by Geraldine Smith, RN, BS, CNOR and Maryann Tiknis, RN, CSN, CAPA

Postoperative nausea and vomiting (PONV) is a common problem for patients’ who receive general anesthesia. PONV can be so distressing that some patients report they would rather feel pain than nausea. In an effort to maintain a high-level of patient satisfaction in Peri-Op services, and to prevent possible post operative complications the nurses at our facility have decided to use a tool to assess for PONV.
The Apfelscore Simplified Assessment Risk Score tool is useful for identifying patients with a high-risk “for PONV.” The Apfel tool score considers four risk characteristics: gender, previous history of PONV or motion sickness, non-smoking status and postoperative use of opioids. At our facility we looked at a performance improvement project and displayed it at the Barnabas Health Quality Fair in October 2013.


A retrospective medical record review of surgical outpatients was performed. Ten cases were reviewed on a monthly basis over a three month period. The results of the study showed that 10 percent of the patients experienced PONV in March compared with 40 percent in April and 30 percent in May. In June, the Apfel Risk Assessment Scoring tool was implemented in pre-admission testing (PAT) or at the time of the pre-op interview where the peri-op nurses calculated the Apfel Score. The registered nurse notified the anesthesiologist if the patient’s Apfel score was 2 or greater – which indicated risk for PONV. Anti-emetics were recommended to prevent PONV.


The results showed that in June 3 percent of surgical outpatients developed PONV. Thirty-three patients were assessed, nine were pre-medicated and one patient developed PONV.

In July 2013, 0.8 percent of the patients experienced PONV. Using the Apfel Score, 23 of the 125 patients assessed were pre-medicated with an anti-emetic, one patient developed PONV.

In August 2013, 2.6 percent of the surgical outpatients assessed experienced PONV. One hundred seventeen patients were assessed, 13 were pre-medicated and three developed PONV.
The results from Sept. 3-10 showed that 10 percent of the patients developed PONV. Forty patients were assessed using the Apfel Score, seven were pre-medicated and four developed PONV.


Predictors of PONV using a risk tool (APFEL); include gender, history of motion sickness, nonsmokers and plan for opioid pain management post operatively provide the clinical team with data indicating a patient’s likelihood of PONV. Identification of patients at risk for PONV and providing preoperative anti-emetics decreases the incidence of PONV.


Apfel C. C (2002, Feb 8). Comparison of predictive models for post operative nausea and vomiting Br J Anesthesia p. 234-40

Hambridge, K. (2013, Jan 2) Assessing the risk of postoperative nausea and vomiting.

Nursing Standard p. 35-43

Weilbach C. (2006) Post operative nausea and vomiting (PONV): Usefulness of Apfel score for identification of high-risk patients for PONV Acta AnesthesaiBelg.