Didn't take vital signs

[Battybaa]

I am looking for advice, particularly those in the medical profession. My elderly father requested to see his usual GP, but he was not available. He was booked to an advanced nurse practitioner by reception for what my father told her was ongoing issues, feeling worn out. The appointment lasted forty minutes. He told the nurse he had no energy. He had not been seen for almost a month at the practice. He had chronic anaemia Hb 9, for which he had only started iron tablets a month earlier (even though it had been first discovered 9 months earlier he had not been offered treatment or made aware of the anaemia until recently). He also has lung cancer with some nodule involvement. The nurse chatted at length to my father, and he explained he has a mostly vegetarian diet and asked how he could improve his iron through diet. The nurse measured his 02 and pulse with an oximeter which were 97% and 88. She did not take his temperature, respiratory rate or his blood pressure. She told him to contact the cancer consultant about his tiredness and sent him on his way. It was a Friday. Two days later my father collapsed as he was so weak. His blood pressure reading was 77/36. I would prefer not to go into further detail regarding what happened to him. The point of my post is:
Am I being unreasonable in expecting that the nurse should have done a full set of observations on my father rather than tell him to contact his cancer consultant at a hospital 40 miles away on a Friday afternoon? What steps would other medical professionals have taken if my father had walked through their door?

I only generally take the observations that are indicated to be taken, for a consultation for ongoing tiredness that wouldn't necessarily include blood pressure or temperature. If he wasn't having collapsing episodes, dizzy on standing, new infection signs, headaches... Then it would include a BP.

Anaemia is going to be high on the list for cause so pulse, pallor, and possible songs of bleeding would be on the list as well as discussing other causes of chronic tiredness. They say 80% of a consultations worth comes from the history taking with only 20% from the exam/obs.

I suspect that if he's not been referred for bloods there are probably already a recent set on the system taken during the symptoms, or some understanding of the cause and it was felt that his consultant would be the best person for onwards care planning.

Consultations aren't perfect and with hindsight the wrong decision can be made. It doesn't mean the clinician was neglegent. The ANP spent 40minutes discussing the symptoms experienced and examining him, that shows more consideration then a quick 10min 'oh so no recent changes', quick set of obs (which could well have been fine 2 days ago) and sent on their way being told to come back in a few weeks if no better.

I hope your dad is doing better now.

Well if I’d taken his pulse and oxygen levels I would have automatically taken his BP and temperature. I would have probably arranged for a repeat blood test too but this wouldn’t have helped if he collapsed 2 days later.

Hope he’s doing better now

Where you there at the appointment? Was the blood pressure definitely not taken? His pulse and oxygen were normal, so it may have be that everything was fine at the time of the appointment, but unfortunately, things do change.

I second what @SleepyRich has said.

Just to add, you also don’t know that the ANP didn’t check your father’s respiratory rate. We try not to tell patients when we’re doing that, as if I tell you I’m checking your breathing you become conscious of it and don’t breathe as you normally would.

Nurse practitioner here, I do a full set of observations. Especially with tiredness and anaemia. What's the point in doing a half arsed job and sticking a 02 sats probe on?
Hope your dads ok OP xx

Thank you for replies. I know only the pulse and 02 was done as this has been confirmed to me by the practice. I just don't understand why she felt no need to check his blood pressure?
We have found out since the appointment that blood results from almost a month prior to this appointment had not been followed up. He had a white blood cell count of 25. The GP who ordered the bloods had left a message for the consultant asking for advice. The consultant left a message with instructions but the GP did not follow up on the advice to bring him in for a review and further blood tests. I don't know why the nurse at his last appointment did not pick up on this. The Practice has not given an explanation yet. My concerns with them are ongoing.
It makes no sense to me that a complete set of ob's were not taken. When I saw him the next day he was sat on the floor and looked a bit euphoric and so relaxed, if that makes sense? And, also a bit spaced out? I couldn't understand why he was on the floor and he got up by himself. The next day it became far more serious, he was on the floor, on his knees for an hour when I arrived. he could not get up as he felt so weak.
He had been left for almost a month to his own devices with a white cell count of 25 and his exhaustion became evident in the week that he booked the appointment. He was usually active , by the time he went to the practice he felt so weak.

It really is quite common not to take a 'full set' of observations.

If someone's well enough to walk into clinic, has a regular pulse rate, isn't describing dizzy collapses, looking dehydrated etc, and is coming with chronic symptoms relating to a condition that's diagnosed and treatment has started I would jump to do a BP either but would be well exploring the hx of symptoms and prev asessme nts/treatment.

Ultimately elderly people with cancer are expected to have an element of abnormality in their blood work, treatment changes normally come from the consultant specialist over seeing the treatment.

ANP appointments are normally 20mins so 40mins suggests discussion with GP mentor or the specialist.

There was no discussion with GP mentor or the specialist. She took his pulse and 02 and spoke to him about iron rich foods for 40 minutes. They have told me the nurse had the impression he wanted a chat. I know because they have given me an account of the appointment. The consultant had said the raised white blood cells indicates infection but he was not followed up for a month. He was very weak going to the appointment (a family member drove him). He has always been physically very strong and he forced himself to that GP Surgery seeking help not a chat! Surely a normal pulse and 02 does not rule out the need for other checks that take a few minutes?

The GP should have read the consultant's letter and flagged about the further blood tests, that's not down to the practice nurse, as such.
As for a full set of obs in general practice--it depends on the how the patient presents at the time off the appointment and what symptoms are discussed.
General practice isn't like hospital care where you have full sets of obs done routinely.

Me too!

I am a ANP working out in the community. We always always do a full set of obs on our patients even if their symptoms aren't indicative of a problem with BP etc. Surely that is just basic practice is it not?!

If you are checking some obs , you might as well check all of them, apart from anything else, it gives other people who check them at a later date a base line to refer to.

Thank you for replies. My father's neighbour saw him on his way to the GP surgery that day and told me he thought that dad looked awful. I just find it so hard to accept that something as basic as blood pressure in an elderly patient who had made the effort to book an appointment was not taken. I don't know about others experience but elderly parents often put off booking appointments until they really are feeling awful. I would like to think if I was a medical professional, I would have taken the ob's. They have said that because his pulse and 02 were ok and that he walked into the room without difficulty the need for a bp check was not necessary. I am obsessing on the bp because if it had been measured, she would have been alerted to the fact that he really was not ok and needed urgent medical attention. Before the appointment he had started avoiding moving about too much at home and sitting in his chair more because he felt too weak when he walked about. I just wish he had been treated more seriously. I really think it is unacceptable and shameful and the reasons they give are poor excuses. Sorry, I am very angry about what happened.

I would also like to say to all medical professionals please keep taking full observations on patients. I feel I am stating the obvious but due to my father's experience maybe some don't feel the need. It is in situations like this that mistakes happen. Something that could have so easily been picked up on and treated had been missed and it can mean the difference between life and death.

Not taking his BP is not necessarily a concern, but what most certainly is that neither the GP or the nurse practitioner picked up on his blood results and that she told him to refer to his onchologist regarding his fatigue without checking his previous blood results

I completely understand your anger OP. In my opinion the NHS is far too reliant on nurse practitioners, they aren't doctors and just don't have anywhere near the same depth of medical training. It is a slippery slope, but with a shortage of doctors it is difficult to know what the solution is. His blood pressure should have been checked as standard here. I would raise this as an issue to the practice manager or clinical partner lead as it sounds like she needs additional training.