Site:______________________
Barren County Schools
Barren River District Health Department
Orthostatic Intolerance/ Hypertension Individualized Health Plan
Please fax back to:_____________________________________________
Student Name__________________________ Date of Birth_____________
Classroom ______________________Hospital of Choice_________________________
DIAGNOSIS:
(SPECIFY): ________________________________________________________________
RESTRICTIONS/ EXCLUSION AT SCHOOL:___________________________________
____________________________________________________________________________
____________________________________________________________________________
INTERVENTIONS TO BE PROVIDED AT SCHOOL:
___Drink at least 100 ounces daily (Two, 12 ounce glasses with each meal)
___Begin the day with fluids
___Increase salt in diet (saltine crackers, pretzels, pickles, potato chips)
___Eliminate caffeine
___Moderate amount of exercise 3-4 times/ week
___Carry a water bottle and drink throughout the school day
___Allow to use restroom as needed
___OTHER:_______________________________________________________________________
_________________________________________________________________________________
SIGNS/ SYMPTOMS OF A ORTHOSTATIC INTOLERANCE CAN INCLUDE, BUT
ARE NOT LIMITED TO:
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

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Lightheadedness
Headache
Fatigue
Altered vision (blurred vision, "white outs," black outs)
Weakness
Hyperpnea or sensation of difficulty breathing or swallowing (see also hyperventilation
syndrome)
Tremulousness
Sweating
Anxiety
Heart palpitations, as the heart races to compensate for the falling blood pressure
Exercise intolerance


Sensitivity to heat
Nausea

Neurocognitive deficits, such as attention problems
(4-2014) 6A-1 BC
Site:______________________


Sleep problems
Pallor
EMERGENCY PLAN OF ACTION FOR ALL STAFF:
1. If student exhibits any of the signs/ symptoms of a possible orthostatic intolerance, as listed above,
or you have any other concerns, please send to nurse immediately.
2. If student’s color becomes pale, cyanotic (bluish), or ashen OR student has other signs of
respiratory distress (difficulty breathing, gasping, etc.), call 911.
3. If student complains of chest pain or pressure, call 911.
4. Notify school personnel trained in CPR/first aid to stay with student and initiate CPR if needed
prior to EMS arrival.
5. Contact parent/guardian immediately.
6. If EMS is called student must be transported via EMS to emergency facility, or parent/guardian
must sign release with EMS and parent/guardian then assumes responsibility for student. Student may
not return to school that day.
7. When student is transported via EMS a staff member must accompany the student unless parent
and/or emergency contact accompanies them.
8. Other: ____________________________________________________________________
____________________________________________________________________________
This order and plan of care is valid for current school year. Parent must supply all special
needs equipment.
______________________________________ _________________ _____________
PRINTED NAME OF PHYSICIAN/ ARNP
PHONE NUMBER
DATE
____________________________________
SIGNATURE OF PHYSICIAN/ ARNP
____________________________
FAX NUMBER
____________________________________________________________________________
ADDRESS OF PHYSICIAN
I give permission for (name of child) _________________ to receive the above stated medication(s) at school according to standard
school policy and expressly hold harmless and waive any liability on behalf of, the Barren County School District / Barren River District
Health Department or either of its employees and agents concerning any injuries or reactions resulting from the administration of the
above medication unless such is the result of negligence or misconduct on behalf of the school, Health Department or any of their
employees.
________________________________
Parent Signature
_______________
Phone Number
__________________
Date
Reviewed by School Nurse________________
Copy to Pertinent school staff_____________
Copy to District Nurse______________
Copy to medication delegated trained bus driver_______________
(4-2014) 6A-1 BC
Site:_______________________
(4-2014)
6A-5 BC