REIMBURSEMENT ISSUES

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Chapter 30 Basic Pediatric Nursing Care
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History of Child Care?Then and Now

• Industrializion in America
• Population shifted from rural to urban settings.
• People lived in overcrowded and unsanitary
  conditions.
• Children were looked at as little adults and
  worked in factories 12 to 14 hours a day.
• They had no legal rights and there were no work
  laws.

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History of Child Care?Then and Now

• 1860 Dr. Abraham Jacobi, a New York physician
  referred to as the father of pediatrics, first
  lectured to medical students on the special
  diseases and health problems of children.
• At milk stations, infants were weighed and
  mothers were taught how to prepare milk before
  giving it to their babies.
• Late 1800s Increasing concern developed for the
  social welfare of children, especially those who
  were homeless or employed as factory laborers.

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History of Child Care?Then and Now

• Lillian Wald founder of public health or
  community nursing
• Early 1900s Children with contagious diseases
  were isolated from adult patients parents were
  prohibited form visiting.
• 1940s Famous works of Spite and Robertson on
  institutionalized children the effects of
  isolation and maternal deprivation were
  recognized.
• 1909 White House Conference on Children focused
  on issues of child labor, dependent children, and
  infant care.
• 1912 U.S Childrens Bureau was established.

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History of Child Care?Then and Now

• 1919 First funded program for mothers and
  children
• 1929 Depression caused conditions for children
  to decline, once again
• 1987 National Commission on Children formed
  served as a forum on behalf of the children of
  the nation
• Children are the focus of many reform initiatives
  in the twenty-first century, and solutions will
  emphasize collaboration among various disciplines.

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Pediatric Nursing

• Purpose of Pediatric Nursing
• Preventing disease or injury
• Assisting all children, including those with a
  permanent disability or health problem, to
  achieve and maintain an optimum level of health
  and development
• Treating and rehabilitating children who have
  health deviations

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Pediatric Nursing

• Must enjoy working with children of all ages
• Family-centered nursing in its truest sense
• Must have keen observation skills
• Support children through difficult procedures or
  illnesses
• Requires establishing a level of trust
• Must convey respect, talk at their level, and be
  honest
• Function as a child and family advocate
• Ability to communicate effectively essential

8
Pediatric Nursing

• Children with Special Needs
• Infants and children may have congenital
  abnormalities, malignancies, gastrointestinal
  disease, or central nervous system anomalies.
• With appropriate services and support, even
  children with very severe disabilities are living
  at home with their families and attending school
  with their peers.

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Pediatric Nursing

• A philosophy of care that recognizes the family
  as the constant in the childs life and holds
  that systems and personnel must support, respect,
  encourage, and enhance the strengths and
  competence of the family
• Nurses and other in the community support
  families in their natural caregiving and
  decision-making roles by building on the familys
  and individual members unique strengths.

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Pediatric Nursing

• Partnerships with Parents
• Concept of partnerships with parents
• Parental involvement in their childrens care has
  evolved from that of relinquishing their role to
  institutions to todays role of planners, in
  addition to recipients, of services.
• Parents are treated as equals and have a rightful
  role in deciding what is important for themselves
  and their family.
• Parents of special needs children often become
  experts on their childs condition.

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Pediatric Nursing

• Future Challenges for the Pediatric Nurse
• The shift from treatment of disease to promotion
  of health is likely to further expand nurses
  roles in ambulatory care, with prevention and
  health teaching receiving a major emphasis.
• Technological advances will influence the
  pediatric nurse to increase technical skills
  related to patient care.
• Nurses will need to keep abreast of developments
  in adolescent medicine and continually adapt
  their care to the cultural environment in which
  they practice.

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Pediatric Nursing

• Nursing Implications of Growth and Development
• One of the nurses primary responsibilities is to
  identify an infant or child who is demonstrating
  cognitive impairment.
• Knowledge of child development allows the nurse
  to use a developmental rather than a chronologic
  approach to pediatric nursing care.
• Understanding normal growth and development
  enables a nurse to select age-appropriate toys
  for the infant or young toddler and to devise
  activities that appeal to the school-aged child
  or adolescent.

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Pediatric Nursing

• Nursing Implications of Growth and Development
  (continued)
• A knowledge of growth and development also is the
  basis for anticipatory guidance with parents.
• Psychological preparation of a patient for an
  event expected to be stressful.

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Physical Assessment of the Pediatric Patient

• Growth Measurements
• Measurement of physical growth is a key element
  in evaluation of the health status of children.
• Measurements are plotted by percentiles on growth
  carts and compared with those of the general
  pediatric population to determine deviation from
  the norm.

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Physical Assessment of the Pediatric Patient

• Growth Measurements (continued)
• Length
• Measurements are taken when children are supine
  recumbent length is usually measured until 2
  years of age.
• Height
• Measurement is of a child standing upright.

16
Figure 30-1
(From Hockenberry-Eaton, M.J., Wilson, D.,
Winkelstein, M.L., Kline, M.D. 2003. Wongs
nursing care of infants and children. 7th ed..
St. Louis Mosby.)
Measurement of head, chest, and abdominal
circumference and crown-to-heel measurement.
17
Physical Assessment of the Pediatric Patient

• Growth Measurements (continued)
• Weight
• Fluid loss and inadequate calories are reflected
  in a childs weight, especially that of infants
  and toddlers.
• Same scale should be used, and the child should
  be weighed at the same time every day.
• Skin Thickness
• Skinfold thickness should be determined at one
  site with at least two measurements.
• Arm circumference measures muscle mass.

18
Figure 30-2
(From Hockenberry-Eaton, M.J., Wilson, D.,
Winkelstein, M.L., Kline, M.D. 2003. Wongs
nursing care of infants and children. 7th ed..
St. Louis Mosby.)
A, Infant on scale. B, Toddler on scale.
19
Physical Assessment of the Pediatric Patient

• Vital Signs
• Temperature
• Reflects metabolism
• Fairly stable from infancy through adulthood
• Primary purpose of measuring body temperature to
  detect abnormally high or low values
• Routes oral, rectal, axillary, and tympanic
• Normal findings approximately 97 F to 99 F

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Physical Assessment of the Pediatric Patient

• Vital Signs (continued)
• Heart Rate/Pulse
• Great variations exist.
• Infection and physical activity increase heart
  rate. Note any irregularities in volume, rate,
  and rhythm.
• Apical pulse is taken on infants and young
  children a radial pulse is often taken on
  children 5 years of age and older.
• Pulse rate should be counted for 1 full minute.
• Apical beat of a newborn may be 152 beats per
  minute and gradually slows to 72 to 75 beats by
  adolescence.

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Physical Assessment of the Pediatric Patient

• Vital Signs (continued)
• Respirations
• Infants respirations are mainly diaphragmatic
  observe abdominal movement for 1 full minute.
• In older children, respirations are chiefly
  thoracic.
• Respiratory rate slows as a child progresses from
  infancy to adolescence.
• Newborns are obligate nasal breathers.
• Rate, depth, and quality should be assessed.
• Rate may be as rapid as 40 to 50 breaths per
  minute, gradually slowing to 25 to 32 per minute.

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Physical Assessment of the Pediatric Patient

• Vital Signs (continued)
• Blood Pressure
• Blood pressure should be measured in children 3
  years of age and older.
• Blood pressure is low in a newborn and gradually
  rises at the end of adolescence, it is about
  120/78.
• It is important to use the correct size cuff to
  ensure accuracy.
• Measure blood pressure before any
  anxiety-producing procedures.

23
Figure 30-3
(From Hockenberry-Eaton, M.J., Wilson, D.,
Winkelstein, M.L., Kline, M.D. 2003. Wongs
nursing care of infants and children. 7th ed..
St. Louis Mosby.)
Sites for measuring blood pressure.
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Physical Assessment of the Pediatric Patient

• Head-to-Toe Assessment
• Skin
• Genetic and physiologic factors affect assessment
  of color.
• Pallor may be a sign of anemia, chronic disease,
  edema, or shock.
• Erythema may be the result of increased
  temperature, local inflammation, or infection.
• Skin texture should be smooth, soft, and slightly
  dry to the touch.

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Physical Assessment of the Pediatric Patient

• Head-to-Toe Assessment (continued)
• Accessory Structures
• Hair
• Should be lustrous, silky, elastic
• Nails
• Should be pink, convex, smooth, and hard but
  flexible
• Handprints and footprints
• Palm normally shows three flexion creases

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Physical Assessment of the Pediatric Patient

• Head-to-Toe Assessment (continued)
• Eyes
• At birth, visual acuity is 20/400 when holding a
  baby, assume an en face position.
• By the second week of life, tear glands begin to
  function.
• Newborns can follow bright, colorful objects by
  the second or third week of life.
• Vision improves to 20/30 by age 2 to 3 years.
• Accommodation and refraction are present by
  school age.

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Physical Assessment of the Pediatric Patient

• Head-to-Toe Assessment (continued)
• Ears
• Inspect for general hygiene.
• Advise parents and children to clean the ears
  with a washcloth wipe only the outer portion of
  the canal with a swab.
• Mineral oil may be used to soften cerumen.

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Physical Assessment of the Pediatric Patient

• Head-to-Toe Assessment (continued)
• Nose, Mouth, and Throat
• Nose should lie from the center point between the
  eyes to the notch of the upper lip.
• Normally there is no discharge from the nose.
• Inspect the lining of the mouth and the number of
  teeth.

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Physical Assessment of the Pediatric Patient

• Head-to-Toe Assessment (continued)
• Lungs
• Make sure the child is not crying.
• Have them blow out.
• Listen systematically.
• Chest
• Chest is almost circular.
• As the child grows, the chest normally increases
  in a transverse direction.
• Asymmetry may indicate serious underlying
  problems.

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Physical Assessment of the Pediatric Patient

• Head-to-Toe Assessment (continued)
• Back
• Newborn is C-shaped.
• Older child typically has S-shaped curve.
• Marked curvature in posture is abnormal.
• Abdomen
• Inspection cylindrical and flat
• Auscultation listen for peristalsis

31
Figure 30-7
(From Hockenberry-Eaton, M.J., Wilson, D.,
Winkelstein, M.L., Kline, M.D. 2003. Wongs
nursing care of infants and children. 7th ed..
St. Louis Mosby.)
Development of spinal curvatures.
32
Physical Assessment of the Pediatric Patient

• Head-to-Toe Assessment (continued)
• Extremities
• Examine for symmetry, range of motion, and signs
  of malformation.
• Fingers and toes should be counted.
• Toddlers are usually bowlegged.
• Observe for arch development and correct gait.
• School-aged walking posture is more graceful and
  balanced.
• During puberty, adolescents may experience
  awkward posture from rapid growth of extremities.

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Physical Assessment of the Pediatric Patient

• Head-to-Toe Assessment (continued)
• Renal Function
• There is a functional deficiency in the kidneys
  ability to concentrate urine and to cope with
  conditions of fluid and electrolyte fluctuation,
  such as dehydration or fluid overload.
• Urine output varies and depends on the size of
  the infant or child.
• Urine is colorless and odorless.

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Physical Assessment of the Pediatric Patient

• Head-to-Toe Assessment (continued)
• Anus
• Check the anal sphincter.
• History of bowel movements should be noted.
• Assess for perianal itching may be pinworms.
• Genitalia
• This is an excellent time to elicit questions
  concerning body functions or sexual activity.

35
Factors Influencing Growth and Development

• Nutrition
• Nutrition is probably the single most important
  influence on growth.
• A childs appetite fluctuates in response to
  growth spurts.
• Infants begin life outside the womb, nursing at
  the breast or ingesting formula or breast milk
  via bottle or tube.
• Most infants are given solid foods at 4 to 6
  months of age, when they begin to need more iron
  in the diet and their teeth begin to erupt.

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Factors Influencing Growth and Development

• Nutrition (continued)
• It is important for each new food to be
  introduced at weekly intervals so that food
  allergies can be identified.
• By 9 months, several teeth have erupted and
  junior foods, which are a more coarse texture,
  can be offered.
• By 12 to 15 months, toddlers should be eating
  table food prepared for the family.
• As the child moves through toddler and preschool
  stages, fads with strong preferences develop
  encourage a balanced diet.

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Factors Influencing Growth and Development

• Metabolism
• Metabolic needs vary among individuals.
• Rate of metabolism is highest in the newborn
  infant because of ratio of total body surface to
  body weight is much greater than it is in the
  adult.
• The body uses energy provided by foods.
• Because metabolism is so high in infants and
  children, their ability to recover from surgery
  or a fractured bone is swift compared with that
  of an adult.

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Factors Influencing Growth and Development

• Sleep and Rest
• Children spend less total time sleeping as they
  mature.
• Most babies are sleeping through the night by the
  latter part of their first year and take one or
  two naps a day the 3-year-old has usually given
  up daytime naps.
• The best way to prevent sleep problems with the
  infant/child is to establish bedtime rituals that
  do not foster problematic patterns.

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Factors Influencing Growth and Development

• Speech and Communication
• Crying at birth is the earliest evidence of
  speech, followed by other sounds?cooing,
  laughing, or babbling.
• By 9 months, infants practice and painstakingly
  repeat the noises they can make.
• A 1-year-old has a three- to four-word
  vocabulary by 18 months, they usually know 25 to
  50 words by 2 years, they may know more than 250
  words.
• The nurse should know what typifies speech at
  certain stages of childhood.

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Factors Influencing Growth and Development

• Nonverbal Communication
• Young children become very adept at understanding
  nonverbal communication.
• They sense anxiety or fear by the rise in pitch
  of the parents voice.
• Nonverbal symbols include nodding of the head,
  using direct eye contact tapping finger or foot
  avoiding eye contact and sign language.

41
Hospitalization of a Child

• Preadmission Programs
• Many hospitals have orientation programs for
  children who are to be admitted.
• Programs are based on the childs level of
  understanding and stage of development.
• Children should be allowed to prepare for this
  new experience in their own way.
• An emergency admission thrusts the child into an
  unknown environment surrounded by strange
  equipment, frightening sounds, and unfamiliar
  adults.

42
Hospitalization of a Child

• Admission
• Child may be assigned to a nursing unit according
  to their age group.
• Characteristics of providers should include
  compassion, warmth, understanding, and an ability
  to communicate with the child.
• Pediatric units are usually bright, colorful, and
  cheery areas with cartoon figures on the walls.
• Instruct on how equipment works, when meals are
  served, visiting hours, etc.

43
Hospitalization of a Child

• Hospital Policies
• Parents who are involved in care have a sense of
  contribution to the childs recovery.
• Certain hospitals allow children to wear their
  own clothes.
• After a child is admitted, a nursing history is
  obtained an identification bracelet is usually
  worn on the wrist.
• Vital signs and weight are measured and recorded.
• All newly admitted infants and children have
  routine blood samples drawn by a laboratory
  technician.

44
Hospitalization of a Child

• Developmental Support for the Child
• Hospitalization interrupts childrens normal
  routines and threatens their normal developmental
  process.
• It is not unusual for children to regress when
  hospitalized this often persists for several
  months after discharge.
• Nurses should be especially concerned with
  meeting the psychosocial needs of children with
  special needs who are hospitalized.

45
Hospitalization of a Child

• Pain Management
• Health care professionals tend to underestimate
  pain in children.
• Anything that is painful to adults should be
  assumed to be painful to infants and children.
• Knowing when a child is in pain and how intense
  the pain is can sometimes be difficult the nurse
  must rely on physiologic variables and behavioral
  variable.
• Wong-Baker Faces Scale may be helpful in
  assessing pain level.

46
Hospitalization of a Child

• Surgery
• Preparing a child for surgery entails providing
  information to parents and the child about what
  will happen and what the child will experience.
• Six Common Stress Points
• Admission, blood tests, the afternoon of the day
  before surgery, injection of preoperative
  medication before and during transport to the
  operating room, and return to the postanesthesia
  care unit

47
Hospitalization of a Child

• Parent Participation
• It is essential to establish an effective working
  relationship with parents as soon as possible.
• Parents are the most significant individuals to a
  child they know their child better than anyone
  else.
• On admission parents need specific information on
  routines, hospital policies that affect them, any
  limitations that exist, and what is expected of
  them.
• Explain diagnostic tests, medications, or
  procedures.
• As the parents comfort increases, they become
  more involved in meeting their childs physical
  needs.

48
Common Pediatric Procedures

• Bathing
• This provides an opportunity for skin assessment.
• Check temperature of water.
• Protect child from drafts.
• Bathe from the trunk down.
• If umbilical cord is still present, give sponge
  bath and clean around cord with alcohol.
• Be careful to remove soap, rinse, and dry
  creases.
• Cotton-tipped applicators are never used inside
  the ear canal.

49
Common Pediatric Procedures

• Bathing (continued)
• Infants enjoy being placed in basins for baths.
• Use dry hands to pick up the infant.
• Allow this child to play and splash.
• Most toddlers love to be placed in a tub for
  their bath.
• Toys should be provided.
• The child should never be left in a tub without
  supervision.
• School-aged children may be reluctant to bathe
  encourage them to participate in their care.
• Adolescents bathe or shower daily privacy is
  important.

50
Common Pediatric Procedures

• Feedings
• Breastfeeding
• The mother may wish to continue breastfeeding her
  baby who is ill or hospitalized.
• Provide a quiet environment and a comfortable
  chair for nursing.
• If the mother is unable to be present for every
  feeding, encourage her to use a breast pump
  bottles of breast milk can be frozen and given
  later by bottle or tube feeding.

51
Common Pediatric Procedures

• Feedings (continued)
• Formula
• Positioning should be comfortable for the adult
  and the infant infant should be held securely.
• If a burp is not elicited in one position, try
  another.
• After feeding, the infant is positioned on the
  right side.

52
Common Pediatric Procedures

• Feedings (continued)
• Solids
• Infant should be fed in an infant seat.
• Older infants can be placed in a high chair with
  a safety strap.
• Toddlers may resist high chairs nurse may need
  to try an alternative to prevent injury.
• Parents should provide three regular meals and
  planned snacks each day so that the child eats
  about every 2 to 3 hours.
• Children should sit down to eat choking is more
  likely if children eat on the run.

53
Common Pediatric Procedures

• Feedings (continued)
• Gavage
• Some infants and children require the passing of
  a feeding tube through the nose or mouth, down
  the esophagus, and into the stomach.
• To measure for placement measure from the nose
  to the bottom of the earlobe and then to the end
  of the xiphoid process or go by height.
• Restraint may be needed to pass the tube.
• Because infants are nose breathers, the mouth is
  preferred.

54
Common Pediatric Procedures

• Feedings (continued)
• Gavage
• Older children can be asked to swallow as the
  tube is placed.
• Once the tube is in place, secure with tape.
• Before feeding, check placement.
• Infants are given a pacifier to associate sucking
  with satisfying hunger.
• Allow to flow into the stomach via gravity.
• At the completion of feeding, flush the tube with
  sterile water.

55
Common Pediatric Procedures

• Feedings (continued)
• Gastrostomy
• This is often used in children when passing a
  gastric tube is contraindicated or in children
  who require tube feeding over an extended period.
• A tube is inserted into the abdominal wall and
  into the stomach and secured with a purse-string
  suture.
• Feedings are carried out in the same manner and
  rate as in gavage feeding.
• After feedings, the child is placed on the right
  side or in Fowlers position.

56
Common Pediatric Procedures

• Feedings (continued)
• Total Parenteral Nutrition
• A highly concentrated solution of protein,
  glucose, and other nutrients is infused
  intravenously through conventional tubing with a
  special filter attached to remove particulate
  matter and microorganisms.
• Wide-diameter vessels, such as the subclavian
  vein, are the usual sites of infusion.
• Nursing responsibilities include control of
  sepsis, monitoring infusion rate, and continuous
  observation.

57
Common Pediatric Procedures

• Safety Reminder Devices
• At times, for safety, children should be
  restrained after surgery or during a procedure or
  examination.
• This is used only as a last resort.
• The device should be applied correctly, and
  circulation and skin integrity must be monitored
  closely.
• The device should be removed every 2 hours so
  that the body area can be exercised.
• Release extremities one at a time so that the
  child cannot pull out an IV or NG tube.

58
Common Pediatric Procedures

• Safety Reminder Devices (continued)
• Types
• Elbow safety reminder
• Mummy safety reminder
• Clove-Hitch safety reminder
• Jacket safety reminder

59
Figure 30-10
(From Lowdermilk, D.L., Perry, S., Bobak, I.M.
1997. Maternity womens health care. 6th
ed.. St. Louis Mosby.)
Mummy restraint.
60
Common Pediatric Procedures

• Urine Collection
• Collecting a urine specimen can be a major
  problem in pediatrics when the child is not
  toilet trained.
• Methods of Collection
• Suprapubic bladder tap
• Plastic urine collection bags
• Catheterizations

61
Figure 30-11
Suprapubic bladder aspiration.
62
Figure 30-12
(From Wong D.L., Perry, S.E., Hockenberry-Eaton,
M.J. 2002. Maternal-child nursing care. 2nd
ed.. St. Louis Mosby.)
Application of a urine collection bag.
63
Common Pediatric Procedures

• Venipunctures to Obtain Blood Specimens
• In infants and young children, a jugular or
  femoral vein may be used to obtain a blood
  specimen.
• The nurses responsibility is to prepare,
  position, and restrain the child.
• Holding the head or lower extremities absolutely
  immobile is critical.
• Pressure should be applied to the site to prevent
  the formation of a hematoma.
• Sometimes the veins of the extremities,
  especially the arm and the hand, are used.

64
Figure 30-13
(From Wong D.L., Perry, S.E., Hockenberry-Eaton,
M.J. 2002. Maternal-child nursing care. 2nd
ed.. St. Louis Mosby.)
Correct position for jugular venipuncture
procedure.
65
Figure 30-14
(From Wong D.L., Perry, S.E., Hockenberry-Eaton,
M.J. 2002. Maternal-child nursing care. 2nd
ed.. St. Louis Mosby.)
Position for femoral venipuncture procedure.
66
Common Pediatric Procedures

• Lumbar Puncture
• Explain the procedure and answer any questions.
• EMLA, a local anesthetic cream, may be applied to
  the lumbar area it should be applied at least 1
  hour before procedure.
• Position the child at the edge of the exam bed,
  on the side, facing nurse with neck and legs
  gently flexed.
• Observe for any signs of difficulty.
• A toddler may need to have the legs wrapped in a
  blanket
• The child should be held securely until the
  spinal tap is completed.

67
Figure 30-15
(From Wong D.L., Perry, S.E., Hockenberry-Eaton,
M.J. 2002. Maternal-child nursing care. 2nd
ed.. St. Louis Mosby.)
A, Modified side-lying position for lumbar
puncture. B, Older child in side-lying position.
68
Common Pediatric Procedures

• Oxygen Therapy
• This is used to improve the childs respiratory
  status by increasing the amount of oxygen in the
  blood it is also used in children who have
  cardiac or neurologic disorders.
• Infants and young children receiving oxygen are
  monitored on an oximeter.
• Methods
• Hood and incubator
• Mist tents
• Nasal cannula

69
Figure 30-16
(From Wong D.L., Perry, S.E., Hockenberry-Eaton,
M.J. 2002. Maternal-child nursing care. 2nd
ed.. St. Louis Mosby.)
Oxygen is administered to an infant by means of a
plastic hood (Oxy-Hood).
70
Common Pediatric Procedures

• Suctioning
• Suctioning should be used when secretions are
  audible in the airway or when signs of airway
  obstruction or oxygen deficit are present.
• Various devices are used to suction children such
  as a bulb syringe or a straight suction catheter.
• Depth approximately 1/4 to 1/2 inch
• Timing not more than 5 seconds
• Frequency allow 30 seconds between attempts

71
Common Pediatric Procedures

• Intake and Output
• Many health disorders require accurate monitoring
  of the amount of solids and liquids taken in and
  the amount excreted.
• All fluids given to a child are documented on a
  record kept at the bedside.
• All urine voided is measured before it is
  discarded weigh diapers if appropriate.

72
Common Pediatric Procedures

• Medication Administration
• The nurse must know how to compute the dose
  correctly and administer it properly.
• All computed dosages must be checked by a second
  nurse for safety.
• The right amount of the right medication must be
  given to the right child at the right time and
  via the right route.
• Nurses must also observe and document a childs
  response to the drug.
• Methods of calculating dosages for children
  consider age, body weight, and body surface area.

73
Common Pediatric Procedures

• Medication Administration (continued)
• Routes of Administration
• Oral
• Intradermal, subcutaneous, and intramuscular
• Intravenous
• Optic, otic, and nasal
• Rectal

74
Figure 30-17
(Courtesy of Marjorie Pyle, RNC, Lifecircle,
Costa Mesa, California.)
Intramuscular injection sites.
75
Safety

• Protecting a child from harm is a major issue in
  pediatrics.
• Anticipatory guidance for parents of infants and
  toddlers and health teaching for school-age
  children and adolescents are two methods of
  preventing accidents.
• Injuries cause more deaths and disabilities in
  children than do all causes of disease combined.
• Parents and children should talk and listen to
  each other to prevent many accidents.
• The adult who is a role model can influence a
  child immensely.