The Drowsy Stroke Patient and the Dinner Tray
You are a patient care assistant on the evening shift in a 40-bed general hospital. A 74-year-old man is on day 14 after a stroke and has been admitted with pneumonia. He has right-sided weakness, a nasogastric tube in place, and slurred, weak speech. At 7:30 pm the nurse is busy with a new admission and asks you to 'give him his dinner by mouth - the NG tube is blocked anyway'. The tray has soft khichdi and a glass of water. The patient is drowsy, his head is flat on the pillow, and he coughs after the first two spoonfuls. While turning him you notice dark red marks over both heels and the lower back. His breathing sounds gurgly. The ward has a suction machine at the nursing station and pulse oximeters on each trolley.
1. Should you continue feeding him by mouth? Justify your decision step by step.
Read the worked answer
No. Stop now.
The evidence in front of you, taken together:
- Drowsy after a stroke - reduced alertness alone makes swallowing unsafe.
- Coughing on the first two spoonfuls - the most reliable bedside sign of aspiration; food is going towards the airway, not the oesophagus.
- Gurgly breathing - suggests material already in the throat or chest, and he has been admitted with pneumonia, which may itself have followed aspiration.
- An NG tube in place means someone has already judged his swallow unsafe. A blocked tube does not make oral feeding safe; it makes the tube a nursing problem to solve.
What to do instead: stop, sit him up as far as his condition allows, keep him turned to the side if he is vomiting, ensure suction is at hand, check SpO2 and respiratory rate, and call the nurse immediately. Do not give water to 'clear' the throat.
Scope: feeding a patient with known dysphagia is not a delegated task for an assistant. The nurse must reassess and arrange tube feeding as prescribed, or a formal swallow screen before any oral trial.
2. What will you do about the blocked NG tube and the marks on his heels and back?
Read the worked answer
Blocked NG tube:
- Do not push water forcefully, and never push a wire or a stilette down the tube - that risks perforating the oesophagus or the stomach.
- Do not reinsert or reposition it yourself if that is outside your training; the nurse or doctor must reassess and reinsert.
- Report the block at once so that feeding and medicines are not simply skipped; a missed feed in an already weak patient matters.
Heels and lower back:
- The dark red marks that do not fade when pressed are an early pressure injury, not a cosmetic mark. In a stroke patient who cannot move himself, they will deepen within days.
- Reposition every 2 hours, using pillows to keep the heels off the mattress and to tilt him slightly side to side.
- Keep the skin clean and dry; do not rub or massage a reddened area.
- Report to the nurse so a pressure-area chart is started, and record the site and size.
Reasoning: both findings are the kind of small observation that is worthless unless it reaches the person who can act on it.
3. Which changes would make you call for urgent help, and why those specifically?
Read the worked answer
Call at once for:
- Choking or inability to speak or breathe - an immediate airway emergency; start the ward's emergency call and stay with him.
- SpO2 falling below about 92%, or a rising respiratory rate (above roughly 24 per minute) - in a patient with pneumonia and possible aspiration, this is the earliest objective sign that his lungs are worsening, often before he looks ill.
- Cyanosis of lips or fingertips, or increasing drowsiness - failing oxygenation and possibly rising carbon dioxide.
- A new fever or a change in the character of his sputum - possible worsening chest infection.
- Any vomit with distress, or a distended abdomen - aspiration risk and possible feeding intolerance.
Why these and not everything: in a stroke patient who cannot report symptoms, the observations you can measure are your only early warning. Respiratory rate is the cheapest and most neglected of them.
Also report the feed he already took and the coughing, even if he seems fine now. Aspiration can declare itself hours later, and the nurse needs the timeline.