By Mary Ellen Posthauer RDN, CD, LD, FAND

In 2010, experts at a consensus conference convened by the National Pressure Ulcer Advisory Panel (NPUAP):

• Defined an unavoidable pressure ulcer as one that may occur even though providers have evaluated the individual's clinical condition and pressure ulcer risk factors,
• Defined and implemented interventions consistent with individual needs, goals, and recognized standards of practice,
• Monitored and evaluated the impact of the interventions,
• And revised the approaches as appropriate.

This definition formed the framework for the 2014 "Unavoidable Pressure Injury: State of the Science and Consensus Outcomes" conference.

The goal of this multidisciplinary conference was to explore the issue of pressure ulcer unavoidability within an organ system framework, which considered the complexities of non-modifiable intrinsic and extrinsic risk factors. Prior to the conference, an extensive literature review was conducted to analyze and summarize the state of the science in the area of unavoidable pressure ulcer development and items were developed for discussion and consensus. An interactive process among stakeholders of various organizations and audience members was used to gain consensus on these items. When 80% agreement was obtained, consensus was reached.

Both the consensus organization and the audience reached 91% on the consensus statement: Individuals with malnutrition in combination with multiple comorbidities are at increased risk for the development of unavoidable pressure ulcers. Currently there are multiple definitions of malnutrition, which is why the Academy of Nutrition and Dietetics and A.S.P.E.N. are continuing their effort to accumulate evidence on the recommended characteristics for the identification and documentation of adult malnutrition.

Who Meets the Criteria for an Unavoidable Pressure Ulcer?

Inflammation—the body's natural response to trauma, critical illness or injury—negatively impacts nutritional status by elevating energy expenditure and nitrogen excretion. While this process increases the body's energy and protein needs, inflammation can limit the effectiveness of nutrition interventions and lead to malnutrition.

So, who are these individuals with malnutrition and multiple comorbidities that are at increased risk for unavoidable pressure ulcers? Is it the 95-year-old individual with a hip fracture and limited mobility who also has COPD and dementia? Is it the 25-year-old with a critical illness that has multi-organ failure? Is it the bed bound individual with multiple sclerosis (an inflammatory disease), aspiration pneumonia and a recent diagnosis of cancer?

While all of these individuals may meet the criteria for an unavoidable pressure ulcer, our challenge as wound care clinicians is to evaluate the pressure ulcer and nutrition risk factors, and define and implement interventions that are consistent with the individual's needs and goals. Since nutrition is just one element of a prevention plan, as team members we should consider and articulate the multiple conditions that may overwhelm the individual's ability to prevent a pressure ulcer. We should communicate, work as a team, and document the reasons why, despite all of our efforts, some pressure ulcers are unavoidable.

About the Pressure Ulcer Registry

The results of the 2014 conference are the foundation for the NPUAP's Pressure Ulcer Registry, the first database of its kind to let clinicians input cases of pressure ulcers in an effort to provide statistically significant rigorous analysis of the variables associated with the development of unavoidable pressure ulcer.

I urge you to access the article "Unavoidable Pressure Injury State of the Science and Consensus Outcomes" published in the Journal of Wound Ostomy and Continence Nursing (2014; 41(4):313-334). Stay tuned for further discussion of this important topic.

About The Author
Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Advisory Panel and the American Dietetic Association's Unintentional Weight Loss work group.