Swallowing difficulty (dysphagia) is common after stroke, affecting a large proportion of patients in the early days. It can be “silent”: patients may aspirate food or fluid into their lungs without coughing. Aspiration pneumonia is a leading cause of death after stroke. Nurses are usually the first to assess swallowing, and good practice saves lives.
Nil by mouth until screened
Stroke guidelines recommend that patients with acute stroke have their swallowing screened by a trained professional before being given any food, fluid or oral medication, ideally within 4 hours of arrival. Until then, keep them nil by mouth, provide mouth care, and arrange alternative hydration and routes for essential medicines if screening is delayed.
How a bedside swallow screen works
Hospitals use validated nurse-led tools. Typical steps include:
- Pre-checks: Is the patient alert enough? Can they sit upright? Can they control their saliva, cough voluntarily, and speak? If not, stop and remain nil by mouth.
- Teaspoons of water: give small amounts while watching for coughing, choking, a wet or gurgly voice, or breathing changes.
- Larger volume: if teaspoons are safe, a sip or a measured glass of water.
- Any sign of difficulty = fail. Keep nil by mouth and refer to speech and language therapy (SLT).
Only nurses trained and competent in the specific tool should perform screening.
Signs of aspiration
- Coughing or choking during or after eating and drinking.
- Wet, gurgly voice.
- Watery eyes, breathlessness, colour change.
- Food left in the mouth (pocketing).
- Recurrent chest infections, fever, falling oxygen saturations.
- Silent aspiration may have no obvious signs.
Safe eating and drinking
- Sit fully upright (90° if possible) for meals and for at least 30 minutes after.
- Follow SLT recommendations exactly: texture-modified diets and thickened fluids are often described using the International Dysphagia Diet Standardisation Initiative (IDDSI) levels.
- Small mouthfuls; slow pace; ensure each swallow is complete.
- Minimise distractions; avoid talking while eating.
- Supervise or assist as recommended.
- Check the mouth is clear after meals.
Medicines
Don’t assume tablets can be crushed and mixed with food. Ask a pharmacist for suitable formulations. Crushing modified-release tablets can be dangerous.
Mouth care
Good oral hygiene reduces the bacteria that cause aspiration pneumonia, even in patients who are nil by mouth. See our mouth care guide.
Nutrition and hydration
Monitor intake with food and fluid charts, weigh regularly, and involve dietitians. If oral intake isn’t safe or sufficient, nasogastric feeding may be needed. See enteral feeding.
Beyond stroke
Dysphagia is also common in dementia, Parkinson’s disease, motor neurone disease, head and neck cancer, and frailty. The same principles apply.
Related: Stroke recognition · Pneumonia care
Based on the National Clinical Guideline for Stroke (UK and Ireland, 2023), IDDSI framework and stroke nursing guidance. Educational content: follow local protocols and training.