A nurse is caring for a patient with hyperthermia. Which nursing intervention should be the priority?
1Administer antipyretic medications immediately
2Apply ice packs to the patient's extremities
3Encourage oral fluid intake
4Remove clothing and initiate cooling measures✓ 정답
해설
Priority for hyperthermia is immediate cooling by removing clothing and initiating measures to prevent complications. Antipyretics, ice packs to extremities, or oral fluids are not the first actions.
Understanding Hyperthermia and the Priority Intervention
Hyperthermia represents an elevated core body temperature resulting from the body's inability to dissipate heat effectively, distinguishing it from fever where the hypothalamic set-point is altered. In conditions like heatstroke, the most severe form of heat-related illness, thermoregulatory failure leads to a core temperature exceeding 40°C and central nervous system dysfunction [1]. The pathophysiological cascade involves systemic inflammation and can rapidly progress to multiorgan failure, making immediate temperature reduction the cornerstone of care [1,3].
Analysis of the Correct Answer: Option 4
The priority intervention is to remove clothing and initiate cooling measures. This approach directly addresses the underlying pathophysiology by maximizing heat dissipation. Removing clothing eliminates insulation, promoting evaporative and convective heat loss. Initiating external cooling is critical because the goal in hyperthermia, particularly heatstroke, is rapid reduction of core temperature to prevent irreversible cellular damage and organ dysfunction [1,2]. The systematic review and meta-analysis emphasizes that active cooling methods are essential for achieving faster cooling rates compared to passive measures alone, highlighting the urgency of this intervention [2]. Delaying cooling to administer medications or fluids first can prolong the duration of hyperthermia, increasing the risk of complications such as myocardial dysfunction, which can manifest as arrhythmias or heart failure [3].
Why Other Options Are Not the Priority
- Option 1: Administer antipyretic medications immediately. Antipyretics like acetaminophen or NSAIDs work by lowering the hypothalamic set-point raised by pyrogens during fever. In hyperthermia, the set-point is normal, and the temperature elevation is due to excessive heat production or inadequate dissipation. Therefore, these medications are ineffective and do not address the primary problem of heat accumulation [1].
- Option 2: Apply ice packs to the patient's extremities. While ice packs are a cooling measure, applying them only to extremities is a less effective strategy. It can cause vasoconstriction in the skin, which paradoxically reduces heat loss from the body's core. Furthermore, it does not represent the comprehensive, whole-body cooling strategy required as the initial priority. The evidence supports methods that maximize heat exchange over a large surface area [2].
- Option 3: Encourage oral fluid intake. Hydration is vital for managing hyperthermia, but it is not the immediate priority. A patient with severe hyperthermia or heatstroke often presents with central nervous system dysfunction, including an altered level of consciousness, which makes oral intake unsafe due to aspiration risk [1]. Additionally, fluid replacement alone does not provide the rapid conductive or evaporative heat loss necessary to lower core temperature quickly. Cooling must take precedence to stabilize the patient [1,2].
References (research sources)
[1]
Heat-Related Illness and Heatstroke: A Narrative and Clinical Review for Emergency Clinicians.Research articleBridwell RE, Long B, Koyfman A, Lacy AJ. (2026) · DOI: 10.7759/cureus.107294
[2]
Comparative efficacy of portable active cooling vs. passive cooling for reducing core temperature in exertional heat stroke: a systematic review and meta-analysis.Meta-analysis/systematic reviewShi C, Zhang T, Xia L, Shi W, Qu J, Song L, Liu J. (2026) · DOI: 10.3389/fpubh.2026.1811173
[3]
Mechanisms and Intervention Strategies for Heat Stroke-Associated Myocardial Dysfunction: A Narrative Review.Research articleZhuang Y, Zhuang XH, Zhang XY, Wang DC, Yang Y. (2026) · DOI: 10.5811/westjem.53045
Clinical Management of Hyperthermia
Immediate Priority Actions
Rapid Cooling Initiation: Remove all clothing immediately to maximize heat dissipation. Initiate whole-body cooling measures such as cold water immersion (1-2 degrees Celsius) or evaporative cooling with tepid water misting and fanning. These methods achieve faster cooling rates than passive measures alone.
Continuous Monitoring: Monitor core temperature rectally or via esophageal probe every 5-10 minutes. Discontinue active cooling once core temperature reaches 38-39 degrees Celsius to prevent rebound hypothermia.
Airway and Breathing Support: Assess for altered mental status and airway compromise. Administer high-flow oxygen and prepare for intubation if the Glasgow Coma Scale score is 8 or less or if the patient is unable to protect their airway.
Pharmacological Considerations
Avoid Antipyretics: Do not administer acetaminophen or NSAIDs. These medications target the hypothalamic set-point, which is not altered in hyperthermia, and they provide no benefit while potentially causing renal or hepatic injury.
Manage Shivering: If shivering occurs during cooling, administer intravenous benzodiazepines such as midazolam or diazepam. Shivering generates endogenous heat and counteracts cooling efforts.
Fluid and Electrolyte Management
Intravenous Rehydration: Establish large-bore intravenous access and administer chilled isotonic crystalloid solutions such as 0.9% sodium chloride or lactated Ringer's. Fluid resuscitation corrects dehydration and aids in cooling.
Electrolyte Correction: Monitor serum electrolytes, particularly sodium and potassium, as rapid shifts can occur during cooling. Correct imbalances according to institutional protocols.
Disseminated Intravascular Coagulation: Assess for bleeding from puncture sites or mucosal membranes. Monitor coagulation studies including PT, aPTT, fibrinogen, and platelets.
Hepatic Failure: Monitor transaminases and bilirubin. Hepatic injury typically peaks 24-48 hours after the hyperthermic event.
Hyperthermia — Elevated core body temperature due to failed thermoregulation and heat dissipation, distinct from fever which involves an altered hypothalamic set-point.
Heatstroke — The most severe heat-related illness, defined by a core temperature above 40 degrees Celsius and central nervous system dysfunction, leading to multiorgan failure.
Evaporative heat loss — The process of heat dissipation through the conversion of sweat to vapor on the skin surface, enhanced by removing clothing and using water or fans.
Convective heat loss — The transfer of heat from the body to the surrounding air or fluid, maximized by removing insulating layers and increasing air movement.