Volume 28, Issue 3 (6-2018)                   J Holist Nurs Midwifery 2018, 28(3): 163-170 | Back to browse issues page


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Ebrahimi Hosein Abadi S, Paryad E, Ghanbari Khanghah A, Pasdaran A, Kazem Nezhad Leyli E, Sadeghi Meibodi A M. Effects of Aromatherapy Using Lavender Oil on Hemodynamic Indices After Coronary Artery Bypass Graft Surgery. J Holist Nurs Midwifery. 2018; 28 (3) :163-170
URL: http://hnmj.gums.ac.ir/article-1-552-en.html
1- Nursing (MSN), School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran.
2- Social Determinants of Health Research Center (SDHRC), Department of Nursing (Medical-surgical), Instructor, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran. , e_paryad@gums.ac.ir
3- School of Nursing and Midwifery, Guilan University of Medical Sciences
4- Medicinal Plants Processing Research Center, Department of Pharmacognosy, Assistant Professor, Shiraz University of Medical Sciences, Shiraz, Iran.
5- Social Determinants of Health Research Center (SDHRC), Biostatistics, Associate Professor, Guilan University of Medical Sciences, Rasht, Iran.
6- Department of Cardiovascular, Assistant Professor, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran.
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Introduction
Coronary Artery Bypass Graft (CABG) surgery is one of the main treatment methods for coronary artery disease [1, 2] and the most common type of heart surgery [3, 4]. However, surgery is a stressor that can cause pathological stress involving psychological (anxiety and fear) and physiological (neuroendocrine responses) reactions. The physiological changes due to stress increase with the increase in the extent of the surgery [4]. CABG surgery is commonly associated with stress and disruption of vital signs [1].
Anxiety [2, 5, 6] and pain [7-9] are common problems experienced by patients undergoing cardiac surgery, both of which stimulate the sympathetic nervous system, causing an increase in the blood pressure and heart rate as well as shallow and rapid respiration. Both anxiety and pain increase the oxygen demand of the body and especially of the heart muscles, consequently increasing the load on the heart [7, 10]
In addition to being expensive, drugs used to treat these problems have many adverse physical and psychological effects [11], such as sleepiness, suppression of the immune system [12], imbalance, mild amnesia, and extreme dose-dependent sedation [13]. Complementary and alternative therapies are less harmful compared with the pharmacological methods [14] and can be used alone or in combination with other methods [15]. Aromatherapy has recently become a common complementary treatment used in many countries [16, 17]
Lavender essential oil is the most popular and widely used essential oil in aromatherapy [18]. It is prepared from the flowering parts of Lavandula spica L. [19, 20], and to date, there has been no report about its toxicity [18]. Studies on the effects of aromatherapy with lavender essential oil on the hemodynamic indices of patients have reported controversial results. In the study by Tahmasebi et al. [21], the lavender scent significantly reduced the systolic blood pressure, pulse rate, and respiratory rate of patients undergoing coronary angiography but had no significant effect on the diastolic blood pressure. Chien et al. [22] reported a significant reduction in the mean heart rate of midlife women with insomnia on the 4th and 12th week of lavender aromatherapy. 
Few studies have evaluated on the effects of lavender aromatherapy on the hemodynamic indices of patients after CABG surgery. Given the importance of the stability of hemodynamic indices in these patients and considering that complementary therapeutic interventions can be performed by nurses [23], the current study aimed to determine the effects of aromatherapy with lavender essential oil on the hemodynamic indices of patients after CABG surgery.
Materials and Methods
The present study was a randomized, double-blind, placebo-controlled clinical trial that was performed using permuted block randomization of patients who 3 days after underwent CABG surgery and were admitted to one of the teaching medical centers of Rasht City. The inclusion criteria were as follows: age of ≥18 years; ability to comprehend; no history of medications affecting the nervous system according to the patient’s records; no olfactory disorder; complete awareness; no history of allergies, contact dermatitis, or allergy to plants, especially lavender or cosmetic fragrances; no acute illness; no history of aromatherapy (according to the patient); no history of diseases of as the lung or liver, chronic headaches, migraines, or active mental disorders; no history of thyroid disease or heart surgery; willingness to cooperate; no addiction to drugs, smoking, or alcohol (according to the patient’s records); and a systolic blood pressure of ≥95 mmHg at the start of the study [24]
The exclusion criteria were as follows: sudden onset of any severe changes in vital signs, signs of possible respiratory allergies, or a systolic blood pressure of <95 mmHg on each day of the study intervention [24]. Thus, of the 280 patients who underwent CABG surgery during the sampling period, 28 who used drugs for nervous system disorders, 12 for pulmonary diseases, 5 for active psychological illness, 21 for thyroid disease, 19 for unwillingness to participate in the study, 33 for drug addiction, 12 for smoking, 2 for sensitivity to plants, 5 for allergy to cosmetic fragrances, 6 for >72-h hospitalization in the ICU, 12 for >8-h intubation duration, and 10 for lack of comprehension ability were not included in the study. In addition, 14 patients due to respiratory symptoms, one patient due to transfer to the cardiac care unit, one due to early discharge (before the end of 3 days of intervention), and one due to systolic blood pressure <95 mm Hg were excluded from the study.
In accordance with the study by Tahmasebi et al. [21], a sample size of 49 patients in each of the two groups (experimental and placebo)was determined for the two-tailed test, with 95% confidence level, 95% power, and a significance level of 0.05. Data were collected using a researcher-made questionnaire containing three sections: The first section included demographic data (age, gender, education level, marital status, place of residence, and employment status); the second section contained information about medical history (history of previous hospitalization for non-surgical reasons and history of non-cardiac surgery); and the third section included information about vital signs (systolic blood pressure, diastolic blood pressure, pulse rate, and respiratory rate). An OMAX chronometer (Switzerland) was used for measuring pulse and respiratory rates, and a barometer model ALPK2 (Japan) was used for measuring the systolic and diastolic blood pressure of all participants.
The content validity method was used to determine the validity of the demographic questionnaire and of the questions related to medical history. For this purpose, after reading the related books and published papers, the questionnaire was adjusted and distributed among 13 faculty members. The final version of the questionnaire was prepared after reviewing their comments.
Patients were randomly assigned to the experimental and placebo groups after being discharged from the intensive care unit and admitting in the cardiac surgery ward. Signed written consent forms were obtained from the patients, and the patients were asked to complete the questionnaire. All patients underwent a skin test to ensure that they were not allergic to lavender. In this test, one drop of lavender oil (Barij Essence Pharmaceutical Co., Kashan, Iran) was dabbed on the inner side of the patients’ wrist, and their wrists were dressed with compression bandages to prevent inhalation of the aroma; 2 min later [25], the location of oil on the wrists was observed for the presence of allergic symptoms (redness, hives, itching, etc.), in the absence of which, the patients were entered into the study. No patient showed allergic reactions to lavender. The study intervention was then performed as follows.
On the first day of the study, five drops of 20% concentrated lavender essential oil for the experimental group, and five drops of distilled water for the placebo group were poured onto sterile gauze. The gauze was then fixed at the middle of a 70-cm band, which was then tied around the patients’ neck like a necklace for three successive days. On the second and third days, five more drops of the essential oil and distilled water were added to the sterile gauze in the corresponding groups. For all participants, this intervention was performed between 12:00 and 13:00 on all three successive days of the study.
To observe the double-blind nature of the study, data on hemodynamic indices were collected by a fellow examiner who was blinded to the group allocation. He measured hemodynamic indices before each intervention and half an hour after the intervention. The pulse and respiratory rates were measured and recorded for a full minute. Blood pressure was measured from the right arm of all subjects in the supine position.
The obtained data were analyzed by SPSS v.16 using descriptive and inferential statistics. The chi-square test, independent t-test, Mann–Whitney U test, repeated measures ANOVA, Kolmogorov–Smirnov test (for examining the normality of the variables), and regression analysis were used for determining the effects of aromatherapy on the hemodynamic indices of the patients.
Results
The chi-square test and t-test revealed that the distribution of socio-demographic variables was not significantly different between the experimental and placebo groups; thus, the two groups were matched in this regard (Table 1). In addition, the t-test and Mann–Whitney U test indicated that the mean values of all variables, except the respiratory rate, before the intervention on the first day were significantly different between the two groups. The Mann–Whitney U test revealed significant differences between the two groups in terms of the mean systolic blood pressure on the second day of the intervention and the mean diastolic blood pressure on the first day of the intervention (P=0.046 0.029, respectively). The t-test revealed no significant difference between the two groups in terms of the mean pulse and respiratory rates after aromatherapy on any day of the intervention (Table 2).

The regression analysis showed that the intervention was group associated with changes in systolic and diastolic blood pressure; the systolic and diastolic blood pressure were lower in the experimental group than in the placebo group (P=0.002 and 0.001, respectively). The blood pressure was not affected by any other interventional variables. In addition, the intervention group, education level, and gender were associated with changes in the pulse rate after the intervention in the experimental group. Thus, the pulse rate was lower in the experimental group than in the placebo group (P=0.0001), higher education level was associated with lower pulse rate (P=0.027), and the pulse rate was lower in women than in men (P=0.045). Moreover, the gender variable was associated with changes in the respiratory rate after the intervention in the experimental group; thus, the respiratory rate was lower in women than in men (P=0.031) (Tables 3 and 4).

Discussion
In the study, the difference in the mean systolic blood pressure after the second day of the intervention was significant between the experimental and placebo groups. Kim et al. [26] have also reported the positive effect of lavender essential oil on the blood pressure of individuals. Seong et al. [27] evaluated the short- and long-term effects of inhaling lavender aroma on the systolic blood pressure of the patients and found a decrease in blood pressure after 2 min of inhalation two times a week [27]. Thus, their finding is consistent with our results. Lavender essence stimulates the receptors in the olfactory bulb that transmits the olfactory message to the limbic system [15, 24, 28, 29]
The limbic system is the center of sensation in the brain, which influences the pulse rate, blood pressure, and respiratory system [29, 30], thus causing a decrease in blood pressure. However, all patients who have undergone CABG surgery are also prescribed blood pressure-lowering medicines; therefore, the significant decrease in systolic blood pressure observed in the placebo group on the second and third days compared with the pressure on the first day can be explained as the effect of these drugs. By contrast, Shiina et al. [31] reported that the lavender aroma has no effect on the blood pressure. This discrepancy in the findings may be due to differences in the concentration of the essential oil as they used four drops of lavender essential oil diluted with 20 mL of hot water for aromatherapy. The difference in the mean diastolic blood pressure after the intervention was significant between the two groups, a finding consistent with the results of Heidari et al. [32] who evaluated the effect of inhaling the aroma of lavender essential oil on anxiety and some physiological parameters of patients undergoing open heart surgery. The main sedative compounds of lavender essential oil are linalool and linalyl acetate [33], which stimulate the parasympathetic system [16] as well as the limbic system [29, 30]; this explains the reduction in diastolic blood pressure in the experimental group. By contrast, Bikmoradi et al. [1] reported no significant changes in the hemodynamic indices due to lavender essential oil. This discrepancy in the findings may be explained by differences in the concentration and dose of the essential oil and/or the methods used for measuring these indices between the studies. Bikmoradi et al. used a monitoring device was used to record hemodynamic indices, whereas we used a barometer model ALPK2 to measure blood pressure.
The t-test revealed no significant difference after the intervention on any day between the two groups in terms of the mean pulse and respiratory rates. Consistent with our findings, Seifi et al. [14] reported no statistically significant effect of lavender essential oil on the heart rate and Bikmoradi et al. [1] found no effect of this oil on the respiratory rate. 
The regression analysis showed that the intervention group, education level, and gender were associated with changes in the pulse rate and that the gender variable was associated with changes in the respiratory rate after the intervention in the experimental group. This indicated that individuals with higher education levels are more likely to accept changes in physical, mental, and environmental conditions. This explains the effect of lavender essential oil on the hemodynamic indices of these individuals, including the pulse rate. In addition, the relationship between gender variable and changes in the pulse and respiratory rates was possibly due to the difference in the number of women and men between the two groups.
One limitation of the current study was the lack of standard tools for use in aromatherapy. Although the same method of inhalation was used for all patients, the concentration of the essential oil used in our study was higher than that normally used in aromatherapy; this could have caused more effects on the hemodynamic indices.
Nevertheless, the findings of this study showed that lavender essential oil is effective in maintaining blood pressure on the second day of the intervention in patients who have undergone CABG surgery. Future studies are required to evaluate the long-term effects of this oil on the blood pressure of patients by performing aromatherapy at their home after discharge from the hospital.
Ethical Considerations
Compliance with ethical guidelines

Ethics Committee of the Vice Chancellor for Research in Guilan University of Medical Sciences (No: 2930382805, registered in IRCT with No: IRCT2014102119617N1) has confirmed the present paper. Signed written informed consent forms were obtained from the patients, and then the patients were asked to complete the questionnaire.
Funding 
This paper was extracted from a Master’s thesis of nursing approved by the Ethics Committee of the Vice Chancellor for Research in Guilan University of Medical Sciences (GUMS) with license number 2930382805 and was registered by Iranian Registry of Clinical Trials under number IRCT2014102119617N1.
Conflict of interest
No conflict of interest has been declared by the authors.
Acknowledgements
The authors would like to thank the Research Center and Research Deputy of GUMS, Personnel of surgical, ICU, and CCU wards in Dr. Heshmat Medical Education Center of Rasht City, Barij Essence Pharmaceutical Co., and all study participants who helped us with this research.


References
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  2. Tung HH, Hunter A, Wei J. Coping, anxiety and quality of life after coronary artery bypass graft surgery. Journal of Advanced Nursing. 2008; 61(6):651-63. [DOI:10.1111/j.1365-2648.2007.04557.x] [PMID]
  3. Forouzannia SK, Abdolahi MH. [An epidemiologic study of 2000 cases the heart surgery in Afshar Hospital of Yazd (Persian)]. Journal of Shahid Sadoughi University of Medical Sciences. 2003; 11(2):3-9.
  4. Emami Zeydi A, Jafari H, Khani S, Esmaeili R, Gholipour Baradari A. [The effect of music on the vital signs and SpO2 of patients after open heart surgery: A randomized clinical trial (Persian)]. Journal of Mazandaran University of Medical Sciences. 2011; 21(82):73-82.
  5. Esmaeeli Douki Z, Vaezzadeh N, Shahmohammadi S, Shahhosseini Z, Tabary SZ, Mohammadpour RA, et al. Anxiety before and after coronary artery bypass grafting surgery: relationship to QOL. Middle-East Journal of Scientific Research. 2011; 7(1):103-8.
  6. Rigi F, Bazdar P, Salehi Ardabili SH, Naseri M, Feizi A. [The effect of foot reflexology on anxiety in patients with coronary artery bypass surgery referred to Seyed-Al-Shohada teaching hospital, Urmia, 2012 (Persian)]. The Journal of Urmia Nursing and Midwifery Faculty. 2013; 11(8):578-83.
  7. Fayazi S, Shariati A, Momeni M, Latifi M. [The efficacy of Benson’s relaxation technique on postoperative pain in coronary artery bypasses graft (Persian)]. Jundishapur Scientific Medical Journal. 2010; 8(4):479-89.
  8. Firoozabadi MD, Ebadi A. Effect of relaxation on postoperative pain in patients after Coronary Artery Bypass Graftin (CABG) surgery. Nationalpark-Forschung In Der Schweiz (Switzerland Research Park Journal). 2014; 103(1):185-91.
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  11. Sobhani AR, Sharami H, Shokohi F, Oodi M. [The effect of Lavendula essence on post cesarean pain relief (Persian)]. Journal of Guilan University of Medical Sciences. 2007; 16(62):80-6.
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  13. Shaw D, Norwood K, Leslie J. Chlordiazepoxide and lavender oil alter unconditioned anxiety-induced c-fos expression in the rat brain. Behavioural Brain Research. 2011; 224(1):1-7. [DOI:10.1016/j.bbr.2011.05.014] [PMID]
  14. Seifi Z, Beikmoradi A, Oshvandi K, Poorolajal J, Araghchian M, Safiaryan R. The effect of lavender essential oil on anxiety level in patients undergoing coronary artery bypass graft surgery: A double-blinded randomized clinical trial. Iranian Journal of Nursing and Midwifery Research. 2014; 19(6):574-81. [PMID] [PMCID]
  15. Babashahi M, Babashahi F, Fayazi S. [Comparing the effect of massage aromatherapy and massage on anxiety level of the patients in the preoperative period: A clinical trial (Persian)]. Evidence Based Care. 2012; 2(2):19-28. [DOI:10.22038/EBCJ.2012.395]
  16. Bagheri M, Soltani R, Hajhashemi V, Soheilipour S, Asghari GhR. [Analgesic effect of lavender oil aromatherapy methods (Persian)]. Journal of Islamic and Iranian Traditional Medicine. 2012; 3(4):483-8.
  17. Imanishi J, Kuriyama H, Shigemori I, Watanabe S, Aihara Y, Kita M, et al. Anxiolytic effect of aromatherapy massage in patients with breast cancer. Evidence-Based Complementary and Alternative Medicine. 2009; 6(1):123-8. [DOI:10.1093/ecam/nem073] [PMID] [PMCID]
  18. BabashahiKohanestani F, Ahmadi F, Memarian R. [The effect of Lavender aromatherapy program on the pain intensity of patients with AML undergoing chemotherapy (Persian)]. Journal of Urmia Nursing And Midwifery Faculty. 2013; 11(3):180-6.
  19. Tahmasbi H, Mahmoodi G, Mokhberi V, Hassani S, Akbarzadeh H, Rahnamai N. [The effect of Aromatherapy on the anxiety of the patients experiencing coronary Angiography (Persian)]. Zahedan Journal of Research in Medical Sciences. 2012; 14(1):47-53.
  20. Mohamadkhani Shahri L, Sabet Birjandi S, Mohamadkhani Shahri H. [Effect of massage Aromatherapy with lavandula on the duration of first and second stage of labor in nulliparous women (Persian)]. Bimonthly Journal of Hormozgan University of Medical Sciences. 2013; 17(2):145-54.
  21. Tahmasebi H, Abbasi E, Zafari M, Darvishi H. [The impact of aromatherapy on hemodynamic condition of patients experiencing coronary angiography (Persian)]. Medical-Surgical Nursing Journal. 2013; 2(1-2):26-32. 
  22. Chien LW, Cheng SL, Liu CF. The effect of lavender aromatherapy on autonomic nervous system in midlife women with insomnia. Evidence-Based Complementary and Alternative Medicine. 2012; 2012:1-8. [DOI:10.1155/2012/740813]
  23. Babashahi M, Fayazi S, Aghel N, Haghighizadeh M. [Effect of aromatherapy on anxiety level among preoperative patients (Persian)]. Jundishapur Scientific Medical Journal. 2010; 9(5):507-16.
  24. Vakilian K, Karamat A, Mousavi A, Shariati M, Ajami E, Atarha M. [The effect of Lavender essence via inhalation method on labor pain (Persian)]. Journal of Shahrekord University of Medical Sciences. 2012; 14(1):34-40. 
  25. Kim JT, Wajda M, Cuff G, Serota D, Schlame M, Axelrod DM, et al. Evaluation of aromatherapy in treating postoperative pain: Pilot study. Pain Practice. 2006; 6(4):273-7. [DOI:10.1111/j.1533-2500.2006.00095.x] [PMID]
  26. Kim IH, Kim C, Seong K, Hur MH, Lim HM, Lee MS. Essential oil inhalation on blood pressure and salivary cortisol levels in prehypertensive and hypertensive subjects. Evidence-Based Complementary and Alternative Medicine. 2012; 2012: 984203. [DOI:10.1155/2012/984203]
  27. Seong K, Hong JH, Hur MH, Lee MS. Two-week aroma inhalation effects on blood pressure in young men with essential hypertension. European Journal of Integrative Medicine. 2013; 5(3):254-60. [DOI:10.1016/j.eujim.2012.12.003]
  28. Stea S, Beraudi A, De Pasquale D. Essential oils for complementary treatment of surgical patients: State of the art. Evidence-Based Complementary and Alternative Medicine. 2014; 2014.
  29. Vakilian K, Atarha M, Bekhradi R, Chaman R. Healing advantages of lavender essential oil during episiotomy recovery: A clinical trial. Complementary Therapies in Clinical Practice. 2011; 17(1):50-3. [DOI:10.1016/j.ctcp.2010.05.006] [PMID]
  30. Vakilian K, Atarha M, Bekhradi R, Ghebleh F, Hatami Z, Seraj A. [The effect of Lavender essential oil in the care of postpartum episiotomy (Persian)]. Journal of Shahrekord University of Medical Sciences. 2008; 10(3):63-9.
  31. Shiina Y, Funabashi N, Lee K, Toyoda T, Sekine T, Honjo S, et al. Relaxation effects of lavender aromatherapy improve coronary flow velocity reserve in healthy men evaluated by transthoracic Doppler echocardiography. International Journal of Cardiology. 2008; 129(2):193-7. [DOI:10.1016/j.ijcard.2007.06.064] [PMID]
  32. Heidari A, Vakili M A, Moghaddam S, Taziki S A, Badeleh M T. [The effect of lavender oil inhalation on anxiety and some physiological parameters of open- heart surgery patients (Persian)]. Journal of Research Development in Nursing and Midwifery. 2013; 10:1-6.
  33. Kialashaki A, Shokouhi F, Tofighi M, Zafari M, Zarenegad N. [Effect of lavandula essence on premenstrual syndrome (Persian)]. Journal of Mazandaran University of Medical Sciences. 2012; 22(93):48-56.
Article Type : Research | Subject: Special
Received: 2015/11/10 | Accepted: 2016/01/13

References
1. Bikmoradi A, Seifi Z, Poorolajal J, Araghchian M, Safiaryan R, Oshvandi K. Effect of inhalation aromatherapy with lavender essential oil on stress and vital signs in patients undergoing coronary artery bypass surgery: A single-blinded randomized clinical trial. Complementary Therapies in Medicine. 2015; 23(3):331-8. [DOI:10.1016/j.ctim.2014.12.001] [PMID] [DOI:10.1016/j.ctim.2014.12.001]
2. Tung HH, Hunter A, Wei J. Coping, anxiety and quality of life after coronary artery bypass graft surgery. Journal of Advanced Nursing. 2008; 61(6):651-63. [DOI:10.1111/j.1365-2648.2007.04557.x] [PMID] [DOI:10.1111/j.1365-2648.2007.04557.x]
3. Forouzannia SK, Abdolahi MH. [An epidemiologic study of 2000 cases the heart surgery in Afshar Hospital of Yazd (Persian)]. Journal of Shahid Sadoughi University of Medical Sciences. 2003; 11(2):3-9.
4. Emami Zeydi A, Jafari H, Khani S, Esmaeili R, Gholipour Baradari A. [The effect of music on the vital signs and SpO2 of patients after open heart surgery: A randomized clinical trial (Persian)]. Journal of Mazandaran University of Medical Sciences. 2011; 21(82):73-82.
5. Esmaeeli Douki Z, Vaezzadeh N, Shahmohammadi S, Shahhosseini Z, Tabary SZ, Mohammadpour RA, et al. Anxiety before and after coronary artery bypass grafting surgery: relationship to QOL. Middle-East Journal of Scientific Research. 2011; 7(1):103-8.
6. Rigi F, Bazdar P, Salehi Ardabili SH, Naseri M, Feizi A. [The effect of foot reflexology on anxiety in patients with coronary artery bypass surgery referred to Seyed-Al-Shohada teaching hospital, Urmia, 2012 (Persian)]. The Journal of Urmia Nursing and Midwifery Faculty. 2013; 11(8):578-83.
7. Fayazi S, Shariati A, Momeni M, Latifi M. [The efficacy of Benson's relaxation technique on postoperative pain in coronary artery bypasses graft (Persian)]. Jundishapur Scientific Medical Journal. 2010; 8(4):479-89.
8. Firoozabadi MD, Ebadi A. Effect of relaxation on postoperative pain in patients after Coronary Artery Bypass Graftin (CABG) surgery. Nationalpark-Forschung In Der Schweiz (Switzerland Research Park Journal). 2014; 103(1):185-91.
9. Langley ME. Pain management after cardiac surgery. Greenville, Carolina: East Carolina University; 2009.
10. Ip H, Abrishami A, Peng P, Wong J, Chung F. Predictors of postoperative pain and analgesic consumption: A qualitative systematic review. Anesthesiology. 2009; 111(3):657-77. [DOI:10.1097/ALN.0b013e3181aae87a] [PMID] [DOI:10.1097/ALN.0b013e3181aae87a]
11. Sobhani AR, Sharami H, Shokohi F, Oodi M. [The effect of Lavendula essence on post cesarean pain relief (Persian)]. Journal of Guilan University of Medical Sciences. 2007; 16(62):80-6.
12. Braden R, Reichow S, Halm MA. The use of the essential oil lavandin to reduce preoperative anxiety in surgical patients. Journal of Perianesthesia Nursing. 2009; 24(6):348-55. [DOI:10.1016/j.jopan.2009.10.002] [PMID] [DOI:10.1016/j.jopan.2009.10.002]
13. Shaw D, Norwood K, Leslie J. Chlordiazepoxide and lavender oil alter unconditioned anxiety-induced c-fos expression in the rat brain. Behavioural Brain Research. 2011; 224(1):1-7. [DOI:10.1016/j.bbr.2011.05.014] [PMID] [DOI:10.1016/j.bbr.2011.05.014]
14. Seifi Z, Beikmoradi A, Oshvandi K, Poorolajal J, Araghchian M, Safiaryan R. The effect of lavender essential oil on anxiety level in patients undergoing coronary artery bypass graft surgery: A double-blinded randomized clinical trial. Iranian Journal of Nursing and Midwifery Research. 2014; 19(6):574-81. [PMID] [PMCID]
15. Babashahi M, Babashahi F, Fayazi S. [Comparing the effect of massage aromatherapy and massage on anxiety level of the patients in the preoperative period: A clinical trial (Persian)]. Evidence Based Care. 2012; 2(2):19-28. [DOI:10.22038/EBCJ.2012.395]
16. Bagheri M, Soltani R, Hajhashemi V, Soheilipour S, Asghari GhR. [Analgesic effect of lavender oil aromatherapy methods (Persian)]. Journal of Islamic and Iranian Traditional Medicine. 2012; 3(4):483-8.
17. Imanishi J, Kuriyama H, Shigemori I, Watanabe S, Aihara Y, Kita M, et al. Anxiolytic effect of aromatherapy massage in patients with breast cancer. Evidence-Based Complementary and Alternative Medicine. 2009; 6(1):123-8. [DOI:10.1093/ecam/nem073] [PMID] [PMCID] [DOI:10.1093/ecam/nem073]
18. BabashahiKohanestani F, Ahmadi F, Memarian R. [The effect of Lavender aromatherapy program on the pain intensity of patients with AML undergoing chemotherapy (Persian)]. Journal of Urmia Nursing And Midwifery Faculty. 2013; 11(3):180-6.
19. Tahmasbi H, Mahmoodi G, Mokhberi V, Hassani S, Akbarzadeh H, Rahnamai N. [The effect of Aromatherapy on the anxiety of the patients experiencing coronary Angiography (Persian)]. Zahedan Journal of Research in Medical Sciences. 2012; 14(1):47-53.
20. Mohamadkhani Shahri L, Sabet Birjandi S, Mohamadkhani Shahri H. [Effect of massage Aromatherapy with lavandula on the duration of first and second stage of labor in nulliparous women (Persian)]. Bimonthly Journal of Hormozgan University of Medical Sciences. 2013; 17(2):145-54.
21. Tahmasebi H, Abbasi E, Zafari M, Darvishi H. [The impact of aromatherapy on hemodynamic condition of patients experiencing coronary angiography (Persian)]. Medical-Surgical Nursing Journal. 2013; 2(1-2):26-32.
22. Chien LW, Cheng SL, Liu CF. The effect of lavender aromatherapy on autonomic nervous system in midlife women with insomnia. Evidence-Based Complementary and Alternative Medicine. 2012; 2012:1-8. [DOI:10.1155/2012/740813] [DOI:10.1155/2012/740813]
23. Babashahi M, Fayazi S, Aghel N, Haghighizadeh M. [Effect of aromatherapy on anxiety level among preoperative patients (Persian)]. Jundishapur Scientific Medical Journal. 2010; 9(5):507-16.
24. Vakilian K, Karamat A, Mousavi A, Shariati M, Ajami E, Atarha M. [The effect of Lavender essence via inhalation method on labor pain (Persian)]. Journal of Shahrekord University of Medical Sciences. 2012; 14(1):34-40.
25. Kim JT, Wajda M, Cuff G, Serota D, Schlame M, Axelrod DM, et al. Evaluation of aromatherapy in treating postoperative pain: Pilot study. Pain Practice. 2006; 6(4):273-7. [DOI:10.1111/j.1533-2500.2006.00095.x] [PMID] [DOI:10.1111/j.1533-2500.2006.00095.x]
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