Running Head: PATTERNS OF KNOWING

PATTERNS OF KNOWING

By

Christiana Ikome

Presented to
Dr. A. Johnson

In partial fulfillment of the requirements of

Nursing 620 Theoretical foundations for the practice of nursing

COPPIN STATE UNIVERSITY

HELENE FULD SCHOOL OF NURSING
Winter 2013

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Client situation:
Mr. Gambrills is an 87 years old African American male with a history of diabetes
mellitus, HTN, end stage renal disease, (ESRD), for which he is on hemodialysis three days a
week, has a history of congestive heart failure (CHF), coronary artery disease (CAD, for which
he had a stent placed about a year ago. He lives at home with his 82 years old wife, Elena, with
whom he has been married for over fifty years. Mr. Gambrills came to the hemodialysis clinic
recently, was noted to have lost a lot of weight, confused, pale and disoriented. His blood
pressure was 89/45mmHg, he said I feel fine however, he acknowledged that he has not been
eating because Elana was in the hospital and that he was afraid she was not going to make it.
Staff nurse placed a call to Mr. Gambrillss daughter, Lakisha, who is the power of attorney and
who frequents her parents home. Lakisha acknowledged that she has not been to see Mr.
Gambrills for about a week but said that she found the meals delivered by meals on wheels
untouched at home the last time she visited.
Lakisha claimed that she is overwhelmed by her mothers situation and confirmed to staff
that Elana, Gambrills wife is on hospice, however, she does not want her father to know because
he shall not be able to deal with the situation. Lakisha was also concerned about her fathers
change of status however, insisted that her father should not be sent to the hospital because she
cannot handle her both parents being sick in the hospital. Upon assessment, Mr. Gambrills, was
noted to have gangrene on two of his left toes. The toes appeared as if they were about to fall
off. Mr. Gambrills said he did not want to bother his daughter with his toes and insisted that the
nurse should not let his daughter know. The nurse called for an emergency meeting with the
social worker, Mr. Gambrillss primary care provider, and nephrologists who all decided that the

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nurse should send Mr. Gambrills to the hospital. Mr. Gambrills ended up with an amputation of
the left leg.
Interventions:
The nurses assessment was critical and imperative as the nurse was able to notice and
identify a change of condition immediately on this patient. The nurses contact to the patients
daughter, social worker, primary care provider as well as his Nephrologists facilitated a change
in the plan of care for this patient. The patient clearly needed more evaluation as he was
hypotensive, confused and emaciated. Despite the fact that the patients daughter insisted that
the patient should not be sent to the hospital, the health care team made a unanimous decision to
send the patient to the hospital where he ended up with an amputation of the gangrenous leg.
The nurse and the other health care team members ignored the fact that the patients daughter did
not want her father to be sent to the hospital because it is overwhelming for her. The nurses
intervention by way of involving the social worker, primary care provider and nephrologists was
to make the decision that is best for the patient and not to suit the patients daughter.
How patterns of knowing contributed to the nurses actions:
Four patterns of knowing exist, which attempt to distinguish or classify the different
sources from which knowledge and beliefs in the nursing professional practice is derived.
Carper identified empirics, the science of nursing, aesthetics, the art of nursing, the component of
a personal knowledge in nursing and ethics, the component of moral knowledge in nursing as the
four patterns of knowing (Carper 1978, pg 13-14). In the case of Mr. Gambrills, empirics
contributed to the nurses action by informing the nurse that the patients blood pressure was low.

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The nurse was able to measure the pressure in the patients arterial blood pressure by
way of using a stethoscope. The nurse was also able to measure the patients weight. These
actions alerted the nurse that the circulatory volume of blood in the patient is low. Empirics also
aided the nurse to know that when a patient with diabetes has dead tissues, the skin on the areas
is black and gangrenous due to poor blood circulation. This empirical knowledge alerted the
nurse to send the patient to the hospital, where he ended up with an amputation. Aesthetic
knowing contributed to the nurses action by way of making the nurse aware of the patients
situation as it occurred, and as a unique one, requiring immediate resolution and she took
practical actions including calling for an urgent meeting, contacting patients daughter as well as
sending the patient to the hospital for further evaluation and treatment. The nurse examined the
whole situation including the age of the patient, his nutritional status/needs, his confused state,
his pale and frail appearance, his poor vital signs to make a decision based on aesthetic
knowledge. Personal knowledge and attitude was a major contributor in the nurses decision as
she immediately knew that something was not right with this patient as soon as she saw the
patient. The nurse used empathy and personal experience to rally everyone to get help for this
patient as soon as possible. Ethical knowing was an outstanding contributor in the nurses
decision as the nurse was put in a difficult situation because she was caught between two
choices which included either to listen to the patients daughter who was already burning out
from her mothers illness or to do the right thing for the patient. The nurse ignored the patients
daughters instructions and did what she thought was morally acceptable and better for the
patient. Although the patient ended up with an amputation, the nurse helped save this patients
live using the patterns of knowing, as all her decisions were greatly influenced by empirics,
aesthetics, personal knowing and ethics.

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Most challenging pattern of knowing:

The most challenging pattern of knowing would be the ethical or moral pattern as there
were interventions that required moral or ethical judgment. The nurse was caught between either
listening to the patients daughter because she is the power of attorney or to make decisions
which are morally better for the patient. Irrespective of what the power of attorney had decided,
the nurse did what she and the rest of the health care providers thought was the best decision
given the circumstances for the patient.
What makes the pattern most challenging is that the nurse has to examine her own self,
use her own morals and beliefs to make a decision which can make or mar the patients life, and
which may be different from the moral and beliefs of the patient. For instance, in the above
scenario, the patient requested that the nurse should not let his daughter know that he has
gangrene in his toes. The patients daughter also did not want the nurse to let her father know
that his beloved wife is in hospice care. The nurse was put by both the patient and the patients
family member in a difficult situation which prompted her to make decisions based on what she
thought was morally right for the patient, more than the patients daughter.

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References:
Barbara A. Carper (1978), "Fundamental Patterns of Knowing in Nursing", Advances
in Nursing Science
1(1), 1323.