Nursing Diagnosis and Interventions for BPAD Patient with Manic Psychosis

from docx import Document
from docx.shared import Pt, Inches, RGBColor, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.enum.table import WD_TABLE_ALIGNMENT, WD_ALIGN_VERTICAL
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import copy

doc = Document()

# ── Page margins ──────────────────────────────────────────────
section = doc.sections[0]
section.page_width  = Inches(11)
section.page_height = Inches(8.5)
section.left_margin   = Inches(0.5)
section.right_margin  = Inches(0.5)
section.top_margin    = Inches(0.6)
section.bottom_margin = Inches(0.6)

# ── Default font ──────────────────────────────────────────────
style = doc.styles["Normal"]
style.font.name = "Calibri"
style.font.size = Pt(9)

def set_cell_bg(cell, hex_color):
    tc = cell._tc
    tcPr = tc.get_or_add_tcPr()
    shd = OxmlElement("w:shd")
    shd.set(qn("w:val"), "clear")
    shd.set(qn("w:color"), "auto")
    shd.set(qn("w:fill"), hex_color)
    tcPr.append(shd)

def set_cell_borders(cell, border_color="999999"):
    tc = cell._tc
    tcPr = tc.get_or_add_tcPr()
    tcBorders = OxmlElement("w:tcBorders")
    for side in ("top", "left", "bottom", "right"):
        el = OxmlElement(f"w:{side}")
        el.set(qn("w:val"), "single")
        el.set(qn("w:sz"), "4")
        el.set(qn("w:color"), border_color)
        tcBorders.append(el)
    tcPr.append(tcBorders)

def cell_para(cell, text, bold=False, size=9, color=None, align=WD_ALIGN_PARAGRAPH.LEFT, italic=False):
    cell.vertical_alignment = WD_ALIGN_VERTICAL.TOP
    para = cell.paragraphs[0]
    para.alignment = align
    para.paragraph_format.space_before = Pt(2)
    para.paragraph_format.space_after  = Pt(2)
    run = para.add_run(text)
    run.bold   = bold
    run.italic = italic
    run.font.size = Pt(size)
    if color:
        run.font.color.rgb = RGBColor.from_string(color)
    return para

def add_bullet(cell, text, size=8.5):
    """Add a bullet-point paragraph to a cell (additional para)."""
    para = cell.add_paragraph()
    para.paragraph_format.left_indent    = Inches(0.15)
    para.paragraph_format.space_before   = Pt(1)
    para.paragraph_format.space_after    = Pt(1)
    run = para.add_run(u"\u2022  " + text)
    run.font.size = Pt(size)
    return para

# ══════════════════════════════════════════════════════════════
# TITLE BLOCK
# ══════════════════════════════════════════════════════════════
title_para = doc.add_paragraph()
title_para.alignment = WD_ALIGN_PARAGRAPH.CENTER
title_para.paragraph_format.space_before = Pt(0)
title_para.paragraph_format.space_after  = Pt(4)
r = title_para.add_run("NURSING CARE PLAN")
r.bold = True
r.font.size = Pt(14)
r.font.color.rgb = RGBColor(0x1F, 0x35, 0x64)

sub_para = doc.add_paragraph()
sub_para.alignment = WD_ALIGN_PARAGRAPH.CENTER
sub_para.paragraph_format.space_before = Pt(0)
sub_para.paragraph_format.space_after  = Pt(8)
r2 = sub_para.add_run("Bipolar Affective Disorder (BPAD) with Manic Psychosis")
r2.font.size = Pt(11)
r2.italic = True
r2.font.color.rgb = RGBColor(0x1F, 0x35, 0x64)

# ══════════════════════════════════════════════════════════════
# COLOUR PALETTE
# ══════════════════════════════════════════════════════════════
HEADER_BG   = "1F3564"   # dark navy
SECTION_BG  = "D6E4F7"   # light blue
ROW_ODD     = "F0F5FB"
ROW_EVEN    = "FFFFFF"
ACTUAL_TAG  = "C00000"   # dark red for actual dx
POTENTIAL_TAG = "7030A0" # purple for potential dx
PRIORITY_TAG  = "1F3564" # navy for priority dx

# ══════════════════════════════════════════════════════════════
# COLUMN WIDTHS  (total ~ 10 inches for landscape)
# ══════════════════════════════════════════════════════════════
COL_WIDTHS = [Inches(1.5), Inches(1.8), Inches(1.4), Inches(2.1), Inches(1.7), Inches(1.5)]

HEADERS = [
    "Nursing Diagnosis",
    "Goals / Expected Outcomes",
    "Assessment Cues",
    "Nursing Interventions",
    "Rationale",
    "Evaluation Criteria"
]

def create_table():
    tbl = doc.add_table(rows=1, cols=6)
    tbl.alignment = WD_TABLE_ALIGNMENT.CENTER
    tbl.style = "Table Grid"
    # header row
    hdr = tbl.rows[0]
    for i, (hdr_cell, hdr_text) in enumerate(zip(hdr.cells, HEADERS)):
        hdr_cell.width = COL_WIDTHS[i]
        set_cell_bg(hdr_cell, HEADER_BG)
        cell_para(hdr_cell, hdr_text, bold=True, size=9, color="FFFFFF", align=WD_ALIGN_PARAGRAPH.CENTER)
    return tbl

def add_section_label(tbl, label, color):
    row = tbl.add_row()
    row.cells[0].merge(row.cells[5])
    set_cell_bg(row.cells[0], color)
    p = row.cells[0].paragraphs[0]
    p.alignment = WD_ALIGN_PARAGRAPH.LEFT
    p.paragraph_format.space_before = Pt(3)
    p.paragraph_format.space_after  = Pt(3)
    run = p.add_run(label)
    run.bold = True
    run.font.size = Pt(9.5)
    run.font.color.rgb = RGBColor(0xFF,0xFF,0xFF) if color == HEADER_BG else RGBColor(0x1F,0x35,0x64)

def add_dx_row(tbl, dx, goals, cues, interventions, rationale, evaluation, shade):
    row = tbl.add_row()
    for i, cell in enumerate(row.cells):
        cell.width = COL_WIDTHS[i]
        set_cell_bg(cell, shade)
        set_cell_borders(cell)

    # Col 0 – Diagnosis
    cell_para(row.cells[0], dx, bold=True, size=8.5)

    # Col 1 – Goals (bulleted)
    first = True
    for g in goals:
        if first:
            cell_para(row.cells[1], u"\u2022  " + g, size=8.5)
            first = False
        else:
            add_bullet(row.cells[1], g, size=8.5)

    # Col 2 – Assessment cues
    first = True
    for c in cues:
        if first:
            cell_para(row.cells[2], u"\u2022  " + c, size=8.5)
            first = False
        else:
            add_bullet(row.cells[2], c, size=8.5)

    # Col 3 – Interventions
    first = True
    for idx, iv in enumerate(interventions, 1):
        if first:
            cell_para(row.cells[3], f"{idx}. {iv}", size=8.5)
            first = False
        else:
            p = row.cells[3].add_paragraph()
            p.paragraph_format.space_before = Pt(1)
            p.paragraph_format.space_after  = Pt(1)
            run = p.add_run(f"{idx}. {iv}")
            run.font.size = Pt(8.5)

    # Col 4 – Rationale
    first = True
    for idx, rat in enumerate(rationale, 1):
        if first:
            cell_para(row.cells[4], f"{idx}. {rat}", size=8.5)
            first = False
        else:
            p = row.cells[4].add_paragraph()
            p.paragraph_format.space_before = Pt(1)
            p.paragraph_format.space_after  = Pt(1)
            run = p.add_run(f"{idx}. {rat}")
            run.font.size = Pt(8.5)

    # Col 5 – Evaluation
    first = True
    for e in evaluation:
        if first:
            cell_para(row.cells[5], u"\u2022  " + e, size=8.5)
            first = False
        else:
            add_bullet(row.cells[5], e, size=8.5)

# ══════════════════════════════════════════════════════════════
# DATA
# ══════════════════════════════════════════════════════════════

# ─── TABLE 1  (Actual + Potential + Priority) ─────────────────
tbl = create_table()

# ---- SECTION: PRIORITISED NURSING DIAGNOSIS ------------------
add_section_label(tbl, "  PRIORITISED NURSING DIAGNOSIS", HEADER_BG)

add_dx_row(
    tbl,
    dx="Violence: Self-Directed\nR/T manic excitement and panic\nAEB loud verbal outbursts, threatening body language, reacting to hallucinations",
    goals=[
        "Patient will remain free from self-directed injury throughout hospitalisation",
        "Patient will demonstrate decreased agitation and threatening behaviours within 24-48 hours",
        "Patient will verbally express distress without acting out within 72 hours",
        "Patient will identify triggers and use safe coping strategies before discharge"
    ],
    cues=[
        "Loud verbal outbursts",
        "Threatening body language (clenched fists, pacing)",
        "Reacting to hallucinations (command type)",
        "Manic excitement and panic",
        "Impaired impulse control",
        "Psychomotor agitation"
    ],
    interventions=[
        "Perform continuous safety assessment each shift using validated tool (e.g., STAMP); document escalation signs",
        "Maintain a safe, low-stimulation environment; remove sharps, ligature risks, and hard objects",
        "Approach in a calm, non-threatening manner using de-escalation techniques; maintain safe personal space",
        "Set clear, consistent limits on harmful behaviour using firm but non-punitive tone",
        "Administer prescribed antipsychotic (e.g., haloperidol, olanzapine) and/or benzodiazepine (lorazepam) IM as ordered; monitor BP, RR, sedation level post-administration",
        "Use least-restrictive intervention hierarchy: verbal de-escalation -> chemical restraint -> seclusion per hospital protocol",
        "Assign 1:1 observation if risk is high; document every 15 minutes",
        "Involve multidisciplinary team (psychiatrist, social worker) for comprehensive risk management"
    ],
    rationale=[
        "Early detection of escalation signs allows prompt intervention before violence occurs",
        "Removing means and reducing stimulation lowers the likelihood of impulsive self-injury",
        "A calm approach avoids power struggles that can trigger reactive aggression",
        "Consistent limit-setting provides predictability and reduces anxiety-driven outbursts",
        "Antipsychotics reduce dopaminergic overactivity; lorazepam provides rapid sedation. Monitoring prevents respiratory depression and hypotension",
        "Least-restrictive approach upholds patient dignity and legal/ethical standards",
        "Close observation prevents opportunity for self-harm and provides real-time data",
        "Collaborative planning ensures a holistic, coordinated safety strategy"
    ],
    evaluation=[
        "No self-inflicted injuries throughout admission",
        "Agitation score decreases within 24-48 hrs",
        "Patient uses verbal expression instead of physical acting-out",
        "Patient identifies at least one trigger before discharge"
    ],
    shade=ROW_ODD
)

add_dx_row(
    tbl,
    dx="Disturbed Thought Process\nR/T disorientation and decreased concentration\nAEB disruption in activities, inability to focus on reality",
    goals=[
        "Patient will demonstrate improved orientation to person, place, and time within 48-72 hours",
        "Patient will maintain focus on a task for at least 5 minutes by day 3",
        "Patient will distinguish delusional content from reality with staff assistance before discharge",
        "Patient will engage in reality-based conversation within 5 days"
    ],
    cues=[
        "Disorientation (time, place, person)",
        "Inability to focus on reality",
        "Disruption in activities",
        "Flight of ideas / looseness of associations",
        "Responding to internal stimuli (hallucinations)",
        "Grandiose or paranoid delusions"
    ],
    interventions=[
        "Re-orient patient to person, place, date, and situation at each interaction using calm, concrete language",
        "Do not argue with or reinforce delusional content; acknowledge feelings neutrally ('I hear that you believe that')",
        "Redirect attention to reality-based, here-and-now activities when patient is preoccupied with delusional content",
        "Administer prescribed antipsychotic medications as ordered; assess for therapeutic effect and side effects (EPS, metabolic changes)",
        "Provide brief, simple instructions; avoid lengthy explanations during acute phase",
        "Maintain consistent daily routine and structured milieu to reduce disorientation",
        "Decrease environmental stimuli (noise, crowding, TV) that can worsen thought disorganisation",
        "Document specific delusional content, frequency, and intensity at each assessment"
    ],
    rationale=[
        "Repeated re-orientation reinforces accurate perception of reality and reduces confusion",
        "Arguing strengthens engagement with delusion; neutral acknowledgement maintains rapport without validating false beliefs",
        "Behavioural redirection interrupts rumination and refocuses cognitive resources",
        "Atypical antipsychotics target dopaminergic overactivity underlying psychotic thought disorder",
        "Short, concrete communication matches the reduced cognitive capacity during acute mania",
        "Structure and routine provide external framework when internal cognitive organisation is impaired",
        "Reduced stimulation prevents sensory overload that amplifies disorganised thinking",
        "Objective documentation tracks treatment response and informs medication adjustments"
    ],
    evaluation=[
        "Patient correctly states name, date, and location within 48-72 hrs",
        "Patient focuses on task for >= 5 min by day 3",
        "Frequency of delusional statements decreases over admission",
        "Patient engages in reality-based conversation with staff"
    ],
    shade=ROW_EVEN
)

# ---- SECTION: ACTUAL NURSING DIAGNOSIS -----------------------
add_section_label(tbl, "  ACTUAL NURSING DIAGNOSES", "C9DAF8")

add_dx_row(
    tbl,
    dx="Self-Care Deficit\n(Hygiene, Grooming, Toileting)\nR/T hyperactivity, distractibility, impaired judgment, psychomotor agitation\nAEB poor hygiene and inappropriate dress",
    goals=[
        "Patient will participate in basic hygiene (bathing, oral care) with nurse assistance within 24 hours",
        "Patient will dress in appropriate clothing with minimal prompting within 3 days",
        "Patient will complete at least one ADL independently each day by day 4",
        "Patient will maintain adequate hydration and toileting by end of shift"
    ],
    cues=[
        "Poor hygiene (body odour, unwashed hair)",
        "Inappropriate or dishevelled dress",
        "Psychomotor agitation (unable to sit still)",
        "Distractibility and impaired judgment",
        "Does not initiate or complete self-care tasks"
    ],
    interventions=[
        "Assist with all ADLs as needed; provide structured, step-by-step prompts ('Now let's brush your teeth')",
        "Offer simple clothing choices to promote autonomy while ensuring appropriateness",
        "Schedule bathing and hygiene activities at the same time each day to build routine",
        "Monitor for urinary/bowel urgency; prompt and escort to bathroom regularly to prevent incontinence",
        "Ensure patient changes into clean clothing daily; check skin integrity during hygiene care",
        "Reinforce and praise any self-care attempts to encourage participation",
        "Involve occupational therapist if ADL deficits persist beyond acute phase"
    ],
    rationale=[
        "Structured prompts compensate for the distractibility and impaired initiation seen in mania",
        "Limited choices reduce decision-making burden and prevent agitation from over-stimulation",
        "Consistent scheduling leverages routine as an external organising structure",
        "Patients in a manic state may ignore basic physiological signals; regular prompting prevents skin and hygiene complications",
        "Skin assessment during hygiene care identifies pressure areas or self-inflicted injuries early",
        "Positive reinforcement strengthens desired self-care behaviours via operant conditioning",
        "Occupational therapy can provide specialised ADL retraining during stabilisation"
    ],
    evaluation=[
        "Patient completes hygiene with assistance within 24 hrs",
        "Patient dresses appropriately with prompting by day 3",
        "Patient initiates at least one ADL independently by day 4",
        "No skin breakdown or incontinence complications noted"
    ],
    shade=ROW_ODD
)

add_dx_row(
    tbl,
    dx="Ineffective Coping / Non-Adherence Risk\nR/T poor insight into illness, perceived benefits of mania, distrust of medication\nAEB denial of illness, minimising symptoms, reacting to hallucinations",
    goals=[
        "Patient will acknowledge that current symptoms are related to bipolar disorder within 4 days",
        "Patient will accept prescribed medication voluntarily during hospitalisation",
        "Patient will identify at least two consequences of non-adherence before discharge",
        "Patient will engage in psychoeducation session with nurse or team before discharge"
    ],
    cues=[
        "Denial of illness ('I am not sick')",
        "Minimising symptoms ('I am just energetic')",
        "Refuses or questions medications",
        "Reacting to hallucinations as if real",
        "Perceived enjoyment of manic state",
        "Poor insight and judgment"
    ],
    interventions=[
        "Build therapeutic alliance before attempting to challenge illness denial; listen without judgment",
        "Provide psychoeducation on BPAD, mood cycling, and medication purpose when patient is in a relatively calm state (not at peak mania)",
        "Explore and acknowledge patient's specific concerns about medication (fear of side effects, losing 'energy', identity loss)",
        "Use motivational interviewing techniques to explore ambivalence about treatment",
        "Administer mood stabilisers (lithium, valproate) and antipsychotics as prescribed; monitor serum levels and side effects closely",
        "Involve family/support person in psychoeducation sessions with patient's consent",
        "Provide written educational material about BPAD at appropriate literacy level",
        "Develop a collaborative relapse prevention plan including early warning signs and crisis contacts before discharge"
    ],
    rationale=[
        "Therapeutic alliance is the prerequisite for influencing insight; confrontation during mania worsens resistance",
        "Psychoeducation delivered at the right moment (partial recovery) improves retention and attitude toward treatment",
        "Addressing specific fears is more effective than generic teaching; patients may resist medication due to fear of losing the 'benefits' of mania",
        "Motivational interviewing is evidence-based for increasing treatment engagement in people with poor insight",
        "Mood stabilisers are the pharmacological foundation; lithium has additional anti-suicidal properties. Level monitoring prevents toxicity",
        "Social support is a strong predictor of medication adherence and relapse prevention",
        "Written materials reinforce verbal teaching and can be reviewed after discharge",
        "A collaborative relapse plan empowers the patient and provides a roadmap for managing future episodes"
    ],
    evaluation=[
        "Patient acknowledges BPAD diagnosis within 4 days",
        "Patient accepts medications voluntarily during admission",
        "Patient states at least two risks of stopping medication",
        "Patient participates in at least one psychoeducation session"
    ],
    shade=ROW_EVEN
)

# ---- SECTION: POTENTIAL NURSING DIAGNOSIS --------------------
add_section_label(tbl, "  POTENTIAL NURSING DIAGNOSES", "EAD1FB")

add_dx_row(
    tbl,
    dx="Risk for Injury\nR/T extreme hyperactivity\nAEB increased agitation and lack of control over purposeless and potentially injurious movement",
    goals=[
        "Patient will not sustain any physical injury related to hyperactivity during hospitalisation",
        "Patient will demonstrate decreased purposeless motor activity within 48 hours of medication initiation",
        "Patient will remain in a safe area of the ward without requiring physical restraint"
    ],
    cues=[
        "Extreme hyperactivity and restlessness",
        "Purposeless and uncontrolled movement",
        "Increased agitation",
        "Impaired coordination and judgment due to mania",
        "Wandering and inability to stay in one place"
    ],
    interventions=[
        "Assess and document level of psychomotor activity every 2-4 hours using structured observation",
        "Maintain a clutter-free, obstacle-free ward environment; pad sharp corners if needed",
        "Accompany patient during ambulation if hyperactivity is severe and falls risk is high",
        "Provide structured, channelled physical activity (e.g., supervised walking) to reduce restless energy safely",
        "Administer prescribed sedating medications as ordered; monitor vital signs and sedation level",
        "Instruct patient and family about fall prevention and environmental safety",
        "Ensure patient wears appropriate footwear at all times"
    ],
    rationale=[
        "Frequent objective assessment detects deterioration and guides timely intervention",
        "Removing hazards in the environment eliminates the opportunity for accidental injury during uncontrolled movement",
        "Close accompaniment prevents falls and abrupt self-harm during peak agitation",
        "Channelled physical activity reduces restlessness in a controlled way without increasing stimulation",
        "Medication reduces psychomotor agitation; monitoring prevents over-sedation and associated fall risk",
        "Education empowers family to contribute to safety and prevent accidents post-discharge",
        "Proper footwear reduces slip and fall risk on smooth ward floors"
    ],
    evaluation=[
        "No physical injuries sustained during admission",
        "Purposeless motor activity decreases within 48 hrs of medication",
        "Patient remains in safe ward areas without physical restraint"
    ],
    shade=ROW_ODD
)

add_dx_row(
    tbl,
    dx="Risk for Violence: Other-Directed\nR/T impulsivity, irritability, psychosis",
    goals=[
        "Patient will not harm other patients, staff, or visitors during hospitalisation",
        "Patient will demonstrate controlled, non-threatening behaviour with staff within 48-72 hours",
        "Patient will use verbal communication to express frustration rather than physical actions"
    ],
    cues=[
        "Impulsivity and poor impulse control",
        "Irritability and labile mood",
        "Psychotic features (paranoid delusions, hallucinations)",
        "History of verbal/physical aggression during prior manic episodes",
        "Threatening gestures or statements directed at others"
    ],
    interventions=[
        "Monitor continuously for escalating behavioural cues (raised voice, pacing, threatening stance); intervene early",
        "Set firm, calm, consistent limits on threatening behaviour; communicate consequences clearly",
        "Reduce environmental provocations: manage other patients' interactions with this patient; avoid crowded group settings initially",
        "Administer prescribed antipsychotic/benzodiazepine combination IM (e.g., haloperidol + lorazepam) for acute agitation as ordered",
        "Implement seclusion as last resort per hospital protocol after less restrictive options have failed",
        "Alert security or code team if imminent violence appears unavoidable",
        "Debrief with patient after any violent or near-violent episode in a non-judgmental manner"
    ],
    rationale=[
        "Early recognition of escalation allows de-escalation before aggression occurs",
        "Consistent limit-setting across all staff prevents manipulation and reduces behavioural testing",
        "Limiting provocative situations decreases triggers for aggression in a psychotic, irritable patient",
        "Haloperidol + lorazepam IM is the most commonly used combination for rapid control of acute agitation with fast onset",
        "Seclusion is a last resort; its use must be justified, documented, and time-limited per legal and ethical standards",
        "Early security involvement prevents staff and patient injury during acute violent episodes",
        "Post-episode debriefing maintains therapeutic relationship and helps the patient understand consequences of violence"
    ],
    evaluation=[
        "No harm to others during admission",
        "Non-threatening behaviour with staff by 48-72 hrs",
        "Patient uses verbal communication to express anger"
    ],
    shade=ROW_EVEN
)

# ══════════════════════════════════════════════════════════════
# FOOTER NOTE
# ══════════════════════════════════════════════════════════════
doc.add_paragraph()
note = doc.add_paragraph()
note.alignment = WD_ALIGN_PARAGRAPH.LEFT
r = note.add_run(
    "References: Kaplan & Sadock's Comprehensive Textbook of Psychiatry; "
    "Varcarolis' Foundations of Psychiatric-Mental Health Nursing, 9th ed. (Halter, 2022); "
    "NANDA-I Nursing Diagnoses 2021-2023; Maudsley Prescribing Guidelines in Psychiatry, 15th ed."
)
r.font.size = Pt(7.5)
r.italic = True
r.font.color.rgb = RGBColor(0x60, 0x60, 0x60)

out_path = "/tmp/workspace/bpad-ncp/BPAD_Manic_Psychosis_NCP.docx"
doc.save(out_path)
print(f"Saved: {out_path}")