ELMA, N.Y. - "Nurse Zak's" health office at Elma Primary School in suburban Buffalo has all the Band-Aids, ice packs and cotton balls expected in a place tasked with treating the bumps, bruises and paper cuts of school life.
But there's also a rocking chair and stuffed animal for when comfort is the best medicine, a few pairs of sneakers to lend so forgetful kids don't miss gym and some shirts and pants in case of a spill or mishap in the lab.
Nurse Zak -- Jane Zakrzewski -- has found that being prepared as a school nurse means being ready for pretty much anything.
In her 30 years on the job, the tummy aches, headaches and bouts of lice and strep throat have remained consistent, she said. But today, school nurses also see things like life-threatening food allergies, behavioral and emotional issues and, in today's culture of inclusion, conditions that would have kept children out of the mainstream in the past.
Now, school nurses might suction tracheostomies, clean gastrostomy tubes, monitor wearable insulin pumps, keep track of inhalers and EpiPens, give medicine for ADHD and seizures and dispense birth control.
It's a far cry from what Lina Rogers Struthers might have seen in 1902, when she was made the nation's first school nurse as an experiment to stem the spread of contagious diseases like diphtheria and scarlet fever in New York City schools.
"In general, people want their children to be as normal as possible so they want to send their children to a public school setting and want them to be part of the public school community and grow up just as any other child would grow up," Zakrzewski said.
"I really, in my heart of hearts, feel like there's nothing we can't handle," she said.
Zakrzewski is one of about 74,000 registered nurses working as school nurses in the nearly 100,000 public elementary and secondary schools. Their offices are seen as an intersection between health and education.
"Students that are healthy stay in school, have fewer absences and they learn better," said Carolyn Duff, president of the National Association of School Nurses, "and students that are well educated become healthier adults."
School nurses, through annual screenings, are often the ones to catch hearing and vision loss in students and identify those at risk for obesity and related problems.
They also can influence school policy on topics from concussion management to hand-washing, said Mark Bishop, spokesman for the Chicago-based Healthy Schools Campaign. The initiative offers school nurse leadership training as part of its efforts to create healthy school environments.
"School nurses can really provide leadership and direction in a school," Bishop said, "to really create this environment of health, whether it is identifying conditions that are hampering students' ability to learn through looking at the exposures to chemicals and indoor air quality to really providing prevention services in schools."
The goal is to keep attendance as high as possible at a time of increasingly challenging curricula and graduation requirements, he and others said.
It's a tall order, especially considering a school nurse is often the lone medical professional in buildings with hundreds of students, varying numbers of whom may be without access to outside health care.
"It's not for every nurse," said Duff, who practices in a Columbia, S.C. elementary school with 430 students. She said confidence, independence and the ability to interact with teachers and parents are musts, as well as continued education to keep up with ever-changing issues, from the peanut allergies that emerged in the 1990s to the H1N1 pandemic of 2009 and anti-bullying efforts of today.
"It's a different milieu than a hospital setting" where in an emergency, help is always near, Duff said. "That isn't the case in schools," she said. "You can call one of your colleagues in another school, but basically it's you."
It's not just physical ailments that fill nurses' days. A 2005 study published by the Department of Health and Human Services found that school nurses spend about a third of their time providing mental health services, ranging from referrals and crisis planning to simply listening.
"When I worked in the high school I may have been more of a counselor than an actual nurse at times because of the amount of time I spent listening to students and their issues," Zakrzewski said. "Boyfriend-girlfriend relationships ... I've had children speak to me about doing drugs and drinking and situations with their parents."
Rochester, N.Y., school nurses in February joined the expanding list of those handing out condoms in high schools and providing guidance on safe sex. Regulations on contraception vary from state to state and district to district, Duff said.
The average ratio of nurse to student varies from state to state, according to NASN, which recommends a 1-to-750 ratio for well students and 1-to-225 ratio in schools with students who require daily services.
Vermont had the lowest average ratio at 1-to-396 in 2010, the most recent year studied, according to NASN. Michigan posted the highest ratio at 1-to-4,411.
U.S. Rep. Carolyn McCarthy, D-N.Y., a school nurse for more than 30 years before her election to Congress, introduced legislation in May to create federal grants to help states lower nurse-to-student ratios. More than half of the country's public schools don't have a nurse on site all day, every day, and up to one-quarter don't have a nurse in the building at all, McCarthy said.
The legislation is supported by NASN and the American Federation of Teachers.