Shock Signs and Symptoms: CHORD ITEM Cold, clammy skin Hypotension Oliguria Rapid, shallow breathing Drowsiness, confusion Irritability Tachycardia

our Name: Your Title: :B? D#: 4nsqsG:i2 Patient Name: _D......_-'-'--')-),._,_ __________ _ Age and DOB: 2--:1 Y / 6'Gender: M/F/Other: Current height/weight with percentiles: 141 G ""- / LlO Weight on admission with percentile: 4 Q 1£.. j Grade in School: __ ]._~-~----------- Reason for being there: Attending Healthcare Provider: 1>1 b6.~"·,.s .£ / 01. 5 chub Patient Chief Complaint/Primary Medical Diagnosis and Clinical Significance: Erickson level (Chronological vs. Developmental): . ...I -y,...t.l,..J c,"15'.e.~ ao+ 1l.,',tn~,t"I vs. ~alt. (oY"-&'uSo""' Piaget level (Chronological vs. Developmental) : Pathophysiology of Primary Medical Diagnosis : Code Status: _ __..F_u=...(_,_I __________ _ -~"'-- :Jlooc-l s.lj o.,,< ,-t,veAS Chief Informant (caregiver) : ... .. Medication Name Home or Current Medication f> 0.iA-C:..~ c.c.S I n.-i aiert--e. +c r'" od.v c e ·1 u V' Classification of Medication Safe Dose Range for Client