Acetaminophen is a widely used over-the-counter (OTC) medication that is commonly prescribed to relieve pain and reduce fever. As a nurse, it is important to educate patients on the safe use of acetaminophen and to monitor for any potential side effects. Learn about the nursing considerations and nursing implications for acetaminophen in this drug guide.
What is Acetaminophen?
Acetaminophen, also known as paracetamol in many countries, is a common over-the-counter pain reliever and fever reducer. It is the active ingredient in many products such as Tylenol. Acetaminophen works by blocking the production of certain chemicals in the body that cause pain and inflammation. It is generally considered safe when taken as directed, but taking too much can cause liver damage. It is important to read and follow the label instructions when taking acetaminophen and not exceed the recommended dosage. It should also be used with caution in combination with alcohol or other medications.
Acetaminophen is the active ingredient in many over-the-counter (OTC) medications and is available under various brand names. Some of the most common brand names of acetaminophen products include:
- Children Feverhalt
- Infant’s Feverall
- Ofirmev (injectable form)
It is important to note that this list may not be exhaustive and there might be other brand names for acetaminophen depending on the country or region.
Drug Classification of Acetaminophen
The drug classification of acetaminophen is:
- antipyretics. Acetaminophen is an antipyretic, which means it reduces fever.
- nonopioid analgesics. It is also an analgesic, which means it relieves pain.
Indications and Therapeutic Effects
Acetaminophen is indicated for the relief of mild to moderate pain and fever. Some of the common conditions for which it is used include:
- Headaches and migraines. Acetaminophen is generally considered a safe and effective treatment for mild to moderate headaches, but it may not be as effective for severe migraines.
- Toothaches. It can also be used to relieve pain caused by toothaches. It works by blocking the production of certain chemicals in the body that causes pain and inflammation. It is generally considered a safe and effective treatment for mild to moderate toothaches. However, it is important to note that toothaches can be caused by various underlying conditions and may require dental treatment.
- Menstrual cramps. Acetaminophen is also considered a safe and effective treatment for mild to moderate menstrual cramps. Some studies have suggested that taking acetaminophen regularly during the menstrual period can reduce the severity of cramps. However, it is important to note that menstrual cramps can be caused by various underlying conditions and may require medical treatment.
- Back pain. During back-pain flare-ups, an over-the-counter pain reliever such as acetaminophen can help through. Healthcare providers often suggest first trying acetaminophen because it is gentler on the stomach, even though NSAIDs tend to work better for back pain.
- Sore throat. Ibuprofen (Advil, Motrin) is a preferred over-the-counter (OTC) medicine for treating a sore throat. But it may not be the safest choice for people with certain health conditions, like heart disease and kidney problems. Acetaminophen (Tylenol) may be a safer throat pain treatment for people who can’t take ibuprofen.
- Cold and flu symptoms. Ibuprofen and acetaminophen can relieve cold-related symptoms such as headaches, earaches, and joint pain. For some people, acetaminophen is the best way to reduce certain cold and flu symptoms. For others, ibuprofen does the trick.
- Fevers. Acetaminophen is primarily used to reduce fever and pain. It is an over-the-counter medicine, meaning it can be bought without a doctor’s prescription.
Mechanism of Action
Acetaminophen is an over-the-counter pain reliever and fever reducer. Its mechanism of action is not fully understood, but it is thought to work by inhibiting the production of prostaglandins, which are substances in the body that contribute to pain and inflammation. Additionally, it also affects the activity of certain neurotransmitters in the brain that are involved in the perception of pain. It does not have any anti-inflammatory properties.
Precautions and Contraindications
Acetaminophen is generally considered safe when taken as directed, but there are some precautions and contraindications to be aware of.
Some of the precautions include:
- Overdosage. Overdose can be dangerous and potentially fatal, so it is important to follow the recommended dosage and not exceed the maximum daily dose.
- Hepatic or Renal disease. Individuals with liver or kidney disease should use caution when taking acetaminophen, as it is metabolized by the liver and excreted by the kidneys.
- Alcoholism. People who consume three or more alcoholic drinks daily should avoid taking acetaminophen.
- Allergy. Acetaminophen should be used with caution in people with a history of allergies, asthma, or other breathing problems.
Acetaminophen is contraindicated in certain situations, such as:
- Hypersensitivity. It should not be used in people who are allergic to acetaminophen or any of its inactive ingredients.
- Certain compounds. Products containing alcohol, aspartame, saccharin, sugar, or tartrazine should be avoided in patients who have hypersensitivity or intolerance to these compounds.
- Hepatic or Renal disease. It should be avoided in people with severe liver disease; lower chronic doses are recommended.
- Other medications. It should not be used in combination with other medications that contain acetaminophen, as it can increase the risk of overdose.
- Warfarin. It should not be taken by people who are taking blood-thinning medications such as warfarin, as it may increase the risk of bleeding.
- Alcoholism. Chronic alcohol abuse or mixing too much alcohol with any acetaminophen (or too much acetaminophen with any alcohol) can make the removal of this substance even more difficult. The excess substance attacks the liver. This can cause severe liver damage.
- Malnutrition. Malnourished individuals are at increased risk of acetaminophen hepatotoxicity.
- Pregnancy. Use in pregnancy only if clearly needed.
- Lactation. Acetaminophen is a good choice for analgesia, and fever reduction in nursing mothers. Amounts in milk are much less than doses usually given to infants. Use cautiously for IV.
When administering acetaminophen, the nurse should consider the following drug interactions:
Acetaminophen (Tylenol) can interact with several other medications, including blood thinners, certain antidepressants, and certain antibiotics. It can also interact with alcohol, leading to an increased risk of liver damage.
- Chronic high-dose acetaminophen (>2 g/day) may increase the risk of bleeding with warfarin (INR should not exceed 4).
- Hepatotoxicity is additive with other hepatotoxic substances, including alcohol.
- Concurrent use of isoniazid, rifampin, rifabutin, phenytoin, barbiturates, and carbamazepine may increase the risk of acetaminophen-induced liver damage (limit self-medication); these agents will also decrease the therapeutic effects of acetaminophen.
- Concurrent use of NSAIDs may increase the risk of adverse renal effects (avoid chronic concurrent use).
- Propranolol decreases metabolism and may increase its effects.
- May decrease the effects of lamotrigine and zidovudine.
- Foods high in pectin, including jellies, carbohydrates, and various types of cruciferous vegetables such as broccoli, Brussels sprouts, cabbage, and others, can inhibit acetaminophen absorption. It is unclear how much effect this interaction has on acetaminophen activity.
- Alcohol may increase the risk of hepatotoxicity.
- Acetaminophen can be taken with or without food. The absorption is unaffected by food.
Acetaminophen (Tylenol) is generally considered safe when taken as directed, but like all medications, it can cause side effects in some people.
Some common side effects of acetaminophen include:
- CNS: agitation, anxiety, headache, fatigue, insomnia
- Resp: atelectasis, dyspnea
- CV: hypertension, hypotension
- GI: hepatotoxicity, constipation, increased liver enzymes, nausea, vomiting
- F & E: hypokalemia
- GU: renal failure
- Hemat: neutropenia, pancytopenia
- MS: muscle spasms, trismus
- Derm: acute generalized exanthematous pustulosis, steven-johnson syndrome, toxic epidermal necrolysis
Less common side effects include:
- Swelling of the face, lips, tongue, or throat
- Difficulty breathing
- Unusual bleeding or bruising
In rare cases, acetaminophen can cause serious side effects such as yellowing of the skin or eyes, dark urine, and severe stomach pain.
Acetaminophen is available in the following forms:
- Chewable tablets (fruit, bubblegum, or grape flavor): 80 mg, 160 mg.
- Tablets: 160 mg, 325 mg.
- Caplets: 325 mg.
- Solution (berry, fruit, and grape flavor): 100 mg/mL.
- Liquid (mint): 160 mg/5 mL.
- Elixir (grape and cherry flavor): 160 mg/5 mL.
- Drops: 160 mg/ 5 mL.
- Suspension: 100 mg/mL, 160 mg/5 mL.
- Syrup: 160 mg/5 mL.
- Suppositories: 80 mg, 120 mg, 325 mg.
- Solution for intravenous infusion: 1000 mg/100 mL in 100-mL vials.
- In combination with: many other medications.
Dosage for Neonates
- PO (Neonates): 10 – 15 mg/kg/dose every 6 – 8 hr as needed.
- IV (Neonates Birth – 28 days): 12.5 mg/kg every 6 hr (not to exceed 50 mg/kg [by all routes]).
- Rect (Neonates): 10 – 15 mg/kg/dose every 6 – 8 hr as needed.
Dosage for Infants
- PO (Infants): 10 – 15 mg/kg/dose every 6 hr as needed (not to exceed 5 doses/24 hr).
- IV (Infants 29 days-2 yr): 15 mg/kg every 6 hr (not to exceed 60 mg/kg/day [by all routes]).
- Rect (Infants): 10 – 20 mg/kg/dose every 4 – 6 hr as needed.
Dosage for Children
Children ≤12 yr should not receive >5 PO or rectal doses/24 hr without notifying physician or other healthcare professional. No dose adjustment needed when converting between IV and PO acetaminophen in children ≥50 kg.
- PO (Children >12 yr): 325 – 650 mg every 6 hr or 1 g 3–4 times daily or 1300 mg every 8 hr (not to exceed 3 g or 2 g/24 hr in patients with hepatic/renal impairment).
- PO (Children 1 – 12 yr): 10 – 15 mg/kg/dose every 6 hr as needed (not to exceed 5 doses/24 hr).
- IV (Children ≥13 yr and ≥50 kg): 1000 mg every 6 hr or 650 mg every 4hr (not to exceed 1000 mg/dose, 4 g/day [by all routes], and less than 4 hr dosing interval).
- IV (Children ≥13 yr and <50 kg): 15 mg/kg every 6 hr or 12.5 mg/kg every 4 hr (not to exceed 15 mg/kg/dose [up to 750 mg/dose], 75 mg/kg/ day [up to 3750 mg/day] [by all routes], and less
- IV (Children 2 – 12 yr): 15 mg/kg every 6 hr or 12.5 mg/kg every 4 hr (not to exceed 15 mg/kg/dose [up to 750 mg/dose], 75 mg/kg/day [up to 3750 mg/day] [by all routes], and less than 4 hr dosing interval).
- Rect (Children >12 yr): 325 – 650 mg every 4–6 hr as needed or 1 g 3–4 times/day (not to exceed 4 g/24 hr).
- Rect (Children 1 – 12 yr): 10 – 20 mg/kg/dose every 4–6 hr as needed.
Dosage for Adults
No dose adjustment is needed when converting between IV and PO acetaminophen in adults.
- PO (Adults): 325 – 650 mg every 6 hr or 1 g 3–4 times daily or 1300 mg every 8 hr (not to exceed 3 g or 2 g/24 hr in patients with hepatic/renal impairment).
- IV (Adults ≥50 kg): 1000 mg every 6 hr or 650 mg every 4hr (not to exceed 1000 mg/dose, 4 g/day [by all routes], and less than 4 hr dosing interval).
- IV (Adults <50 kg): 15 mg/kg every 6 hr or 12.5 mg/kg every 4 hr (not to exceed 15 mg/kg/dose [up to 750 mg/dose], 75 mg/kg/ day [up to 3750 mg/day] [by all routes], and less than 4 hr dosing interval).
- Rect (Adults): 325 – 650 mg every 4–6 hr as needed or 1 g 3–4 times/day (not to exceed 4 g/24 hr).
- Absorption. Acetaminophen is rapidly absorbed from the gastrointestinal tract, with peak plasma concentrations occurring within 30-60 minutes of oral administration. Rectal absorption is variable. Intravenous administration results in complete bioavailability.
- Distribution. Widely distributed. Crosses the placenta; enters breast milk in low concentrations.
- Metabolism and Excretion. 85 – 95% metabolized by the liver (CYP2E1 enzyme system). The drug is metabolized primarily in the liver by conjugation with glucuronide and sulfate, and to a lesser extent by oxidation to N-acetyl-p-benzoquinone imine (NAPQI), which can cause toxicity in high doses. The majority of the metabolized drug is excreted in the urine, with only a small portion excreted in the feces. Metabolites may be toxic in overdose situations.
- Half-life. Neonates: 7 hr; Infants and Children: 3 – 4 hr; Adults: 1 – 3 hr. In general, the half-life of acetaminophen is 1 – 4 hours. This means that it takes 1 – 4 hours for half of the drug to be eliminated from the body. The elimination half-life of acetaminophen is shorter in healthy adults, with a median of 2 hours and a range of 1 – 4 hours, and slightly longer in children, the elderly, and individuals with liver or kidney dysfunction.
Nursing Considerations for Acetaminophen
It is important to note that acetaminophen should not be used as a substitute for medical treatment, and it should be used with caution in patients with liver or kidney disease. It should also be used with caution in combination with other medications, especially those that may also affect the liver. When administering acetaminophen to patients, several nursing considerations should be taken into account.
There are several important aspects of a nursing assessment for a patient taking acetaminophen, including:
1. Assess the patient’s pain level before administering the medication.
Assessing a patient’s level of pain before administering acetaminophen is an important nursing consideration. This will help the healthcare provider determine the appropriate dosage of the medication.
2. Assess overall health status and alcohol usage before administering acetaminophen.
Patients who are malnourished or chronically abuse alcohol are at higher risk of developing hepatotoxicity with chronic use of usual doses of this drug.
3. Assess the patient’s pain level using appropriate tools.
A variety of tools can be used to assess a patient’s pain level, such as the Visual Analog Scale (VAS), the Numeric Rating Scale (NRS), and the Wong-Baker FACES Pain Rating Scale. These tools allow the patient to rate their pain on a scale, usually from 0-10, with 0 indicating no pain and 10 indicating the worst pain imaginable.
4. Assess the amount, frequency, and type of drugs taken in patients self-medicating, especially with OTC drugs.
Prolonged use of acetaminophen increases the risk of adverse hepatic and renal effects. For short-term use, combined doses of acetaminophen and salicylates should not exceed the recommended dose of either drug given alone. Do not exceed maximum daily dose of acetaminophen when considering all routes of administration and all combination products containing acetaminophen.
5. Monitor the patient’s response to the medication.
It is also important to note that pain assessment should be performed regularly and to monitor the patient’s response to the medication throughout the course of treatment to ensure that the medication is effectively managing the patient’s pain and to make any necessary adjustments to the dosage or treatment plan.
6. Assess the patient’s allergies and previous reactions to medications before administering acetaminophen.
The patient’s allergies and previous reactions to medications are important things to consider to avoid potential allergic reactions. Acetaminophen may cause Stevens-Johnson syndrome. Discontinue therapy if rash (reddening of skin, blisters, and detachment of upper surface of skin peeling) or if accompanied by fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis, and/or eosinophilia.
7. Monitor patients with liver or kidney dysfunction for potential adverse effects and adjust the dosage accordingly.
Individuals with liver or kidney disease should be extra careful when taking acetaminophen, as it is metabolized by the liver and excreted by the kidneys.
8. Assess fever; note the presence of associated signs (diaphoresis, tachycardia, and malaise).
Assessing a patient’s fever is an important nursing consideration when administering acetaminophen. Fever is a common symptom of many illnesses and can be an indicator of an underlying infection or condition.
Several nursing diagnoses may be appropriate for a patient taking acetaminophen, depending on the patient’s individual situation. Some examples include:
- Acute pain related to inflammation, injury, or surgery, as evidenced by verbalization of pain and physiologic indicators such as increased heart rate and blood pressure.
- Hyperthermia related to inflammation, as evidenced by an increase in body temperature higher than the normal range.
- Deficient knowledge regarding the safe use of acetaminophen, as evidenced by the patient’s lack of understanding of the recommended dosage, potential side effects, and interactions with other medications.
- Ineffective health maintenance related to inadequate pain management, as evidenced by the patient’s verbalization of ongoing pain and poor sleep quality.
If the patient is suspected of acetaminophen overdose, the following nursing diagnosis may be appropriate:
- Risk for injury related to excessive use of acetaminophen, as evidenced by the patient’s history of exceeding the recommended dosage or use of multiple products containing acetaminophen.
- Risk for impaired liver function related to excessive use of acetaminophen, as evidenced by the patient’s history of exceeding the recommended dosage or use of multiple products containing acetaminophen.
It’s important to note that nursing diagnoses are based on the patient’s specific situation, and a comprehensive assessment should be done to identify the correct diagnosis.
Acetaminophen Nursing Interventions
When caring for a patient taking acetaminophen, there are several nursing interventions that can be implemented to ensure the safe and effective use of the medication:
1. Administer the medication in the appropriate dosage, as prescribed by a healthcare provider.
Acetaminophen is generally considered safe when taken as directed, but t is important to follow the recommended dosage and not exceed the maximum daily dose to avoid overdose and potential liver damage. Overdose can be dangerous and potentially fatal.
2. Do not confuse Tylenol with Tylenol PM.
Tylenol PM is a combination medicine used to treat occasional insomnia associated with minor aches and pains. Tylenol PM is not for use in treating sleeplessness without pain, or sleep problems that occur often.
3. Do not exceed the maximum recommended daily dose of acetaminophen when combined with opioids
When administering acetaminophen in combination with opioids, it is important to be aware of the maximum recommended daily dose of acetaminophen. Exceeding the maximum recommended daily dose can increase the risk of liver damage. The maximum recommended daily dose of acetaminophen is 4,000 milligrams per day for adults and 90 milligrams per kilogram per day for children. It is important to note that this is the maximum recommended dose when taken alone and when combined with opioids, the maximum recommended daily dose of acetaminophen may be lower.
4. Administer acetaminophen with a full glass of water.
Acetaminophen can be taken on an empty stomach, but make sure to advise the patient to take it with a full glass of water to avoid an upset stomach.
5. Acetaminophen may be taken with food or on an empty stomach.
Acetaminophen can be taken with food or on an empty stomach but always with a full glass of water. Sometimes, taking the medication with food can lessen any upset stomach that may occur.
6. Intravenous Administration
- 6.1. Intermittent Infusion
- For 1000 mg dose. Insert vented IV set through the septum of a 100 mL vial; may be administered without further dilution.
- For doses <1000 mg. Withdraw the appropriate dose from the vial and place it in a separate empty, sterile container for IV infusions. Place small volume pediatric doses up to 60 mL in a syringe and administer via syringe pump. The solution is clear and colorless; do not administer discolored solutions or contain particulate matter. Administer within 6 hrs of breaking the vial seal.
- Rate. Infuse over 15 min. Monitor the end of infusion in order to prevent air embolism, especially if acetaminophen is the primary infusion.
- Y-Site Compatibility
- buprenorphine, butorphanol, cefoxitin, ceftriaxone, clindamycin, D5W, dexamethasone, dexmedetomidine, D10W, D5/LR, D5/0.9% NaCl, diphenhydramine, dolasetron, droperidol, esmolol, fentanyl, gentamicin, granisetron, heparin, hydrocortisone, hydromorphone, ketorolac, LR, lidocaine, lorazepam, mannitol, meperidine, methylprednisolone, metoclopramide, midazolam, morphine, nalbuphine, 0.9% NaCl, ondansetron, oxytocin, piperacillin/tazobactam, potassium chloride, prochlorperazine, ranitidine, sufentanil, vancomycin.
- Y-Site Incompatibility
- Additive Incompatibility
- Do not mix with other medications.
Patient Education and Teaching
1. Educate patients on the safe use of acetaminophen, including the importance of not exceeding the recommended dosage.
Overdose can be dangerous and potentially fatal, so it is important to follow the recommended dosage and not exceed the maximum daily dose. Chronic excessive use of 4 g/day (2 g in chronic alcoholics) may lead to hepatotoxicity, renal, or cardiac damage.
2. Advise patients to seek medical attention if they experience signs of overdose, such as nausea, vomiting, loss of appetite, sweating, confusion, or yellowing of the skin or eyes.
Overdose can be dangerous and potentially fatal.
3. Advice the patient to not take acetaminophen longer than ten days and children not longer than five days unless directed by a healthcare professional.
Taking too much acetaminophen can harm the liver, occasionally leading to a liver transplant or death. The body breaks down most of the acetaminophen in a normal dose and eliminates it in the urine. But some of the drug is converted into a byproduct that is toxic to the liver.
4. Advise patients to take the medication with food or a glass of water.
Acetaminophen can be taken on an empty stomach, but make sure to advise the patient to take it with a full glass of water to minimize stomach upset.
5. Advise the patient to discontinue acetaminophen and notify the healthcare professional if rash occurs.
Acetaminophen may seldom cause severe skin reactions. Symptoms may include skin reddening, rash, blisters, and the upper surface of the skin may become separated from the lower layers.
6. Advise patients to check the label of other medications they are taking, as acetaminophen is often found in combination with other drugs.
Acetaminophen (Tylenol) can interact with several other medications, including blood thinners, certain antidepressants, and certain antibiotics. It can also interact with alcohol, leading to an increased risk of liver damage.
7. Advise the patient to avoid alcohol while taking the medication.
Mixing alcohol with any acetaminophen can make the removal of this substance even more difficult. The excess substance attacks the liver. This can cause severe liver damage.
8. Discuss with the patient the potential risks of excessive use of acetaminophen over a long period of time.
Educating patients about the potential risks of excessive use of acetaminophen over a long period of time is an important nursing consideration. Acetaminophen is metabolized primarily in the liver and in high doses, it can cause toxicity, leading to liver damage.
9. Inform the patients with diabetes that acetaminophen may alter the results of blood glucose monitoring. Advise patient to notify healthcare professional if changes are noted.
Acetaminophen interferes with continuous glucose monitor (CGM) sensing, resulting in falsely elevated CGM glucose values in both sensors currently approved by the U.S. Food and Drug Administration (FDA).
10. Advise the patient to consult healthcare professional if discomfort or fever is not relieved by routine doses of this drug or if fever is greater than 39.5°C (103°F) or lasts longer than three days.
Viruses are extremely heat resistant which is why viral infections usually result in very high temperatures and are not easily controlled with normal fever medication like acetaminophen. For example, dengue fever symptoms do not diminish entirely with acetaminophen or paracetamol.
11. For Children
- 11.1. Advise the parents or caregivers to check concentrations of liquid preparations.
All OTC single-ingredient acetaminophen liquid products now come in a single concentration of 160 mg/5 mL. Errors have resulted in serious liver damage.
- 11.2. Have parents or caregivers determine the correct formulation and dose for their child based on the child’s age or weight, and demonstrate how to measure it using an appropriate measuring device.
Evaluation and Desired Outcomes
The desired outcome of using acetaminophen is pain relief and fever reduction. The drug’s effectiveness can be evaluated by measuring the patient’s reduction in pain and fever after taking the medication. Additionally, the safety of the drug can be evaluated by monitoring for any side effects or adverse reactions that may occur. Regular monitoring of liver function tests is required for long-term use. A healthcare professional should be consulted for appropriate use and dosing.
Our recommended nursing pharmacology resources and books:
Pharm Phlash! Pharmacology Flash Cards #1 BEST SELLER!
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