{"id":64,"date":"2022-09-19T09:09:49","date_gmt":"2022-09-19T13:09:49","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/?post_type=chapter&#038;p=64"},"modified":"2022-12-21T15:21:14","modified_gmt":"2022-12-21T20:21:14","slug":"pain-assessment-in-critical-care","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/chapter\/pain-assessment-in-critical-care\/","title":{"raw":"Pain Assessment in Critical Care","rendered":"Pain Assessment in Critical Care"},"content":{"raw":"<span style=\"color: #000000\">A vital part of client care is assessing pain assessment in those who are <strong>critically ill and\/or in intensive care<\/strong>. If they are alert and oriented, they may be able to self-report. They can do so verbally or by pointing to a number if they cannot speak, but clients are often too critically ill to communicate. Additionally, they may be unable to self-report due to factors such as altered levels of consciousness, distress, sedation, and mechanical ventilatory support (G\u00e9linas, 2016; Suzuki, 2017).<\/span>\r\n\r\n<span style=\"color: #000000\">In this context, the <strong>nurse\u2019s observations of pain indicators<\/strong> are <strong>vital to pain assessment<\/strong>. These observations are most often focusing on the <strong>behavioural dimensions<\/strong> of pain. Typically, <strong>physiological pain indicators<\/strong> do not provide a valid assessment of pain because vital signs are influenced by the client\u2019s condition (i.e., pathological processes) and medications (i.e., [pb_glossary id=\"214\"]sedation[\/pb_glossary] and [pb_glossary id=\"215\"]vasopressors[\/pb_glossary]) that are often used in critical care situations.<\/span>\r\n\r\n<span style=\"color: #000000\">Of the many tools used in clinical practice, the Behavioral Pain Scale and the Critical Care Pain Observation Tool are recommended for assessing pain intensity, and often used in critical care (Suzuki, 2017). They are also the most validated and translated tools (Kerbage et al., 2021).<\/span>\r\n<h2><span style=\"color: #000000\"><strong>Behavioral Pain Scale (BPS)<\/strong><\/span><\/h2>\r\n<span style=\"color: #000000\">The development and psychometric testing of the BPS was published in 2001 by Payen and colleagues (2001), and used for <strong>assessment of pain in critically ill clients who are on mechanical ventilation<\/strong>. It is user-friendly and has strong psychometric properties in terms of assessing pain in non-communicative critical care clients (Payen &amp; Gelinas, 2014).<\/span>\r\n\r\n<span style=\"color: #000000\">The BPS incorporates<strong> three items<\/strong>:<\/span>\r\n<ul>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Facial expression.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Upper limb movement.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Compliance with ventilation.<\/span><\/li>\r\n<\/ul>\r\n<p style=\"padding-left: 40px\"><span style=\"color: #000000\">(Payen et al., 2001).<\/span><\/p>\r\n<span style=\"color: #000000\">Each item is scored from one to four with higher scores indicating more pain. The cut-off score for when pain is identified as present is greater than five (Payen et al., 2007).<\/span>\r\n\r\n&nbsp;\r\n\r\n<span style=\"color: #000000\">See external link to view the tool: <a href=\"https:\/\/www.mdcalc.com\/calc\/3622\/behavioral-pain-scale-bps-pain-assessment-intubated-patients\" target=\"_blank\" rel=\"noopener\">https:\/\/www.mdcalc.com\/calc\/3622\/behavioral-pain-scale-bps-pain-assessment-intubated-patients<\/a><\/span>\r\n<h2><span style=\"color: #000000\"><strong>Critical-Care Pain Observation Tool (CPOT)<\/strong><\/span><\/h2>\r\n<span style=\"color: #000000\">The CPOT was developed for assessing <strong>pain in ventilated and non-ventilated clients<\/strong> (G\u00e9linas et al., 2006). It was initially developed in French and later translated into English (G\u00e9linas et al., 2009) and other languages.<\/span>\r\n\r\n<span style=\"color: #000000\">The CPOT has <strong>four components<\/strong>:<\/span>\r\n<ul>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Facial expression.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Body movement.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Muscle tension.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Compliance with the ventilator for intubated clients or vocalization for extubated clients.<\/span><\/li>\r\n<\/ul>\r\n<span style=\"color: #000000\">Each of these sections is scored from 0 to 2, yielding a total score from 0 to 8 (G\u00e9linas et al., 2006). The cut-off score indicating pain is a score of greater than two (G\u00e9linas et al., 2009).<\/span>\r\n\r\n<span style=\"color: #000000\"><strong>Tips for using the CPOT<\/strong>:<\/span>\r\n<ul>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">While at rest, observe the client\u2019s facial expression, body movements, and presence of vocalization for one minute.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Next, perform a passive range of motion of the lower arm (flexion and extension of elbow) while holding the client\u2019s hand and elbow to assess for muscle tension.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Upon movement (such as turning them on their side), observe the client\u2019s facial expression, body movements, and presence of vocalization.<\/span><\/li>\r\n<\/ul>\r\n<p style=\"padding-left: 40px\"><span style=\"color: #000000\">(Kaiser Permanente National Patient Care Services, 2011).<\/span><\/p>\r\n<span style=\"color: #000000\">Check out this external link for the CPOT: <a href=\"https:\/\/kpnursing.org\/professionaldevelopment\/CPOTHandout.pdf\" target=\"_blank\" rel=\"noopener\">https:\/\/kpnursing.org\/professionaldevelopment\/CPOTHandout.pdf<\/a><\/span>\r\n\r\n<span style=\"color: #000000\">For more information, check out this video on the<\/span> <a href=\"https:\/\/www.sccm.org\/LearnICU\/Resources\/Critical-Care-Pain-Observation-Tool-How-to-Use-it\" target=\"_blank\" rel=\"noopener\">Critical-Care Pain Observation Tool: How to use it in your ICU<\/a> <span style=\"color: #000000\">Additional guidelines and instructions on using the tool can be located at:<\/span> <a href=\"https:\/\/kpnursing.org\/professionaldevelopment\/CPOTHandout.pdf\" target=\"_blank\" rel=\"noopener\">https:\/\/kpnursing.org\/professionaldevelopment\/CPOTHandout.pdf<\/a>\r\n\r\n&nbsp;\r\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\r\n<h2 class=\"textbox__title\" style=\"text-align: center\"><strong>Clinical Tip<\/strong><\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n\r\n<span style=\"color: #000000\">Use critical thinking when assessing pain in a critical care client, because self-reporting is often compromised. In critical care, you will encounter situations where pain indicators other than behavioural responses should be considered. Behavioural pain assessment tools should only be used when the client\u2019s motor function is intact: consider other practices for clients with limited or altered motor function such as in cases of deep sedation, paralysis, and brain injury (G\u00e9linas, 2016). Another limitation of behavioural pain assessment tools is they only evaluate the presence of pain and no other characteristics such as intensity (Kerbage et al., 2021).<\/span>\r\n\r\n<\/div>\r\n<\/div>\r\n<h2><span style=\"color: #000000\"><strong>References<\/strong><\/span><\/h2>\r\n<span style=\"color: #000000\">G\u00e9linas, C., Fillion, L., Puntillo, K., Viens, C., &amp; Fortier, M. (2006). Validation of the Critical-Care Pain Observation Tool in adult patients. American Journal of Critical Care, 15, 420-427.<\/span>\r\n\r\n<span style=\"color: #000000\">G\u00e9linas, C., Harel, F., Fillion, L., Puntillo, K., &amp; Johnston, C. (2009). Sensitivity and specificity of the Critical-Care Pain Observation Tool for the detection of pain in intubated adults after cardiac surgery. Journal of Pain and Symptom Management, 37(1), 58-67.<\/span>\r\n\r\n<span style=\"color: #000000\">G\u00e9linas, C. (2016). Pain assessment in the critically ill adult: Recent evidence and new trends. Intensive and Critical Care Nursing, 34, 1-11.<\/span> <a href=\"https:\/\/doi.org\/10.1016\/j.iccn.2016.03.001\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1016\/j.iccn.2016.03.001<\/a>\r\n\r\n<span style=\"color: #000000\">Kerbage, S., Garvey, L., Lambert, G., &amp; Willetts, G. (2021). Pain assessment of the adult sedated and ventilated patients in the intensive care setting: A scoping review. International Journal of Nursing Studies, 122. 1-22.<\/span> <a href=\"https:\/\/doi.org\/10.1016\/j.ijnurstu.2021.104044\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1016\/j.ijnurstu.2021.104044<\/a>\r\n\r\n<span style=\"color: #000000\">Payen, J., Bru, O., Bosson, J., Lagrasta, A., Novel, E., Deschaux, I., Lavagne, P., &amp; Jacquot, C. (2001). Assessing pain in critically ill sedated patients by using a behavioral pain scale. Critical Care Medicine, 29(12), 2258-2263.<\/span>\r\n\r\n<span style=\"color: #000000\">Payen, J., Chanques, G., Mantz, J., Hercule, C., Auriant, I., Leguillou, J., Binhas, M., Genty, C., Rolland, C., &amp; Bosson, J. (2007). Current practices in sedation and analgesia for mechanically ventilated critically ill patients: a prospective multicenter patient-based study. Anesthesiology, 106(4), 687-695.<\/span> <a href=\"https:\/\/doi.org\/10.1097\/01.anes.0000264747.09017.da\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1097\/01.anes.0000264747.09017.da<\/a>\r\n\r\n<span style=\"color: #000000\">Payen, J., &amp; Gelinas, C. (2014). Measuring pain in non-verbal critically ill patients: Which pain instrument? Critical Care, 18,(5).<\/span> <a href=\"https:\/\/doi.org\/10.1186\/s13054-014-0554-5\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1186\/s13054-014-0554-5<\/a>\r\n\r\n<span style=\"color: #000000\">Suzuki, T. (2017). Does the combination use of two pain assessment tools have a synergistic effect? Journal of Intensive Care, 5(1), 1-3.<\/span>","rendered":"<p><span style=\"color: #000000\">A vital part of client care is assessing pain assessment in those who are <strong>critically ill and\/or in intensive care<\/strong>. If they are alert and oriented, they may be able to self-report. They can do so verbally or by pointing to a number if they cannot speak, but clients are often too critically ill to communicate. Additionally, they may be unable to self-report due to factors such as altered levels of consciousness, distress, sedation, and mechanical ventilatory support (G\u00e9linas, 2016; Suzuki, 2017).<\/span><\/p>\n<p><span style=\"color: #000000\">In this context, the <strong>nurse\u2019s observations of pain indicators<\/strong> are <strong>vital to pain assessment<\/strong>. These observations are most often focusing on the <strong>behavioural dimensions<\/strong> of pain. Typically, <strong>physiological pain indicators<\/strong> do not provide a valid assessment of pain because vital signs are influenced by the client\u2019s condition (i.e., pathological processes) and medications (i.e., <button class=\"glossary-term\" aria-describedby=\"64-214\">sedation<\/button> and <button class=\"glossary-term\" aria-describedby=\"64-215\">vasopressors<\/button>) that are often used in critical care situations.<\/span><\/p>\n<p><span style=\"color: #000000\">Of the many tools used in clinical practice, the Behavioral Pain Scale and the Critical Care Pain Observation Tool are recommended for assessing pain intensity, and often used in critical care (Suzuki, 2017). They are also the most validated and translated tools (Kerbage et al., 2021).<\/span><\/p>\n<h2><span style=\"color: #000000\"><strong>Behavioral Pain Scale (BPS)<\/strong><\/span><\/h2>\n<p><span style=\"color: #000000\">The development and psychometric testing of the BPS was published in 2001 by Payen and colleagues (2001), and used for <strong>assessment of pain in critically ill clients who are on mechanical ventilation<\/strong>. It is user-friendly and has strong psychometric properties in terms of assessing pain in non-communicative critical care clients (Payen &amp; Gelinas, 2014).<\/span><\/p>\n<p><span style=\"color: #000000\">The BPS incorporates<strong> three items<\/strong>:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Facial expression.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Upper limb movement.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Compliance with ventilation.<\/span><\/li>\n<\/ul>\n<p style=\"padding-left: 40px\"><span style=\"color: #000000\">(Payen et al., 2001).<\/span><\/p>\n<p><span style=\"color: #000000\">Each item is scored from one to four with higher scores indicating more pain. The cut-off score for when pain is identified as present is greater than five (Payen et al., 2007).<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"color: #000000\">See external link to view the tool: <a href=\"https:\/\/www.mdcalc.com\/calc\/3622\/behavioral-pain-scale-bps-pain-assessment-intubated-patients\" target=\"_blank\" rel=\"noopener\">https:\/\/www.mdcalc.com\/calc\/3622\/behavioral-pain-scale-bps-pain-assessment-intubated-patients<\/a><\/span><\/p>\n<h2><span style=\"color: #000000\"><strong>Critical-Care Pain Observation Tool (CPOT)<\/strong><\/span><\/h2>\n<p><span style=\"color: #000000\">The CPOT was developed for assessing <strong>pain in ventilated and non-ventilated clients<\/strong> (G\u00e9linas et al., 2006). It was initially developed in French and later translated into English (G\u00e9linas et al., 2009) and other languages.<\/span><\/p>\n<p><span style=\"color: #000000\">The CPOT has <strong>four components<\/strong>:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Facial expression.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Body movement.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Muscle tension.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Compliance with the ventilator for intubated clients or vocalization for extubated clients.<\/span><\/li>\n<\/ul>\n<p><span style=\"color: #000000\">Each of these sections is scored from 0 to 2, yielding a total score from 0 to 8 (G\u00e9linas et al., 2006). The cut-off score indicating pain is a score of greater than two (G\u00e9linas et al., 2009).<\/span><\/p>\n<p><span style=\"color: #000000\"><strong>Tips for using the CPOT<\/strong>:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">While at rest, observe the client\u2019s facial expression, body movements, and presence of vocalization for one minute.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Next, perform a passive range of motion of the lower arm (flexion and extension of elbow) while holding the client\u2019s hand and elbow to assess for muscle tension.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Upon movement (such as turning them on their side), observe the client\u2019s facial expression, body movements, and presence of vocalization.<\/span><\/li>\n<\/ul>\n<p style=\"padding-left: 40px\"><span style=\"color: #000000\">(Kaiser Permanente National Patient Care Services, 2011).<\/span><\/p>\n<p><span style=\"color: #000000\">Check out this external link for the CPOT: <a href=\"https:\/\/kpnursing.org\/professionaldevelopment\/CPOTHandout.pdf\" target=\"_blank\" rel=\"noopener\">https:\/\/kpnursing.org\/professionaldevelopment\/CPOTHandout.pdf<\/a><\/span><\/p>\n<p><span style=\"color: #000000\">For more information, check out this video on the<\/span> <a href=\"https:\/\/www.sccm.org\/LearnICU\/Resources\/Critical-Care-Pain-Observation-Tool-How-to-Use-it\" target=\"_blank\" rel=\"noopener\">Critical-Care Pain Observation Tool: How to use it in your ICU<\/a> <span style=\"color: #000000\">Additional guidelines and instructions on using the tool can be located at:<\/span> <a href=\"https:\/\/kpnursing.org\/professionaldevelopment\/CPOTHandout.pdf\" target=\"_blank\" rel=\"noopener\">https:\/\/kpnursing.org\/professionaldevelopment\/CPOTHandout.pdf<\/a><\/p>\n<p>&nbsp;<\/p>\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<h2 class=\"textbox__title\" style=\"text-align: center\"><strong>Clinical Tip<\/strong><\/h2>\n<\/header>\n<div class=\"textbox__content\">\n<p><span style=\"color: #000000\">Use critical thinking when assessing pain in a critical care client, because self-reporting is often compromised. In critical care, you will encounter situations where pain indicators other than behavioural responses should be considered. Behavioural pain assessment tools should only be used when the client\u2019s motor function is intact: consider other practices for clients with limited or altered motor function such as in cases of deep sedation, paralysis, and brain injury (G\u00e9linas, 2016). Another limitation of behavioural pain assessment tools is they only evaluate the presence of pain and no other characteristics such as intensity (Kerbage et al., 2021).<\/span><\/p>\n<\/div>\n<\/div>\n<h2><span style=\"color: #000000\"><strong>References<\/strong><\/span><\/h2>\n<p><span style=\"color: #000000\">G\u00e9linas, C., Fillion, L., Puntillo, K., Viens, C., &amp; Fortier, M. (2006). Validation of the Critical-Care Pain Observation Tool in adult patients. American Journal of Critical Care, 15, 420-427.<\/span><\/p>\n<p><span style=\"color: #000000\">G\u00e9linas, C., Harel, F., Fillion, L., Puntillo, K., &amp; Johnston, C. (2009). Sensitivity and specificity of the Critical-Care Pain Observation Tool for the detection of pain in intubated adults after cardiac surgery. Journal of Pain and Symptom Management, 37(1), 58-67.<\/span><\/p>\n<p><span style=\"color: #000000\">G\u00e9linas, C. (2016). Pain assessment in the critically ill adult: Recent evidence and new trends. Intensive and Critical Care Nursing, 34, 1-11.<\/span> <a href=\"https:\/\/doi.org\/10.1016\/j.iccn.2016.03.001\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1016\/j.iccn.2016.03.001<\/a><\/p>\n<p><span style=\"color: #000000\">Kerbage, S., Garvey, L., Lambert, G., &amp; Willetts, G. (2021). Pain assessment of the adult sedated and ventilated patients in the intensive care setting: A scoping review. International Journal of Nursing Studies, 122. 1-22.<\/span> <a href=\"https:\/\/doi.org\/10.1016\/j.ijnurstu.2021.104044\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1016\/j.ijnurstu.2021.104044<\/a><\/p>\n<p><span style=\"color: #000000\">Payen, J., Bru, O., Bosson, J., Lagrasta, A., Novel, E., Deschaux, I., Lavagne, P., &amp; Jacquot, C. (2001). Assessing pain in critically ill sedated patients by using a behavioral pain scale. Critical Care Medicine, 29(12), 2258-2263.<\/span><\/p>\n<p><span style=\"color: #000000\">Payen, J., Chanques, G., Mantz, J., Hercule, C., Auriant, I., Leguillou, J., Binhas, M., Genty, C., Rolland, C., &amp; Bosson, J. (2007). Current practices in sedation and analgesia for mechanically ventilated critically ill patients: a prospective multicenter patient-based study. Anesthesiology, 106(4), 687-695.<\/span> <a href=\"https:\/\/doi.org\/10.1097\/01.anes.0000264747.09017.da\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1097\/01.anes.0000264747.09017.da<\/a><\/p>\n<p><span style=\"color: #000000\">Payen, J., &amp; Gelinas, C. (2014). Measuring pain in non-verbal critically ill patients: Which pain instrument? Critical Care, 18,(5).<\/span> <a href=\"https:\/\/doi.org\/10.1186\/s13054-014-0554-5\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1186\/s13054-014-0554-5<\/a><\/p>\n<p><span style=\"color: #000000\">Suzuki, T. (2017). Does the combination use of two pain assessment tools have a synergistic effect? Journal of Intensive Care, 5(1), 1-3.<\/span><\/p>\n<div class=\"glossary\"><div class=\"glossary__tooltip\" id=\"64-214\" hidden><p>is medication that relaxes the client, induces sleep, and reduces agitation and irritability.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"64-215\" hidden><p>are medications that support blood pressure.<\/p>\n<\/div><\/div>","protected":false},"author":34,"menu_order":17,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-64","chapter","type-chapter","status-publish","hentry"],"part":3,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/pressbooks\/v2\/chapters\/64","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/wp\/v2\/users\/34"}],"version-history":[{"count":20,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/pressbooks\/v2\/chapters\/64\/revisions"}],"predecessor-version":[{"id":1431,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/pressbooks\/v2\/chapters\/64\/revisions\/1431"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/pressbooks\/v2\/parts\/3"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/pressbooks\/v2\/chapters\/64\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/wp\/v2\/media?parent=64"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/pressbooks\/v2\/chapter-type?post=64"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/wp\/v2\/contributor?post=64"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/wp\/v2\/license?post=64"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}