**9. Summary**

Caregivers or the individual with a pressure ulcer need to be educated on the cause of the pressure ulcer, the contributing factors, prevention measures, proper nutrition, appropriate wound treatment and appropriate times to contact a provider. Education should include materials in a format understandable for the caregivers and individuals. For individuals with chronic conditions, such as spinal cord injuries, there are often times formal education programs in rehabilitation centers. It is also common to request a caregiver to receive education in the hospital prior to a patient being discharged. Education is crucial to an effective preven‐

In 2014, the NPUAP hosted a multidisciplinary international conference to explore the issue of unavoidable pressure ulcers. This conference brought experts together to explore, within the context of organ systems, the issue of unavoidable pressure ulcers [14]. At a previous conference in 2010, also hosted by the NPUAP, an unavoidable PU was defined *as one that may occur even though providers have evaluated the individual's clinical condition and PU risk factors have been evaluated and defined and interventions have been implemented that are consistent with individual*

It was agreed upon by those in attendance at the 2014 conference that unavoidable pressure ulcers do occur. This conference also established consensus on risk factors that have in some situations been shown to increase the likelihood of the development of unavoidable pressure ulcers. In summary, the organ systems which were identified that may in some situations contribute to the development of unavoidable pressure ulcers included; (a) impaired tissue oxygenation/cardiopulmonary dysfunction—an individual cannot be repositioned due to the potential for a fatal event related to hemodynamic status, (b) hypovolemia—an individual is hemodynamically unstable which often leads to an inability to reposition an individual, (c) body edema/anasarca–leads to decrease pressure‐loading tolerance and increased risk of pressure ulcer development, (d) peripheral vascular disease, lower extremity arterial and venous disease—compromised circulation that contributes to ischemia which leaves tissues more vulnerable to pressure ulcer development. Within this category, other subcategories were identified including chronic kidney disease, whereas the change in tissue tolerance may increase the likelihood of pressure ulcer development, hepatic injury which results in hypo‐ albuminemia that leads to edema and anasarca, sensory impairment, skin issues related to extremes in age, multiorgan dysfunction syndrome, critical status and burns all which leave patients prone to pressure ulcer development, (e) body habitus—obesity compromises an individual's ability to prevent shear injury during movement, pressure ulcer development related to moisture due to increased diaphoresis and inability to redistribute pressure over bony prominences and (f) immobility—associated with vascular congestion, dependent edema, compromised lung aeration, decreased red blood cell mass, dyspnea and activity tolerance leading to increased risk for unavoidable pressure ulcer development. The consensus panel also agreed that further research is necessary to examine the issue of unavoidable

tion and treatment plan.

pressure ulcers [21].

**8. Unavoidable pressure ulcers**

338 Wound Healing - New insights into Ancient Challenges

*needs, goals and recognized standards of practice.*

A pressure ulcer rate is considered a quality care indicator in most health care settings and being an international health care concern. Most pressure ulcers are preventable. With a thorough assessment, including an assessment of an individual's skin and an assessment of pressure ulcer development risk, a comprehensive prevention and treatment plan can be developed and implemented to enhance positive outcomes.
