Assura MEWS Vital Signs Scoring Chart

Enter Vital Readings & Clinical Notes

Column

📅 Date ( DD/MM)

⏰ Time ( HH:mm)

✗ Respiration

SpO₂ scale

● SpO₂

Air / Oxygen

▲ BP systolic

▼ BP diastolic

● Heart rate

○ Temp (°C)

Additional clinical information & hygiene

Pain score

HGT (mmol/L)

Fluid intake (mL)

Urine output (mL)

Bowel

Stool type

Days of BNO

Personal hygiene

Fluid balance

Wound status

Live EWS: –

🫁 Mechanical Ventilation Flowsheet & Reference Settings

/

Airway Type:

Tube Size (mm ID):

Depth (Lips/Teeth):

Cuff Target: 20 – 30 cmH₂O

＋ Record Ventilator Observation Target Peak Pressure < 30–35 cmH₂O · Pplat < 30 cmH₂O

Time

Mode

Set Vt / Exp Vt

Set RR / Tot RR

FiO₂

PEEP (cmH₂O)

Ppeak / PIP

Pplat (cmH₂O)

PS / Pinsp

Cuff (cmH₂O)

Suction / Sputum

ABG summary

Time	Mode	Vt (Set/Exp)	RR (Set/Tot)	FiO₂	PEEP	PIP	Pplat	PS	Cuff	Suction / Sputum	ABG	Staff	Action

🧮 Predicted Body Weight (PBW) & Lung-Protective Tidal Volume Calculator

Gender :

Height ( cm):

Calculated PBW:

— kg

4 mL/kg (Severe ARDS): — mL

6 mL/kg (Lung Protective): — mL

8 mL/kg (Normal Lung): — mL

📋 Recommended Initial Ventilator Settings by Indication

Clinical Indication	Mode	Target Vt	RR	PEEP & FiO₂	Key Targets & Precautions
ARDS / Hypoxemic Sepsis	VCV / PCV / PRVC	4 – 6 mL/kg PBW	18 – 28 bpm	PEEP 8–16 cmH₂O FiO₂ titrated >88-92%	Pplat < 30 cmH₂O; Driving Press < 14; Permissive hypercapnia (pH ≥ 7.20).
COPD / Asthma / Air Trapping /	VCV / SIMV+PS	6 – 8 mL/kg PBW	10 – 12 bpm (Slow)	PEEP 3–5 cmH₂O FiO₂ titrated 88-92%	Long Expiratory Time (I:E 1:3 to 1:4) to prevent auto-PEEP / dynamic hyperinflation.
Post-Operative / Normal Lung /	SIMV / VCV / PSV	6 – 8 mL/kg PBW	12 – 16 bpm	PEEP 5 cmH₂O FiO₂ 30–40%	Ppeak < 25 cmH₂O; Maintain normocapnia (PaCO₂ 35–45 mmHg).

🩸 ABG Correction Rules

High PaCO₂ (Acidosis): Increase Minute Ventilation (↑ RR or ↑ Vt).
Low PaCO₂ (Alkalosis): Decrease Minute Ventilation (↓ RR or ↓ Vt).
Low PaO₂ (Hypoxemia): Increase FiO₂ and/or PEEP per ARDSNet table.
Metabolic Acidosis: Investigate perfusion/lactate/renal; avoid over-ventilation.

⚠ High Peak Pressure (PIP) Diagnostic Flow

High PIP + Normal Pplat (<30): Airway Resistance (Suction sputum, bite block, bronchodilator for spasm).
High PIP + High Pplat (>30): Decreased Compliance (Pneumothorax, pulmonary edema, ARDS, ETT in right bronchus).
Weaning RSBI: RSBI = RR / Vt (L) < 105 indicates readiness for extubation.

🩸 Clinical Laboratory Reference Ranges & Panic Value Guide

🚨 CRITICAL / PANIC VALUE MANDATE: Any result meeting panic thresholds requires immediate verbal read-back confirmation with the laboratory, notification of the attending physician within 15 minutes, and documentation in nursing progress notes.

🩸 Arterial Blood Gas (ABG )

Parameter	Normal Range	🚨 Critical / Panic
pH	7.35 – 7.45	< 7.20 / > 7.60
PaCO₂	35 – 45 mmHg	< 20 / > 60 mmHg
PaO₂	80 – 100 mmHg	< 60 mmHg (Hypoxemia)
HCO₃⁻	22 – 26 mmol/L	< 10 / > 40 mmol/L
Lactate	0.5 – 2.0 mmol/L	> 4.0 mmol/L (Sepsis Alert)
P/F Ratio	> 300 mmHg	< 200 (Mod-Severe ARDS)

🧪 Renal Profile & Electrolytes (RP / )

Parameter	Normal Range	🚨 Critical / Panic
Potassium (K⁺ )	3.5 – 5.0 mmol/L	< 2.8 / > 6.0 (Arrhythmia)
Sodium (Na⁺ )	135 – 145 mmol/L	< 120 / > 160 mmol/L
Creatinine	50 – 110 µmol/L	> 350 µmol/L (Acute AKI)
Total Calcium	2.15 – 2.55 mmol/L	< 1.75 / > 3.00 mmol/L
Magnesium	0.70 – 1.05 mmol/L	< 0.50 / > 1.80 mmol/L

🩸 Full Blood Count (FBC / CBC )

Parameter	Normal Range	🚨 Critical / Panic
Hemoglobin (Hb)	12.0 – 16.0 g/dL	< 7.0 g/dL (Transfusion)
WBC	4.0 – 11.0 ×10⁹/L	< 2.0 / > 30.0 ×10⁹/L
Platelets	150 – 400 ×10⁹/L	< 50 ×10⁹/L (Bleeding Risk)

🔬 Coagulation & Biomarkers

Parameter	Normal Range	🚨 Critical / Panic
INR (Warfarin)	0.8 – 1.2 (target 2-3)	> 4.5 (Major Hemorrhage)
Troponin I/T	< 0.04 ng/mL	≥ 0.04 ng/mL (Acute MI)
Procalcitonin (PCT)	< 0.25 ng/mL	> 2.0 ng/mL (Severe Sepsis)
Random Glucose	4.0 – 8.0 mmol/L	< 3.0 (Coma) / > 20.0 (DKA)

MEWS VITAL SIGNS SCORING CHART

⚠ EWS Alert

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