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Pain Chronic (Persistent) (Adult Inpatient)

Clinical Description

  • Care of the hospitalized patient experiencing persistent pain of sufficient duration and intensity to adversely affect wellbeing, level of function and quality of life.

Key Information

  • Pain is a symptom, not a diagnosis. It is real to the patient and it is what he/she says it is (subjective, not objective).
  • Chronic pain frequently results in depressive symptoms, including trouble sleeping, appetite disturbances, loss of interest or pleasure in activities or relationships and isolation.
  • In treating chronic pain, consider presence of depression, substance use or chemical dependency associated with long-term pain management.
  • Lack of physiologic response or absence of pain behavior does not equate with “no pain”. Being quiet, withdrawn or sleeping should not be interpreted as absence of pain.
  • Vital signs tend to “normalize” over time as the body adapts to the presence of chronic pain. It does not indicate that pain is not present.
  • Chronic pain can occur in single or multiple body regions.

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Acceptable Pain Control and Functional Ability

B. Patient, family or significant other will teach back or demonstrate education topics and points:
  • Education: Overview
  • Education: Self Management
  • Education: When to Seek Medical Attention

Correlate Health Status

  • Correlate health status to:

    • history, comorbidity
    • age, developmental level
    • sex, gender identity
    • baseline assessment data
    • physiologic status
    • response to medication and interventions
    • psychosocial status, social determinants of health
    • barriers to accessing care and services
    • health literacy
    • cultural and spiritual preferences
    • safety risks
    • family interaction
    • plan for transition of care

Pain Chronic (Persistent)


  • altered time perception
  • anxiety
  • body posture abnormal
  • concentration impaired
  • constant pain
  • eating pattern change
  • fatigue
  • fidgeting
  • flat affect
  • focused on medication timing
  • guarding
  • irritability
  • pacing
  • pain present at rest
  • pain worsens with activity
  • pleasure or interest in activity decreased
  • reluctance to move
  • reluctance to perform self-care
  • reports pain over time
  • restlessness
  • rocking
  • rubbing
  • self-focused
  • sleep pattern altered
  • social withdrawal
  • splinting
  • tense expression
  • weakness

Problem Intervention

Develop Pain Management Plan

  • Acknowledge patient as the expert in pain self-management.
  • Use a consistent, validated tool for pain assessment; include function and quality of life.
  • Evaluate risk for opioid use.
  • Set pain management goals; determine acceptable level of discomfort to allow for maximal functioning and quality of life.
  • Determine mutually-agreed-upon pain management plan, including both pharmacologic and nonpharmacologic measures.
  • Identify and integrate past successful treatment measures, if able.
  • Encourage patient and caregiver involvement in pain assessment, interventions and safety measures.
  • Re-evaluate plan regularly.

Associated Documentation

  • Pain Management Interventions

Problem Intervention

Manage Persistent Pain

  • Evaluate pain level, effect of treatment and patient response at regular intervals.
  • Minimize pain stimuli; coordinate care and adjust environment (e.g., light, noise, unnecessary movement); promote sleep/rest.
  • Match pharmacologic analgesia to severity and type of pain mechanism (e.g., neuropathic, muscle, inflammatory); consider multimodal approach (e.g., nonopioid, opioid, adjuvant).
  • Provide medication at regular intervals; titrate to patient response.
  • Manage breakthrough pain with additional doses; consider rotation or switching medication.
  • Monitor for signs of substance tolerance (increased dose to reach desired effect, decreased effect with same dose).
  • Avoid abrupt withdrawal of medication, especially agents capable of causing physical dependence.
  • Manage medication-induced effects, such as constipation, nausea, urinary retention, somnolence and dizziness.
  • Provide multimodal treatment interventions, such as physical activity, therapeutic exercise, yoga, TENS (transcutaneous electrical nerve stimulation) and manual therapy.
  • Train in functional activity modifications, such as body mechanics, posture, ergonomics, energy conservation and activity pacing.
  • Consider addition of complementary or alternative therapy, such as acupuncture, hypnosis or therapeutic touch.

Associated Documentation

  • Bowel Elimination Promotion
  • Complementary Therapy
  • Medication Review/Management
  • Sleep/Rest Enhancement

Problem Intervention

Optimize Psychosocial Wellbeing

  • Facilitate patient’s self-control over pain by providing pain information and allowing choices in treatment.
  • Consider and address emotional response to pain.
  • Explore and promote use of coping strategies; address barriers to successful coping.
  • Evaluate and assist with psychosocial, cultural and spiritual factors impacting pain.
  • Modify pain perception by using techniques, such as distraction, mindfulness, guided imagery, meditation or music.
  • Assess and monitor for signs and symptoms of behavioral health concerns, such as unhealthy substance use, depression and suicidal ideation.
  • Consider referral for ongoing coping support, such as cognitive behavioral therapies and mindfulness-based stress reduction.

Associated Documentation

  • Diversional Activities
  • Family/Support System Care
  • Spiritual Activities Assistance
  • Supportive Measures


CPG-Specific Education Topics


  • risk factors

  • signs/symptoms

Self Management

  • activity

  • coping strategies

  • medication management

  • nonpharmacologic pain management

  • pain self-advocacy

  • sleep/rest

When to Seek Medical Attention

  • signs of medication tolerance

  • unresolved/worsening symptoms

General Education Topics

General Education

  • admission, transition of care

  • orientation to care setting, routine

  • advance care planning

  • diagnostic tests/procedures

  • diet modification

  • opioid medication management

  • oral health

  • medication management

  • pain assessment process

  • safe medication disposal

  • tobacco use, smoke exposure

  • treatment plan

Safety Education

  • call light use

  • equipment/home supplies

  • fall prevention

  • harm prevention

  • infection prevention

  • MDRO (multidrug-resistant organism) care

  • personal health information

  • resources for support

Population-Specific Considerations


  • Hearing and vision impairments may hamper use of pain tools that are based on verbal and visual communication.
  • Elderly adults are more likely to tolerate pain versus report it.
  • Prior to the use of opioids, the elderly patient should be assessed for risk of falls, renal impairment, respiratory dysfunction and cognitive limitations to assist in determining dosages.
  • In elderly patients with cognitive deficits, ineffective pain management may increase dementia-related behaviors, which may result in decreased pain treatment.


  • Women of childbearing age and those who are currently pregnant or lactating should have the specific risks of opioid use reviewed prior to administration.


  • Afolalu, E. F.; Ramlee, F.; Tang, N. K. Y. Effects of sleep changes on pain-related health outcomes in the general population: A systematic review of longitudinal studies with exploratory meta-analysis. Sleep Medicine Reviews. 2018;39, 82-97. doi:10.1016/j.smrv.2017.08.001 Source[Metasynthesis,Meta-analysis,Systematic Review]
  • Alperstein, D.; Sharpe, L. The efficacy of motivational interviewing in adults with chronic pain: A meta-analysis and systematic review. Journal of Pain. 2016;17(4), 393-403. doi:10.1016/j.jpain.2015.10.021 [Metasynthesis,Meta-analysis,Systematic Review]
  • Banerjee, A.; Hendrick, P.; Bhattacharjee, P.; Blake, H. A systematic review of outcome measures utilized to measure change in self-management in clinical trials in non-cancer chronic pain. Physiotherapy. 2016;102, e135. doi:10.1016/j.physio.2016.10.153 [Metasynthesis,Meta-analysis,Systematic Review]
  • Benzon, H. T.; Rathmell, J. P.; Wu, C. L.; Turk, D. C.; Argoff, C. E.; Hurley, R. W. (2014). Practical management of pain. Philadelphia: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Calati, R.; Bakhiyi, C. L.; Artero, S.; Ilgen, M.; Courtet, P. The impact of physical pain on suicidal thoughts and behaviors: Meta-analyses. Journal of Psychiatric Research. 2015;71, 16. [Metasynthesis,Meta-analysis,Systematic Review]
  • Derry, S.; Wiffen, P. J.; Kalso, E. A.; Bell, R. F.; Aldington, D.; Phillips, T.; Gaskell, H.; Moore, R. A. Topical analgesics for acute and chronic pain in adults - an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews. 2017;(5) doi:10.1002/14651858.CD008609.pub2 [Metasynthesis,Meta-analysis,Systematic Review]
  • Dowell, D.; Haegerich, T. M.; Chou, R.. CDC guideline for prescribing opioids for chronic pain - United States 2016. JAMA: Journal of the American Medical Association. 2016;315(15), 1624-1645. doi:10.1001/jama.2016.1464 [Quality Measures,Clinical Practice Guidelines]
  • Drew, D. J.; Gordon, D. B.; Morgan, B.; Manworren, R. C. "As-Needed" Range Orders for Opioid Analgesics in the Management of Pain: A consensus statement of the American Society for Pain Management Nursing and the American Pain Society. Pain Management Nursing. 2018;19(3), 207-210. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Els, C.; Jackson, T. D.; Kunyk, D.; Lappi, V. G.; Sonnenberg, B.; Hagtvedt, R.; Sharma, S.; Kolahdooz, F.; Straube, S. Adverse events associated with medium- and long-term use of opioids for chronic non-cancer pain: An overview of Cochrane Reviews. Cochrane Database of Systematic Reviews. 2017;(10) doi:10.1002/14651858.CD012509.pub2 [Metasynthesis,Meta-analysis,Systematic Review]
  • Geneen, L. J.; Moore, R. A.; Clarke, C.; Martin, D.; Colvin, L. A.; Smith, B. H. Physical activity and exercise for chronic pain in adults: An overview of Cochrane Reviews. Cochrane Database of Systematic Reviews. 2017;(4) doi:10.1002/14651858.CD011279.pub3 [Metasynthesis,Meta-analysis,Systematic Review]
  • Gibson, W.; Wand, B. M.; Meads, C.; Catley, M. J.; O'Connell, N. E. Transcutaneous electrical nerve stimulation (TENS) for chronic pain - an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews. 2019;(2) doi:10.1002/14651858.CD011890.pub2 [Metasynthesis,Meta-analysis,Systematic Review]
  • Gordon, R.; Bloxham, S. A systematic review of the effects of exercise and physical activity on non-specific chronic low back pain. Healthcare. 2016, Jun;4(2), 22. doi:10.3390/healthcare4020022 [Metasynthesis,Meta-analysis,Systematic Review]
  • Hamlin, A. S.; Robertson, T. M. Pain and complementary therapies. Critical Care Nursing Clinics. 2017;29(4), 449-460. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Hegmann, K. T.; Weiss, M. S.; Bowden, K.; Branco, F.; DuBrueler, K.; Els, C.; Mandel, S.; McKinney, D. W.; Miguel, R.; Mueller, K. L.; Nadig, R. J. ACOEM practice guidelines: Opioids for treatment of acute, subacute, chronic, and postoperative pain. Journal of Occupational and Environmental Medicine. 2014;56(12), e143-e159. [Quality Measures,Clinical Practice Guidelines]
  • Herr, K.; Coyne, P. J.; McCaffery, M.; Manworren, R.; Merkel, S. (2011). Pain assessment in the patient unable to self-report: A position statement. Overland, KS: American Society for Pain Management Nursing.[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Hooten, M.; Thorson, D.; Bianco, J.; Bonte, B.; Clavel Jr., A.; Hora, J.; Johnson, C.; Kirksson, E.; Noonan, M. P.; Reznikoff, C.; Schweim, K.; Wainio, J.; Walker, N.. (2016 [updated 2017, Aug]). Pain: Assessment, non-opioid treatment approaches and opioid management. (pp.160). Bloomington (MN): Institute for Clinical Systems Improvement (ICSI). Source[Quality Measures,Clinical Practice Guidelines]
  • Howick, J.; Moscrop, A.; Mebius, A.; Fanshawe, T. R.; Lewith, G.; Bishop, F. L.; Mistiae, P.; Roberts, N. W.; Dieninyte, E.; Hu, K. Y.; Onakpoya, I. J.; Aveyard, P. Effects of empathic and positive communication in healthcare consultations: A systematic review and meta-analysis. Journal of the Royal Society of Medicine. 2018;111(7), 240-252. doi:10.1177/0141076818769477 Source[Metasynthesis,Meta-analysis,Systematic Review]
  • IsHak, W. W.; Wen, R. Y.; Naghdechi, L.; Vanle, B.; Dang, J.; Knosp, M.; Dascal, J.; Marcia, L.; Gohar, Y.; Eskander, L.; Hanna, S.; Sadek, A.; Aguilar-Hernandez, L.; Danovitch, I.; Louy, C.; Yadegar, J. Pain and depression: A systematic review. Harvard Review of Psychiatry. 2018;26(6), 352-363. doi:10.1097/HRP.0000000000000198 [Metasynthesis,Meta-analysis,Systematic Review]
  • Krupić, F.; Čustović, S.; Jašarević, M.; Šadić, S.; Fazlić, M.; Grbic, K.; Samuelsson, K. Ethnic differences in the perception of pain: A systematic review of qualitative and quantitative research. Medicinski Glasnik. 2019;16(1), 108-114. doi:10.17392/966-19 [Metasynthesis,Meta-analysis,Systematic Review]
  • Lee, J. H. The effects of music on pain: A meta-analysis. Journal of Music Therapy. 2016;53(4), 430-477. doi:10.1093/jmt/thw012 Source[Metasynthesis,Meta-analysis,Systematic Review]
  • Majeed, M. H.; Ali, A. A.; Sudak, D. M. Mindfulness-based interventions for chronic pain: Evidence and applications. Asian Journal of Psychiatry. 2018;32, 79-83. doi:10.1016/j.ajp.2017.11.025 Source[Metasynthesis,Meta-analysis,Systematic Review]
  • McClintock, A. S.; McCarrick, S. M.; Garland, E. L.; Zeidan, F.; Zgierska, A. E. Brief mindfulness-based interventions for acute and chronic pain: A systematic review. Journal of Alternative and Complementary Medicine. 2018; doi:10.1089/acm.2018.0351 Source[Metasynthesis,Meta-analysis,Systematic Review]
  • Miller, R. M.; Kaiser, R. S. Psychological characteristics of chronic pain: A review of current evidence and assessment tools to enhance treatment. Current Pain and Headache Reports. 2018;22(3), 22. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Paice, J. A.; Portenoy, R.; Lacchetti, C.; Campbell, T.; Cheville, A.; Citron, M.; Constine, L. S.; Cooper, A.; Glare, P.; Keefe, F.; Koyyalagunta, L.; Levy, M.; Miaskowski, C.; Otis-Green, S.; Sloan, P.; Bruera, E. Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology Clinical Practice Guideline. Journal of Clinical Oncology. 2016;34(27), 3325-3345. doi:10.1200/JCO.2016.68.5206 [Quality Measures,Clinical Practice Guidelines]
  • Pasero, C.; Quinlan-Colwell, A.; Rae, D.; Broglio, K.; Drew, D. (2016). Prescribing and administering opioid doses solely on pain intensity:  A position statement by the American Society for Pain Management Nursing. Overland Park, KS: American Society for Pain Management Nursing. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Pendleton, H. M.; Schultz-Krohn, W. (2018). Pedretti's occupational therapy: Practice skills for physical dysfunction. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Racine, M. Chronic pain and suicide risk: A comprehensive review. Progress in Neuro-Psychopharmacology and Biological Psychiatry. 2018;87, 269-280. [Metasynthesis,Meta-analysis,Systematic Review]
  • Registered Nurses' Association of Ontario. (2013). Assessment and management of pain. Source[Quality Measures,Clinical Practice Guidelines]
  • Scottish Intercollegiate Network (SIGN). (2013, Dec). Management of chronic pain. SIGN publication no. 136). Edinburgh: Scottish Intercollegiate Guidelines Network (SIGN). Source[Quality Measures,Clinical Practice Guidelines]
  • Skelly, A. C.; Chou, R.; Dettori, J. R.; Turner, J. A.; Friedly, J. L.; Rundell, S. D.; Fu, R.; Brodt, E. D.; Wasson, N.; Winter, C.; Ferguson, A. J. R. (2018, June). Noninvasive nonpharmacological treatment for chronic pain: A systematic review. Comparative effectiveness review no. 209. (Prepared by the Pacific Northwest Evidence-based practice center under Contract No. 290-2015-00009-I). Rockville, MD: Agency for Healthcare Research and Quality. [Metasynthesis,Meta-analysis,Systematic Review]
  • Sturgeon, J. A.; Zautra, A. J. Social pain and physical pain: Shared paths to resilience. Pain Management. 2016;6(1), 63-74. doi:10.2217/pmt.15.56 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Subnis, U. B.; Starkweather, A.; Menzies, V. A current review of distraction-based interventions for chronic pain management. European Journal of Integrative Medicine. 2016;8(5), 715-722. doi:10.1016/j.eujim.2016.08.162 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Tick, H.; Nielsen, A.; Pelletier, K. R.; Bonakdar, R.; Simmons, S.; Glick, R.; Ratner, E.; Lemmon, R. L.; Wayne, P.; Zador, V. Evidence-based nonpharmacologic strategies for comprehensive pain care: The Consortium Pain Task Force white paper. Explore. 2018;14(3), 177-211. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Turk, D. C.; Fillingim, R. B.; Ohrbach, R.; Patel, K. V. Assessment of psychosocial and functional impact of chronic pain. Journal of Pain: Official Journal of the American Pain Society. 2016;17(9 Suppl), T21-49. doi:10.1016/j.jpain.2016.02.006 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • U. S. Department of Health and Human Services. (2016). National Pain Strategy: A comprehensive population health-level strategy for pain. Washington, DC: U. S. Department of Health and Human Services. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Williams, A. C. D. C.; Eccleston, C.; Morley, S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews. 2012;(11) doi:10.1002/14651858.CD007407.pub3 [Metasynthesis,Meta-analysis,Systematic Review]


Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.