International Journal of Advances in Nursing Management 3(3): July- Sept.

2015

ISSN 2347-8632 (Print) www.anvpublication.org

2454-2652 (Online)

RESEARCH ARTICLE

Effectiveness of Guided Imagery on Level of Blood Pressure among PIH

Mothers in Selected Hospital at Trichy
V. Komathi
Lecturer, Joitiba College of Nursing, Bhandu, Gujarat
*Corresponding Author’s Email: komathiv96@yahoo.in

ABSTRACT:
INTRODUCTION: Pregnancy can be one of life's most exciting and fulfilling adventures. A healthy mom and
healthy baby--that's the goal for every pregnancy. Sometimes this is easy, sometimes it requires intensive efforts
by the mother, her physicians, her nurses, other health care givers, family members and newborn child's
physicians. OBJECTIVE: To evaluate the effectiveness of Guided Imagery on level of blood pressure among
PIH mothers. DESIGN: A quantitative approach using quasi experimental pre-test post-test design with control
group. PARTICIPANTS: 60 PIH mothers were selected using Non-probability purposive sampling technique in
Pankajam Sitharam Hospital at Trichy District, Tamilnadu. INTERVENTIONS: Guided Imagery was given to
the mothers in experimental group for 10 minutes duration twice a day for 3 days. TOOL: Sphygmomanometer
was used to assess the level of blood pressure. RESULTS: Analysis using paired ‘t’ test was found to be
significant. CONCLUSION: The findings of the study revealed that Guided Imagery helps in reducing blood
pressure among PIH mothers.

KEYWORDS: Guided Imagery, Blood Pressure, Pregnancy Induced Hypertension.

INTRODUCTION:
“Mothers reflect God’s loving presence on earth”
William R. Webb
Maternity is a strange yet breathtaking experience in a
woman’s life. A clear joy that comes in her life is
overwhelming, when she becomes aware of new life
growing inside of body. Every woman wants to have the
best possible pregnancy in terms of experience as well as
outcomeN2. Some of the medical and obstetric
complications during pregnancy may affect the joy of
motherhood, imposing threat on physical and Hypertensive disorders are one among the common
psychological well being.
Received on 04.06.2015 Modified on 26.06.2015
Accepted on 27.07.2015 © A&V Publication all right reserved mmHg, in 4 hours or more apart intervalsB4. However a
Int. J. Adv. Nur. Management 3(3): July- Sept. 2015; Page 245-252
DOI: 10.5958/2454-2652.2015.00011.6
Every minute of every day, somewhere in the world, a
woman dies from complications related to pregnancy or
childbirth. That is, 3,58,000 women, at a minimum,
dying every year worldwide. 99% of these deaths occur
in developing countries, making maternal mortality the
health statistic with the largest disparity between
developed and developing countries. In India, one
woman dies in every 5 minutes from a pregnancy related
causeN19.
medical complications reported during pregnancy.
Pregnancy induced hypertension (PIH) is a form of high
blood pressure which develops at the time of pregnancy,
usually after 20 weeks in a previously normotensive
women. Generally PIH is defined by systolic blood
pressure >140 mmHg or diastolic blood pressure >90
rise in systolic blood pressure of 20-30 mmHg or 10-15

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 International Journal of Advances in Nursing Management 3(3): July- Sept. 2015

mmHg of diastolic blood pressure or both from pre decades. PIH occurs in about 5% to 8% of all
pregnant baseline value on two or more occasions, 4 pregnancies globally. Pre eclampsia and eclampsia
hours or more apart is also diagnostic B5. If PIH is left accounts for more than 50,000 maternal deaths each
untreated, it may lead to severe complications including year. PIH is also associated with fivefold increase in
eclampsia, shock and hemorrhage for the mother. The perinatal mortality. Globally, 12% of all maternal deaths
risk for fetus due to PIH includes intrauterine death, are caused by eclampsia. Women younger than 20 or
intrauterine growth retardation, asphyxia and older than 35 have significantly higher morbidity rates.
prematurityB5. Hypertension in pregnancy also increases the woman’s
risk for a caesarean birth. Thus, PIH is a dangerous
The conventional treatment modalities of PIH include disorder which can affect the well being of both mother
the use of anti- hypertensive drugs, diuretics, protein rich and fetusN8.
diet and quiet rest. There is a lot of interest in alternative
and complementary therapies for high blood pressure Imagery is the center of all relaxation techniques
nowadays. This is understandable, since most regular designed to release brain chemicals that act as the body’s
medicines for high blood pressure have undesirable side natural brain tranquilizers, which helps in lowering
effects. These side effects often include drowsiness, blood pressure, reducing heart rate, decreasing pain
impaired judgment (sometimes leading to serious perception, decreasing stress and anxiety. Advocates of
accidents), nausea and allergic reactions. Most imagery contend that the imagination is a potent healer
alternative and complementary medicines for high blood that has long been overlooked by practitioners of western
pressure offer relief from the problem without these medicine. Imagery can relieve pain, speed healing and
unwanted effectsN9. help the body subdue hundreds of ailments including
depression, impotence, allergies and asthma. The power
Mind – body interventions, particularly biofeedback, of mind to influence the body is quite remarkable.
Guided Imagery and yoga, have been found to modestly Although it is n’t always curative, imagery can be
reduce high blood pressure compared with placebo. helpful in 90% of problems that people bring to the
Guided Imagery is the conscious use of imagination and attention of their primary care physiciansN12.
the mind to create positive images or a setting in order to
bring about healthful changes in the body and mind. Diane L Tusek., (2006) in his article had reviewed
Guided Imagery was defined by Bresler and Rossman various clinical studies to show that stress during
(2003), co founders of the academy for Guided Imagery pregnancy and labour can have a negative effect on the
as “a range of techniques from simple visualization and health of the mother and baby. Stress during pregnancy
direct imagery based suggestion through metaphor and can lead to complications during pregnancy and labour,
story telling”. Guided Imagery is basically used to learn more lower back pain, anxiety, low birth weight,
and rehearse skills, more effectively problem solving increased risk of miscarriage, premature delivery and
through visualizing possible outcomes of different soon. Guided meditation and imagery are relaxation
alternatives and increase creativity and imaginationN15. techniques clinically proven to help manage pregnancy
stress, ease labour pain, improve sleep and reduce
One of the most appealing and forgiving features about complication during pregnancy, labour and DeliveryN6.
imagery is that almost anyone can use it. Imagery skips
across the barriers of education, class, race, gender and Zablocki., (2009) in his article “pathways to healing”
age – a truly equal opportunity intervention. People can had reviewed about the various complementary therapies
invent their own imagery (mental imagery) or they can which can be used as pathways to healing. In this article,
listen to imagery that has been created for them (Guided the author had quoted that Guided Imagery can help to
Imagery). Thus, Guided Imagery is a simple and relax and elevate mood, lower blood pressure, reduce
convenient relaxation techniqueN15. painN6. Guided Imagery can be integrated into the
current nursing practice which will help to reduce blood
NEED FOR THE STUDY: pressure of mothers who were diagnosed to have PIH.
Any medical complication during pregnancy is a threat The researcher wants to try a non pharmacological
for two lives – the mother and the fetus. This demand for method for reducing blood pressure among mothers with
utmost and efficient care of a woman during pregnancy. PIH. So the researcher had selected the topic.
India is among the countries which have a very high
maternal mortality ratio. The MMR in India is about STATEMENT OF THE PROBLEM:
230/1, 00,000 live births for the year 2008. India has set Effectiveness of Guided Imagery on Level of Blood
the target of achieving MMR of 109/1, 00,000 live births Pressure among PIH Mothers in Selected Hospital at
by the year 2015N19. The problem of PIH is like an Trichy.
iceberg interestingly and it has been one of the major
causes of mortality in some countries during last two
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 International Journal of Advances in Nursing Management 3(3): July- Sept. 2015
OBJECTIVES:
1. To evaluate the effectiveness of Guided Imagery on
level of blood pressure among PIH mothers.
2. To determine the association between the level of
blood pressure among PIH mothers with their selected
demographic variables.
HYPOTHESIS:
H1: Guided Imagery is effective in reducing blood
pressure among PIH mothers.
H2: There is a significant association between the level
of blood pressure among PIH mothers with their selected
demographic variables (Age, Educational qualification,
Occupation, Monthly income, Duration of sleep at night,
Family history of PIH, Family history of HT, Body mass
index)
OPERATIONAL DEFINITIONS:
Effectiveness:
It refers to the outcome of Guided Imagery in terms of
reducing blood pressure among PIH mothers.
Guided Imagery:
A technique that involves using the imagination and
mental images with the help of a picture of natural
scenery and related audio script to promote relaxation,
thereby bringing about change in level of blood pressure.
Blood Pressure:
The term blood pressure refers to the systolic and
diastolic pressure measured at a person’s upper arm
using sphygmomanometer.
PIH:
PIH is raised blood pressure (> 140/90 mm of Hg)
developing in a woman during the second and third
trimester of pregnancy.
ASSUMPTIONS:
 Guided Imagery is a simple and convenient
relaxation technique.
 Guided Imagery has positive impact on health.
 Guided Imagery lowers level of anxiety and stress.
 Guided Imagery is useful for conditions that are
made worse by stress such as high blood pressure,
pain and headache.
 Guided Imagery promotes relaxation and improves
quality of life.
 Guided Imagery has no side effects on PIH mothers.
 Guided Imagery promotes overall well being of PIH
mothers.
247
DELIMITATIONS
 The study is limited to the mothers who are
diagnosed to have PIH in Pankajam Sitharam Hospital,
Trichy.
 The study is limited to the data collection period of
six weeks.
PROJECTED OUTCOME:
 The study will help the nurses to identify the
effectiveness of Guided Imagery on level of blood
pressure among PIH mothers.
 The study will help the nurses to incorporate Guided
Imagery in routine nursing care while caring for a
woman with PIH.
REVIEW OF LITERATURE:
Lylaine Gavette, Joyce Roberts., (2006) conducted a
retrospective study among pregnant adolescents to
justify the use of mean arterial pressure to predict
pregnancy induced hypertension. Using retrospective
chart review, data were gathered from 84 nulliparous
adolescents, 27 of whom developed PIH and 57 who did
not. Second trimester MAP values proved significantly
higher for the group with PIH (M=82.2) than for those
who remained normotensive (M=71.3) [t (82) =5.74,
p=0.000] It was revealed that the mean arterial pressure
values proved significantly higher for the group with
PIH than for those who remained normotensive. Sandhya
Sivakumar., B Vishnu Bhat., Bhawana Ashok Badhe.,
(2000) conducted an experimental study to evaluate the
effect of pregnancy induced hypertension on mothers
and their babies. The effects of maternal hypertension on
the hematological profiles of neonates were studied in 50
cases comparing the values with that of infants born to
normotensive mothers. It was found that there was a
higher number of pre term, intra uterine growth
retardation and small for gestational age babies among
infants born to hypertensive mothers.
Emily A. Holmes., Andrew Mathews., (2010) in his
article had reviewed the evidences on Guided Imagery
and concluded that imagery can evoke emotion in at
least three ways: direct influence on emotional systems
in the brain, overlap between processes involved in
mental imagery and perception which can lead to
responding as if to real emotion arousing events and the
capacity of images to make contact with memories for
emotional episodes in the past. Thus, imagery will be
useful in managing emotional disorders and
psychological disorders. The authors have also stressed
the role of imagery in maintaining emotional disorders
and its uses in psychological treatment. Janet.A.Dipietro
et.al., (2007) conducted an experimental study at
Baltimore, United states among pregnant women to
assess the fetal responses to induced maternal relaxation
through Guided Imagery. A pre test post test control
 International Journal of Advances in Nursing Management 3(3): July- Sept. 2015
group design was used. The18 minute Guided Imagery
relaxation generated significant changes in maternal
heart rate, skin conductance and respiration period.
Significant alterations in fetal neurobehaviour were
observed, including decreased fetal heart rate, increased
FHR variability and suppression of fetal motor activity.
Evaluation of correspondence between changes within
individual maternal fetal pairs revealed significant
associations between maternal autonomic measures and
fetal cardiac patterns. Ackerman et.al., (2000) had
reviewed that Guided Imagery is a therapeutic technique
that allows a person to use his or her own imagination to
connect their body and mind to achieve desirable
outcomes such as decreased pain and reduced anxiety.
Wight Moffatt, Faith. C., (2006) conducted a
randomized control trial at Toronto among hypertensive
pregnant women regarding the effects of Guided
Imagery on blood pressure. They had selected 66
samples who were diagnosed to have PIH, and were
allotted to either 15 minute period of Guided Imagery or
of quiet rest. Intervention was given twice daily for 4
weeks or until delivery whichever came first. Women
allocated to Guided Imagery had significantly lower
average daytime ambulatory mean MAP when compared
with women allocated quiet rest (GI: M = 1.58 mmHg,
SD = 7.63; QR : M = 5.93 mmHg, SD = 6.55; t = 2.36, p
248
= 0.02). It was concluded that guided imagery is easy to
use, low cost, acceptable to women, has no risks and it is
effective in reducing level of blood pressure among
hypertensive pregnant women.
Baha Sibai., (2008) in his article in Science Direct
reviews that Guided Imagery is a learning process to
listen to someone’s voice, relax the breathing and
consciously direct the ability to imagine. The effect of
vivid imagery sends a message to the emotional control
center of the brain. From there the message is passed
along to the body’s endocrine, immune & autonomic
nervous systems. These systems influence a wide range
of bodily functions including heart & breathing rates and
blood pressure.
CONCEPTUAL FRAMEWORK:
Conceptual framework of this present study was
developed based on modified “Ela Joy Lehrmann and
Mortens Framework of Midwifery Care”. Lehrman has
identified the concepts underlying antenatal care being
provided. The author says that there is significant
association between the quantitative extent to which
midwives are able to put the concepts of midwifery care
into practice and the qualitative difference in the care
experienced by the woman.
 International Journal of Advances in Nursing Management 3(3): July- Sept. 2015
METHODOLOGY:
Description of Guided Imagery Procedure:
The script for Guided Imagery was selected after
consulting with a psychologist. The script was translated
in Tamil language with the help of language experts. The
contents of the script was spoken with soft and clear
voice, with correct pronunciation and pacing and
recorded in an audio tape. The colour photograph to be
used for the specific Guided Imagery script was
downloaded from the internet.
Pre interventional level of blood pressure was checked
for the participants. The researcher asked the participant
to wear comfortable and loose clothing. She asked the
participant to sit comfortably in a chair. The researcher
explained about the scene to be imagined and asked the
mother to relax. The theme picture was then handed over
to the mother, and the recorded audio was played with
the help of a headphone. Other environmental stimuli
were kept to the minimum as much as possible in the
249
room. Blood pressure was checked 10 minutes after
administering Guided Imagery.
Data Collection Procedure:
Prior permission was sought from the selected hospital
and obtained. Mothers were informed about the package
and procedure of intervention. Informed consent was
obtained. The demographic and obstetric data was
collected using structured interview questionnaire.
Mothers were assigned to experimental and control
group, with careful matching of selected demographic
variables and pre test MAP level on day 1 of the two
groups. Intervention of Guided Imagery was given to the
mothers in experimental group using photo and audio
CD for 10 minutes, twice a day at 8 am and 8 pm. Blood
pressure was checked 10 minutes before and after
intervention in experimental group. For control group,
blood pressure was checked in the morning and evening
at the same time as that of the experimental group.
 International Journal of Advances in Nursing Management 3(3): July- Sept. 2015

DATA ANALYSIS AND INTERPRETATION

Table 1: Frequency and Percentage Distribution of Mean Arterial Pressure Among Clients with PIH in Experimental Group N = 30
S.NO Variable Pretest Post test
n % n %
1. Mild (non significant)(MAP-94-105) 0 0 8 26.67
2. Moderate(MAP-106-120) 15 50 20 66.67
3. Severe(MAP->120) 15 50 2 6.66

Table 2: Frequency and Percentage Distribution of Mean Arterial Pressure among Clients with PIH in Control Group N =30
S.NO Variable Pretest Post test
n % n %
1. Mild (non significant)(MAP-94-105) 0 0 0 0
2. Moderate(MAP-106-120) 15 50 17 56.67
3. Severe(MAP->120) 15 50 13 43.33

TABLE 3. - Paired T Test of Level of Blood Pressure among PIH Mothers In Experimental and Control Group. N = 60
S.No Group Mean S.D M.D t-Value
1. Experimental group
Pre test 119.87 5.424 9.57 22.52*
Post test 110.3 5.172
2. Control Group
Pre test 119.1 5.558 0.35 NS
Post test 118.75 5.983 0.84
P< 0.05

Table 4: Mean, standard deviation, mean deviation and independent t test on level of blood pressure among PIH mothers N = 60
S No variable Mean SD MD t value
1. Pre test NS
Experimental group 119.87 5.424 0.77 0.534
Control group 119.1 5.558
2. Post test
Experimental group 110.3 5.172 8.45 5.751*
Control group 118.75 5.983
P< 0.05 level ; * - significant, NS – non significant

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 International Journal of Advances in Nursing Management 3(3): July- Sept. 2015

MAJOR FINDINGS OF THE STUDY: Nursing education:

Major study findings include: Health personnel may separate the theory and practice
With regard to effectiveness of guided imagery on level while treating the PIH mothers and tend to reduce the
of blood pressure, the obtained t value for level of blood level of blood pressure, which cannot be beneficial for
pressure in control group was 0.84 which is not the mothers. So nursing educators should motivate
significant at p<0.05. For experimental group, the t value students to:
obtained was 22.52, which is highly significant at p<0.05  Provide adequate clinical exposure to students
level. where guided imagery is used in reduction of blood
pressure.
With regard to the association between the level of blood  Arrange for participation in demonstrating guided
pressure with their selected demographic variables such imagery techniques by audio visual aids, group
as age, education, occupation, income, duration of sleep conference and bedside clinics.
at night, family history of PIH, family history of HT and  Conduct competitions in developing the best script
body mass index; there were significant association and audio CD for relaxation through guided imagery.
found with occupation, duration of sleep at night, family  Make available literature related to guided imagery
history of PIH, family history of HT and body mass techniques in reduction of blood pressure in the library,
index. Other variables like age, education, income were for student reference.
not found to have any significant association with the
level of blood pressure. Nursing administration:
 Collaborate with the hospital authorities in
IMPLICATIONS OF THE STUDY: formulating policies to employ the specially qualified
Nursing practice nurses in antenatal ward and periodically supervise their
The findings of the study clearly point out that guided application of guided imagery intervention.
imagery intervention is effective in reduction of blood  Collaborate with hospital authorities in allocating a
pressure of PIH mothers. small budget for purchase of guided imagery pictures,
The reduction of level of blood pressure of PIH mothers audio CD, CD player, head phones and video projector.
has an important role to play in enabling effectiveness of  Conduct inservice education program on guided
guided imagery intervention as an independent nursing imagery and its application in various fields.
intervention. This can be facilitated by motivating nurses  Provide opportunity for nurses to attend training
to: program on guided imagery techniques while handling
 Learn accurate assessment of level of blood pressure the PIH mothers.
with sphygmo manometer
 Develop sensitivity to the effects of guided imagery Nursing research
on reduction of blood pressure among PIH mothers.  Encourage further research studies on the
 Understand the importance of guided imagery effectiveness of guided imagery intervention in reduction
intervention as an adjunct to pharmacological therapy. of blood pressure among PIH mothers.
 Encourage peer use of guided imagery intervention  As is evident from the review of literature, more
as a form of relaxation among PIH mothers. research needs to be conducted on the effectiveness of
 Encourage the use of guided imagery intervention in guided imagery intervention along with other routine
reduction of blood pressure to minimize the requirement procedure in reduction of blood pressure, pain, anxiety,
of other non - pharmacological management. stress, insomnia etc.
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 International Journal of Advances in Nursing Management 3(3): July- Sept. 2015
 Disseminate the findings through conferences,
seminar publication in professional national and
international journals and world wide web.
RECOMMENDATIONS:
 The study can be replicated with a large sample size.
 The study can be conducted on patients with high
blood pressure due to reasons other than PIH.
 The intervention guided imagery have good effects
and can be taught to all the care givers including family
members.
 A study can be conducted to assess the attitude and
practice of guided imagery among nurses posted in
antenatal ward.
 The study can be conducted using time series design
to evaluate the duration of effectiveness of each guided
imagery intervention.
 A comparative study can be conducted between
guided imagery with any other relaxation therapies.
CONCLUSION:
The main conclusion from this present study is that most
of the PIH mothers in experimental group had severe and
moderate level of elevation of mean arterial pressure in
pre test and mild and moderate elevation of mean arterial
pressure in post test. This shows the imperative need to
understand the utilities of guided imagery techniques in
reduction of blood pressure among PIH mothers and it
will improve the quality of life by preventing the
complications of high blood pressure which includes the
stability in physiological, psychological, vocational and
lifestyle aspects.
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