A 45-year-old construction worker is brought to the emergency department after collapsing at a job site on a hot summer day. His vital signs are: temperature 104.2°F (40.1°C), pulse 120 bpm, respirations 28/min, and blood pressure 90/60 mmHg. The patient is conscious but appears confused and has hot, dry skin. A nurse is caring for this patient with hyperthermia. Which nursing intervention should be implemented first to reduce the patient's body temperature?
1Remove excess clothing and apply cool, wet cloths to the skin✓ 정답
2Administer acetaminophen 650 mg orally
3Encourage the patient to drink cold fluids
4Place the patient in a warm blanket to prevent shivering
해설
Immediate external cooling (removing clothing and applying cool cloths) is the priority to rapidly reduce core temperature in hyperthermia. Other options are less effective or inappropriate for initial management.
Clinical Context and Priority Setting
This patient presents with classic signs of heat stroke, a medical emergency defined by a core temperature above 104°F (40°C) and central nervous system dysfunction (confusion). The critical pathophysiological concern is the failure of the body's thermoregulatory mechanisms, leading to hyperthermia—a state distinct from fever. In fever, the hypothalamic set point is elevated by pyrogens; in heat stroke, the set point is normal, but the body's ability to dissipate heat is overwhelmed. This distinction is the foundation for prioritizing nursing interventions.
Why Antipyretics Are Contraindicated
Administering acetaminophen (option 2) is ineffective and potentially harmful in this scenario. Antipyretics work by inhibiting cyclooxygenase in the central nervous system, which lowers an elevated hypothalamic temperature set point back to normal. Since the patient’s hyperthermia is not caused by a pyrogen-driven shift in the set point but by environmental heat gain and failed dissipation, antipyretics will not reduce the temperature. Furthermore, in a patient with heat stroke, there is a risk of hepatic injury, and administering acetaminophen could compound hepatotoxicity.
Rationale for Immediate External Cooling
The correct first intervention is to remove excess clothing and apply cool, wet cloths to the skin (option 1). This initiates evaporative cooling and conduction, the two primary mechanisms for rapid heat dissipation in the absence of a functional thermoregulatory response. The patient’s hot, dry skin indicates that the body’s primary cooling mechanism—evaporative heat loss through sweating—has failed. Applying cool water to the skin and maximizing air exposure artificially restores this process. The goal is to reduce the core temperature as quickly as possible to prevent irreversible neurological and cellular damage. The cited guidelines on clinical management emphasize that in hyperthermic emergencies, physical cooling measures are the cornerstone of immediate treatment, as pharmacological interventions are not directed at the underlying mechanism of heat accumulation.
Analysis of Other Options
Encouraging oral fluid intake (option 3) is contraindicated in a patient with an altered level of consciousness due to the high risk of aspiration. While fluid resuscitation is critical for the hypotensive state (blood pressure 90/60 mmHg) caused by dehydration and peripheral vasodilation, it must be achieved through intravenous access, not oral administration. Placing the patient in a warm blanket to prevent shivering (option 4) is counterproductive. Shivering is a thermogenic response that can occur during aggressive cooling, but the immediate priority is to lower the dangerously high core temperature. If shivering occurs, it is managed with benzodiazepines per protocol, not by halting the cooling process. The primary objective remains rapid temperature reduction through external cooling measures.
Clinical Management of Heat Stroke
The priority for a patient with suspected heat stroke is immediate and aggressive cooling to reduce core body temperature. The goal is to reach a core temperature of 102°F (38.9°C) or below as quickly as possible. Cooling should begin in the prehospital setting or immediately upon arrival to the emergency department and must not be delayed for diagnostic testing.
Immediate Cooling Methods
Remove all clothing and equipment.
Apply ice packs to the neck, axillae, and groin.
Cover the patient with cool, wet sheets and use fans to promote evaporative cooling.
For severe cases, consider cold-water immersion if available and the patient's condition allows.
Key Contraindications
Antipyretics: Acetaminophen and NSAIDs are ineffective and potentially hepatotoxic.
Oral Fluids: Avoid in patients with altered mental status due to high aspiration risk.
Shivering: Do not use warming blankets; if shivering occurs, manage with benzodiazepines as it generates heat.
Ongoing Monitoring and Support
After initiating cooling, continuously monitor core temperature (rectal or esophageal probe), cardiac rhythm, and neurological status. Begin intravenous fluid resuscitation with cooled isotonic crystalloids for hypotension. Stop active cooling when the core temperature reaches 102°F (38.9°C) to prevent rebound hypothermia. Admit the patient for observation of complications such as rhabdomyolysis, acute kidney injury, and disseminated intravascular coagulation.
Heat Stroke — A medical emergency defined by a core temperature above 104°F (40°C) and central nervous system dysfunction, caused by the failure of thermoregulatory mechanisms.
Hyperthermia — An elevated body temperature due to failed thermoregulation, distinct from fever; the hypothalamic set point remains normal, but heat production exceeds heat dissipation.
Antipyretic — A medication, such as acetaminophen, that reduces fever by lowering an elevated hypothalamic set point; ineffective for hyperthermia not caused by pyrogens.
Evaporative Cooling — A heat dissipation method where water on the skin evaporates, drawing heat from the body; a primary intervention for heat stroke.