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Nursing Guide to Obstructive Sleep Apnea (OSA): Nursing Diagnosis, Interventions, & Care Plans

Updated On 9 Minute Read

Obstructive Sleep Apnea Definition 

Obstructive sleep apnea (OSA) is a sleep condition in which the upper airway becomes repeatedly blocked during sleep, either fully (apneas) or partially (hypopneas). This results in disrupted breathing, reduced oxygen levels, disturbed sleep, and excessive daytime tiredness. 

Etiology and Epidemiology 

OSA affects certain groups disproportionately (Yeghiazarians et al., 2021): 

  • Around 34% of men and 17% of women in middle age meet the criteria for a diagnosis of obstructive sleep apnea (OSA).
  • Prevalence is higher among Black people, postmenopausal women, and people with comorbidities like hypertension.
  • The risk of obstructive sleep apnea increases in men with a neck circumference greater than 17 inches and in women with a neck circumference greater than 16 inches. 

 ICD-10 Code:  

OSA has several underlying causes, including: 

  • Anatomical causes such as narrow or collapsible upper airway due to retrognathia, micrognathia, or maxillary constriction. Enlarged adenoids, tonsils, or tongue also contribute to airway obstruction.
  • Lifestyle factors such as obesity increase fat deposits in the neck and pharyngeal regions, narrowing the airway. A 10% weight gain can increase the apnea-hypopnea index (AHI) by 32%. Smoking contributes to inflammation and fluid retention in the upper airway. Alcohol and sedative use relax pharyngeal muscles, increasing airway collapsibility during sleep.
  • Comorbidities, such as hypothyroidism and acromegaly, can thicken soft tissues around the throat. Cardiovascular diseases, such as heart failure and hypertension, are also closely associated with OSA.
  • Demographics and genetics which can affect OSA. The risk of OSA is higher in males, those over 50, and postmenopausal women. A family history of OSA increases the likelihood due to inherited craniofacial features or shared lifestyle factors. 

OSA Diagnostic Criteria 

Diagnostic evaluation for OSA includes: 

  • Polysomnography (PSG)
    • The gold standard for assessing brain activity, oxygen saturation, airflow, and muscle effort. The PSG results divide AHI severity into three categories: mild, moderate, and severe.
  • Home Sleep Apnea Testing (HSAT)
    • Measures oxygen desaturation and airflow using portable devices. It is best for diagnosing moderate-to-severe OSA.
  • Hypoxia Burden
    • Quantifies cumulative oxygen deprivation during apneas.
  • Loop Gain
    • Identifies abnormal respiratory control that increases airway instability. 

Screening for OSA involves tools to identify high-risk people. 

These tools include: 

  • The STOP-BANG questionnaire. It evaluates snoring, tiredness, observed apneas, high blood pressure, body mass index (BMI), age, neck circumference, and gender. It is widely used for simplicity and highly sensitivity in identifying people at risk for moderate-to-severe OSA.
  • The Epworth Sleepiness Scale (ESS). It measures daytime sleepiness by rating the likelihood of dozing off in various situations. It helps assess excessive sleepiness, a common OSA symptom. 

Common Signs and Symptoms 

Symptoms of OSA may vary depending on the severity of OSA, comorbid conditions, and individual factors like age or gender. 

Symptoms typically seen at night include: 

  • Loud, persistent snoring that often disrupts others' sleep.
  • Observed episodes of choking, gasping, or apnea during sleep.
  • Frequent awakenings or restless tossing and turning throughout the night.
  • Nocturia, which can be caused by sleep interruptions and changes in nighttime physiology.
  • Waking up with a dry or sore throat due to mouth breathing or snoring. 

Symptoms typically noted during the daytime include: 

  • Excessive daytime sleepiness, which can impair work or driving and increase the risk of accidents.
  • Morning headaches caused by oxygen deprivation during sleep and associated changes in blood pressure.
  • Cognitive impairments, such as trouble concentrating, memory lapses, or reduced mental acuity.
  • Mood disturbances, including irritability, anxiety, or depression, related to poor sleep quality.
  • Difficulty maintaining alertness during monotonous activities like reading or watching TV. 

OSA Red Flags 

Critical symptoms or events that may signal the need for immediate intervention include: 

  • Severe apnea events such as prolonged breathing pauses (>20 seconds) accompanied by oxygen saturation <90% or observed choking or gasping during sleep.
  • Sudden chest pain or palpitations during sleep which may indicate cardiovascular complications.
  • Rapid cognitive decline or confusion which may signify hypoxia-induced brain dysfunction.
  • Daytime sleepiness impairing alertness which may lead to increased accident risk. 

Potential Complications 

Complications for OSA include: 

  • Resistant hypertension, with up to 80% of hypertensive people having comorbid OSA.
  • Increased risk of atrial fibrillation, heart failure, and coronary artery disease.
  • Long-term hypoxia, which can cause memory loss, impaired attention, and increased risk of dementia.
  • Chronic conditions such as insulin resistance, metabolic syndrome, and type 2 diabetes.
  • Increased risk of sudden cardiac death by up to 30%.
  • Increased blood pressure in the lung arteries, causing pulmonary hypertension when repeated episodes of oxygen deprivation during sleep occur. 

Obstructive Sleep Apnea Treatments 

Treatment options for OSA range from pharmacological to lifestyle or surgical interventions. 

Pharmacological 

Until recently, pharmacological treatment for OSA was supportive care only. Pharmacological treatment includes: 

  • Modafinil (Provigil®), which may improve excessive daytime sleepiness in OSA patients already on continuous positive airway pressure (CPAP).It is not a substitute for CPAP.
  • Tricyclic antidepressants such as amitriptyline (Elavil®) which may improve OSA by increasing REM sleep latency.
  • Selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft®), which may improve OSA by increasing serotonin in the brain and upper airway muscle tone.
  • Tirzepatide (Zepbound®) which is the first FDA-approved medication specifically for adults with moderate-to-severe OSA and obesity. It functions by stimulating receptors for hormones released by the intestine, glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), to decrease appetite and food consumption. Research indicates that by promoting weight loss, Zepbound also leads to improvements in OSA symptoms. 

Non-Pharmacological 

Non-pharmacological treatment for OSA includes: 

  • CPAP, which reduces AHI by 75% in moderate-to-severe cases. It improves cardiovascular outcomes, but adherence remains a challenge.
  • Mandibular advancement devices which reposition the jaw to open the airway. They are best for mild-to-moderate OSA or people who are CPAP-intolerant.
  • Regular weight loss and exercise which improves airway patency. A 10% weight loss can significantly reduce a person’s apnea events. 

Surgical 

There are several surgical treatments for OSA, including: 

  • Hypoglossal nerve stimulation which has been approved for people with moderate-to-severe OSA who cannot tolerate CPAP.
  • Maxillomandibular advancement (MMA) which is a surgical procedure that involves moving the upper (maxilla) and lower (mandible) jaws forward to open up the airway and improve breathing during sleep.
  • Trans oral robotic surgery (TORS) which uses a 3-D image to remove tissue from behind the tongue.
  • Uvulopalatopharyngoplasty (UPPP) which opens the throat to improve breathing.
  • Genioglossus muscle advancement which moves the genioglossus muscle forward to stabilize the tongue base.
  • Nasal surgery to remove polyps or correct a deviated septum.
  • Tonsillectomy and adenoidectomy if tonsils or adenoids are enlarged.
  • Alar batten graft implants to prevent collapse in the sidewall of the nose. 

Nursing Management 

Assessment and Interventions 

Key nursing considerations for OSA include: 

  • Use of pulse oximetry during sleep to identify oxygen desaturation patterns. Look for desaturation events below 90%.
  • Assess for signs of labored breathing, such as nasal flaring or accessory muscle use during sleep.
  • Documentation of apneas and respiratory effort changes.
  • Arrange for PSG testing if ordered.
  • Document trends in blood pressure, particularly signs of resistant or poorly controlled hypertension.
  • Evaluate for tachycardia, irregular rhythms, or other indicators of cardiovascular strain.
  • Screen for excessive daytime sleepiness.
  • Observe for anatomical features associated with OSA, such as a large neck circumference (>17 inches in men and >16 inches in women), craniofacial abnormalities, or tonsillar hypertrophy.
  • Coordinate with respiratory therapists for CPAP device optimization and dietitians for weight management. 

Interventions 

Nursing interventions should focus on promoting effective breathing patterns and managing symptoms of OSA. These interventions include: 

  • Promote sleep hygiene by encouraging consistent bedtime routines and avoidance of alcohol or sedatives before bed.
  • Encourage oral hygiene and use of mouth moisturizers before bed.
  • Encourage sleeping in a lateral or semi-upright position to prevent airway collapse. Elevate the head of the bed to improve airflow.
  • Assist with fitting and maintaining CPAP or bilevel positive airway pressure (BiPAP) devices.
  • Monitor the person’s tolerance to therapy and address barriers, such as mask discomfort or nasal congestion.
  • Provide supplemental oxygen for individuals with severe desaturation events or concurrent conditions like pulmonary hypertension.
  • Teach proper CPAP maintenance, including mask cleaning and checking for air leaks.
  • Address adherence barriers, such as mask discomfort or social stigma. 

Psychosocial and Cultural Considerations 

Psychosocial Support 

Psychosocial support includes: 

  • Assess for anxiety or depression related to chronic sleep deprivation and provide resources for counseling or support groups.
  • Discuss the stigma a person may feel about using CPAP devices and provide reassurance. 

Cultural Considerations 

Cultural considerations include: 

  • Consider cultural or religious practices that may influence treatment adherence, such as fasting or preferences for natural remedies.
  • Use interpreters when needed to provide clear instructions on CPAP use or treatment regimens. 

Home Management 

Self-Care 

Self-care includes: 

  • Instructing the person to use CPAP nightly and track effectiveness through built-in monitoring apps.
  • Educating the person on recognizing and responding to symptoms of oxygen deprivation or worsening fatigue.
  • Encouraging positional therapy using devices to prevent supine sleeping.
  • Promoting weight loss through calorie management and regular aerobic activity. 

Safety Measures 

Safety measures include: 

  • Avoiding the operation of heavy machinery or driving until daytime fatigue is resolved.
  • Following up with a healthcare provider regularly for adjustments in CPAP. 

FAQs

Additional Information

Content Release Date 

3/31/2022

Content Expiration

12/31/2028

Course Contributor 

The content for this course was revised by Kathleen Koopmann, RN, BSN. Kathleen is a subject matter expert in post-acute care, with over 37 years of clinical and teaching experience spanning both acute and post-acute care settings. She earned her Bachelor of Science in Nursing from Western Governors University and received specialized infection control training through the North Carolina Statewide Program for Infection Control and Epidemiology, in collaboration with NCDHHS and the University of North Carolina. Kathleen's diverse career includes roles in long-term care, acute care, occupational health, and nursing education. Most recently, she served as a Staff Development Coordinator and Infection Control Practitioner in long-term care, where she played a pivotal role in staff education and infection prevention. 

Resource 

References 

 

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Kathleen Koopmann, RN, BSN, PCCN

Kathleen earned her Associate Degree in nursing in 1987 at Mid-Michigan Community College and her Bachelor of Science in nursing in 2018 from Western Governor’s University. She has training from the North Carolina Statewide Program for Infection Control and Epidemiology through NCDHHS and the University of North Carolina. Kathleen has worked in long-term care, outpatient care, acute care, and nursing education. She has hospital experience in Med-Surg, OR/PACU, Critical Care, Telemetry, and outpatient experience in Occupational Health. Kathleen has experience as a clinical instructor for the LPN program at Susquehanna County Career and Technical Center in Pennsylvania. Most recently, she worked in long-term care as a Staff Development Coordinator and Infection Control Practitioner.