Health and Trans exam review - #1.docx

Health and Trans exam review - #1 Feb 26th, 2024 safe and accurate medication administration: Nurses must: Have the necessary authority to perform medication practices Ensure they have the knowledge, skill, and judgement to perform med practice safely Promote safe care, and contribute to a culture o...

Health and Trans exam review - #1 Feb 26th, 2024 safe and accurate medication administration: Nurses must: Have the necessary authority to perform medication practices Ensure they have the knowledge, skill, and judgement to perform med practice safely Promote safe care, and contribute to a culture of safety within their practice environments Pharmacological concepts: Classification: The effect of the medication on a body system, the symptom the medication relieves, or the medications desired effect Generic name: given by the manufacturer and is protetced by the law Trade name: also known as the brand name, proprietary name, marked name Pharmacokinetics: Study of how Drugs enter the body Reach the site of action Are metabolized and exit the body Absorption: Passage of the medication from the site of administration into the blood influenced by Route Ability to dissolve Blood flow Body surface area Lipid solubility Distribution: Once absorbed the medication is distributed to the tissues and organs and specific sites of action Factors affecting distribution Circulation Membrane permeability Protein binding Metabolism Excretion (kidneys are main source) Types of medication action: Therapeutic effects: the expected or predictable physiological response to a drug Side effects: unintended secondary effects that a medication predictably will cause Adverse effects: severe negative responses to a medication Toxic effects: excess amounts of medication in the blood that develop after prolonged intake or as a result of impaired metabolism or excretion can cause these types of effects Idiosyncratic effects: unpredictable effects caused by a medication Allergic reactions: a reaction that occurs after the drugs has been taken at least once before Medication interactions: a situation in which one medication modifies or alters the action of another Law and nusring: Legal knowledge is imporant for nuses: Nurses are expected to function within the legislation, legal policies, statutes relevant to the profession and practice setting, and professional standards. The standard of practice of the College of Nurses of Ontario states that registered nurses must base their practice on an understanding and analysis of the legislation that influences nursing. Nurses are now being, and will continue to be given increased responsibility, thereby increasing their exposure to lawsuits Functions of law in society: To define relationships among members of society and to declare which actions are and are not permitted To describe what constraints may be applied to maintain rules and by whom they may be applied To furnish solutions to problems To redefine relationship between people and groups when circumstance of life change Common law: Also called Public law – includes criminal, administrative, and constitutional law a collection of judges decisions refined over the centuries Each case expresses a legal principle which is applied by judges to resolve a legal issue in a given situation Precedents - developed and applied Consistency is achieved with same principles, same circumstances, similar manner over time Sources of law: Constitutional Law - formal sets of rules and principles that describe the powers of a government and the rights of the people (Charter of Rights and Freedom Constitution Act 1982 Statutory/Legislative Law – formal laws written and enacted by federal, provincial, or local legislatures Ryan's Law Statute law - created by elective legislative bodies Most authoritative in common law courts Overrides case law Formal written laws and regulations passed by government that set forth rules and principles governing a particular subject Eg. Ontario Highway Traffic Act Administrative Law – involves the operation of government agencies (education, public health, social welfare, CNO) Charter of rights and freedoms: Entrenched as part of the constitution Codifies as constitutional law rights and freedoms enjoyed in Canadian society. Eg. freedom of religion, freedom of thought and expression, freedom of the press, freedom of peaceful assembly.Presumption of Innocence – Considered innocent until proven guilty. Crown must prove all essential elements of a case – beyond a reasonable doubt Criminal law: Breach of rules that threaten peace, order, and well being of all citizens Federal government makes criminal laws of Canada Criminal law is contained in the Criminal Code of Canada Classes of criminal offences: Indictable offences Murder, manslaughter, criminal negligence Summary conviction offences Loitering, trespassing, vagrancy Dual procedure or hybrid offences Offences can be tried either way Crown makes the choice Due process: All people are equal before the law and entitled to the same rights and benefits No matter how rich or poor, famous, powerful, known, unknown they are entitled to be treated by the law in exactly the same manner as another Civil law: Also called Private law Body of rules and legal principles that govern relations, rights and obligations among individuals, corporations, and institutions. Includes law related to contracts, property, family, marriage and divorce, tort and negligence, wills, inheritance, insurance, copyright, patents, employment, and labour Includes substantive law (sets out detailed rights and obligations of citizens in private dealings ie. Spouse or employees) and procedural law (regulates how rights are asserted and enforced – which court, time frames, documents filled etc) Types of law: Private Law (Civil law ) – determines a person’s legal rights and obligations in many kinds of activities that involve other people Contract Law – deals with the rights and obligations of people who make contracts Tort Law – laws that apply to situations in which a wrong or injury a person suffers is a result of someone else’s actions Torts: Civil wrong committed against a person or property such as to cause that other some injury or damage to either person or property Classified as intentional or unintentional ***Define the following: Assault: Battery: Invasion of privacy: Defamation of character: Fraud: False imprsionment: Intentional infliction of emotional distress: Unitentional torts: Negligence – conduct that falls below the standard of care Three elements in negligence Defendant must owe a duty to care in law towards the plaintiff The defendant must have failed to carry out that duty The defendant must have caused suffering or injury to the plaintiff caused by the breach of duty Common negligent acts: Medication errors that result in injury to the client Failure to use aseptic technique as required Failure to give report to an incoming shift of health care staff Failure to notify a physician of a significant change in a client’s status Failure to document in a timely manner – ‘not documented, not done’ Ethics: Ethics is the philosophical study of morality, the study of what is right and wrong behaviour Based on value: what you believe you should do or should not do. Values influence behaviour Bioethics: Addresses issues relevant to health care Moral decision making should be guided by four principles: Autonomy Make choices for onself based on ful understanding and free from controlling influences Beneficence Doing or promoting good for others - benefit vs risk Non maleficence Avoidance of harm or hurt - balance risk and benefits Justice Fairness - depends on communty values - decisions should be made on ‘need alone’ not higher social position Bioethics are obligation based, outcome oriented, based on reason (Oberle & Raffin Bouchal, 2009) CNO code of conduct: Nurse respects clients’ dignity Nurses provide inclusive and culturally safe care by practicing cultural humility Nurses provide safe and competent care Nurses work respectfully with the health care team to best meet clients’ needs Nurses ace with integrity in clients’ best interest Nurses maintain public confidence in the nursing profession Responsiblity and accountability: Responsbility: Characteristics of reliability and dependability Ability to distinguish between right and wrong Duty to perform actions well and thoughtfully Accountability: Applies to everyone involved in health care Is a legal obligation Accountability is the ability and willingness to assume responsibility for one’s actions and accepting the consequences of one’s behaviour. Nurses are accountable for: their actions and decisions knowing and understanding the roles and responsibilities of other team members, and collaborating, consulting and taking action on client information when needed taking action to ensure client safety, including informing the employer of concerns related to the conduct and/or actions of other care providers, and collaborating with clients, with each other and with members of the interprofessional care team for the benefit of the client. Accountability for clients: Clinical competence Safe care Allow client autonomy Respect individuals Altruistic intentions Client advocate Professional approach Commitment to Duty of Care Accountability to health care team: Bring specialized nursing knowledge and skill Share information Confront potential errors Perform nursing tasks with competence Treat members with dignity and respect Accountabily to employer: Quality of work Protect against unsafe practice and situations Attitude conveyed about the agency Accountabilty to self: Practice nursing to personal standards using professional standards as a basis Be true to self Take care of personal, physical, mental & spiritual health Protect self from harm Theories of growth and development: Growth and development: Each affecting the other and are affacted by various ekements. Growth = physical size and quantitative changes developments = capabilities or functions Qualitive changes progressive and continous process (rolling, craling, walking) Result of complex interactions between biological and environmnetal influences Leads to increase in skill and capability Patterns of growth and development: Directional trends Cephalocaudal Proximodistal Bilateral Differentiation Sequential trends Developmental pace Sensitive periods/critical periods Cephalocaudal growth → growth occurs from the head down Proximodistal growth → growth occurs from the center of the body out Factors affectong growth and development categorized based on determints of health: Income and social status Social support networks Education and literacy Employment and working conditions Physical environments Biological and genetic endowment Individual health practices and coping skills Healthy child development Health services Gender Culture Social environments Theories of growth and development: Organicism: development is a result of biologically driven behaviours and the person’s adaptation to the environment Biophysical developmental theories: physical growth and changes, how does the body age? ( Gesell, Chess & Thomas) Cognitive theories: address how we think (Piaget) Moral development: address how we make decisions in the moral/ethical domain (Kohlberg ) Psycholanalytic & Psychosocial: address how we develop throughout our life (Freud, Erikson, Havighurst, etc) Mechanistic Tradition: development depends on stimulation from the environment ( the level, kind and history) Social Learning theory: (Bandura) Contextualism: relationship between the individual and social context Bioecological: importance of the interaction between the individual and social environments (Bronfenbrenner) Dialectism: all developmental theories are mutually interactive. Ability to incorporate multiple theories. Population Health: see strong association b/t health of a population, developmental outcomes, and the social and economic forces affecting society (Keating & Hertzman) Resiliance theory: maintenance of positive adjustment under challenging life conditions biophysical theory: Gesell’s maturational development theory: Directed by activity of the genes Environmental factors can change, support and modify the pattern of developmen Pattern of maturation follows a fixed developmental sequence with critical periods the presence or absence of particular experiences makes or hinders a biological function Temperament theory: 9 parameters of personality Activity level - degree of motion during all activities Rhythmicity – regularity of schedule maintained Approach or withdrawal - response to new stimuli Adaptability – degree of adaptation to new situations Threshold of responsiveness – intensity of stimulation to elicit response to sensory input Intensity of reaction – degree of response to situations Quality of mood – predominant mood during activity Distractibility – ability of environmental stimuli to interfere with activity Attention span and persistence – amt of time devoted to activities & ability to stick to the activity Cognitive development - piaget: Sensorimotor (birth to 2 yrs) Preoperational (2 to 7 years) Concrete Operational (7 to 11 years) Formative Operation (11 to adulthood) Assimilation & Accommodation Moral development - Kohlberg: Three levels: Pre-conventional Conventional Post-conventional Gilligan: felt Kohlgers theory was gender biased Female moral development focuses on interpersonal relationships Behaviorism: Watson, John behaviors can be elicited by positive reinforcement Psychoanalytical theory - Freud: Psychosexual focus on personality development Stages: Oral (birth – 1 yr) Anal (1-3 yr) Phallic (3-6 yr) Latency (6-12yr) Genital (12 to adulthood) Personality Development: Id (instincts) Ego (reality) Superego (morality) Defense mechanisms of children: Regression Repression Rationalization Fantasy 8 stages of psychosocial development - erikson HEALTHY VS UNHEALTHY OUTCOMES Trust/mistrust (birth – 1 yr) Autonomy/shame & doubt (1-3 yr) Initiative/Guilt (3-6 yr) Industry/Inferiority (6-12 yr) Identity/Role confusion (12-18 yr) Intimacy/Isolation (young adult) Generatively/Stagnation (mid adult) Ego Integrity/Despair (older adult) Nursing Implications: Need to provide health promotion that is necessary for transition at each stage in a positive manner Havinghurst: critical tasks arise at certain times in life. Successful mastery encourages to go onto new challenges, difficulty slows future progress (built upon Erikson’s theory) 6 major age groups: Infancy & early childhood Middle childhood Adolescence Early adult Middle adult Later maturity Nursing Implications: same as Erikson’s Social learning theory - bandura Children learn attitudes, beliefs, customs & values through social contacts with adults & other children (modeling) Key elements: External environment & child’s internal processes Determinant of behavior is self efficacy (the expectation that someone can produce the desired outcome) Contextualism: ecological theory Levels and systems - bronfenbrenner Microsystem Mesosystem Exosystem Macrosystem Chronosystem Nursing implications: nursing practice beyond individual to higher levels of social context-primary health care Population health theory - keating and heartzmans Health behavior and cognitive functions are largely set in early life and then influenced further by succeeding events in the socioeconomic environment Developmental health: the physical & mental health, well being, coping and competence of human populations Nursing implications: need to take into account the impact of the socioeconomic context on the health of the individuals in society Resiliency theory - dialectism Individual’s characteristics & interaction of characteristics with the environment Resiliency Protective factors Risk factors Coping techniques Response Nursing implications: nurses interact with individuals, families during stressful/challenging times – acknowledge the complexity of these moments – what can nurses use to help the family succeed Growth and development in the infant Infant milestones: Rapid physical, emotional cognitive growth & development of motor abilities Reflexes decrease/disappear Feeding patterns emerge Sleep/wake cycles Bonding/interaction with care givers evident Refexes, beginning motor development - decrease/disappear by: Startle (moro) 2 month Tongue extrusion 4-6 month Walking/stepping 4 months Rooting 4 months Grasp palmar 6 months Plantar 8-12 months Motor skill development/milestones: Muscle contro begins at first week of age 2- 3 months – head and neck control Kicking arms & legs – begins to move => rolls 4 months: rolls over 3 -4 months sits up when propped 4 – 6 months holds feet & pulls to mouth 6 months: rolls over completely 6 – 8 crawls to explore the world – transfers objects from one hand to another 7 months: sits alone without support 8 – 10 months – pulls up and stands, uses pincer grasp 9 months: creeps or crawls 12 months: stands alone; may take 1 – 2 steps 12 – 13 months – walking, muscle strength, confidence 15 months: walks alone ​​​ Infant growth: Weight Doubles by 6 months Triples by 1 year Height 2.5 cm per month x 1st 6 months 1.25 cm per month from 6 – 12 months Overall average growth: 22.5 cm Fontanelles Posterior: closes 8 – 12 weeks Anterior: closes 12 – 18 months Teeth – erupt around 6 months (average) Lower central incisors (2) Upper central incisors (2) Upper lateral incisors (2) Psychosocial development: Freud: oral Erickson: trust vs mistrust Social development Social smile: begins 8 – 12 weeks Emotional development Attachment - Increasing attachment develops by 6 -12 months Separation fear Stranger fear Social & Emotional development temperament theory Cognitive development - sensorimotor Reflex behaviour: first month Primary circular reactions: 1 – 4 months Chance Secondary circular reactions: 4 – 8 months Repeating pleasurable actions Coordination of secondary schema: 8 – 12 months Applies learning to new situations Develops object permanence Beginning to use symbols (language) increased motor skills Intelligence – Understanding cause and effect. Important to feel secure enough to explore their environment. 0 – 4 mos. ‘En face’ position 4 – 7 mos. Face outward; discover hands and feet; recognize patterns/responses Myelinization of cortex of brain begins at 7-8 months 8 mos. + - establish object permanence Memory – Studies show infants retain memory of traumatic events. Creativity & Music: respond to music before birth – quiet music induces sleep Simple songs with finger play are well received Language development - preverbal stage Expressive Receptive 3-4 mos. Repetitive sounds; babbling 7-8 mos. Syllables using D,P,B 9 -10 mos. Specific sounds used for objects 10 – 13mos. First words – word has multiple meanings. Health maintenance: Nutrition Sleep patterns Role of play Immunization Accident prevention: Aspiration Suffocation/drowning Falls Poisoning Burns Bodily injuries – Car seats, toy safety Infections Feeding: Feeding – 0 – 6 months formula/breastmilk 6 months need more nourishment - to start solid foods must be able to hold head up and push foods to back of mouth with tongue and swallow 7 – 9 months begins to feed self – may indicate food preference Variations exist in pace Infants at play: Play is “work of childhood” Contributes to cognitive, physical and social development Primarily enjoy solitary play Others may teach infants how to play with new objects Progress from reacting to objects (rattle) to manipulating them Once they become mobile, sphere of play enlarges Immunization schedule: At 2, 4, 6, 18 months & 4 – 6 years Pertussis, Diphtheria, Tetanus Polio HIB (haemophilus influenza Type B)*Not at 4-6! ‘Prevnar’ – Pneumonia, Bacteremia, Otitis media* Not at 4-6 At 12 months Measles, Mumps & Rubella (MMR) Meningococal C At 15 mos. - Varicella (Chicken pox) + Prevnar At 18 mos. MMR Hepatitis B – Grade 7 HPV – Grade8 Growth and developments in toddlers: Toddlers at a glance: Typically independent and negative Proud of new accomplishments Rate of growth and food intake slows Walk Physical growth: Height 1 à 2 yr grows 9 -12 cm. & 2 à 3 yr grows 5 – 7cm Average ht of 2 yr old 85 cm. Weight At 2 ½ years, 4x birth weight Teeth: have all 20 primary teeth by 2 ½ yr Elimination Daytime bladder control Full bowel control Motor development: Gross Motor Development Walks, forward, back, runs, climbs, jumps(both feet), throws a ball overhand, rides a tricycle Fine Motor Development Feeds self Uses cup, spoon, and fork No table manners Can undress (by 2 1/2) & dress self draws circles, crosses, stick people, finger paints May have a hand preference Cognitive development: Sensorimotor – sub-stages 5 & 6 12 – 18 months – increasing use of trial & error 18 – 24 month – makes new mental combinations (stage of representation) Beginning the Preoperational stage(2 - 7 years) Egocentric ( cannot assume the view of another) Centration (can only think of 1 thing at a time) Animistic Developing “deferred imitation” Increasing use of symbols through language devel’p (about 300 words) Language Development: Uses short sentences Limited attention span Names body parts Psychosocial development: Freud: Anal stage → Freud is fruity Erikson: Autonomy vs. shame and doubt Feeding Walking Dressing Toileting Verbal expression Toddlers at play: Increased motor skills allow new types of toys and play Play becomes more social, often with other toddlers – parallel play Sharing becomes difficult Imitates behaviours Manipulating objects help them to learn about their qualities (square- round) Social learning theory: Self-efficacy Start to learn attitudes, customs through social contacts with adults & other children Parents with confidence in their abilities helps the toddler develop their own confidence Positive Role modelling & positive reinforcement of desired behavior Nurturing-Ecologic theory: Children exposed to positive pleasant, stimuli will develop & refine skills faster Temperment theory: Good fit – when properties of environment are in accord with the toddler's capabilities May notice slight changes in temperament as they strive for independence Issues that aise in toddlerhood: Negativism Temper tantrums Ritualism Regression Jealousy and sibling rivalry Fears: the dark, Being alone, Separation from parents, Santa Claus Loud noises Nightmares Health concerns: Nutrition Dental health Injury prevention (table 22-4 in Astle & Duggleby) Discipline Sexuality Toddler nutrition: Metabolic rate slows, so appetite decreases Prefers small portion size Physiological anorexia Begin to learn to eat with others Toddler nutrition interventions: Guidance for parents – healthy meals and snacks; milk, fruit, allow for self feeding Toilet training procedures Accept regression during hospitalization Encourage independent behavior Give short explanations Reward appropriate behavior WEEK 7 GROWTH AND DEVELOPMENT IN TODDLERS AND MIDDLE ADULTS Young adult aged 20 - 40 Middle adult good 40 -65 Physical Development Young Adults – Fully complete – All systems functioning at peak efficiency – Organ reserve capacity – Active – ++ energy – Excellent health – but often postpone seeking health care – Focus on reproduction and family planning COGNITIVE DEVELOPMENT Young Adults – (Post) formal operations – Knowledge is _____________& ______________ – Able to comprehend _______________________________ – Quick thinkers – use trial & error – Abstract thinking and logical reasoning enhanced by technology Psychosocial Development in Young Adults Erikson: Intimacy vs isolation – Involves more than sexual behaviour – Includes ability to ____________________________________ Havighurst – Selecting a mate – Starting a family – Rearing children – Getting a job – Having friendships – Doing your civic duty Ethnicity & gender issues Self concept stabilizes FAMILY LIFE CYCLE between family’s Joining families Families with young children Families with adolescents Launching children Familes later in life MORAL DEVELOPMENT IN YOUNG AND MIDDLE ADULTS KOHLBERG Most adults are at the level of conventional thinking, pleasing, or following the laws of duty Education is directly related to moral development Taking responsibility for care of others, dealing with different view ponints and understanding how actions affect others Common health concerns job Parents bf Money Leisure Time Health Safe sex Stress Obesity It is easier to develop positive health habits as a young adult than to change habits later in life HEALTH LITERACY Act on information Weigh options Nursing techniques- teach back MIDDLE ADULTHOOD Age of mastery The settling down and pay off years “Midlife crisis time” COGNITIVE DEVELOPMENT IN MIDDLE ADULTS (Post) formal operations Often return to school The voice of experience PSYCHOSOCIAL DEVELOPMENT IN MIDDLE ADULTS ERIKSON- Generativity vs Self Absorption may regress to younger ways of behaving Concern for establishing and guiding the next generation HAVIGHURST Assisting teenage children to become more responsible Accepting/ adjusting to physiological changes Adjusting to aging parents GROWTH AND DEVELOPMENT IN ADOLESCENTS Adolescence- 13 - 19 years Physiological development growth spurts Increased sweating Acne Hormone influences Cognitive Development Formal operations (11-15 years) Thinks abstractly Understands cause and effect Imaginative and idealistic Uses logical scientific thinking Developmental Tasks establishing sense of identity Separation from family Career planning Intimacy Psychosocial Self absorbed Self conscious Sense of curiosity Sees self as unique Psychosocial Development FREUD- genitalia stage ERIKSON- identity and role confusion vocational Sexual Group Family Teenagers fight the battles of trust, industry, autonomy Group loyalty Intense loyalty to group Allows separation from family Dating Popularity Family identity spends less time with family Need for education Need trust, flexibility Self concept- Body image likes themselves Many changes in body Bullying influences Many changes occurring in body Moral Identity moral judgment depends on conflictive and communication skills as well as peer interactions Adolescents judge themselves KOHLBERG- transition to post conventional stage- equating what is right based on justice based actions GILLIGAN- female adolescents involving self sacrifice and caring for the relationships in her life Stress career Money Sexuality Relationships Experimentation Sex Drugs Education Sexual activity start dating Time for experimenting Look for role models Oral sex Risky behavior feelings of invincibility/ immortal Sees self as unique Health what do peers eat Problems with obesity Need more sleep due to physical growth Career planning allowed to try out roles Need access to resources High pressure to achieve grades GROWTH DEVELOPMENT IN THE SCHOOL AGE CHILD Physiological development increases by 5cm/ year Fat is redistributed Bones grow faster than muscle Not fully developed Weight increases by 1.8-3.2kg/year Cognitive development concrete operations from 7-11 years School- spelling, math, grammar Mastered motor control Present minded Language development very rapid Attention span of 45 mins Concrete operations Seriation Classification Transitivity Decentering Conservation Reversibility Psychosocial development FREUD- latency ERIKSON- industry vs inferiority gains satisfaction from small goals Thirst for knowledge Learn more independent Building self esteem Latchkey children Plays cooperatively but competitive Moral/ spiritual development reward and punishment guides behaviour in 6-7 year old Moral behaviour learned through positive reinforcement Lying stealing and cheating are common Pray for tangible things but learns they aren’t always answered Temperament and Personality children classified as difficult and may have trouble in the classroom Creative Slow to warm up to try new things Easy child will adapt well to school and new experiences Issues in school age children school Dishonesty Optimal nutrition Limit setting and discipline Stressed and fears- being hurt, dying Health teaching Prevention of injury Regular dental care Screening got scoliosis Developing an active lifestyle Nursing interventions explain treatments and procedures Encourage school work Encourage hobbies and favourite activities PRESCHOOLER AGE 3-5 Mostly in daycare or school Language skills well developed Writing improves Physical skills improved Major tasks expresses feelings through play and words Less negative Refit ment or gross and fine motor Develop impulse control of behaviors Physical Growth Grows 6-7.5 cm a year At 5 years should be 1 meter tall Weight gains approximately 2.3kg: year Fully toilet trained and independent Preschool nutrition growth is slow and steady Food jags Meals are a social event Assist in food preparation Motor development skips and jumps well Caches hall reliably May learn to ride a bike Fine motor development ties shoe laces Uses scissors Cognitive development - Piaget: Preoperational ( 2 – 7 years) Conservation Thinking between 4 – 7 years is more intuitive: no rational explanation, learning cause & effect Can be taught simple rules Can follow simple directions Centration is still evident Can classify by attribute, know 4 colours By 5 years has vocabulary of 2000 works or more Language is used for social interaction Has many questions, exaggerates Sentences are more elaborate Sense of time is developing Psychosocial development: Freud: phallic stage Erikson: initiative vs. guilt Testing limits, what can they do, what are the rules Great imagination, fantasies Magical thinking/wishing Social awareness of others is developing Negativity and temper tantrums disappear Still ritualistic Temperament Play: Associative, becoming cooperative Role playing Imaginary friends Increased manual dexterity Enjoys large motor activities moral /spiritual development: Capable of being kind Do things in own interests (preconventional development) Conscience is developing Learn from modeling Imagine God, angels, the devil Issues that arise in the preschool years: Imagination Misinterpretation Sex education “Why” questions Fears: the dark, thunder storms, being alone, animals, ghosts, monsters, bodily harm such as needles, medical personnel Nightmares Health concerns: Communicable diseases Accidents: traffic, bicycle, fire safety Dental health Abuse: physical, psychosocial, sexual, strangers