Three nurses at Boston Medical Center are taking a proactive rather than reactive approach to skin care. The skin team RNs — two full time and one part time — constantly emphasize the importance of assessing patients’ skin from head to toe.

Because ongoing documentation of pressure ulcers is necessary to ensure Medicare reimbursement, the nurses review with staff on a regular basis how to properly report finding pressure ulcers and whether a patient already has one on admission. If patients fall at home but are not found for several days, for example, they often are admitted with pressure ulcers because of lack of hygiene and position changes.

If a pressure ulcer is noted by a nurse on assessment, that nurse puts in a consult for a nurse from the skin care team to come and examine the wound. To provide the best skin care possible for each patient, the skin care team collaborates with dieticians, CNAs, nursing directors, nurse managers, and doctors.

As an education outreach for patients, the nurses implemented the PUPPIE (Pressure Ulcer Prevention Program Includes Everyone) sticker program, says Linda Alexander, RN, MSN, CWOCN. After patients have their skin assessed, they are given a name tag sticker that says PUPPIE and has a photo of a dog. PUPPIE posters also hang throughout the hospital where staff can easily review different degrees of wounds with pictures and explanations.

Other ways the skin team reminds staff about proper skin assessment and care is through a mannequin referred to as “Uncle Ulcer,” which features interchangeable wound and ostomy parts. The mannequin, purchased with grant funds, has proven to be a great hands-on teaching tool, says Lauren H. Laubenstein, RN, BSN, CWON, wound/ostomy nurse, because it helps staff learn to recognize and care for different stages of pressure ulcers in the classroom setting. “If you put him in a wheelchair and wheel him around, staff will ask you if they can help him with his toe [which has a wound on it],” she jokes.

A skin Web site also is under development to reinforce what the nurses already know, says Siobhan Nevin, RN, BSN CWOCN. The site will showcase information from the PUPPIE posters throughout the hospital.

One common mistake nurses make is using more than one draw sheet under a patient, Laubenstein says. The multiple layers provide a moist environment that increases the likelihood of developing a pressure ulcer. “It’s all behavior change,” Laubenstein says. “Learning to work together instead of singularly.”