SIOUX CITY -- Graham crackers and glucose tablets for a diabetic boy feeling weak from low blood sugar, fluids for a girl with a stomach ache, a phone call to a parent to bring a student's skin cream to school -- along with handing out daily medications and compiling immunization records for an annual audit, it's all in a day's work for a school nurse.

And it's work nurses can't ignore or put off even when, as was the case two weeks ago at Unity Elementary School, their offices are inundated with 30 to 40 kids a day showing signs of the H1N1 influenza virus.

Tina Gray, the nurse at Irving Elementary School, described a comparable scene at her school.

"There were so many kids, at one point, we had the kids with the fevers waiting to go home in this room (the nurse's office), which is fairly large," Gray said. "Then the kids without the fevers ... I didn't want them any more exposed than they had to be. We had a little clinic out in the lobby where they could sit and rest."

The Sioux City Community School District has nine registered nurses to care for nearly 14,000 students. Gray works full time at Irving, thanks to a grant, but the other eight nurses are responsible for between three and six schools each, according to the district's head nurse, Julie Lambert. A nurse may be assigned to two elementary and one middle or high school, or to six elementary schools, depending on the number of students.

During the week of Oct. 19, 10 percent or more of the students at 11 of the district's 25 schools were down with the flu or other ailments, an absentee rate the district is required to report to the Siouxland District Health Department. No doubt a number of those students visited a school nurse to have their symptoms checked before being kept home from classes.

The wave has subsided, and for the moment, the district's nurses are able to catch up on paperwork, such as immunization records. But the reprieve could be brief. Linda Drey, nursing director for the local health department, said students could fall ill en masse again if another strain of H1N1 or the seasonal flu strikes.

The department is holding H1N1 immunization clinics at school districts and for the most at-risk individuals as vaccine shipments arrive.

But epidemic or not, said Lambert, "You still have to deal with your day-to-day things like a student coming in that doesn't feel well or has an injury. We have the daily medications and procedures that we deal with, like a student with diabetes or asthma. We also have tube feedings and bladder catheterization, and we all have meetings we go to during the day and even after our day is done."

Budgetary constraints keep the district from hiring more nurses, and in fact, the district has dropped a half-time nursing position in the past five years. When nurses are not immediately available, secretaries and teacher's aides trained by the nurses provide some care.

"Nothing can take the place of a nurse or a nurse's judgment," said Gray, who said she's grateful she can serve Irving full time instead of rotating among several schools.

But with limited finances, it's the best the district can do. And Sioux City is not alone.

"I think there are many districts that probably only have one nurse," said Steve Crary, human resources director for the district. "Unfortunately, with today's budget, we're running on bare resources everywhere while still providing quality nursing and education."

Quite often, the school nurse provides some of both.

When a student was sent to her office Wednesday morning with a red eye, Gray asked her several questions, including what she thought had caused the irritation.

"I like to ask them what they think because it helps them learn," she said. "It helps with critical thinking skills. I'd like to think I can help the teachers."