As the new nurse case manager at a home health agency that provides in-home support services to adults with disabilities, you’re excited about your role and eager to meet some of the clients served by the agency. You’ve worked with many individuals with cognitive impairments as well as physical disabilities in both the hospital and clinic setting, and are confident that your clinical skills are up-to-date. During your job interview, you told the agency director that you’ll need time to familiarize yourself with community resources and options. The director has arranged for you to spend the first week of orientation with Nancy, the nurse case manager who is leaving to go back to graduate school.

After you and Nancy drive across town to the apartment complex that houses several of your adult clients with Down syndrome, she introduces you to Marguerite, Leonard, Esperanza, Lejon, and Esther. Jotting notes rapidly in the files you’ve brought along, you note the issues that each adult discusses with you and Nancy:

• Marguerite is frustrated with her physician, who wants her to go for a hearing test and vision exam. "My eyes and ears are okay. He wants to do those stupid tests again. And he wants to stick me with a needle to get more blood. I just want some birth control pills. Can you talk to that man?" She also tells you that her trust funds are not coming on time, and that she’s supposed to apply for some government benefits, but can’t remember which ones.
• Leonard is happy to meet you, and wants to know if you can talk with his job coach. "I like working at the store. But they think I’m dumb. I want to help the customers. I don’t like sweeping in the back." He also mentions that his feet hurt when he stands up all day, and that he’s too tired working five days a week. In his apartment, you notice that the chart for testicular self-exams hasn’t been completed for the past month or so.
• Esperanza, shy and hesitant, finally blurts out, "I forget a lot. Cry every day. Not happy here." Checking her apartment, you notice that it’s dirty and cluttered, and that there are a lot of fast food containers lying around. She shows you a notice from her adult day center, asking when she’ll be returning to the program. As you leave, you see several empty prescription bottles but no current prescriptions.
• Lejon, boisterous and loud, complains that his pants are too tight again. When you ask what he does for exercise, he smiles and says, "I watch TV." In response to your suggestions for organized sports and activities, he tells you, "No bus." Listening to his heart sounds, you notice a distinct murmur that suggests mitral valve prolapse.
• Esther hands you a jumble of papers and flyers, asserting, "I want to go to one of these schools. I like to learn." Leaning close to you, she confides that she’d like to live on campus "like the other kids." She also asks you to help her register for a summer camp that has horseback riding, and to find a good helmet and some riding lessons before she goes. Almost as an aside, she mentions that her gums are so sore that she’s not brushing her teeth very often.
  

Taking a deep breath as you and Nancy drive away at the end of the morning, you ply her with questions and try to sort out the priorities of the adults in your caseload.