Risk Factors for Enteral Nutrition Intolerance in ICU Patients and Corresponding Optimized Nursing Strategies.

BACKGROUND: Enteral nutrition intolerance (ENI) is common among critically ill patients and may interfere with the effective delivery of enteral nutrition. Identifying patients at increased risk and potentially modifiable care-related factors may help inform more targeted nursing management. AIM: This study aimed to identify independent risk factors for ENI in critically ill patients, evaluate nurse-modifiable protective factors and develop risk-stratified nursing optimization strategies. METHODS: A single-centre retrospective cohort study was conducted, including adults patients receiving EN for ≥ 72 h in the ICU (January 2023 to December 2025). The primary outcome was a composite endpoint of ENI. Independent predictors were identified using multivariable logistic regression. Risk stratification was performed based on predicted probabilities. Population attributable fractions (PAFs) were calculated to estimate potential benefits from modifying modifiable factors. RESULTS: ENI incidence was 44.6%. Age, APACHE II score and mechanical ventilation were independent risk factors (OR = 1.037, 1.399, 3.432; all p < 0.05). Probiotic use, nasoenteric tube feeding, gastric residual volume (GRV) monitoring ≥ 3 times/day and a head-of-bed elevation adherence rate > 90% were independent protective factors (OR = 0.226, 0.297, 0.252, 0.180; all p < 0.05). In the high-risk group (predicted probability ≥ 0.66), the ENI incidence reached 86.9%, but coverage of protective measures was low (head-of-bed elevation 52.5%, GRV monitoring 27.9%, nasoenteric tube 11.5%, probiotics 24.6%). PAF analysis suggested that delayed nasoenteric tube placement, non-use of probiotics and inadequate GRV monitoring could potentially avoid 55.3%, 53.7% and 48.9% of ENI events, respectively. CONCLUSION: ENI in ICU patients is influenced by age, disease severity and nurse-modifiable factors. Incorporating standardized probiotics, graded GRV monitoring and high head-of-bed elevation adherence into core quality control measures, along with a bundled strategy for high-risk patients, may substantially reduce ENI incidence. RELEVANCE TO CLINICAL PRACTICE: The identified nurse-modifiable factors provide clinically relevant targets for risk-informed enteral nutrition management. Risk stratification may help nurses identify patients requiring closer monitoring and more individualized nutritional care. For patients at high risk of ENI, attention to feeding-route selection, appropriate GRV monitoring, head-of-bed elevation adherence, and probiotic use may help optimize enteral nutrition management.