const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.author = "Pokhara Academy of Health Sciences";
pres.title = "Open Tibia and Fibula Fracture – Gustilo-Anderson Grade IIIA";

// ─── THEME COLORS ───────────────────────────────────────────────
const C = {
  navyDark:   "0A2463",   // deep navy – header backgrounds
  blue:       "1565C0",   // primary blue
  blueMid:    "1976D2",   // mid blue
  blueLight:  "E3F2FD",   // very light blue – content area BG
  accent:     "FF6F00",   // amber accent
  accentRed:  "C62828",   // alert/danger
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  bodyText:   "212121",
  tableHead:  "1565C0",
  tableAlt:   "E8F4FD",
  notesBg:    "F0F4FF",
  green:      "2E7D32",
};

// ─── HELPER: standard content slide with header bar ─────────────
function makeSlide(title, subtitleText) {
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  // Full background
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      fontSize: 11, italic: true, color: C.blue,
      fontFace: "Calibri", valign: "middle", margin: 0
    });
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  return s;
}

// ─── HELPER: add styled bullet list ─────────────────────────────
function addBullets(slide, items, x, y, w, h, opts = {}) {
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    let txt = item;
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      indent = item.indent || 0;
      isSubBullet = item.sub || false;
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      text: txt,
      options: {
        bullet: isSubBullet
          ? { type: "number", indent: 30 }
          : { code: "25CF", indent: indent > 0 ? 20 : 0 },
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        bold: opts.bold || false,
        fontFace: "Calibri",
        paraSpaceBefore: 4,
        breakLine: i < items.length - 1
      }
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  slide.addText(textArr, { x, y, w, h, valign: "top" });
}

// ─── HELPER: add a two-column table ─────────────────────────────
function addTable(slide, headers, rows, x, y, w, colW, opts = {}) {
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  const headerRow = headers.map(h => ({
    text: h,
    options: { bold: true, fontSize: fontSize, color: C.white, fill: { color: C.tableHead }, align: "center" }
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    colW,
    border: { type: "solid", color: "BDD7EE", pt: 0.5 },
    rowH: opts.rowH || 0.32,
    margin: 3
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}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 1 – TITLE SLIDE
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  // Dark navy full background
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.navyDark } });
  // Decorative circles
  s.addShape(pres.ShapeType.ellipse, { x: 7.8, y: -0.8, w: 3.5, h: 3.5, fill: { color: "0D3080", transparency: 50 }, line: { color: "0D3080" } });
  s.addShape(pres.ShapeType.ellipse, { x: -0.5, y: 3.5, w: 2.5, h: 2.5, fill: { color: "0D3080", transparency: 50 }, line: { color: "0D3080" } });
  // Accent bar
  s.addShape(pres.ShapeType.rect, { x: 0.5, y: 1.55, w: 0.1, h: 2.2, fill: { color: C.accent } });
  // Hospital tag
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.45, fill: { color: "05174A" } });
  s.addText("Pokhara Academy of Health Sciences (PAHS) – B.Sc. Nursing Programme, 2nd Year", {
    x: 0.3, y: 0.06, w: 9.4, h: 0.33,
    fontSize: 10, color: C.white, fontFace: "Calibri", valign: "middle", margin: 0
  });
  // Main title
  s.addText("Open Tibia & Fibula Fracture", {
    x: 0.7, y: 0.8, w: 9, h: 0.8,
    fontSize: 32, bold: true, color: C.white, fontFace: "Calibri", valign: "middle", margin: 0
  });
  s.addText("Gustilo-Anderson Classification – Grade IIIA", {
    x: 0.7, y: 1.6, w: 8, h: 0.55,
    fontSize: 20, color: "90CAF9", fontFace: "Calibri", valign: "middle", margin: 0, italic: true
  });
  // Divider
  s.addShape(pres.ShapeType.rect, { x: 0.7, y: 2.2, w: 5.5, h: 0.04, fill: { color: C.accent } });
  // Subtitle bullets
  s.addText([
    { text: "Subject: Medical-Surgical Nursing  |  Unit: Musculoskeletal System", options: { breakLine: true } },
    { text: "Presenter: [Nursing Faculty / Student Name]  |  Date: July 2026", options: { breakLine: true } },
    { text: "Academic Year: 2082-83 B.S. (2025-26 A.D.)", options: {} }
  ], {
    x: 0.7, y: 2.35, w: 8, h: 1,
    fontSize: 13, color: "B0BEC5", fontFace: "Calibri", valign: "top"
  });
  // Bottom ribbon
  s.addShape(pres.ShapeType.rect, { x: 0, y: 5.0, w: 10, h: 0.625, fill: { color: "05174A" } });
  s.addText("Evidence-Based  |  ATLS Guidelines  |  NANDA Nursing Diagnoses  |  Brunner & Suddarth's Nursing", {
    x: 0.3, y: 5.08, w: 9.4, h: 0.45,
    fontSize: 10, color: "90CAF9", fontFace: "Calibri", align: "center", valign: "middle", margin: 0
  });
  s.addNotes("Welcome the students. Introduce yourself and the topic. Emphasize that tibia-fibula fractures are the most common long bone fractures seen in Nepal due to road traffic accidents. This presentation covers anatomy, pathophysiology, Gustilo-Anderson classification (focusing on Grade IIIA), medical and surgical management, and – most importantly – comprehensive nursing care. Encourage students to relate this to their clinical placements.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 2 – LEARNING OBJECTIVES
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Learning Objectives", "By the end of this session, students will be able to:");
  const objs = [
    "Describe the anatomy and physiology of the tibia and fibula",
    "Define open (compound) fracture and explain its pathophysiology",
    "Identify the Gustilo-Anderson classification and characteristics of Grade IIIA",
    "Outline the clinical features and diagnostic measures for open tibia-fibula fracture",
    "Explain the medical and surgical management using the ATLS approach",
    "Apply the nursing process: assessment, diagnosis, intervention, and evaluation",
    "List potential complications and provide evidence-based patient education",
    "Identify NANDA nursing diagnoses and nursing interventions with rationales",
  ];
  const textArr = objs.map((o, i) => ({
    text: `${i + 1}.  ${o}`,
    options: { fontSize: 14.5, color: C.bodyText, fontFace: "Calibri", paraSpaceBefore: 6, breakLine: i < objs.length - 1 }
  }));
  s.addShape(pres.ShapeType.rect, { x: 0.3, y: 1.1, w: 9.4, h: 4.2, fill: { color: C.blueLight }, line: { color: "B0C4DE", pt: 0.5 } });
  s.addText(textArr, { x: 0.5, y: 1.15, w: 9.1, h: 4.1, valign: "top" });
  s.addNotes("Walk through each objective with students. These objectives align with the nursing curriculum for 2nd Year B.Sc. Nursing at PAHS. By the end of the session, students should be competent to care for a patient with an open tibia-fibula fracture in a clinical setting, whether in an emergency department, OT, or ward. Remind students that in Nepal, the most common cause of tibia fractures is road traffic accidents (RTAs), especially among young males.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 3 – ANATOMY OF THE TIBIA AND FIBULA
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Anatomy of the Tibia and Fibula", "Bones • Blood Supply • Muscles • Nerves");

  // Left column: bone anatomy
  s.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.12, w: 4.4, h: 4.2, fill: { color: C.blueLight }, line: { color: "90CAF9" } });
  s.addText("🦴  Bony Anatomy", { x: 0.35, y: 1.12, w: 4.2, h: 0.35, fontSize: 13, bold: true, color: C.blue, fontFace: "Calibri" });
  addBullets(s, [
    "Tibia (shinbone): larger, medial weight-bearing bone",
    "Has medial, lateral & posterior surfaces; triangular cross-section",
    "Landmarks: tibial plateau (superior), tibial tuberosity, medial malleolus (inferior)",
    "Fibula: slender, lateral bone; mainly for muscle attachment",
    "Fibula carries ~10% of body weight",
    "Lateral malleolus = distal fibula; forms ankle mortise with tibia",
    "Interosseous membrane connects tibia and fibula throughout their length",
  ], 0.35, 1.5, 4.2, 3.7, { fontSize: 12.5 });

  // Right column: vessels, muscles, nerves
  s.addShape(pres.ShapeType.rect, { x: 5.0, y: 1.12, w: 4.7, h: 4.2, fill: { color: C.blueLight }, line: { color: "90CAF9" } });
  s.addText("🩸  Blood Supply, Muscles & Nerves", { x: 5.1, y: 1.12, w: 4.5, h: 0.35, fontSize: 13, bold: true, color: C.blue, fontFace: "Calibri" });
  addBullets(s, [
    "Blood supply: anterior tibial, posterior tibial & peroneal arteries (from popliteal)",
    "Periosteal supply: important for cortical bone healing",
    "Muscles: anterior compartment (tibialis anterior, EDL, EHL), posterior (gastrocnemius, soleus), lateral (peroneals)",
    "Tibia is subcutaneous anteromedially → vulnerable in open fractures",
    "Nerve supply: common peroneal nerve → deep (motor/sensory anterior) & superficial (lateral) branches",
    "Tibial nerve: posterior compartment motor + plantar sensation",
    "⚠️ Neurovascular bundle at risk in displaced fractures",
  ], 5.1, 1.5, 4.5, 3.7, { fontSize: 12.5 });

  s.addNotes("Emphasize the importance of the tibia's subcutaneous medial surface – it has minimal soft tissue cover, meaning fractures are prone to becoming open and wound healing is impaired. The blood supply of the tibia enters via the nutrient artery at the proximal-posterior shaft; significant disruption occurs in high-energy fractures. The common peroneal nerve winds around the fibular neck and is vulnerable in fibular fractures at that level. Always assess dorsiflexion and toe extension (deep peroneal nerve) and sensation over the first web space when assessing a tibia-fibula fracture. Source: Gray's Anatomy for Students; Netter's Atlas; Rockwood & Green's Fractures in Adults 10e.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 4 – PHYSIOLOGY
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Physiology of the Tibia and Fibula", "Functions in weight bearing, movement & hematopoiesis");
  const boxes = [
    { label: "Weight Bearing", icon: "⚖️", x: 0.25, col: [
      "Tibia bears ~90% of body weight transmitted from femur",
      "Fibula provides stability and acts as a strut",
      "Both bones transmit forces to ankle joint during standing and walking",
    ]},
    { label: "Locomotion", icon: "🚶", x: 3.45, col: [
      "Allows plantar flexion / dorsiflexion of ankle",
      "Fibula head articulates with tibia → proximal tibiofibular joint (gliding)",
      "Muscles of leg control knee and ankle movement",
      "Gait cycle requires intact tibio-fibular unit",
    ]},
    { label: "Hematopoiesis & Storage", icon: "🩸", x: 6.65, col: [
      "Proximal tibia: active red bone marrow – site of blood cell production",
      "Bone marrow cavity: stores yellow marrow (fat) in adults",
      "Calcium & phosphorus reservoir for metabolic functions",
      "Tibial intramedullary cavity used for IM nailing in fractures",
    ]}
  ];
  boxes.forEach(b => {
    s.addShape(pres.ShapeType.rect, { x: b.x, y: 1.1, w: 3.1, h: 4.25, fill: { color: C.blueLight }, line: { color: "90CAF9" } });
    s.addText(`${b.icon}  ${b.label}`, { x: b.x + 0.1, y: 1.1, w: 2.9, h: 0.4, fontSize: 13, bold: true, color: C.blue, fontFace: "Calibri", valign: "middle" });
    addBullets(s, b.col, b.x + 0.12, 1.55, 2.85, 3.7, { fontSize: 12 });
  });
  s.addNotes("Physiology links directly to clinical consequences: tibia's weight-bearing role means any fracture immediately impairs mobility; the thin soft tissue cover anteriorly means that even moderate swelling can cause compartment syndrome. The red bone marrow in the proximal tibia is clinically important because intramedullary nailing disrupts this space. In fracture healing physiology, recall the 4 stages: hematoma, soft callus, hard callus, remodelling – all relevant to assessing healing progress in Grade IIIA fractures.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 5 – INTRODUCTION TO TIBIA-FIBULA FRACTURES
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Introduction to Tibia and Fibula Fractures", "Most common long-bone fractures – a nursing priority");
  s.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.1, w: 9.5, h: 4.25, fill: { color: C.blueLight }, line: { color: "90CAF9" } });
  addBullets(s, [
    "Tibia is the most frequently fractured long bone in the body",
    "Approximately 77,000 tibial shaft fractures occur in the USA annually (Brunner & Suddarth's, 14e)",
    "In Nepal, road traffic accidents (RTAs) are the leading cause – accounting for ~60-70% of tibial fractures",
    "Fibula fractures often accompany tibial fractures due to the shared interosseous membrane",
    "The subcutaneous medial surface of tibia makes it highly susceptible to open (compound) fractures",
    "Open fractures are orthopedic emergencies requiring urgent multi-disciplinary management",
    "Mortality from open fractures is low (<1%) but morbidity is high: infection, non-union, amputation",
    "Nursing role is central: early recognition, neurovascular monitoring, wound care, and rehabilitation",
    "Incidence peaks in young males (15-45 yrs) and the elderly (>65 yrs, low-energy falls)",
  ], 0.4, 1.2, 9.2, 4.0, { fontSize: 14 });
  s.addNotes("Set the clinical context. In Nepal, road traffic accidents (RTAs) are the No. 1 cause of tibia fractures. The prevalence is high among young working males, making these fractures a significant public health concern. Emphasize that the tibia's anteromedial subcutaneous position means skin breakdown is common, converting a closed fracture to an open one, or presenting as an open fracture at time of injury. The nurse must be alert to this when assessing a patient brought in following an RTA.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 6 – DEFINITION OF OPEN (COMPOUND) FRACTURE
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Definition of Open (Compound) Fracture", "A fracture communicating with the external environment");
  // Big definition box
  s.addShape(pres.ShapeType.rect, { x: 0.3, y: 1.1, w: 9.4, h: 1.05, fill: { color: C.navyDark }, line: { color: C.navyDark } });
  s.addText("An open (compound) fracture is a fracture in which the broken bone communicates with the external environment through a wound in the overlying skin and soft tissue, carrying a significant risk of bacterial contamination and infection.", {
    x: 0.4, y: 1.1, w: 9.2, h: 1.05, fontSize: 14, color: C.white, fontFace: "Calibri", valign: "middle", italic: true
  });
  // Two columns
  s.addShape(pres.ShapeType.rect, { x: 0.3, y: 2.25, w: 4.55, h: 3.1, fill: { color: C.blueLight }, line: { color: "90CAF9" } });
  s.addText("Key Characteristics", { x: 0.4, y: 2.25, w: 4.4, h: 0.35, fontSize: 13, bold: true, color: C.blue, fontFace: "Calibri" });
  addBullets(s, [
    "Bone may or may not protrude through the wound",
    "Wound may result from bone penetrating skin from inside-out or external trauma",
    "Always associated with soft tissue damage",
    "Risk of deep infection (osteomyelitis) is 2–50% depending on grade",
    "Requires URGENT surgical debridement within 6–24 hours",
    "Tetanus prophylaxis mandatory",
  ], 0.4, 2.62, 4.35, 2.68, { fontSize: 12.5 });

  s.addShape(pres.ShapeType.rect, { x: 5.1, y: 2.25, w: 4.6, h: 3.1, fill: { color: C.blueLight }, line: { color: "90CAF9" } });
  s.addText("vs. Closed Fracture", { x: 5.2, y: 2.25, w: 4.4, h: 0.35, fontSize: 13, bold: true, color: C.blue, fontFace: "Calibri" });
  addBullets(s, [
    "Closed fracture: no communication with skin surface",
    "Open fracture: skin and/or mucous membrane breached",
    "Open = orthopedic emergency (contamination risk)",
    "Closed = can be treated electively in stable patients",
    "Both require immobilization and analgesia",
    "Open fracture has higher complication rate",
  ], 5.2, 2.62, 4.35, 2.68, { fontSize: 12.5 });
  s.addNotes("Clarify that the term 'compound fracture' is synonymous with 'open fracture' and that both terms may be used. The critical point is the communication with the external environment – even a small puncture wound (e.g., from a bone spike inside-out) qualifies as an open fracture and must be treated as an emergency. The wound should NOT be probed in the emergency room. Source: Brunner & Suddarth's Medical-Surgical Nursing 14e; Lewis Medical-Surgical Nursing 11e.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 7 – EPIDEMIOLOGY
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Epidemiology", "Global and Nepal-specific data");
  addTable(s, ["Parameter", "Global Data", "Nepal Context"],
    [
      ["Incidence", "~77,000 tibial shaft fractures/year (USA)", "RTAs: leading cause (~60-70%) of tibial fractures"],
      ["Age Group", "Bimodal: young adults (15-45 yrs) & elderly (>65 yrs)", "Young males 20-40 yrs most affected (WHO Nepal 2022)"],
      ["Sex Distribution", "Male > Female (2:1 ratio)", "Males more affected due to RTA, occupational injury"],
      ["Open Fracture Rate", "~3% of all tibial fractures are open", "Higher rate due to high-speed RTA, poor road safety"],
      ["Mortality", "<1% in isolated fracture", "Higher with polytrauma; limited trauma centres in Nepal"],
      ["Infection Rate", "Type I: 1-2%, Type IIIA: 7-10%", "Higher in resource-limited settings without early care"],
      ["Amputation Rate", "Type IIIC: up to 50-88%", "Limited vascular surgery capacity in rural Nepal"],
      ["Common Causes", "RTA, sports injury, falls, industrial trauma", "RTA (highway), agricultural injury, fall from height"],
    ],
    0.25, 1.1, 9.5, [2.5, 3.5, 3.5], { fontSize: 11.5, rowH: 0.38 });
  s.addNotes("Nepal-specific context is important. Nepal has high rates of RTAs especially on mountain highways. The country has limited level-I trauma centres outside Kathmandu and Pokhara, meaning patients often arrive with delayed care, increasing infection risk. Epidemiological data for Nepal comes from studies published by B.P. Koirala Institute of Health Sciences (BPKIHS), Tribhuvan University Teaching Hospital, and Manipal Teaching Hospital, Pokhara. WHO injury data also supports the high burden of traffic injuries in South-East Asia.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 8 – CAUSES AND MECHANISM OF INJURY
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Causes and Mechanism of Injury", "Direct, indirect, and high-energy mechanisms");
  s.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.1, w: 4.6, h: 4.2, fill: { color: C.blueLight }, line: { color: "90CAF9" } });
  s.addText("🚗  Common Causes", { x: 0.35, y: 1.1, w: 4.4, h: 0.38, fontSize: 13, bold: true, color: C.blue, fontFace: "Calibri" });
  addBullets(s, [
    "Road Traffic Accidents (RTA) – most common in Nepal",
    "Fall from height (construction, farm workers)",
    "Sports injuries (football, skiing)",
    "Industrial trauma (machinery, crush injuries)",
    "Gunshot wounds / blast injuries",
    "Pathological fractures (tumor, osteoporosis)",
    "Stress fractures (military, marathon runners)",
  ], 0.35, 1.5, 4.4, 3.75, { fontSize: 13 });

  s.addShape(pres.ShapeType.rect, { x: 5.1, y: 1.1, w: 4.6, h: 4.2, fill: { color: C.blueLight }, line: { color: "90CAF9" } });
  s.addText("⚡  Mechanism of Injury", { x: 5.2, y: 1.1, w: 4.4, h: 0.38, fontSize: 13, bold: true, color: C.blue, fontFace: "Calibri" });
  addBullets(s, [
    "Direct force: bumper injury → transverse/comminuted fracture",
    "Indirect force: twisting → spiral/oblique fracture",
    "High energy: motorcycle crash, fall from height → Grade III open fracture",
    "Low energy: simple fall in elderly → Grade I or II fracture",
    "Inside-out injury: bone spike punctures skin from inside",
    "Outside-in injury: external wound directly over fracture",
    "Compartment syndrome risk ↑ with crush mechanisms",
  ], 5.2, 1.5, 4.4, 3.75, { fontSize: 13 });
  s.addNotes("Mechanism of injury determines fracture pattern and energy transfer. High-energy mechanisms (as in Grade IIIA) result in extensive periosteal stripping, muscle crush, and bone comminution. The mechanism also determines contamination level – agricultural injuries and animal bites carry faecal pathogens (Clostridium, E. coli), while urban RTAs often involve Staphylococcus aureus and Gram-negative bacteria. Ask the student: 'If a patient arrives after an RTA with an open leg wound, what is your first nursing priority?' – Answer: Airway, breathing, circulation (ABC) using ATLS approach, then wound care.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 9 – RISK FACTORS
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Risk Factors", "Patient and environmental factors increasing fracture risk");
  const cats = [
    { label: "Demographic", icon: "👤", items: ["Young males 15-45 yrs (risk-taking behavior, RTA)", "Elderly >65 yrs (osteoporosis, falls)", "Athletes (stress fractures)", "Military personnel"] },
    { label: "Medical / Metabolic", icon: "🏥", items: ["Osteoporosis / low bone mineral density", "Diabetes mellitus (↑ infection risk)", "Peripheral vascular disease", "Malnutrition / Vitamin D deficiency", "Prolonged steroid use"] },
    { label: "Environmental / Behavioral", icon: "🌍", items: ["Unsafe roads / traffic conditions (Nepal)", "Lack of helmet/seat belt use", "Alcohol intoxication while driving", "Occupational hazard (construction)", "Absence of safety equipment"] },
    { label: "Post-Injury Complications", icon: "⚠️", items: ["Delayed presentation to hospital", "Contaminated wound (farm injury)", "Immunocompromised state", "Smoking (impairs fracture healing)", "Previous tibial fracture"] },
  ];
  const xPos = [0.25, 2.7, 5.15, 7.6];
  cats.forEach((c, i) => {
    s.addShape(pres.ShapeType.rect, { x: xPos[i], y: 1.1, w: 2.3, h: 4.25, fill: { color: C.blueLight }, line: { color: "90CAF9" } });
    s.addText(`${c.icon} ${c.label}`, { x: xPos[i]+0.08, y: 1.1, w: 2.15, h: 0.4, fontSize: 12, bold: true, color: C.blue, fontFace: "Calibri", valign: "middle" });
    addBullets(s, c.items, xPos[i]+0.08, 1.52, 2.1, 3.78, { fontSize: 11.5 });
  });
  s.addNotes("Smoking is a modifiable risk factor that significantly impairs fracture healing – nurses should counsel patients to stop smoking both pre- and post-operatively. Diabetes is increasingly prevalent in Nepal and significantly increases the risk of wound infection and non-union. Emphasize to students that identifying risk factors helps in anticipating complications and tailoring the care plan. Ask: 'What nursing interventions can minimize the risk of infection in a patient with diabetes who has an open fracture?' – Answer: Strict wound asepsis, glucose monitoring, prophylactic antibiotics as prescribed, early nutritional support.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 10 – PATHOPHYSIOLOGY FLOWCHART
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Pathophysiology", "From trauma to fracture and healing (or complications)");

  // Flowchart boxes – vertical cascade
  const boxes = [
    { text: "HIGH-ENERGY TRAUMA\n(RTA, fall, crush)", y: 1.1, color: C.accentRed },
    { text: "Bone Disruption + Soft Tissue Injury\n→ Periosteal stripping, muscle crush", y: 1.75, color: "B71C1C" },
    { text: "Haematoma Formation\n→ Fracture site fills with blood; inflammatory mediators released", y: 2.4, color: C.blue },
    { text: "Open Wound + Contamination\n→ Bacterial entry; infection risk (Staph. aureus, E. coli, Clostridium)", y: 3.05, color: C.accent },
    { text: "Inflammatory Phase (0-5 days)\n→ Osteoclasts clear debris; granulation tissue begins", y: 3.7, color: "1B5E20" },
    { text: "Soft Callus → Hard Callus → Remodelling\n→ (if infection/non-union: complication pathway)", y: 4.35, color: C.green },
  ];
  boxes.forEach(b => {
    s.addShape(pres.ShapeType.rect, { x: 1.5, y: b.y, w: 7, h: 0.55, fill: { color: b.color }, line: { color: b.color }, rounding: 0.1 });
    s.addText(b.text, { x: 1.5, y: b.y, w: 7, h: 0.55, fontSize: 12, bold: false, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
    if (b.y < 4.35) {
      s.addShape(pres.ShapeType.line, { x: 5, y: b.y + 0.55, w: 0, h: 0.2, line: { color: C.gray, width: 1.5, endArrowType: "arrow" } });
    }
  });

  // Side note – complication branch
  s.addShape(pres.ShapeType.rect, { x: 8.65, y: 3.05, w: 1.25, h: 0.55, fill: { color: C.accentRed }, line: { color: C.accentRed } });
  s.addText("→ Osteomyelitis\n   Compartment Syndrome\n   Non-union", { x: 8.65, y: 3.05, w: 1.3, h: 0.55, fontSize: 8, color: C.white, fontFace: "Calibri", valign: "middle" });
  s.addNotes("Walk through each step of the flowchart. Key teaching point: the 4 stages of fracture healing are: (1) Haematoma/Reactive Phase 0-5 days, (2) Soft Callus (fibrocartilage) 5 days–3 weeks, (3) Hard Callus (woven bone) 3–12 weeks, (4) Remodelling – months to years. In Grade IIIA fractures, the soft tissue damage and contamination disrupt stages 1-2, increasing infection risk and impairing healing. The nurse monitors for signs of infection (fever, increased wound discharge, erythema) and neurovascular compromise (6 P's of compartment syndrome: Pain, Pressure, Pallor, Paraesthesia, Paralysis, Pulselessness). Source: Brunner & Suddarth's Medical-Surgical Nursing 14e; Campbell's Operative Orthopaedics 15e 2026.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 11 – GUSTILO-ANDERSON CLASSIFICATION
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Gustilo-Anderson Classification", "Gold-standard classification of open fractures (Gustilo & Anderson, 1976; updated 1984)");
  addTable(s,
    ["Type", "Wound Size", "Soft Tissue Injury", "Bone Injury", "Contamination", "Infection Risk"],
    [
      ["I", "< 1 cm", "Minimal", "Simple, minimal comminution", "Clean", "1-2%"],
      ["II", "1–10 cm", "Moderate; some muscle damage", "Moderate comminution", "Moderate", "2-7%"],
      ["IIIA ★", "> 10 cm (or any)", "Severe crushing; adequate soft tissue covers bone", "Comminuted; coverage possible without flap", "High", "7-10%"],
      ["IIIB", "> 10 cm", "Extensive; periosteal stripping; bone exposed", "Comminuted; requires soft tissue flap reconstruction", "High", "10-50%"],
      ["IIIC", "> 10 cm", "As IIIB + vascular injury requiring repair", "Comminuted; amputation may be needed", "Very High", "Up to 50%"],
    ],
    0.15, 1.1, 9.7, [0.7, 1.2, 2.2, 2.1, 1.2, 1.1], { fontSize: 11, rowH: 0.5 });

  // Highlight IIIA note
  s.addShape(pres.ShapeType.rect, { x: 0.15, y: 4.22, w: 9.7, h: 0.45, fill: { color: "FFF8E1" }, line: { color: C.accent } });
  s.addText("★ Type IIIA is the focus of this presentation. Key distinction from IIIB: adequate soft tissue coverage of bone is still achievable without flap surgery.", {
    x: 0.25, y: 4.22, w: 9.5, h: 0.45, fontSize: 11.5, color: "E65100", fontFace: "Calibri", valign: "middle"
  });
  s.addNotes("The Gustilo-Anderson classification (originally published 1976, updated by Gustilo, Mendoza & Williams 1984) remains the most widely used open fracture grading system worldwide. However, remind students that INTEROBSERVER reliability is only moderate – therefore the OTA/AO Open Fracture Classification (OTA-OFC) is increasingly used in research and high-volume trauma centres. The OTA-OFC assesses 5 domains: Skin, Muscle, Arterial, Bone loss, and Contamination. Grade IIIA is characterized by adequate bone coverage despite high energy and comminution – this is the key distinction from IIIB where flap coverage is needed. Source: Rockwood & Green's Fractures in Adults 10e 2025, pp. 620-625; Campbell's Operative Orthopaedics 15e 2026.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 12 – GRADE IIIA DETAILED EXPLANATION
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Grade IIIA Open Tibia-Fibula Fracture", "Characteristics, prognosis, and clinical significance");
  s.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.1, w: 5.5, h: 4.22, fill: { color: C.blueLight }, line: { color: "90CAF9" } });
  s.addText("Defining Characteristics", { x: 0.35, y: 1.1, w: 5.3, h: 0.38, fontSize: 14, bold: true, color: C.navyDark, fontFace: "Calibri" });
  addBullets(s, [
    "Wound: usually >10 cm (or any size if high-energy mechanism)",
    "Soft tissue: severe crushing, muscle damage – but BONE IS COVERED",
    "No need for free flap or rotational flap to achieve bone coverage",
    "Bone: comminuted fracture pattern (fragmented bone)",
    "Contamination: HIGH – soil, road debris, grass, clothing fragments",
    "Vascular integrity: INTACT (no vascular repair needed – distinguishes from IIIC)",
    "Periosteum: partially stripped (but bone remains covered by soft tissue)",
    "Force involved: high-energy (RTA, industrial, gunshot, blast)",
  ], 0.35, 1.5, 5.3, 3.77, { fontSize: 13 });

  s.addShape(pres.ShapeType.rect, { x: 6.0, y: 1.1, w: 3.75, h: 4.22, fill: { color: "FFF8E1" }, line: { color: C.accent } });
  s.addText("Prognosis & Key Facts", { x: 6.1, y: 1.1, w: 3.55, h: 0.38, fontSize: 14, bold: true, color: "E65100", fontFace: "Calibri" });
  addBullets(s, [
    "Deep infection rate: 7-10%",
    "Osteomyelitis risk: 3-5%",
    "Non-union rate: 10-15%",
    "Amputation: rare if well managed",
    "Average healing time: 6-12 months",
    "Multiple surgeries often needed",
    "Best treated in specialised trauma centre",
    "Early debridement within 6-24 hrs → best outcomes",
    "Antibiotic prophylaxis essential",
  ], 6.1, 1.5, 3.55, 3.77, { fontSize: 12.5 });
  s.addNotes("Grade IIIA is the most common high-grade open fracture encountered in trauma practice. The KEY distinguishing feature from IIIB is that soft tissue coverage of bone is ACHIEVABLE without complex flap surgery. Students should know: if bone is exposed and requires a flap → IIIB. If a vascular injury requiring repair is present → IIIC. Emphasize that Grade IIIA fractures, despite having adequate bone coverage, still require: urgent irrigation and debridement, IV antibiotics (cephalosporin + aminoglycoside), external fixation or intramedullary nailing, and serial wound checks every 24-48 hours. Source: Rockwood & Green's Fractures in Adults 10e 2025; Campbell's Operative Orthopaedics 15e 2026.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 13 – CLINICAL FEATURES
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Clinical Features", "Local and systemic signs and symptoms");
  s.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.1, w: 4.55, h: 4.2, fill: { color: C.blueLight }, line: { color: "90CAF9" } });
  s.addText("🦵  Local Signs", { x: 0.35, y: 1.1, w: 4.35, h: 0.38, fontSize: 14, bold: true, color: C.blue, fontFace: "Calibri" });
  addBullets(s, [
    "PAIN – severe, at fracture site, worsens on movement",
    "OPEN WOUND >10 cm with visible bone/tissue",
    "SWELLING and local oedema around fracture",
    "DEFORMITY – angulation, shortening, rotation",
    "CREPITUS – grating of bone ends (do NOT elicit)",
    "LOSS OF FUNCTION – unable to bear weight",
    "BRUISING / ECCHYMOSIS around wound",
    "ACTIVE HAEMORRHAGE from wound",
    "Foreign material / contamination in wound",
    "Neurovascular deficit if associated injury",
  ], 0.35, 1.5, 4.35, 3.75, { fontSize: 12.5 });

  s.addShape(pres.ShapeType.rect, { x: 5.05, y: 1.1, w: 4.7, h: 4.2, fill: { color: C.blueLight }, line: { color: "90CAF9" } });
  s.addText("🌡️  Systemic Signs", { x: 5.15, y: 1.1, w: 4.5, h: 0.38, fontSize: 14, bold: true, color: C.blue, fontFace: "Calibri" });
  addBullets(s, [
    "SHOCK – tachycardia, hypotension (blood loss)",
    "PALLOR – due to haemorrhage",
    "FEVER – if infection develops (>38°C)",
    "DIAPHORESIS – pain and shock response",
    "NAUSEA and vomiting (pain response, shock)",
    "ANXIETY / AGITATION – pain, fear, shock",
    "Decreased level of consciousness (severe shock)",
    "In POLYTRAUMA: associated head, chest, abdominal injuries",
    "Fat embolism syndrome (PE risk): dyspnoea, petechiae",
    "SIRS criteria if wound infection develops",
  ], 5.15, 1.5, 4.5, 3.75, { fontSize: 12.5 });
  s.addNotes("When a patient presents with an open tibia fracture following RTA, the nurse must think ATLS: first identify and treat life-threatening conditions (haemorrhage, airway compromise). Tachycardia and hypotension indicate haemorrhagic shock and require immediate IV access and fluid resuscitation. Local signs tell us about fracture severity – the large wound (>10 cm) with comminution in Grade IIIA. The 'P's of fracture are: Pain, Point tenderness, Pallor, Paraesthesia, Pulselessness, Paralysis (important for compartment syndrome assessment). Do NOT elicit crepitus as it causes pain and further tissue damage.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 14 – DIAGNOSTIC MEASURES
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Diagnostic Measures", "History • Examination • Investigations");
  addTable(s,
    ["Investigation", "Details", "Purpose / Expected Findings"],
    [
      ["History Taking", "MOI, time of injury, contamination, medications, allergies, tetanus status", "Guides classification and management plan"],
      ["Physical Examination", "Inspect wound, measure wound size, check deformity, document neurovascular status", "Confirms open fracture, assesses severity"],
      ["Neurovascular Assessment", "Pulse (pedal, popliteal), capillary refill, sensation, motor power, Doppler if needed", "Detects vascular injury / compartment syndrome"],
      ["X-Ray (AP + Lateral)", "Both tibia-fibula views including ankle & knee joints", "Confirms fracture, pattern, displacement, comminution"],
      ["CT Scan", "3D reconstruction of fracture pattern; angiography if vascular injury suspected", "Plans surgical approach, detects occult fractures"],
      ["CBC", "Hb, WBC, platelets", "Assess blood loss, infection (↑WBC), coagulopathy"],
      ["Blood Group & Cross-match", "ABO typing, crossmatch 2-4 units PRBC", "Preparation for possible blood transfusion"],
      ["Metabolic Panel", "BMP, LFT, coagulation profile (PT, APTT)", "Pre-operative assessment, nutritional status"],
      ["Wound Swab Culture", "Aerobic + anaerobic swab before antibiotics ideally", "Identifies infecting organism for targeted therapy"],
      ["Doppler / Angiography", "If distal pulse absent or ABI <0.9", "Rule out vascular injury (IIIC)"],
    ],
    0.15, 1.1, 9.7, [1.8, 3.8, 4.1], { fontSize: 11, rowH: 0.38 });
  s.addNotes("Emphasize to students the sequence: ABC first → then X-ray → then CT if needed. X-ray of the injured extremity must include the joint above AND below (knee AND ankle for tibia fractures) to detect associated injuries. Doppler assessment is performed by the nurse – place the probe over the dorsalis pedis and posterior tibial arteries. An absent or asymmetric pulse requires immediate surgical consultation to rule out vascular injury. Wound swab should ideally be taken before antibiotics but should NOT delay antibiotic administration in a contaminated wound. Source: ATLS Student Course Manual 10e; Brunner & Suddarth's 14e.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 15 – MEDICAL MANAGEMENT
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Medical Management", "ATLS Approach • Antibiotics • Tetanus • Analgesia • Wound Care");
  s.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.1, w: 9.5, h: 0.5, fill: { color: C.navyDark }, line: { color: C.navyDark } });
  s.addText("ATLS Protocol: Airway → Breathing → Circulation → Disability → Exposure (ABCDE)", {
    x: 0.35, y: 1.1, w: 9.3, h: 0.5, fontSize: 13.5, bold: true, color: C.white, fontFace: "Calibri", valign: "middle", align: "center"
  });
  addTable(s,
    ["Management Area", "Specific Intervention", "Rationale"],
    [
      ["Airway & Breathing", "O₂ via mask; secure airway if GCS <8; assist ventilation if needed", "Prevent hypoxia; support fracture healing with adequate oxygenation"],
      ["Circulation / Shock", "2 large-bore IV (16G), IV fluids (NS/RL), blood transfusion if Hb <7-8", "Restore circulating volume; prevent haemorrhagic shock"],
      ["Wound Management", "Sterile saline irrigation; sterile dressing; DO NOT probe; photograph wound", "Prevent further contamination; document for classification"],
      ["Antibiotic Prophylaxis", "Cefazolin 2g IV (1st gen) + Gentamicin 1.5mg/kg IV for Grade III", "Prevent deep infection (Staph aureus, Gram-negatives); standard of care"],
      ["Tetanus Prophylaxis", "Tetanus toxoid 0.5 mL IM + TIG 250 units IM if >5 yrs since booster", "Prevent Clostridium tetani infection in contaminated wound"],
      ["Analgesia", "Morphine 0.1mg/kg IV titrated; Paracetamol 1g IV 6-hourly; NSAIDs if no contraindication", "Humane pain control; reduces stress response; enables examination"],
      ["Limb Immobilisation", "Back-slab POP splint / temporary external splint; elevate limb >heart level", "Prevent further injury; reduce swelling; improve circulation"],
      ["Monitoring", "Hourly urine output (>0.5 ml/kg/hr), neurovascular obs q1h, vital signs", "Early detection of compartment syndrome, shock, infection"],
    ],
    0.15, 1.65, 9.7, [1.8, 3.85, 4.1], { fontSize: 10.5, rowH: 0.38 });
  s.addNotes("The ATLS approach is the framework for ALL trauma patients. Remind students that in Nepal, hospitals like PAHS, Gandaki Medical College, and Manipal Teaching Hospital follow ATLS protocols. Key drug note: Cefazolin (1st generation cephalosporin) covers Gram-positive organisms; adding gentamicin covers Gram-negatives in Grade III fractures. Metronidazole is added if heavy soil contamination is present (covers anaerobes / Clostridium). Penicillin VK is added if agricultural injury. These follow EAST Practice Management Guidelines for open fractures. Tetanus immunoglobulin (TIG) provides passive immunity while toxoid stimulates active immunity. Source: ATLS Student Manual 10e; Brunner & Suddarth's 14e; Rockwood & Green's 10e.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 16 – SURGICAL MANAGEMENT
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Surgical Management", "Debridement • Fixation • Closure • Rehabilitation");
  addTable(s,
    ["Procedure", "Description", "Nursing Role"],
    [
      ["Irrigation & Debridement (I&D)", "Thorough washout (6–9L saline); excise all devitalised tissue, bone fragments, foreign material – within 6-24 hours", "Prepare OT; document pre-op neurovascular status; post-op wound monitoring"],
      ["External Fixation (Ex-Fix)", "Temporary stabilisation with external frame and percutaneous pins; preferred initial management in Grade IIIA", "Pin site care every 24-48 hrs; check for pin loosening, infection, skin necrosis"],
      ["Intramedullary Nailing (IMN)", "Definitive fixation: nail inserted through tibia medullary canal; preferred once wound is clean (48-72 hrs)", "Monitor for fat embolism, infection; neurovascular checks q4h post-op"],
      ["Plate Osteosynthesis (ORIF)", "Used when IMN not possible; open reduction with metal plate and screws", "Monitor wound site closely; neurovascular checks; ambulation guidance"],
      ["Wound Closure / Skin Grafting", "Primary closure usually delayed 48-72 hrs after I&D; skin graft if needed; in IIIA, direct closure often possible", "Wound care protocol; dressing changes per surgeon order; graft site care"],
      ["Fasciotomy", "Emergency release of compartment if compartment syndrome develops (pressure >30 mmHg or >30 below DBP)", "Monitor compartment syndrome signs; prepare for emergency surgery"],
      ["Rehabilitation", "Early physiotherapy: active/passive ROM, weight bearing as tolerated; crutch training", "Encourage exercises, pain management, prevent DVT, patient teaching"],
    ],
    0.15, 1.1, 9.7, [1.9, 4.2, 3.6], { fontSize: 10.5, rowH: 0.48 });
  s.addNotes("Surgical management of Grade IIIA fractures follows a staged approach: emergency I&D first, then definitive fracture fixation once the wound is clean and the patient is stable. Key teaching point: external fixation is the INITIAL preferred choice in contaminated Grade III fractures as it maintains bone alignment while allowing wound management. Intramedullary nailing can follow once wound conditions allow (typically 48-72 hours). Pin site care is a key nursing responsibility: clean pins with normal saline or chlorhexidine per hospital protocol; do not use hydrogen peroxide as it impairs healing. Fasciotomy is performed emergently if compartment syndrome is confirmed – pressure >30 mmHg is an indication for surgery. Source: Campbell's Operative Orthopaedics 15e 2026; Rockwood & Green's 10e 2025.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 17 – NURSING ASSESSMENT
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Nursing Assessment", "Primary (ABCDE) • Secondary • Neurovascular • Pain • Wound");
  s.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.1, w: 4.55, h: 4.2, fill: { color: C.blueLight }, line: { color: "90CAF9" } });
  s.addText("🔍 Primary & Secondary Survey", { x: 0.35, y: 1.1, w: 4.35, h: 0.38, fontSize: 13, bold: true, color: C.navyDark, fontFace: "Calibri" });
  addBullets(s, [
    "Airway: patent? secretions? need suction?",
    "Breathing: RR, SpO₂, bilateral chest movement",
    "Circulation: HR, BP, cap refill, skin colour",
    "Disability: GCS, pupil response, pain score (NRS)",
    "Exposure: fully expose and assess all injuries",
    "Head-to-toe secondary survey",
    "Last meal (NBM for surgery)",
    "Allergies: esp. penicillin, latex, iodine",
    "Immunisation: tetanus history",
    "Medications: anticoagulants, steroids",
  ], 0.35, 1.5, 4.35, 3.75, { fontSize: 12 });

  s.addShape(pres.ShapeType.rect, { x: 5.05, y: 1.1, w: 4.7, h: 4.2, fill: { color: C.blueLight }, line: { color: "90CAF9" } });
  s.addText("🩺 Neurovascular + Wound Assessment", { x: 5.15, y: 1.1, w: 4.5, h: 0.38, fontSize: 13, bold: true, color: C.navyDark, fontFace: "Calibri" });
  addBullets(s, [
    "PULSE: dorsalis pedis, posterior tibial (compare bilaterally)",
    "COLOUR: pallor vs cyanosis vs erythema",
    "CAPILLARY REFILL: <2 seconds normal",
    "SENSATION: light touch / pin-prick → first web space (deep peroneal)",
    "MOTOR: dorsiflexion (deep peroneal) + plantarflexion (tibial)",
    "PAIN: NRS/VAS; pain out of proportion → compartment syndrome alarm",
    "TEMPERATURE: cold limb → vascular compromise",
    "WOUND: size (cm), depth, edges, discharge, contamination, exposed structures",
    "SWELLING: measure thigh/calf circumference bilaterally",
  ], 5.15, 1.5, 4.5, 3.75, { fontSize: 12 });
  s.addNotes("Neurovascular assessment is a CORE nursing competency in fracture care. Students must be able to perform the 6-P assessment: Pain (especially on passive stretch of muscles), Pressure (firmness of compartment), Pallor, Paraesthesia (tingling), Paralysis, and Pulselessness. In early compartment syndrome, pain on passive stretch is the earliest and most sensitive sign. Absent pulse is a late sign. Capillary refill >2 seconds and cold limb suggest vascular compromise. Neurological assessment: ability to dorsiflex the foot (deep peroneal nerve) and plantarflex (tibial nerve) should be checked and documented. Source: Brunner & Suddarth's Medical-Surgical Nursing 14e; Lewis Medical-Surgical Nursing 11e.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 18 – NURSING DIAGNOSES (NANDA)
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Nursing Diagnoses (NANDA-Based)", "Priority-ordered nursing diagnoses for Grade IIIA open fracture");
  addTable(s,
    ["#", "NANDA Nursing Diagnosis", "Related To (Etiology)", "As Evidenced By"],
    [
      ["1", "Acute Pain", "Fracture, soft tissue injury, surgical procedure", "Reports pain NRS 8/10; facial grimacing; guarding"],
      ["2", "Risk for Infection", "Open wound, contamination, surgical incision, invasive fixation", "Open wound >10 cm; soil contamination; external fixator pins"],
      ["3", "Impaired Skin/Tissue Integrity", "Trauma, open wound, surgical debridement", "Visible wound with tissue loss; disrupted skin surface"],
      ["4", "Impaired Physical Mobility", "Pain, fracture, surgical fixation, prescribed weight restriction", "Inability to ambulate; restricted ROM of affected limb"],
      ["5", "Risk for Peripheral Neurovascular Dysfunction", "Bone fragment compression, swelling, compartment syndrome", "Decreased sensation; altered pulses; swelling of extremity"],
      ["6", "Deficient Knowledge", "Unfamiliarity with fracture care, rehabilitation, pin site care", "Asks questions about care; non-compliance with exercises"],
      ["7", "Anxiety", "Uncertain outcome, pain, loss of function, prolonged hospitalization", "Verbalized fear; restlessness; tachycardia"],
      ["8", "Risk for DVT / Impaired Circulation", "Immobility, trauma, venous stasis", "Prolonged bed rest; swelling; Homan's sign"],
    ],
    0.15, 1.1, 9.7, [0.4, 2.7, 3.0, 3.6], { fontSize: 11, rowH: 0.43 });
  s.addNotes("These nursing diagnoses follow NANDA International nomenclature (NANDA-I 2024-2026). Students should understand the 3-part nursing diagnosis format: Problem (NANDA label) + Etiology (related to) + Signs/Symptoms (as evidenced by). Priority diagnoses follow Maslow's hierarchy: physiological needs first (pain, infection risk, neurovascular dysfunction) → then safety needs → then psychosocial needs. The nursing diagnosis 'Risk for Peripheral Neurovascular Dysfunction' is specific to fracture care and requires hourly neurovascular checks in the immediate post-injury/post-operative period. Source: NANDA International Nursing Diagnoses: Definitions and Classifications 2024-2026; Brunner & Suddarth's 14e.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 19 – NURSING INTERVENTIONS WITH RATIONALES
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Nursing Interventions & Scientific Rationales", "Evidence-based nursing care for Grade IIIA open tibia fracture");
  addTable(s,
    ["Nursing Intervention", "Scientific Rationale"],
    [
      ["Perform neurovascular checks (6 Ps) q1hr for first 24h, then q4h", "Early detection of compartment syndrome prevents permanent nerve/muscle damage; timely fasciotomy is life/limb saving"],
      ["Elevate injured limb on pillow above heart level", "Reduces dependent oedema via hydrostatic pressure gradient; improves venous and lymphatic drainage"],
      ["Apply prescribed analgesics; assess pain using NRS before and 30 min after", "Adequate pain control reduces physiological stress response; NRS evaluation ensures therapeutic effect"],
      ["Maintain aseptic technique for wound dressing changes and pin site care", "Prevents nosocomial infection; pin site infections can ascend to bone causing osteomyelitis"],
      ["Administer IV antibiotics (Cefazolin + Gentamicin) as prescribed; monitor renal function", "Prophylactic antibiotics reduce open fracture infection rates by 65-70%; gentamicin is nephrotoxic – monitor creatinine"],
      ["Encourage early active exercises of unaffected limbs; assist with ROM of affected limb", "Prevents muscle atrophy, joint stiffness, DVT; maintains cardiovascular fitness during bed rest"],
      ["Apply TED stockings / LMWH as prescribed; encourage ankle pumps", "Venous thromboembolism prophylaxis; immobility causes venous stasis → DVT risk"],
      ["Ensure adequate nutrition: consult dietitian; encourage protein-rich diet", "Protein and micronutrients (Ca, Vit C, Vit D, Zinc) are essential for fracture healing and wound repair"],
      ["Monitor vital signs, wound, and laboratory results for signs of infection", "Early sepsis recognition: fever >38°C, ↑WBC, ↑CRP, purulent discharge indicate evolving infection"],
      ["Provide psychological support; explain procedures; involve family in care", "Reduces anxiety and promotes cooperation; strong social support improves adherence to rehabilitation"],
    ],
    0.15, 1.1, 9.7, [4.7, 5.0], { fontSize: 10.5, rowH: 0.4 });
  s.addNotes("Each nursing intervention must be evidence-based. Emphasize to students that rationale-based practice is the cornerstone of professional nursing. For pin site care: clean from clean to dirty; use cotton swab soaked in normal saline; avoid hydrogen peroxide as it impairs healing (this is evidence-based). Elevation above heart level is a simple but highly effective intervention for oedema reduction. The evidence for prophylactic antibiotics in open fractures is strong: EAST Practice Management Guidelines recommend antibiotics within 1 hour of injury for all open fractures. Source: Brunner & Suddarth's Medical-Surgical Nursing 14e; Lewis Medical-Surgical Nursing 11e; NANDA-I 2024-2026.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 20 – EVALUATION / EXPECTED OUTCOMES
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Evaluation & Expected Outcomes", "Measuring the effectiveness of nursing care – short, medium, and long-term goals");
  addTable(s,
    ["Nursing Diagnosis", "Short-Term Goal (24-72 hrs)", "Long-Term Goal (Discharge / Follow-up)"],
    [
      ["Acute Pain", "Patient reports pain NRS ≤3/10 with interventions", "Patient performs ADLs with minimal discomfort"],
      ["Risk for Infection", "No signs of wound infection (no fever, wound clean, WBC normal)", "Wound healed; no osteomyelitis; pin sites clean"],
      ["Impaired Skin Integrity", "Wound dressing intact; no new necrosis", "Complete wound closure; skin graft if needed is healing"],
      ["Impaired Mobility", "Patient moves from bed to chair with assistance", "Patient ambulates with crutches/walker independently"],
      ["Risk for Neurovascular Dysfunction", "Intact pulse, sensation, movement in affected limb; cap refill <2s", "No compartment syndrome; no permanent neurological deficit"],
      ["Deficient Knowledge", "Patient verbalizes understanding of pin site care procedure", "Patient demonstrates self-care and follows-up as scheduled"],
      ["Anxiety", "Patient reports reduced anxiety (VAS); participates in care", "Patient copes effectively; strong family support established"],
    ],
    0.15, 1.1, 9.7, [2.6, 3.55, 3.55], { fontSize: 11, rowH: 0.52 });
  s.addNotes("Evaluation closes the nursing process loop. Emphasize that goals must be SMART: Specific, Measurable, Achievable, Realistic, and Time-bound. For each patient, evaluate whether outcomes have been met; if not, revise the care plan. Document all evaluations clearly in the nursing notes. Expected outcomes for Grade IIIA fractures: infection-free wound healing in 4-6 weeks, fracture union in 6-12 months, return to full weight-bearing in 3-6 months, return to occupation in 6-12 months depending on job demands. Source: Brunner & Suddarth's Medical-Surgical Nursing 14e; Lewis Medical-Surgical Nursing 11e.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 21 – POSSIBLE COMPLICATIONS
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Possible Complications", "Early and late complications – recognize and prevent");
  addTable(s,
    ["Complication", "Timing", "Signs & Symptoms", "Nursing Action"],
    [
      ["Compartment Syndrome", "Early (hours)", "Pain on passive stretch, tense compartment, paraesthesia, pulselessness", "Urgent surgical consult; prepare for fasciotomy; do NOT elevate limb above heart"],
      ["Wound Infection / Sepsis", "Early-Late (days)", "Erythema, warmth, purulent discharge, fever, ↑WBC, CRP", "Culture wound; antibiotics; wound debridement; sepsis bundle"],
      ["Osteomyelitis", "Late (weeks-months)", "Chronic wound, bone pain, sinus tract, ↑ESR, CRP; X-ray erosion", "Long-term IV antibiotics; specialist referral; surgical debridement"],
      ["Non-Union / Malunion", "Late (>6 months)", "Persistent pain, mobility at fracture site; X-ray: no callus at 6 months", "Surgical revision: bone graft, nail exchange; physiotherapy"],
      ["DVT / Pulmonary Embolism", "Early-subacute", "Calf swelling, warmth, SOB, tachycardia, hypoxia", "LMWH; TED stockings; elevation; urgent Doppler / CT-PA"],
      ["Fat Embolism Syndrome", "Early (24-48h)", "Petechial rash, hypoxia, confusion, tachycardia", "O₂; ICU; early fracture stabilisation"],
      ["Neurovascular Injury", "Early", "Loss of sensation, motor weakness, absent pulse, cool limb", "Immediate surgical review; Doppler assessment; immobilise"],
      ["Avascular Necrosis (AVN)", "Late", "Chronic pain, joint collapse on X-ray", "Orthopaedic referral; joint replacement if severe"],
    ],
    0.15, 1.1, 9.7, [1.7, 1.0, 3.0, 4.0], { fontSize: 10.5, rowH: 0.42 });
  s.addNotes("Complications must be recognised EARLY for best outcomes. The most dangerous early complication is COMPARTMENT SYNDROME – it is a surgical emergency. The nurse's role: monitor hourly for early signs (pain out of proportion, pain on passive stretch) → alert surgeon IMMEDIATELY → do NOT administer increasing doses of opioids to mask the pain, as this can delay diagnosis. The complication of non-union is more common in open fractures due to periosteal stripping, infection, and poor vascularity. Nurses contribute to prevention by: ensuring adequate nutrition (calcium, Vitamin D, protein), encouraging no smoking, assisting with physiotherapy, and educating patients about weight-bearing restrictions. Source: Campbell's Operative Orthopaedics 15e 2026; Brunner & Suddarth's 14e.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 22 – PATIENT EDUCATION AND DISCHARGE ADVICE
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = makeSlide("Patient Education & Discharge Advice", "Empowering the patient for safe recovery at home");
  const topics = [
    { icon: "🩹", title: "Wound & Pin Site Care", items: ["Keep wound clean and dry", "Clean external fixator pin sites with NS-soaked swab twice daily", "Report redness, swelling, discharge, or foul odour immediately", "Do not remove dressings without medical advice"] },
    { icon: "💊", title: "Medications", items: ["Complete full antibiotic course as prescribed", "Take analgesics before physiotherapy exercises", "Do not stop pain medications abruptly", "Report any side effects immediately"] },
    { icon: "🦯", title: "Mobility & Weight Bearing", items: ["Follow surgeon's weight-bearing instructions precisely", "Use crutches/walker correctly – trained by physiotherapist", "Avoid stairs alone initially", "Attend all physiotherapy appointments"] },
    { icon: "🥗", title: "Nutrition & Lifestyle", items: ["High-protein diet (dal, eggs, meat, milk)", "Calcium & Vitamin D supplementation if advised", "Quit smoking – impairs fracture healing", "Avoid alcohol during recovery"] },
    { icon: "🚨", title: "Red Flag Symptoms – Return to Hospital", items: ["Severe increasing pain not relieved by medication", "Limb becomes cold, blue, or numb", "High fever (>38.5°C)", "Offensive smell or pus from wound or pin sites", "Difficulty breathing"] },
    { icon: "📅", title: "Follow-up Schedule", items: ["OPD review at 1 week post-discharge", "X-ray check at 6 weeks, 3 months, 6 months", "Physio review as advised", "Emergency A&E if red flags develop"] },
  ];
  const xPos2 = [0.2, 3.4, 6.6];
  const yPos2 = [1.1, 3.3];
  let idx = 0;
  topics.forEach((t, i) => {
    const x = xPos2[idx % 3];
    const y = yPos2[Math.floor(idx / 3)];
    s.addShape(pres.ShapeType.rect, { x, y, w: 3.1, h: 2.1, fill: { color: C.blueLight }, line: { color: "90CAF9" } });
    s.addText(`${t.icon} ${t.title}`, { x: x+0.08, y, w: 2.9, h: 0.38, fontSize: 12.5, bold: true, color: C.navyDark, fontFace: "Calibri", valign: "middle" });
    addBullets(s, t.items, x+0.08, y+0.4, 2.9, 1.65, { fontSize: 11 });
    idx++;
  });
  s.addNotes("Patient education is a PRIMARY nursing responsibility. Use simple language – avoid medical jargon. In Nepal, patients may have limited health literacy, so use demonstrations (show-back method), family education, and written instructions in Nepali if available. Emphasize the importance of follow-up: fracture healing requires monitoring with serial X-rays. The red flag symptoms must be taught to both patient AND family/caregiver, as the patient may not recognize the significance of warning signs. The nurse should ensure the patient has a contact number for the hospital emergency department. Source: Brunner & Suddarth's Medical-Surgical Nursing 14e; Lewis Medical-Surgical Nursing 11e; WHO Fracture Care Guidelines.");
}

// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
// SLIDE 23 – SUMMARY / KEY TAKE-HOME MESSAGES
// ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.navyDark } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.7, fill: { color: "05174A" } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0.7, w: 10, h: 0.06, fill: { color: C.accent } });
  s.addText("Key Take-Home Messages", {
    x: 0.3, y: 0.08, w: 9.4, h: 0.6, fontSize: 26, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
  });
  const msgs = [
    ["🦴", "Tibia is the MOST COMMON fractured long bone; its subcutaneous medial surface makes it prone to open fractures"],
    ["🏷️", "Grade IIIA = high-energy, wound >10 cm, severe soft tissue injury but BONE COVERAGE ACHIEVABLE without flap"],
    ["⏱️", "Open fracture = ORTHOPEDIC EMERGENCY: debridement within 6–24 hours, IV antibiotics within 1 hour of injury"],
    ["💉", "ATLS approach (ABCDE) governs initial management: treat shock, immobilize, cover wound, give antibiotics & tetanus"],
    ["🩺", "Nurse's priority: hourly neurovascular assessment (6 Ps) to detect COMPARTMENT SYNDROME early"],
    ["📋", "NANDA diagnoses: Acute Pain, Risk for Infection, Impaired Mobility, Risk for Neurovascular Dysfunction are priority"],
    ["🎓", "Patient education on wound care, red flags, follow-up, and nutrition is essential for successful recovery"],
    ["⚠️", "Complications: compartment syndrome, osteomyelitis, non-union – early recognition prevents permanent disability"],
  ];
  msgs.forEach((m, i) => {
    const col = i < 4 ? 0 : 1;
    const row = i % 4;
    const x = col === 0 ? 0.3 : 5.1;
    const y = 0.9 + row * 1.1;
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.65, h: 0.95, fill: { color: "0D3080" }, line: { color: "1565C0" }, rounding: 0.08 });
    s.addText(`${m[0]}  ${m[1]}`, { x: x+0.1, y, w: 4.45, h: 0.95, fontSize: 12, color: C.white, fontFace: "Calibri", valign: "middle" });
  });
  s.addNotes("This summary slide consolidates the 8 most important messages from the entire presentation. Challenge students: 'Can you name the 5 subtypes of the Gustilo-Anderson classification and the key feature distinguishing IIIA from IIIB?' (Answer: IIIA = bone covered by soft tissue; IIIB = bone exposed, needs flap). 'What are the 6 Ps of neurovascular assessment?' (Pain, Pallor, Pulselessness, Paraesthesia, Paralysis, Pressure). 'Name 3 priority NANDA nursing diagnoses for this patient.' Encourage students to apply this knowledge in their next clinical placement when they encounter a fracture patient.");
}

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// SLIDE 24 – REFERENCES
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  const s = makeSlide("References", "Evidence-based sources used in this presentation");
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  const refs = [
    "1. Hinkle, J.L. & Cheever, K.H. (2022). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (15th ed.). Wolters Kluwer.",
    "2. Lewis, S.L., Bucher, L., Heitkemper, M.M. & Harding, M.M. (2023). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11th ed.). Elsevier.",
    "3. Azar, F.M., Beaty, J.H. & Canale, S.T. (2026). Campbell's Operative Orthopaedics (15th ed.). Elsevier.",
    "4. Browner, B.D., Jupiter, J.B., Krettek, C. & Anderson, P.A. (2025). Rockwood and Green's Fractures in Adults (10th ed.). Wolters Kluwer.",
    "5. American College of Surgeons. (2023). ATLS: Advanced Trauma Life Support (10th ed.). ACS.",
    "6. Gustilo, R.B. & Anderson, J.T. (1976). Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones. J Bone Joint Surg Am, 58(4):453-458.",
    "7. Gustilo, R.B., Mendoza, R.M. & Williams, D.N. (1984). Problems in the management of type III (severe) open fractures. J Trauma, 24(8):742-746.",
    "8. NANDA International. (2024). NANDA-I Nursing Diagnoses: Definitions and Classifications 2024-2026 (13th ed.). Thieme.",
    "9. World Health Organization. (2023). Road Safety in the South-East Asia Region. WHO Regional Office for South-East Asia.",
    "10. Gray, H. (2020). Gray's Anatomy for Students (4th ed.). Elsevier (Drake, Vogl & Mitchell).",
    "11. Netter, F.H. (2022). Netter's Atlas of Human Anatomy (7th ed.). Elsevier.",
  ];
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  s.addNotes("All references follow APA 7th edition format. Encourage students to access the key textbooks: Brunner & Suddarth's and Lewis Medical-Surgical Nursing are available in the PAHS library. The original Gustilo & Anderson (1976) paper is a landmark publication and is freely available on PubMed (PMID: 1270035). The ATLS manual (10th edition) is available from the American College of Surgeons. Rockwood & Green's Fractures in Adults (10e, 2025) is the comprehensive orthopaedic reference used in this presentation. Students are encouraged to practice reading primary references to build evidence-based practice skills.");
}

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