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

Removing excess clothing and blankets is the immediate first-line intervention for hyperthermia as it allows rapid heat dissipation without equipment or medications. Other options like acetaminophen or cooling blankets require orders or equipment and are not the first step.

Understanding the Priority: Why External Cooling Comes First

In a patient who has suffered an acute ischemic stroke, the development of hyperthermia—defined here as a core temperature of 102.8°F (39.3°C)—is a neurological emergency. The priority nursing intervention is to immediately reduce the patient's temperature using the most direct, rapid, and non-invasive physical method available: removing excess clothing and blankets. This action directly addresses the fundamental principle of heat exchange and is the critical first step in targeted temperature management (TTM) for neurocritical care patients [1, 2].

The rationale is rooted in the pathophysiology of secondary brain injury. Following an acute ischemic stroke, the brain tissue exists in a state of compromised perfusion and oxygenation, known as the ischemic penumbra. Hyperthermia dramatically increases the cerebral metabolic rate of oxygen (CMRO2). For every 1°C rise in body temperature, cerebral metabolism increases by approximately 6-10%. This heightened metabolic demand exacerbates the mismatch between oxygen supply and demand, accelerating neuronal cell death and worsening the infarction ^[1]. Furthermore, fever promotes the release of excitatory neurotransmitters and free radicals, increases intracranial pressure (ICP), and impairs the blood-brain barrier. The patient’s restlessness and altered mental status are clinical manifestations of this escalating cerebral distress and increased ICP. Therefore, interventions that lower temperature are not merely for comfort; they are a neuroprotective strategy to salvage at-risk brain tissue [1, 3].

The "first" intervention must be the one that initiates cooling without delay and without introducing potential complications. Removing insulating layers is a passive cooling technique that immediately promotes heat loss through convection and radiation. It prepares the patient for all subsequent cooling measures.

Analysis of Other Options

- Option 2: Administer acetaminophen 650 mg orally as ordered. While antipyretics like acetaminophen are a standard pharmacological intervention for fever, their effect is not immediate. They work by resetting the hypothalamic set-point, which can take 30-60 minutes to take effect. More critically, in a patient with an acute stroke, altered mental status, and signs of increased ICP, the oral route is contraindicated due to the high risk of dysphagia and aspiration. The nurse must first assess the patient's ability to swallow safely, and in this scenario, the patient's neurological status makes the oral route unsafe. The physical intervention of removing clothing is faster and safer as a first step.

- Option 3: Apply cooling blankets to the patient's torso. Applying a cooling blanket is an effective active external cooling method, but it should not be the very first step. Placing a cooling blanket over a patient who is still wrapped in insulating layers of clothing and linen will be significantly less effective. The blankets and clothing trap air, which acts as an insulator, blocking the conductive heat transfer from the cooling blanket to the patient's skin. The correct sequence is to first remove the insulation to maximize skin exposure, and then apply the cooling device ^[2].

- Option 4: Increase intravenous fluid rate to promote heat loss. This is not a primary or recommended intervention for managing hyperthermia in the context of acute ischemic stroke. Aggressive IV fluid administration can lead to fluid overload, hemodilution, and potentially worsen cerebral edema and increase ICP. In neurocritical care, fluid management is carefully balanced to maintain euvolemia and cerebral perfusion pressure, not to serve as a primary cooling mechanism ^[2]. The risks of worsening the patient's neurological injury far outweigh any minimal heat loss achieved through this method.

The Evidence-Based Sequence for Targeted Temperature Management

The best evidence for targeted temperature management (TTM) in severe neurological illness supports a systematic, stepwise approach where physical cooling measures are foundational ^[2]. The immediate goal is to achieve normothermia and prevent further temperature spikes, a strategy shown to provide substantial protection for neurological function ^[1]. The nursing actions follow a logical hierarchy:

1. Initiate Passive Cooling: The first and most immediate nursing action is to remove the patient’s clothing and linens. This simple, non-invasive step reduces insulation and allows the body's natural heat-dissipating mechanisms to begin working.
2. Progress to Active External Cooling: Once the patient is exposed, active surface cooling methods, such as applying cooling blankets or ice packs to the axillae, groin, and torso, can be initiated to accelerate heat loss through conduction.
3. Administer Pharmacological Agents (if ordered and route is safe): Antipyretics can then be administered via a safe route (e.g., intravenous) to address the central thermoregulatory dysfunction. The evidence from studies on combined therapies, such as decompressive hemicraniectomy with mild hypothermia, underscores the importance of aggressive temperature control as a neuroprotective adjunct in managing uncontrolled ICP .

By removing the patient's excess clothing first, the nurse immediately begins the process of heat dissipation, directly combats the hypermetabolic state exacerbating the brain injury, and sets the stage for all other cooling interventions to be maximally effective [1, 2].