially if the patient is reluctant to call anyone during the night and cannot get out of bed. Always offer a bedpan or urinal when settling the patient for the night and allow plenty of time for him to use it. If he is fairly mobile, he may like to have a bedpan, urinal or commode beside him during the night.

Indigestion may be relieved with peppermint water or a simple indigestion tablet, while nausea can often be relieved with soda water. Coughing may be helped by a change of position, together with extra pillows and a spoonful of honey and lemon. If the particular discomfort that disturbs the patient can be alleviated by a simple remedy, the reassurance will help to relax him and prepare him for sleep.

Hunger and thirst

The sick patient is often reluctant to eat and yet he may well feel both hungry and thirsty during the night. Although a large fluid intake last thing at night is probably unwise, a milky drink taken last thing before settling to sleep is often the answer. Stimulants such as tea and coffee, however, are best avoided unless the patient usually drinks these late at night.

If the patient is feverish or the weather very hot, a jug of lemon squash or lemon barley water is refreshing. If the patient wakes in the early hours of the morning feeling hungry or thirsty, a few biscuits in a tin or a hot drink in a thermos left on his bedside table may soothe him to sleep again.

Fear and anxieties

Fear undoubtedly keeps people awake. The sick person always has fears and it is pointless to pretend that they do not exist. In the hours of darkness, they may loom especially large and seem most threatening. The patient may have many different worries: How long shall I get payed? Can we manage on sickness benefits? Shall I be fit to do my old job when I am better? Shall I get my old job back? Shall I be disfigured? Shall I still be attractive to my boyfriend or husband? Am I becoming a burden as I get older? Who will look after me when I cannot cope any longer? Shall I be able to bear the pain? Am I going to die?

All these are very real anxieties, some without solutions. Yet, there is truth in the old adage that a burden shared is a burden halved. Try to get the patient to talk to you. Give him your full attention and listen properly. Most of the time you are probably so busy that you do not really listen. On the other hand, be careful not to pry. At night when the patient is in low spirits, he may find it possible to talk to a sympathetic listener, but the next day he may wish he had not confided in you and may not want to be reminded of your conversation the night before, or may need to be reassured that it was confidential.

Pain

Perhaps the greatest enemy of sleep is pain. Pain can be increased by any or all of the factors discussed above, while attention to these factors will minimize and perhaps even remove the pain.

Inform the doctor of any persistent pain from which the patient is suffering. He will want to know what the pain is like, when it usually occurs and whether anything in particular seems to cause it.

Pain-killing drugs and sleeping tablets may be prescribed by the doctor to help the patient rest, but these should only be given in accordance with his instructions.