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Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) Indicate with a checkmark, which of the items on the PACSLAC occurred during the period of interest. Social/Personality/Mood Present Scoring the sub-scales is derived by counting the checkmarks in each column. To generate a total pain sum all sub-scale totals. Physical Aggression (e.g. pushing people and/or objects, scratching others, hitting others, striking, Facial Expression Present kicking). Verbal Aggression Grimacing Not Wanting to be Touched Sad look Not Allowing People Near Tighter Face Angry/Mad Dirty Look Throwing Things Change in Eyes Increased Confusion (Squinting, dull, bright, increased eye Anxious movements) Upset Frowning Agitated Pain Expression Cranky/Irritable Grim Face Frustrated Clenching Teeth Wincing Open Mouth Other Creasing Forehead (Physiological changes/Eating Present Screwing Up Nose Sleeping Changes/Vocal Behaviors) Pale Face Flushed, Red Face Activity/Body Movement Present Teary Eyed Sweating Fidgeting Shaking/Trembling Pulling Away Cold Clammy Flinching Changes in Sleep Routine (Please circle 1 Restless or 2) Pacing 1) Decreased Sleep Wandering ------------------------------------ Trying to Leave 2) Increased Sleep During Refusing to Move the Day Thrashing Changes in Appetite (Please circle 1 or 2) Decreased Activity 1) Decreased Appetite Refusing Medications ----------------------------------- Moving Slow 2) Increased Appetite Impulsive Behaviours Screaming/Yelling (Repeat Movements) Calling Out (i.e. for help) Uncooperative/Resistance to care Crying Guarding Sore Area A Specific Sound of Vocalization Touching/Holding Sore Area For pain “ow,” “ouch” Limping Moaning and groaning Clenching Fist Mumbling Going into Fetal Position Grunting Stiff/Rigid Total Checklist Score The PACSLAC may not be reproduced or translated without permission. For permission to reproduce the PACSLAC contact the copyright holders (Thomas.email@example.com). THE DEVELOPERS OF THE PACSLAC SPECIFICALLY DISCLAIM ANY AND ALL LIABILITY ARISING DIRECTLY OR INDIRECTLY FOR USE OR APPLICATION OF THE PACSLAC. USE OF THE PACSLAC MAY NOT BE APPROPRIATE FOR SOME PATIENTS AND THE PACSLAC IS NOT A SUBSTITUTE FOR A THOROUGH ASSESSMENT OF THE PATIENT BY A QUALIFIED HEALTH PROFESSIONAL. References Fuchs-Lacelle, S. & Hadjistavropoulos, T. (2004). Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC). Pain Management Nursing, 5(1), 37-49.
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