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“Mary,” a 39-year-old woman, was in acuterespiratory distress when she arrived at the

emergency department. She was gasping and couldspeak only in 2- or 3-word sentences. She was ex-tremely dyspneic, anxious, hyperventilating, andemotionally drained, with tears streaming down herface. She had a history of asthma and was experienc-ing an exacerbation of this condition. Mary’s skin wascool, cyanotic, and diaphoretic. Her vital signs wereas follows: temperature, 98.7° F; heart rate, 132 beatsper minute; and blood pressure, 204/110 mm Hg. Shehad a respiratory rate of 42 breaths per minute. Herbreathing was shallow and labored. The pulse oxime-ter measured the oxygen saturation level at 78%. Herlung sounds were diminished throughout, with audi-ble wheezing. The blood gases reflected respiratoryacidosis (pH, 7.26; partial pressure of oxygen [PO2], 52;partial pressure of carbon dioxide [PCO2], 70; and bi-carbonate [HCO3], 28). The cardiac monitor displayedsinus tachycardia with rare premature contractions.

PlanThe plan for this patient was to organize health issuesaccording to priorities with supportive managementof asthma symptoms.

ActionI centered myself as I took a deep cleansing breath,bringing my body, mind, spirit, and emotions to aquiet focused state of consciousness. I provided oxy-gen delivered by 100% nonrebreather mask, whichraised the saturation level to 85%. An intravenous linewas started and methylprednisolone sodium succi-nate, benzyl alcohol (Solu-medrol), 125 mg, was in-fused. I coached Mary to slow down her breathing.

With a calm, reassuring voice, I instructed her to takeslow deep breaths, to count to 3 as she inhaled andexhaled, and to focus on longer pursed-lip exhala-tions. A respiratory therapist gave a small volumenebulizer treatment with albuterol, 2.5 mg. I closedthe curtains and turned off the bright overhead light.The less intense local lighting was still adequate forthe necessary observations of patient assessment.Turning off this light reduced the stressful environ-ment of the trauma unit as much as possible. Envi-ronmental, spiritual, and emotional stresses are rec-ognized to have a strong effect on the promotion ofhealing.1 Mary’s physical status was constantly beingreassessed along with her ability and willingness tofocus on regulating her breathing.

EvaluationWithin about 20 minutes, Mary was able to be an ac-tive participant in breathing more effectively andmanaged to work with me by taking slower breaths.The monitors in this critical care setting were used asbiofeedback equipment. I asked Mary to watch heroxygen saturation, her heart rate, and her respirationrate. Her vital signs began to show improvement as follows: heart rate, 112 beats per minute; blood pressure, 180/104 mm Hg; and respiratory rate, 36breaths per minute. Mary’s breathing continued to be shallow and labored. Her lung sounds were muchless diminished, with inspiratory and expiratorywheezes throughout. The cardiac monitor showedsinus rhythm/sinus tachycardia with no prematurecontractions. Her oxygen saturation measured 88%

Kathleen Kelly is Staff Nurse, Emergency Department, NavapacheRegional Medical Center, ShowLow, Ariz.For reprints, write: Kathleen Kelly, RN, 6989 Kimball Lane,ShowLow, AZ 85901.J Emerg Nurs 1998;24:489-91.Copyright © 1998 by the Emergency Nurses Association.0099-1767/98 $5.00 + 0 18/1/94169

Case ReviewIntegration of holistic nursing care inthe treatment of asthma: A case studyAuthor: Kathleen Kelly, RN, ShowLow, ArizSection Editor: Patty Campbell, RN, MSN, CCRN, CS, ANP

The slowing of Mary’sbreathing reduced herstress reaction, enhancedpulmonary toilet, andimproved her vital signs.

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while she was receiving oxygen at 4 L via nasal can-nula. Her skin was pale, warm, and dry. The slowing ofMary’s breathing reduced her stress reaction, en-hanced pulmonary toilet, and improved her vital signs.

Creating a holistic care planGenerally I begin by explaining the complementaryhealing methods I wish to use and obtaining verbalpermission from the client to initiate these proce-dures. These methods include reinforcing the relaxa-tion response and breathing techniques, formulatinga personalized guided imagery, incorporating thera-peutic touch, continuing biofeedback evaluation, andintroducing relaxation meditation. Appropriate musictherapy can be selected. Music quiets the body-mind-spirit by inducing a psychophysiologic state ofrelaxation.2 I assess the client’s cognitive distortionsof behaviors that have a negative influence.3 I explainto my clients that I will explore the notable differencesin body symmetry and use a variety of healing ap-proaches that include energy intervention to maxi-mize wellness, balance energy, and evoke body-mindrelaxation. Most patients are receptive to this ap-proach and express interest in participating in theirown care. The client is consulted and encouraged toexpress personal needs and goals. These goals are theprimary tools for the formulation of the care plan.

In this particular case, I focused on empoweringMary during the asthma episodes, which was accom-plished by teaching her methods that would allow herto work through her asthma while giving her ways to gain back control of her body. This approach willdecrease the negative stress and emotional reactionsto her disease. Teaching Mary breathing exercisesand introducing meditation techniques took about 3minutes.

ActionNow that Mary was more physically stable, she wasreceptive to a new and different approach to healing.I asked Mary to describe what her asthma felt like.She perceived her condition as “being attacked by agiant squid that squeezes my chest and closes out allthe air…I want to stop the attacks before they start.”

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She was angry that asthma was “invading” her lifeand felt powerless to do anything about it. I asked herto describe how she feels just before she has an “at-tack.” She was able to identify sensations that signalan “attack is coming on.” Together we designed astrategy to fight back. She created a weapon to takewith her at the onset of her next “attack.” Her imagewas of a giant bellows that would “open all the closedballoons in my lungs.”

Mary return-demonstrated relaxation breathingexercises well. I was then ready to initiate a medita-tive process. I began by relating suggestions that re-inforced Mary’s own imagery of the bellows. WhileMary calmed with the meditation, I fine-tuned my at-tention to Mary’s body-mind-spirit. I focused my con-sciousness to connect with my own inner guidanceand that of my client. Mary was coached to let go oftoxins, worries, stresses, and negativity. She wasguided to relax every part of her body. Soothing relax-ing music was provided with earphones.

Following our therapeutic touch policy and pro-cedure, I positioned my hands about 2 inches overMary’s body, moving from head to foot to assess herenergy field. The body gives cues of energy imbal-ances, blocks, congestion, and hot and cool areas.Awareness and sensitivity to these perceptions is nota rare talent but a skill that can be learned. Rhythmichand movements were used to clear areas of energyimbalances. Energy was directed into areas whereweakness was detected. The technique was repeateduntil no further asymmetries were noted.4 Thisprocess took about 4 minutes. The client then rested,completely undisturbed by the noises and disruptionsin the trauma room.

I returned in 10 minutes to check on Mary. I ex-plained to her where I had found blocks and imbal-ances in her energy field. I showed her where I had di-rected and localized energy to enhance relaxation andbalance. A demonstration was given so that she coulddo this procedure when she feels the onset of herasthma symptoms. While I was teaching her sometechniques to practice at home, I told her that I hadperceived some very strong impressions of recent vi-olent trauma to her chest, head, and arms. No bruiseswere noted, but I wanted her to know that I had astrong hunch that she had been assaulted recently. Itold her that I was very concerned for her safety andasked if she needed help. At this point she began tocry and told me that her asthma attack that morningwas preceded by an incident in which her live-inboyfriend “beat the hell out of me.”

Mary was assisted in identifying several of her dis-tortions of thought that kept her in an abusive relation-ship. The process of centering, calming, and balancing

Music quiets the body-mind-spirit by inducing apsychophysiologic state ofrelaxation.

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her energies enabled Mary emotionally and physicallyto start dealing with the issues that obviously broughther to the emergency department in the first place. Afew episodes occurred in which Mary began experi-encing asthma symptoms while talking about her abu-sive relationship. As I coached her in the use of thetechniques we had practiced, she successfully pre-vented her asthma from escalating, which gave her anempowering sense of pride and confidence. Maryagreed to talk to a counselor from the local “safe house”for victims of domestic violence.

Discharge planMary was referred to a biofeedback clinic to facilitatefurther education and to support the management ofher asthma. She made a contract with herself to prac-tice relaxation and breathing skills. Arrangementswere made so that she would not return to her abu-sive home situation and would follow up with a coun-selor from the “Safe House.”

EvaluationMary was breathing more effectively and was in a verydifferent emotional state than she was in when shefirst arrived. She was calm and her respirations wereeasy and regular with an oxygen saturation of 95% onroom air. Her skin was warm, dry, and pink. Her vitalsigns were as follows: heart rate, 84 beats per minute;blood pressure, 122/86 mm Hg; and respiratory rate, 20breaths per minute. The blood gases were now withinnormal limits (pH, 7.38; PO2, 82; PCO2, 38; and HCO3, 29).The cardiac monitor displayed normal sinus rhythmwith no ectopy. Mary stated that she felt “Much better.... I can get air into my lungs without working so hard.” She was able to talk without shortness ofbreath and was now speaking in full sentences.

Mary’s medical records reflected that she hadbeen a frequent visitor to our emergency departmentfor assorted complaints of asthma, chest pain, andmigraine headaches. Once she came in because she“fell down the stairs” and sustained a fractured clavi-cle. This record is typical of that of victims of domes-tic violence, who may come to the health care systemmany times before this unfortunate yet not uncom-mon underlying cause is discovered.5 Mary’s continu-ing progress with the “safe house” counselor and thebiofeedback clinic significantly decreased her ED vis-its. Mary was averaging 1 or 2 ED visits a month be-

fore this visit. She has not returned to the emergencydepartment in 4 months now.

DiscussionThis holistic health approach may seem like a time-consuming effort, but it actually took only 3 minutesto teach the breathing exercices, and therapeutictouch was completed in about 5 minutes. The patientwas in the emergency department for approximately3 hours, which is a relatively short amount of timewhen compared with the average time of stay in theemergency department for a patient with asthma.The practitioner can use these skills as part of the pro-vision of routine care while assessing the patient,starting an intravenous line, listening to lung andheart sounds, and taking a thorough medical history.When one becomes familiar and comfortable with thevaluable tools of the holistic practitioner, they are eas-ily incorporated as part of critical care.

Although some patients with asthma may haveacute episodes that are triggered by emotional eventssuch as that presented in this case study, other pa-tients may be reacting to potent allergens that inducealmost intractable symptoms. As emergency nurses,remaining vigilant regarding patients who have asth-ma and treating them aggressively with conventionaltherapy is essential. The integration of complementarytherapies is an excellent addition to traditional care.

I have found that treating the client from a body-mind-spirit approach effectively saves time, reducessuffering, and increases the client’s participation andunderstanding of his or her own disease processwhile enhancing overall health.

References

1. Shealy CN, Myss CM. The creation of health: the emo-tional, psychological, and spiritual responses that promotehealth and healing. Walpole (NH): Stillpoint Publishing;1988. p. 61.2. Dossey BM, Keegan L, Guzzetta C, Gooding Kolkmeier L.Instructor’s manual for holistic nursing: a handbook for prac-tice. Gaithersburg (MD): Aspen Publishers; 1995. p. 694.3. Dossey BM. Core curriculum for holistic nursing.Gaithersburg (MD): Aspen Publishers; 1997. p. 143.4. Ulan D. Navapache Regional Medical Center Nursing Ser-vices Policy No. 26.10: therapeutic touch. ShowLow (AZ):Navapache Regional Medical Center; 1994.5. Emergency Medicine Reports 1996;17:15.