Mid-Bite: A Drooping Face, a Weak Arm, and a Cup of Water
Mrs. K, 76, is eating lunch at a table with three other residents. You are across the room. She coughs twice, makes a wet gargling sound, and stops speaking. Her tray is in front of her, her eyes are wide, and she is trying to stand. Her right arm knocks her glass over, and her right cheek looks lower than her left, with drool running from the right side of her mouth. She is moving air, though noisily, and she is not turning blue. The resident beside her picks up a cup of water and says, "Here, honey, wash it down." You are the only CNA in the dining room and the nurse is down the hall.
1. What are your first actions in the next thirty seconds?
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- Stop the water. Take the cup out of the other resident's hand - nothing by mouth until this is sorted out.
- Note the time. Look at the clock and remember it. "Time last known well" is the single most important piece of information for a possible stroke.
- Get help without leaving her. Call out for the nurse, press the call light, or use the emergency system - do not run down the hall and leave her alone and unattended.
- Stay with her, sit her upright, and keep her from standing and falling.
- Watch her breathing and be ready to act if it changes.
She is moving air, so this is not a silent-airway emergency right now - but it can become one. Everything that goes in her mouth from here on is a choking and aspiration risk.
2. How do you reason through choking versus stroke, and what would change your actions?
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Both are on the table, and the two look different:
- Choking fits the timing - it started mid-meal, with coughing and a wet gargle.
- Stroke fits the findings - one-sided facial droop, a weak right arm, and sudden loss of speech. Coughing during eating can also be the first sign of a stroke that has weakened her swallow.
If her cough becomes ineffective, or she stops moving air, turns blue, or cannot make a sound: treat it as choking - call for help, give back blows and abdominal thrusts, and start CPR if she goes unresponsive.
If she keeps moving air but the droop and weakness persist: treat it as a stroke. Keep her NPO, do not give water or food to "test" her swallow, do not give aspirin, and do not let her walk. Note when she was last seen normal, and get her to emergency evaluation as fast as the nurse directs - clot-dissolving treatment is time-limited, generally within a few hours of the first symptom.
3. What do you hand off to the nurse and document?
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Give the nurse a tight, ordered report - this is the information the receiving hospital will ask for first:
- Time last known well and the exact time symptoms were first seen.
- What you saw: Coughing twice, wet gargle, unable to speak, right facial droop, right arm weakness, drooling, and that she was trying to stand.
- Airway: moving air, noisy, not cyanotic at last check.
- What she ate and how much, and that no water or food has been given since.
- Who you called and when, and what you did while waiting.
In the chart, write observations and times, not conclusions: "14:07 - resident coughed twice during lunch and could not speak; right facial droop and right arm weakness noted; no food or fluid given; nurse notified at 14:08." Do not write "had a stroke" - that is the provider's diagnosis, and your job is to make sure the timeline is accurate and nothing else went into her mouth.