Patient 1: Amanda is 17 years old and 32 weeks pregnant with her first child. She was sent home from a prenatal clinic three days ago with blood pressure averaging 140/94 mmHg, and urine was positive for protein (3+, graded 0 to 4 on a urine dipstick). Her platelets and liver enzyme levels were normal, and a nonstress test was reactive. Amanda's mother was advised to keep her on bed rest until she could be reevaluated at home by the clinic nurse (routine management of mild preeclampsia). Amanda appears anxious and reports that her neck and back ache from staying in bed and that she has had trouble falling asleep at night. Now her blood pressure is 130/86 mmHg, her urine positive for protein (1+, graded 0 to 4 on a urine dipstick), and she does not have headache, blurry vision, vaginal spotting, or abdominal cramping.

You ask Amanda whether she would like to learn some exercises to help her with the neck and back discomfort, and she responds enthusiastically. Lightly massaging her trapezius muscles, you find them to be quite tense and direct her to arrange her body in a relaxed position: eyes closed, hands open, mouth slightly open, and feet turned outward. Speaking softly, you direct her attention to muscle groups of the jaw, neck, shoulders, hands, upper back, and lower back, asking her to move them slowly through their ranges of motion by directing her to open her mouth widely and close it again; to gently flex, extend, and rotate her neck, and to move her neck laterally toward each shoulder, shrug, relax, and rotate them; to gently flex and extend the thoracic and lumbar spine; and to gently twist at the waist. While moving muscle groups through their ranges of motion you ask her to focus on feeling each muscle group tense, then become soft, warm, and relaxed. You step back and ask her to return her attention to her jaw and neck muscles, and you take her through the exercises a second time. She smiles and says that they help, and her mother agrees to prompt her to repeat them twice daily and at bedtime to help her fall asleep.

Patient 2. Thirty-year-old Anthony was enjoying a cycling vacation with his wife when a car struck him, throwing him to the pavement. Although he was wearing a helmet and denies loss of consciousness, the helmet was cracked and the ambulance crew reports that he was screaming and disoriented as he was transported to the ED. In addition to an apparent deformity of the left femur and multiple abrasions, he complains of severe headache, is unable to recall the accident, and is increasingly agitated. Although his Glasgow Coma Scale score is 15 and his cranial nerves are intact, the physician orders that he receive no medication until a computed tomography (CT) scan is performed.

You grasp Anthony's hand, make eye contact, and say, "I will help you to be more comfortable." Still maintaining eye contact, you say, "I want you to take a deep breath now, and then breathe with me. Quiet breath in, quiet breath out. Yes, that's right, close your eyes and keep breathing with me-quiet breath in, quiet breath out. You are starting to feel calm and more relaxed. Quiet breath in, quiet breath out. That's right, relax your shoulders. I want you to feel your stomach move out like a balloon as you take quiet, deep breaths through your mouth. I will stay with you and help you to use these quiet, deep breaths to help you to relax. We will have the CT scan finished in just a few minutes. Quiet breath in, quiet breath out. You are doing wonderfully."