HOLY HALITOSIS!!!

I walked into the nursing home to see some patients for the month. It was 0900 and I needed to see patients on station 3. I saw the LPN Joyce and waved and smiled. She was busy at the medication cart passing out the medications. I set my briefcase down on the table I did my charting. Inside was a complete list of the patients I had at the facility in alphabetical order. I focused my attention on those on station 3. The first patient I needed to see was Mrs. O. Mrs. O had a history of dementia, hypertension, CVA, coronary artery disease, and osteoporosis. Her dementia was progressing and she was becoming more confused. I was ready to begin my day.

I walked down the hallway to Mrs. O room. Once there I lightly knocked on the door. Mrs. O was in the second bed next to the window. Many of the residents were participating in a sing-a-long in the activities room. Walking into the room I saw a pair of feet sticking out from around the dividing curtain. They were small feet inside a pair of red slippers. I walked around the dividing curtain and saw Mrs. O sleeping on her bed. I lightly touched her right shoulder and called her name. She opened her eyes and smiled at me.

“How are you doing today Mrs. O?” I asked. She tried to get up and propped herself on her elbow. She smiled and let out a “heeeeee.” I was bending over to talk with her so I did not need to talk too loudly. After letting out the “heeee” I had to step back. Mrs. O had one of the worst cases of halitosis (bad breath) I had ever experienced. I felt my breakfast churning.

“Do you have any pain?” I asked Mrs. O. She once again said nothing except for letting out a “heeee.” There was more air behind this one which caused my nasal hairs to twitch. Mrs. O was confused and usually did not communicate. She was still smiling. I tried to look inside her mouth although the room did not have very bright lighting. When she smiled I noticed her front teeth were light brown.  

“Are you eating okay?” I asked Mrs. O anticipating the “heeee” and what it would do to my breakfast. She kept smiling letting out the “heeeee.” I was not getting used to the odor. I wondered if anybody had done oral care recently. Or even possibly within the last month. I did not want to think of it. I quickly listened to her heart, lungs, and abdomen and got a glimpse of her ankles and feet.

“Have a nice day,” I told Mrs. O from a longer distance. She smiled and let out her “heeee.” Although a longer distance from her mouth I could still smell her bad breath. I knew I needed to look in her mouth to see if there was any evidence of infection. I made a mental note. “Buy wintergreen oil.” This was a necessity while working in the emergency department. I realized it was also a necessity while working in the nursing home.

I walked out to the nurse’s station where Joyce was sitting at the desk charting. She smiled at me as I walked inside the room.

“How long has it been since Mrs. O had oral care?” I asked.

“The aides try after every meal to clean her mouth but she won’t let them. She even bit one of them yesterday. I was glad she didn’t break the skin,” said Joyce.

“She bit one of the aides? Oh boy. What can we do to help her with oral care?” I asked.

“I don’t know. She just won’t let us. I was able to pull out a bunch of food out of her cheeks the other day. That was disgusting,” Joyce replied.

“I need to try to look in there. Can you come in with me once I get my light?” I asked Joyce.

“Sure. Just let me know,” she said. I walked to my kit where I had my otoscope. This would provide good bright lighting if she would let me look in her mouth.

I returned with the otoscope and Joyce was ready to assist me. I grabbed a tongue blade in hope to look at the inside of Mrs. O’s mouth. We walked to the room and saw Mrs. O was sitting on the side of her bed. She smiled at us as we walked inside.

“I would like to look inside your mouth Mrs. O if that is okay with you,” I told her. She sat on the bed and smiled.

“Let her look in your mouth Mrs. O. It won’t hurt,” said Joyce trying to solidify what I wanted to do. She continued to smile and let out a “heeee.” I got my otoscope and tongue blade ready while trying to take in the breath odor.

“Okay Mrs. O. Open your mouth,” I said ready to look inside her mouth. She sat on the bed and looked at me letting out a “heeee.” I was close to that blow and knew my nasal hairs were gone. I tried over and over again and Mrs. O would not open her mouth. With every attempt I was “heeeee’d” and almost “haaaaw’d.”

“This isn’t going to work. She probably has some kind of infection in there. I need to get her a dental appointment and will start her on antibiotics,” I told Joyce. Joyce nodded her head. We walked out of the room. Mrs. O continued to sit on the edge of her bed and smiled.

“Maybe she has some mouth pain too,” I told Joyce.

“That may be part of the problem,” she replied. I wrote the order for oral care after every meal even though I knew it would be difficult. I also wrote for Percocet every 6 hours in hope that if there was a pain problem it would help the aides clean her mouth. Augmentin was the antibiotic I put her on for seven days. I also wrote for a dental evaluation and treatment. Since Mrs. O was not cooperating it was evident she would need a little sedating before the appointment. It had to go through her daughter because she was the power of attorney and if the secondary insurance would not cover the bill it would be out-of-pocket.

After a little over a week of being on the antibiotic and pain medication Mrs. O still would not let the aides do oral care. She bit two more aides in the process. The nurse’s were still taking food out of her mouth that Mrs. O pocketed when they could. Her breath still smelled bad enough to knock over a water buffalo. The dental appointment fell through because it would come totally out of the daughter’s pocket. I thought even if we gave Mrs. O Ativan she probably would not let the dentist to look in her mouth. So we did the best we could to try to give Mrs. O oral care even though she resisted.

Mrs. O’s breath continued to clear sinuses. She allowed only one aide to once in a while give her oral care. If she had an infection I did not know but treated her anyway. Mouth wash was out of the question. I treated her on several occasions with oral medications although she sometimes refused those. I did by the way buy some wintergreen oil in anticipation of talking with Mrs. O again. It gave a minty fresh accent to the “heeee” odor coming out of Mrs. O’s mouth. To be perfectly honest it only made it worse. To this day I cannot eat wintergreen mints. “Heeeee.”