1. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Chapter 06 Promoting Reproductive Health Through an Understanding of Cervical Cytology Screening, Human Papillomavirus, and Cervical Cancer

2. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Human Papillomavirus  DNA tumor virus  Associated with premalignant/malignant cervical disease and other cancers  Over 100 virus types with various manifestations (common warts, plantar warts, skin cancers, anal/genital warts)  Most common STD in the U.S.

3. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Uterine Cervix  Squamous epithelium  Columnar epithelium  Meet at the squamocolumnar junction  Squamous metaplasia: process of change from columnar to squamous cellls  Transformation zone: area between old and new SCJ

4. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Cervical Cancer Screening  Papanicolaou (Pap) test - 1940s  Cytological study for detecting cancer  Worldwide, most widely used cancer screening method  Can detect 95% of all cervical cancers and precancerous abnormalities  Dramatically reduces cervical cancer death rates

5. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Pap Test Technique  Sample the squamocolumnar junction  Perform prior to digital vaginal examination  Perform prior to endocervical sampling  Moisten vaginal speculum with water only  Remove excess cervical discharge with a cotton-tipped applicator prior to sampling

6. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Pap Test Technique (cont’d)  Conventional testing  One or two glass slides  Various sampling devices available  Begin with exocervix, then endocervix  Immediately “fix” with a preservative

7. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Pap Test Technique (cont’d)  Liquid-based process  Cell samples collected with special brush  Brush immediately placed in alcohol-based preservative  Contaminants (e.g., blood, mucus) removed  May test same sample for HPV, gonorrhea, Chlamydia

8. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Cervical Cancer Screening  Begin at age 21  Every 2 years ages 21–29  Age 30+: if three consecutive negative results, screen every 3 years unless special risk factors  HIV+ or DES or previous cervical cancer  Immunosuppressed

9. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Optimizing Cervical Cancer Screening  Collect cytology sample at mid-cycle  Teach patients: for 24–48 hours prior to testing  Avoid intercourse  Avoid vaginal medications  Avoid douching  Document all communication re: Pap testing

10. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Cervical Cancer Screening in Older Women  May discontinue after age 65–70 if three consecutive negative tests and no abnormal test findings in previous 10 years (ACS,USPSTF, ACOG)

11. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Bethesda System  Abnormal cervical cytology  Epithelial cell abnormalities  Glandular cell abnormalities  Adenocarcinoma in situ  Abnormal cervical histology  Cervical intraepithelial neoplasia

12. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Follow-Up for Abnormal Cervical Cytology Screening Results  Reflex HPV DNA testing (ASCUS)  Colposcopy  Endocervical sampling

13. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Management of Abnormal Cervical Cytology Results  Cryosurgery  Laser ablation  Conization  Cold knife  Laser  Loop electrosurgical excision procedure

14. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Genital Human Papillomavirus  Around 40 strains infect the genital tract  HPV types 6 and 11 - “low risk”  HPV type 16 - squamous cell carcinoma  HPV type 18 - cervical adenocarcinoma  Other “high risk” types (e.g., 31, 33, 35, 39, 45, 51, 56, 58, 59, 68, 73)

15. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint High Risk HPV  Produces no symptoms  Detected by DNA testing  Primary cause of cervical neoplasia  Persistent infection associated with cervical cancer

16. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint HPV DNA Testing  Performed on vaginal/cervical cell sample collected for a Pap test  Assesses for one or more potentially cancer-causing HPV types  Recommended for women 30+ years old

17. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint HPV Infection: Manifestations  Abnormal Pap test results  External genital warts (1%)  Condyloma acuminata, smooth papular warts, keratotic genital warts, flat warts  Cervical lesions (10%)  Majority heal through natural immune response  Some persist and progress to cervical cancer

18. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint HPV Infection/HPV-Related Cervical Disease: Risk Factors  Cigarette smoking  Greater than three lifetime sex partners  New sex partner within past 12 months  Drug use within past 12 months  Intercourse while alcohol-impaired  Never married

19. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Patient Teaching to Reduce Cervical Cancer Risk  Healthy lifestyle  Diet  Avoid chemical/environmental hazards  Sexual health awareness (e.g., condoms, monogamous relationship)  Prophylactic HPV vaccination

20. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint HPV Vaccines  Gardasil – HPV types 6, 11, 16, 18  Also approved for use in males  Cervarix – HPV types 16, 18  Three intramuscular injections  Ideally administered before initiation of sexual activity  Avoid during pregnancy

21. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint External Genital Warts: Treatment  Goal: destroy visible lesions, reduce patient symptoms  Provider-administered medications  Patient-applied medications  Surgical therapies

22. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Cervical Cancer  Squamous cell carcinoma (80%–90%)  Adenocarcinoma  Typically slow growing, begins as dysplasia (pre-cancerous condition)  Detected by Pap test  100% curable

23. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Cervical Cancer Risk Factors  HPV infection, immunosuppression  Cigarette smoking, alcoholism, poor nutrition  Co-infection with other STDs  Early onset of sexual activity, multiple sexual partners, early age first full-term pregnancy  Inadequate cervical screening  In utero DES exposure  Family history of cervical cancer

24. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Cervical Cancer Symptoms  When present, may include  Continuous vaginal discharge  Abnormal vaginal bleeding  Heavier, longer menstrual periods  Loss of appetite, weight loss  Fatigue  Pelvic pain, back pain, leg pain

25. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Cervical Cancer Work-Up  To determine spread, testing may include  X-ray computed tomography  Magnetic resonance imaging  Positron emission tomography  Cystoscopy  Chest x-ray  Intravenous pyelogram

26. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Cervical Cancer Treatment  Dependent upon cancer stage  May include  Surgery  Radiation therapy  Chemotherapy  Biological therapy

27. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Cervical Cancer Surgery  With invasive cancer diagnosis  Combined with radiation therapy  Options range from conization to radical hysterectomy  Pelvic exenteration – to treat recurrent metastatic cervical cancer

28. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Radiation Therapy for Cervical Cancer  External therapy  Internal therapy (brachytherapy)  Combination external + internal RT

29. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint External Beam Radiation Therapy  Target area includes entire pelvis  Generally administered 5x/week x 5–6 wks  Education, emotional support essential  Awareness of side effects, danger signs  Comfort strategies  Self-care, healing strategies

30. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Internal Implant Radiation Therapy  Placement of radioactive material as close to tumor as possible  Performed in the hospital (1–3 day stay)  Patient radioactive during treatment  Usually causes sterility  Physical care, emotional support essential

31. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Chemotherapy for Cervical Cancer  Used for metastatic or recurrent cancer  May be oral or intravenous  May be used in combination with other chemotherapeutic agents  May be combined with RT or surgery

32. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Chemotherapy Patient Teaching  Common side effects  Nausea and vomiting  Change in appetite, oral lesions  Vaginal sores  Temporary hair loss  Fatigue  Anemia, bruising, skin rash, infection susceptibility  Menstrual cycle changes, infertility  Pain, swelling in legs and feet

33. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Biological Therapy  Used for metastatic cancer  Interferon most common therapy  Sometimes combined with chemotherapy  Usually administered on outpatient basis  Counsel about side effects: flu-like symptoms, rash, anorexia, bruising

34. Shelton Hisley The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint The Women’s Health Companion aternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint to Maternal-Child Nursing Care: Optimizing Outcomes For Mothers, Children and Families: Enhanced, Revised Reprint Nursing Role in Cervical Health Promotion  Education – all ages  Cervical cancer screening  Cervical cancer symptoms  Relationship between HPV and cervical cancer  Strategies to reduce HPV risk  Support for state, federal funding