**8. Unavoidable pressure ulcers**

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 needs, goals and recognized standards of practice.*

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 pressure ulcers [21].
