The nurse is caring for a client who is immobile and developed a stage IV pressure injury on the sacrum. The nurse identifies eschar in the wound bed. Which intervention is most important for the nurse to implement?

Rationale:

A. Place a foam surface on top of the mattress: A foam surface may help reduce pressure, but for a stage IV pressure injury with eschar, this alone is insufficient. More advanced pressure redistribution systems are needed for adequate management of severe wounds.

B. Raise the head of the bed only to 30 degrees: Limiting the head-of-bed elevation helps reduce shear forces, which worsen pressure injuries, especially over the sacrum. This intervention is critical for preventing further tissue damage and promoting healing of deep wounds with eschar.

C. Perform passive range of motion exercises: While passive ROM supports circulation and prevents contractures, it does not directly address pressure relief or eschar management. It's beneficial, but not the top priority for treating a stage IV ulcer.

D. Increase the daily intake of vitamin C: Vitamin C supports collagen synthesis and immune function, aiding wound healing. However, nutrition alone cannot address mechanical factors like pressure and shear, which are primary contributors to pressure injury progression.

Rationale:

• Avoidance: Avoidance of reminders of the trauma, including people, places, or conversations related to the event, is a core diagnostic criterion for PTSD. The client avoids visiting fellow platoon members, suggesting avoidance behavior linked to her combat trauma.
• Suicidal ideation: Thoughts of death or suicide are hallmark symptoms of MDD. The client was found writing a suicide note and planning to shoot herself, which strongly supports the diagnosis of MDD.
• Nightmares: Recurrent distressing dreams or nightmares related to the traumatic event are common in PTSD. The client reports frequent nightmares linked to her war experience.
• Feelings of guilt: Excessive guilt is common in MDD, often irrational and self-deprecating. In PTSD, survivors’ guilt is prevalent, especially when others died in the traumatic event, as expressed by the client lamenting that her life was spared over her comrades'.
• Lack of interest: Markedly diminished interest or pleasure in previously enjoyed activities is a core symptom of MDD. The client’s withdrawal from social connections reflects this loss of interest.
• Sleep disturbance: Insomnia is prevalent in GAD due to excessive worry, in MDD due to mood dysregulation, and in PTSD due to nightmares and hyperarousal. The client’s reported insomnia applies to all three conditions.