A nurse is planning interventions for a client who has a chronic wound on his lower leg. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Choice A reason:

B cells are not involved in contact dermatitis, as they do not produce antibodies or form immune complexes.

Choice B reason:

T cells are the type of cells that mediate contact dermatitis, which is a type of type IV hypersensitivity. T cells recognize the poison ivy antigens that bind to the skin proteins and release cytokines that recruit macrophages and other inflammatory cells. This leads to a delayed and localized reaction that manifests as erythema, edema, vesicles, and pruritus.

Choice C reason:

T cells are not the same as B cells, as they have different receptors and functions in the immune system.

Choice D reason:

Mast cells are not involved in contact dermatitis, as they do not express IgE antibodies or release histamine.

Choice A reason:

Applying a moist dressing to the wound provides a moist environment for wound healing and protects the wound from contamination and trauma. Moisture prevents dehydration and necrosis of the wound bed and promotes cell migration and growth.

Choice B reason:

Assessing the wound for signs of infection is important to detect and treat any infection that may impair wound healing or cause systemic complications. Signs of infection include increased redness, warmth, swelling, pain, drainage, odor, fever, or leukocytosis.

Choice C reason:

Debriding necrotic tissue from the wound is essential to remove any dead or devitalized tissue that may interfere with wound healing or serve as a source of infection. Debridement can be done by surgical, mechanical, enzymatic, or autolytic methods.

Choice D reason:

Elevating the affected leg above the heart level reduces edema and improves blood circulation to the wound. Edema can impair wound healing by causing tissue hypoxia, increasing bacterial growth, and delaying granulation tissue formation.

Choice E reason:

Massaging the wound edges gently is not recommended for chronic wounds, as it may cause trauma or bleeding to the wound bed or delay epithelialization. Massaging may be beneficial for preventing hypertrophic scars or contractures in healed wounds.