الفهرس 
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Abstract
Nutritional support is a cornerstone in the treatment of critically ill patients. Enteral feeding is the most efficient nutritional support method in the intensive care units. The critical care environment increases the risk of exposure to both physiological and psychological stressors which indeed results in alterations of the patient health status and development of complications. Stress ulcer is one of these complications in the ICU regarding to GIT. Enteral feeding has been demonstrated to protect the gastric mucosa from mucosal damage and stress ulcer lesions. Not only the timing but also the adequacy of nutritional support is crucial in prevention of stress ulcer, malnutrition, and accelerated depletion in critically ill patients. The CCNs must ensure adequacy and early initiation of enteral feeding.
Aim of the study
This study was conducted to identify the relationship between adequate early enteral feeding and occurrence of stress ulcer among mechanically ventilated patients.
Materials and method:
A descriptive prospective design was used to conduct this study in three general ICUs of (Damanhur Medical Institute, Damanhur Chest and Itay Elbaroad) hospitals. Eighty adult patients of either sex were selected according to the inclusion criteria. Two tools were used to collect data of this study. Tool one “Illness Severity Assessment Record” was developed by the researcher to assess socio-demographic and clinical characteristics of patients. Tool two “Nutritional Intervention Sheet” was modified from Al-Sayaghi K (2007) and used by the researcher to record of the adequacy of enteral feeding provided by nurses working in the intended ICUs.
Patients’ sociodemographic and base line data were recorded on admission. Study sample was assessed for illness severity after admission using APACHE II score. Patients were assessed on admission for stress ulcer diagnostic features. Calculation of nutritional requirements was done for the study sample through calculation of daily energy expenditure. Patients total body nutritional requirements were assessed and recorded for seven days using tool two. Patients were monitored for fluid intake and output, daily fluid balance and administered medications were documented using tool two. Patients were assessed daily for the presence of stress ulcer diagnostic features for seven days using tool one. For assessing occult blood in stool, positive guaiac test was used.
Results
More than half of the study sample was female. The mean age of the study sample was 50.7±9.60. The most common diagnosis was related to neurological disorders followed by respiratory disorders. The mean APACHE score was 27.4 ± 2.50. As regard to medication, the majority of study sample was on acid suppressive medications. More than half of the studied patients (51.25%) started enteral feeding after 48 hours, while 48.75% of them had enteral feeding within 48 hours of admission. The majority of study sample did not receive adequate caloric, protein and enteral volume nutritional intake. It was also found that the majority of patients (73.7%) in Damanhur Medical Institute ICU were developed stress ulcer while about 55.2 % of patients in Itay elbarod ICU were developed it. In Damanhur Chest ICU, about 64.2% of patients had stress ulcer.
The occurrence of stress ulcer was 75% in male compared with 52.3% in female, the difference was statistically significant. The highest (81.8%) rate of stress ulcer occurrence was among patients with cardiovascular disorders. The occurrence of stress ulcer in patients with APACHE score of (25-29) was 60%, this percent was significantly elevated to 73.3% in patients with APACHE score of (30-34).
There was a significant decrease in actual enteral feeding intake regarding calories, protein, vitamin c, fibers and enteral volume in studied patients who had stress ulcer as compared to those who hadn’t stress ulcer. Concerning timing of feeding, the results of the current study demonstrate that the highest (92.7%) occurrence rate of stress ulcer was among studied patients who initiated enteral feeding after 48 hours of ICU admission; this result was highly statistically significant. It was found that 94.4% of the study sample who had negative fluid balance had stress ulcer while only 36.4% who had positive fluid balance had stress ulcer, which is considered as a high significant relation between the stress ulcer occurrence and the fluid balance.
Conclusion
The study findings revealed that the majority of the study sample didn’t receive adequate nutritional intake. There was a significant discrepancy between the required and actually delivered nutritional requirements. It was also found that the occurrence rate of stress ulcer was high. It was found that there is a significant relationship between the inadequate nutritional intake and occurrence of stress ulcer. It was also found that the occurrence of stress ulcer was significantly decreased in studied patients who initiate enteral feeding within 48 hours of admission while it was elevated in patients who received enteral feeding after 48hours of their admission.
Recommendations:
Based on the results of the present study, the following recommendations are suggested:
Enteral nutrition should be initiated in the first 24-48 hours of patients admission if they didn’t have absolute contraindications
Critical care nurses must have the skills to use guaiac test to detect occult blood in stool as an early sign of stress ulcer bleeding to ensure proper assessment, and early management.
Adequate protein formula can be used with the high risk category for acquiring stress ulcer unless absolute contraindications.
Educational programs to focus on the concept of stress ulcer as a one of ICU fatal complications and signifying the prophylactic effect of adequate early enteral feeding.
Provide training program to ICU nursing staff to upgrade nurse’s knowledge and practice regarding calculation of nutritional requirements and proper administration of enteral feeding.
Development of guidelines about stress ulcer prophylaxis in critically ill patients.