Endocrine Metabolic

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Trace DC46-6

DiraChart Clinical Reference
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1. Purpose and clinical relevance

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4. Normal findings

“Normal/at-baseline” means metabolic status is within the patient’s individualized ordered targets and the regimen is being managed safely. Each line states the finding, the comparison to the individualized target or baseline, and the skilled reason a nurse was required — a bare “blood sugar fine” does not qualify.

  • Glucose log within the patient’s individualized ordered range, without hypoglycemic events or significant excursions.
  • Monitoring and insulin or pump technique correct on direct observation, with appropriate site rotation and storage.
  • No hypoglycemia symptoms, and a rescue (oral carbohydrate or glucagon per order) available and understood.
  • No signs of acute hyper- or hypoglycemic decompensation; mental status at the cognitive baseline.
  • Feet intact, with protective-sensation status known and documented (cross-reference Touch/Sensation).
  • Thyroid and steroid regimens adherent without symptoms of over- or under-treatment.
  • Metabolic status stable and the current regimen appropriate to continue against the individualized targets.
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