Breath with fruity odor
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. (See Managing fruity breath odor.)
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 any 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 noncompliance with therapy — the most common causes of ketoacidosis in a patient with diabetes. If the patient is suspected of having anorexia nervosa, obtain a dietary and weight history.
Physical assessment
Begin by taking your patient’s vital signs. Then proceed with a complete physical assessment.
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, both 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 diabetic ketoacidosis, 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, stupor, and coma may occur.
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 level of consciousness, 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 a resulting fruity breath odor.
Special considerations
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 nasogastric tube and start him on an appropriate diet. Switch his insulin from the I.V. to the subcutaneous route.
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.
Patient counseling
Teach the patient and make referrals appropriately. 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 starvation ketoacidosis to a psychologist or a support group, and recognize the need for possible long-term follow-up.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Breath odor
» Next page: Halitosis (Signs & Symptoms: A 2-in-1 Reference for Nurses)
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