Site:______________
Barren County Schools
Barren River District Health Department
Brain Bleed Individualized Health Plan
Please fax back to:_____________________________________________
Student Name__________________________ Date of Birth_____________
Classroom ______________________Hospital of Choice_________________________
DIAGNOSIS:(SPECIFY): ____________________________________________________
PRECAUTIONS AT SCHOOL: ________________________________________________
____________________________________________________________________________
____________________________________________________________________________
INTERVENTIONS TO BE PROVIDED AT SCHOOL:_____________________________
_____________________________________________________________________________
____________________________________________________________________________
RESTRICTIONS/EXCLUSIONS AT SCHOOL: __________________________________
____________________________________________________________________________
____________________________________________________________________________
OTHER COMMENTS: _______________________________________________________
SIGNS/ SYMPTOMS OF A BRAIN BLEED CAN INCLUDE, BUT ARE NOT LIMITED
TO:















(4-2014)
A sudden severe headache
Seizures with no previous history of seizures
Weakness in an arm or leg
Nausea or vomiting
Decreased alertness; lethargy
Changes in vision
Tingling or numbness
Difficulty speaking or understanding speech
Difficulty swallowing
Difficulty writing or reading
Loss of fine motor skills, such as hand tremors
Loss of coordination
Loss of balance
An abnormal sense of taste
Loss of consciousness
6A-2 BC
Site:______________
EMERGENCY PLAN OF ACTION FOR ALL STAFF:
1. If student exhibits any of the signs/ symptoms of a possible brain bleed, as listed above, or you
have any other concerns, please send to nurse immediately.
2. If student has any sign of bleeding, please send to nurse immediately. If student has large
amount of uncontrolled bleeding, call 911.
3. If student’s color becomes pale, cyanotic (bluish), or ashen OR student has other signs of
respiratory distress (difficulty breathing, gasping, etc.), call 911.
4. If student has a fall, injury, or any any bump to head, please send to nurse immediately. If
there are concerns for head injury and/ or head trauma, call 911.
5. Notify school personnel trained in CPR/first aid to stay with student and initiate CPR if needed
prior to EMS arrival.
6. Contact parent/guardian immediately.
7. 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.
8. When student is transported via EMS a staff member must accompany the student unless
parent and/or emergency contact accompanies them.
9. 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
______________________________
SIGNATURE OF PHYSICIAN/ ARNP
_________________ _________________
PHONE NUMBER
DATE
___________________________________
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 or its employee.
_______________________________
Parent Signature
_______________
Phone Number
____________
Date
This order and plan of care is valid for current school year.
Reviewed by School Nurse________________Copy to Pertinent school staff______________
Copy to District Nurse______________
Copy to medication delegated trained bus driver_______________
(4-2014)
6A-2 BC
Site:______________
(4-2014)
6A-2 BC
Site:_______________________