Breath odor, fruity
Fruity breath odor results from respiratory elimination of excess acetone. This sign characteristically occurs with ketoacidosis — a potentially life-threatening condition that requires immediate treatment to prevent severe dehydration, irreversible coma, and death.
Ketoacidosis results from the excessive catabolism of fats for cellular energy in the absence of usable carbohydrates. This process begins when insulin levels are insufficient to transport glucose into the cells, as in diabetes mellitus, or when glucose is unavailable and hepatic glycogen stores are depleted, as in low-carbohydrate diets and malnutrition. Lacking glucose, the cells burn fat faster than enzymes can handle the ketones, the acidic end products. As a result, the ketones (acetone, beta-hydroxybutyric acid, and acetoacetic acid) accumulate in the blood and urine. To compensate for increased acidity, Kussmaul’s respirations expel carbon dioxide with enough acetone to flavor the breath. Eventually, this compensatory mechanism fails, producing ketoacidosis.
Act Now: When you detect fruity breath odor, check for Kussmaul’s respirations and examine the patient’s level of consciousness (LOC). Take his vital signs and check skin turgor. Stay alert for fruity breath odor that accompanies rapid, deep respirations; stupor; and poor skin turgor. Try to obtain a brief history, noting if the patient has type 1 diabetes mellitus, nutritional problems such as anorexia nervosa, and fad diets with little or no carbohydrates. Obtain venous and arterial blood samples for complete blood count and glucose, electrolyte, acetone, and arterial blood gas (ABG) levels. Also obtain a urine specimen to test for glucose and acetone. Administer I.V. fluids to maintain hydration and electrolyte balance; dehydration may be profound at the initial diagnosis. In the patient with diabetic ketoacidosis (DKA), give regular insulin to reduce blood glucose levels.
If the patient is obtunded, you’ll need to insert endotracheal and nasogastric (NG) tubes. Suction as needed. Insert an indwelling urinary catheter, and monitor intake and output. Insert central venous pressure and arterial lines to monitor the patient’s fluid status and blood pressure. Place the patient on a cardiac monitor, monitor his vital signs and neurologic status, and draw blood hourly to check glucose, electrolyte, acetone, and ABG levels.
Assessment
History
If the patient isn’t in severe distress, obtain a thorough history. Ask about the onset and duration of fruity breath odor. Find out about changes in breathing pattern. Ask about increased thirst, frequent urination, weight loss, fatigue, and abdominal pain. Ask the female patient if she has had candidal vaginitis or vaginal secretions with itching. If the patient has a history of diabetes mellitus, ask about stress, infections, and adherence to the treatment regimen. If you suspect that the patient has anorexia nervosa, obtain a dietary and weight history.
Physical examination
Perform a full neurologic examination, noting the patient’s LOC. Assess him for signs of dehydration and shock. Assess the patient’s GI system.
Pediatric pointers
Fruity breath odor in an infant or child usually stems from uncontrolled diabetes mellitus. Ketoacidosis develops rapidly in this age-group because of low glycogen reserves. As a result, prompt administration of insulin and correction of fluid and electrolyte imbalance are necessary to prevent shock and death.
Geriatric pointers
Elderly patients may have poor oral hygiene, increased dental caries, decreased salivary function with dryness, and poor dietary intake. In addition, many take multiple drugs. Consider all of these factors when evaluating an elderly patient with mouth odor.
Medical causes
Anorexia nervosa
. Severe weight loss associated with anorexia nervosa may produce fruity breath, usually with nausea, constipation, and cold intolerance as well as dental enamel erosion and scars or calluses in the dorsum of the hand, related to induced vomiting.
Ketoacidosis
Fruity breath odor accompanies alcoholic ketoacidosis, which is usually seen in poorly nourished alcoholics with vomiting, abdominal pain, and only minimal food intake over several days. Kussmaul’s respirations begin abruptly and accompany dehydration, abdominal pain and distention, and absent bowel sounds. Blood glucose levels are normal or slightly decreased.
With DKA, fruity breath odor commonly occurs as ketoacidosis develops over 1 to 2 days. Other findings include polydipsia, polyuria, nocturia, weak and rapid pulse, hunger, weight loss, weakness, fatigue, nausea, vomiting, and abdominal pain. Eventually, Kussmaul’s respirations, orthostatic hypotension, dehydration, tachycardia, confusion, and stupor occur. Signs and symptoms may lead to coma.
Starvation ketoacidosis is a potentially life-threatening disorder that has a gradual onset. Besides fruity breath odor, typical findings include signs of cachexia and dehydration, decreased LOC, bradycardia, and a history of severely limited food intake (anorexia nervosa).
Other causes
Drugs
Any drug known to cause metabolic acidosis, such as nitroprusside and salicylates, can result in fruity breath odor.
Low-carbohydrate diets
Low-carbohydrate diets, which encourage little or no carbohydrate intake, may cause ketoacidosis and the resulting fruity breath odor.
Nursing considerations
Monitor fluid status. Perform neurologic and respiratory assessments. Provide emotional support for the patient and his family. Explain tests and treatments clearly. When the patient is more alert and his condition stabilizes, remove the NG tube and start him on an appropriate diet. Switch his insulin from the I.V. to the subcutaneous route.
Patient teaching
Teach the patient and provide appropriate referrals. For example, teach the patient with uncontrolled diabetes mellitus to recognize the signs of hyperglycemia and to wear a medical identification bracelet. Refer the patient with anorexia nervosa to a psychologist or a support group, and recognize the need for possible long-term follow-up.
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2008 Williams & Wilkins.
More About Causes of Breath odor
» Next page: Breath with fecal odor (Signs & Symptoms: A 2-in-1 Reference for Nurses)
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