Lourdes Costa, a nurse at Nathanael Greene Middle School, in Providence, helps Wayne Thompson Jr. with his backpack before sending him off to class last month. Costa is the only nurse for the 910 children at the school.

The Providence Journal / Bill Murphy

PROVIDENCE — It is 9 a.m. and four — make that five — children are sitting quietly in blue plastic chairs with the typical litany of sniffles, stomachaches and sore throats.

Lourdes Costa, a slightly built woman with short gray hair, glasses and a no-nonsense demeanor, ushers each middle school child behind a blue-and-white checked privacy screen in an office not much bigger than a storage closet.

“OK, child,” Costa, who was born in Portugal, says in her heavily accented English. “What are your miseries? Do we need to call 911?”

Costa performs the impossible every day: ministering to 910 students at the Nathanael Greene Middle School, on Chalkstone Avenue. She bluntly describes herself as overwhelmed, exhausted, stretched thin.

“I try my best, but it’s almost impossible,” says Costa, who has been working at Greene for 14 years. “It’s very hard to answer all of their needs.”

A generation ago, sick children stayed home from school. Now, because both parents are often working (and some are holding down two jobs), children with fevers, with bronchitis and with bad sore throats, are coming to class.

And the medical issues facing school nurses today are much more complex than the skinned knees and runny noses of previous generations. Every day, Costa provides nutrition to a young man with a feeding tube and monitors four students who need to take daily insulin shots for diabetes.

She sees students with asthma and high blood pressure; she has a student who is blind and another who uses a wheelchair. She cares for students with a troubling array of emotional and psychological problems, including children whose parents are abusive, alcoholic or struggling with their own illnesses, some of them serious.

And every year, at least one young girl becomes pregnant.

“Lots of kids, the mother works two jobs, she doesn’t have time to bring her children to the doctor,” Costa says. “The moms say, ‘Go see the school nurse.’ Or the parents are illegal and they are afraid to sign up for RIte Care because they are afraid of being deported. They send the kids to school sick. They send them to work without breakfast. The kids leave the house without coats, in T-shirts.”

The Providence school district has 45 nurses for 25,000 students spread over 42 schools. A handful of public school nurses cover the city’s 21 Catholic schools on a limited basis, where they review student health records and conduct health screenings. State law requires that public schools provide this service to any non-public school that requests it.

According to state law, there is no caseload limit for school nurses. At the larger high schools in Providence, one nurse is responsible for as many as 1,500 students. Compare those numbers with the caseload recommended by the National Association of School Nurses: a ratio of 1 school nurse for every 750 students.

In Rhode Island, school nurses are exceptionally well-trained compared with other states, says Sandi Delack, president-elect of the National Association of School Nurses and a Johnston middle school nurse. Each school nurse must be a registered nurse with five years’ experience in a hospital in addition to having a teaching certificate in health education.

“The nurse is the mother, the guardian, the friend. She is everybody,” says Donna O’Connor, the health-service administrator for the Providence schools. “Nursing involves a lot more than putting on a Band-Aid. We see students getting catheterized, students who can’t talk, students with autism, students with suicidal tendencies.”

Surprisingly, burnout is not an issue, according to Delack.

“I don’t see burnout, I see frustration,” she says. “We can’t do the job we want to do. The mental health issues are huge. So many of our kids come in with a bellyache but they are really dealing with depression, bipolar disorder, school phobia. If I want to have lunch, I have to hide so they can’t see me.”

BACK AT Nathanael Greene, it is lunchtime and Costa has already seen 32 students.

Meanwhile, her office, which once was part of the gym, is freezing. Costa shrugs and places a wool coat over her shoulders.

Jose walks into her office complaining of a toothache. She escorts him behind a hospital screen and asks him if his mother speaks English or Spanish. Told she speaks Spanish, Costa, who is fluent in three languages, including Portuguese, calls her at work.

After a brief conversation, she tells Jose: “Your mom doesn’t have transportation, my dear friend. I can put something on the tooth, OK? Let’s do our best.”

With every student that comes in, Costa reminds them to wash their hands and cough into their upper arms. And she never misses an opportunity to teach. When Angelo complains of a persistent sore throat and a cough, she asks, “Do you bring up sputum?”

“What’s that?” he says.

Costa pulls out a dog-eared dictionary and looks up the word, then has him read the definition. Sputum is a thick mix of saliva and mucus. She takes his temperature, and it turns out he has a fever of 102 degrees.

“You have an infection,” she tells him. “Your mother, she should bring you to a doctor.”

When she discovers that he hasn’t eaten breakfast, she says, “Angelo, look at me. Look at my eyes. Without food, your brain will not function.”

Then she sends him to the cafeteria for a snack.

Two more girls walk into the room. One storms out and slams the door because Costa will not see her without a hall pass. Costa asks the other student, whose eyes are deeply shadowed, to come back after lunch so they can speak in private.

“You did nothing wrong,” she tells the child. “I’m just concerned about some issues.”

Later, Costa explains that the student’s mother is very ill and has no one to help her around the house but this one daughter. The only sibling has special needs. Last year, the student began acting out in class because she was so overwhelmed by what was going on at home.

Not every parent appreciates her perseverance, however. Costa says she called one parent so often that the mother said, “What’s wrong now?”

The mother, who apparently felt that her parenting skills were being questioned, complained to the school psychologist.

“It breaks my heart when a parent says ‘What’s wrong now?’ ” Costa says. “We don’t know what these children are carrying on their shoulders. Education is about so much more than curriculum these days.”

One of the biggest headaches is the paperwork, which consumes 80 percent of her working hours. Every time Costa sees a student, she must log the information into a large notebook. Every student diagnosed with asthma or a seizure disorder must have a written health-care plan and an emergency plan. Records must be kept of every student’s immunizations, and every seventh grader must have documentation that he or she has received a physical examination.

“The paperwork is a killer,” Costa says. “I used to come in Saturday mornings to catch up.”

Clerical help would offer much needed relief, she says, but there is little likelihood that the district will find any additional money for clerks in its cash-starved budget.

So far, Providence has dodged the bullet in terms of cuts in nursing staff. But other districts haven’t been as fortunate. Last year, Johnston lost three of its nine school nurses.

“Sometimes,” Costa says, “I am so overwhelmed I have to leave the building. If I want to take a 10-minute lunch, I have to lock the door.”

Last fall, Costa missed nearly a month of work because she was sick. Because there is no backup staff, the district has to rely on three retired nurses to cover if a nurse is sick.

“I feel guilty,” Costa says. “Some days, I am not so nice. I end up apologizing to the kids.”

For the first time in recent memory, a top School Department administrator met with all of the school nurses to listen to their concerns. What she heard is that the nurses are overwhelmed by the size of their caseloads, by the mountains of paperwork and by the growing mandates from the state.

“I told them I can tell you exactly what is wrong with every one of my 334 seventh graders,” Costa said, “but I can’t say the same for my sixth and eighth graders.”

Costa says she hasn’t had time to document the medical histories of her sixth- and eighth-grade students. The only reason she knows her seventh graders is that the state requires students in that age group to document their immunizations.

It is nearly 1 p.m., and still the children traipse into the nurse’s office. Two boys complain that they have been hit in the eye with a pencil, but they seem fine. A girl complains of a torn fingernail.

According to Costa, many students visit her because they need a time out from the bustle of the school day. In many cases, all they want is someone who will listen to them without interruption for a few minutes.

As always, Costa begins with, “What is your misery today, child?”

Although her voice sounds weary and she complains privately of a headache, Costa radiates tenderness and concern and her students obviously respond.

“They need so much attention,” she says. When a student comes in frequently for no apparent health reason, Costa checks their grades because, if they are dropping, that may indicate that the child is having emotional or social troubles beyond the classroom.

Sometimes, she says, school is the only place her students feel safe.

Despite her complaints, Costa has never seriously contemplated leaving her job for something less pressured or more lucrative.

“I love middle school,” she says. “They love you or they hate you but if they trust you, you have a friend for life.”

lborg@projo.com