Prioritizing respiratory care for an unconscious patient after a CVA

When a patient wakes up from a cerebrovascular accident (CVA) and is unconscious, the first thing a nurse notices isn’t the stroke itself—it’s the air that might be getting in or not getting in. In this moment, the priority nursing concern is respiratory distress. It sounds stark, but it’s the gateway to everything else: oxygen delivery to tissues, brain perfusion, and the chance to stabilize the patient so you can tackle the rest of the care plan.

Let me explain why the airway takes the front seat after a CVA with unconsciousness. When the brain isn’t fully awake, reflexes that protect the airway—like coughing and gagging—can be diminished or lost. That means secretions, blood, or even a small bit of saliva can slip into the trachea. Before you know it, the patient isn’t ventilating effectively, which can lead to hypoxia and, in a worst-case scenario, respiratory failure. The first hours after a CVA are all about keeping the airway clear and ensuring the patient can breathe well enough to keep the brain and other organs well-supplied with oxygen.

Now, what does that look like at the bedside? The care priorities follow a practical rhythm, almost like a safety check you run in your head and out loud for the team.

• Assess airway patency and breathing right away

• Look for signs of obstruction: noisy breathing, gurgling, or stridor. Listen for wheezes or absent breath sounds on one side.

• Note the work of breathing—are the chest and abdomen moving evenly? Are there accessory muscles pulling in?

• Check oxygen saturation continuously with a pulse oximeter. Remember, SpO2 goals may vary by facility, but typically you’re aiming for a level above 92% and higher if the patient has other oxygenation issues.

• Positioning and suction readiness

• Elevate the head of the bed to about 30 degrees unless a higher position is contraindicated. This improves airway patency and reduces aspiration risk.

• Have suction equipment ready and working. In unconscious patients, you’re likely going to suction saliva or secretions to keep the airway clear. Use sterile technique for any suctioning, and limit suctioning to what’s needed to protect the airway and maintain ventilation.

• Oxygen therapy and monitoring

• Provide supplemental oxygen to keep oxygenation adequate. If the patient isn’t maintaining enough oxygen with a simple setup, be prepared to escalate to a more controlled delivery method.

• Continuous monitoring isn’t optional here. Track respiratory rate, rhythm, effort, and depth. Compare these with the patient’s baseline if you know it, and watch for sudden changes.

• Prepare for airway protection, if needed

• In some cases, the unconscious patient can’t maintain a clear airway or adequate ventilation. In those moments, escalation is essential: you may need to secure the airway with an oropharyngeal airway as a temporary measure, or move toward endotracheal intubation to protect ventilation and ensure a patent airway.

• This isn’t a one-person decision. Communicate changes promptly with the physician and the critical care team. Early collaboration can prevent a rapid decline.

• Constant documentation and timely escalation

• Document all assessments, oxygen levels, airway interventions, and the patient’s response. If there are signs of deteriorating ventilation or oxygenation, report them immediately. Time matters in these situations.

• Why the other potential concerns don’t outrank respiratory safety in the moment

• Injury, constipation, and decreased fluid volume are important, sure, but they take a back seat when the airway is compromised. An unobstructed airway and adequate breathing are prerequisites for everything else to matter. If the client isn’t getting air, brain cells don’t get the oxygen they need, and that complicates every other issue you’ll try to address.

A few clinical signals to keep you on your toes include sudden restlessness, cyanosis (blue-tinged lips or fingertips), a drop in oxygen saturation despite supplemental oxygen, increased work of breathing, or a change in breath sounds. These aren’t just numbers on a monitor; they’re a call to act. In those moments, the plan shifts from monitoring to actively protecting and supporting ventilation.

Some practical tips you’ll hear echoed in real-life units:

• Don’t assume a patient will cough up secretions on their own. If effective coughing is absent, suctioning and airway clearance techniques become essential.

• The extent of unconsciousness doesn’t just affect the lungs—it influences swallowing safety too. That’s why we’re cautious about aspiration risk. A nil by mouth order is common until an assessment confirms safe swallowing; meanwhile, airway protection is a must.

• If you’re ever unsure about whether to intubate, remember the rule of thumb: if the patient cannot maintain adequate ventilation or airway patency on their own, escalation is warranted. It’s better to stabilize early than to chase trouble later.

Interwoven with the breathing basics are the human elements—how you talk to families about what you’re seeing and why certain steps are being taken. Clear, calm explanations help families feel included and informed, which can ease anxiety in a moment that feels deeply unsettled for everyone.

Now, you might wonder how to juggle this focus with other CVA-related challenges. Consider this: after you’ve established that the airway is protected and respiration is adequate, you’ll shift attention to other priorities—such as monitoring neurological status, assessing limb function, and preventing complications like deep vein thrombosis or pressure injuries. It’s not that those aren’t important; they’re just not the first domino to fall. In the acute phase after a CVA, the airway and breathing are the anchor. Everything else orbits around that anchor.

A few more practical thoughts to help you think like a bedside nurse:

• Use a short, clear checklist at the start of each shift. It might look like: Is the airway patent? Is SpO2 in the target range? Is there any new secretions or signs of distress? Is the patient stable enough to return to baseline or to escalate?

• Practice good communication with the team. A quick handoff should include the patient’s current respiratory status, oxygen needs, and any changes in airway status. It’s amazing how a well-timed note can prevent a crisis.

• Keep learning from each case. Post-stroke patients aren’t one-size-fits-all. Some recover airway reflexes quickly; others need extended support. The pattern you build—what signs trigger action, what interventions make a difference—becomes your professional instinct over time.

To wrap it up, think of the unconscious patient after a CVA as a reminder that life at the bedside isn’t only about neat medical theories; it’s about keeping the person breathing and alive long enough for healing to happen. Respiratory distress isn’t merely a symptom; it’s the hinge on which a patient’s recovery turns. When you’re in that room, your primary job is simple in concept, demanding in execution: protect the airway, support breathing, and stay ready to escalate if the lungs tell a different story.

If you’re ever unsure, pause and recalibrate with a quick question to yourself: What will I do first to secure the airway and ensure adequate gas exchange? The answer should steer your plan for the next moments and set the stage for the care that follows. And that’s how you move from a moment of crisis to a calmer, care-driven path forward.