A nurse is caring for a patient with hyperthermia following a neurologic injury. Which nursing intervention should be implemented first to manage the patient's elevated body temperature?

Removing excess blankets and clothing is the first intervention for hyperthermia as it promotes natural heat loss without causing shivering. Other options like acetaminophen or ice packs are not immediate or may cause complications.

Understanding the Priority: Why Non-Pharmacological, Non-Invasive Cooling Comes First

In the context of acute neurologic injury, the management of hyperthermia is not merely about comfort; it is a neurologic emergency. The provided rationale from the review by Lavinio et al. establishes that temperature is a key determinant of cerebral vulnerability ^[1]. The evolution of care has shifted toward the early recognition of fever and the maintenance of controlled normothermia to prevent secondary brain injury ^[1]. When prioritizing interventions, the nursing process and the principle of "least invasive first" guide us to select the action that reduces body temperature with the lowest risk of adverse effects, such as shivering or rapid hemodynamic shifts.

Analysis of the Correct Answer: Option 3

Removing excess blankets and clothing is the correct first step. This intervention directly promotes heat loss through radiation and convection without introducing the risks associated with more aggressive physical or pharmacological measures. In neurocritical care, the goal is to achieve a balance where fever is controlled, but the physiological stress of the cooling process itself does not exacerbate the brain injury. By exposing the skin, you allow the body's natural thermoregulatory mechanisms to dissipate heat. This aligns with the contemporary practice of targeted temperature management (TTM), which emphasizes a controlled approach to avoiding hyperpyrexia ^[2]. This simple, non-invasive measure can be implemented immediately and effectively begins the cooling process while you assess the patient's response and prepare for subsequent orders.

Why the Other Options Are Not the First Priority

- Option 1 (Administer acetaminophen): While antipyretics are a common order, their onset of action is delayed and their efficacy in centrally-mediated fever, common after traumatic brain injury, can be variable. The immediate priority is a physical intervention that begins heat dissipation right away. Pharmacological intervention is secondary and works synergistically with external cooling.

- Option 2 (Apply ice packs to axilla and groin): This is an effective conductive cooling method, but it is more invasive and can cause significant discomfort, skin injury, and crucially, shivering. Shivering is a profound physiological stressor that increases metabolic rate and oxygen consumption, counteracting the neuroprotective goal of cooling by potentially raising intracranial pressure ^[2]. A less aggressive step, like removing blankets, should always be attempted first.

- Option 4 (Initiate a cooling blanket at the lowest setting): Starting a cooling blanket at the lowest temperature setting is dangerous. Aggressive surface cooling without a gradual, controlled approach is a primary trigger for severe shivering. The evidence synthesis by Zhang et al. on best practices for TTM emphasizes a systematic, evidence-based approach, not rapid, uncontrolled cooling . The correct method, as seen with advanced devices like the Arctic Sun, involves a servo-controlled mechanism that gradually adjusts water temperature to reach a target, avoiding overshoot and minimizing the shivering response ^[2]. Setting a device to its coldest setting immediately is contraindicated.

Integrating the Evidence into Clinical Reasoning

The clinical framework for brain recovery highlights that post-injury care relies on a multimodal strategy to protect the brain . Every intervention, including temperature management, must be weighed against its potential to cause further harm. The patient's presentation—restlessness, tachycardia (105 bpm), and hypertension (145/85 mmHg)—are already signs of a heightened sympathetic response. A sudden, intense cold stimulus from ice packs or a maximum-setting cooling blanket would dramatically worsen this state, increasing the risk of a dangerous spike in intracranial pressure. The foundational step is to first remove external sources of heat retention, a core principle of targeted temperature management that prioritizes a controlled, stepwise progression from simple to complex interventions [1,3].