Nurse-led non-pharmacological interventions for prevention and management of postoperative nausea and vomiting in adults undergoing laparoscopic surgery: an evidence summary

Abstract

Background

Postoperative nausea and vomiting (PONV), as a common complication in laparoscopic surgery, significantly delays patients’ recovery and increases the incidence of unplanned readmission. Although drug prevention is widely used, nurse-led non-pharmacological interventions can provide safe and effective collaborative management. However, the current evidence is fragmented and there is a lack of guidelines specific to laparoscopic surgery, resulting in significant differences in clinical practice. This study aimed to integrate the best evidence and establish standardized non-pharmacological nursing strategies for the prevention and treatment of PONV in adults undergoing laparoscopic surgery.

Methods

Following the standard methodology of the Fudan University Center for Evidence-based Nursing (registration number: ES20257623) and guided by the “5S” evidence pyramid model, we systematically searched multiple databases and guideline repositories from inception to December 4, 2025. We included evidence summary, clinical decision, guidelines, expert consensus statements, systematic reviews and meta-analyses. Literature screening, quality appraisal, and evidence extraction were performed independently by two reviewers. Methodological quality was assessed using validated screening tools. A summary of findings table was constructed to present the synthesized evidence.

Results

From 1,564 initial records, 39 publications were included: 5 evidence summaries, 1 clinical decision, 8 guidelines, 4 expert consensuses and 21 systematic reviews. We synthesized 28 best practice recommendations across five key domains: pre-operative risk assessment (identification of risk factors, risk quantification tools, stratified PONV prophylaxis), intraoperative preventive interventions (fluid management, acupoint stimulation, high-concentration oxygen), post-operative symptom management (symptom assessment tool, non-pharmacological management), follow-up care (health education, prevention and control of PDNV), system support (organizational management).

Conclusion

This evidence summary provided a comprehensive, clinically actionable framework for nurses to lead proactive, evidence-based PONV care for laparoscopic surgery patients. Effective nursing interventions directly reduced PONV incidence, decreased antiemetic requirements, and improved patient comfort and satisfaction. In addition, nursing practice can shift from reactive management to proactive prevention, thereby delivering patient-centered benefits. The findings should be adapted to local contexts to develop standardized nursing procedures, thereby translating evidence into clinical practice.

Clinical trial number

Not applicable.

Supplementary information

The online version contains supplementary material available at https://doi.org/10.1186/s12912-026-05029-5.

Introduction

Laparoscopy is a minimally invasive technique that involves inserting a camera and surgical instruments through small incisions in the abdominal wall (typically 0.5–1.5 cm) to perform diagnostic and therapeutic procedures [1]. Compared to traditional open surgery, laparoscopic procedures offer advantages such as reduced intraoperative bleeding, minimal trauma, clear visualization, less postoperative pain, shorter hospital stays, and a lower incidence of complications [1, 2]. Laparoscopy has been widely adopted in various surgical procedures (such as laparoscopic cholecystectomy, laparoscopic pancreaticoduodenectomy, laparoscopic sleeve gastrectomy, laparoscopic radical prostatectomy), as well as in the treatment of gynecological conditions (including uterine fibroids, ovarian cysts, and ectopic pregnancies) [3, 4]. Day surgery is an important development direction in minimally invasive surgery. Its core advantages lie in high efficiency, safety, and low cost. Currently, the well-developed surgical procedures are mainly focused on benign lesions of the body surface and abdominal cavity (such as inguinal hernia, gallstones, appendicitis, and ovarian cysts). However, complex surgeries involving organ reconstruction or with a high risk of complications (such as gastrointestinal tumor resection and partial liver resection) still require the traditional inpatient management model. Although laparoscopic surgery has many advantages, it is also associated with certain postoperative complications, such as subcutaneous emphysema, bleeding, infection, postoperative pain, and postoperative nausea and vomiting (PONV) [3, 4].

PONV refers to nausea and vomiting occurring within 24 hours following surgery [4]. The overall incidence of PONV worldwide is 27.7% [5]. Patients undergoing laparoscopic surgery are a high-risk group for PONV, which is significantly higher than that of other surgical procedures. The incidence rate in high-risk groups reaches up to 80% [6–8]. Laparoscopic surgery requires the creation of a pneumoperitoneum [9]. The injected carbon dioxide can stimulate the diaphragm, thereby activating the vomiting center. Additionally, increased pneumoperitoneum pressure compresses abdominal organs, disrupting gastrointestinal motility and digestive function, ultimately causing PONV. PONV is the second most common postoperative complication after pain and a patient-ranked feared surgical outcome [10]. PONV not only heightens patients’ postoperative discomfort and prolongs hospital stays, but may also lead to serious adverse events (such as aspiration and wound dehiscence), thereby significantly impacting both patient recovery and the efficient utilization of medical services [11].

As the primary observers and immediate responders to postoperative symptoms, nurses must promptly identify and intervene to alleviate patient distress and enhance comfort. However, due to various factors, there are numerous obstacles to nurses’ prescribing authority, preventing nurses from directly administering medication to patients [12]. Non-pharmacological interventions have thus become the primary means for nurses to alleviate postoperative symptoms [13].

Currently, the primary treatment strategy for PONV remains predominantly pharmacological, with insufficient emphasis placed on non-pharmacological interventions. In fact, non-pharmacological interventions have become an important adjunctive treatment for PONV due to their unique advantages (such as low risk, ease of implementation, and high patient compliance) [14]. These features align perfectly with nurses’ clinical practice settings. Most non-pharmacological interventions require no invasive procedures, allowing nurses to independently master and implement them through systematic training. Many non-pharmacological therapies (such as acupressure, auricular therapy, aromatherapy) have demonstrated good clinical efficacy in reducing PONV incidence [15, 16], particularly for pediatric and geriatric patients as well as special populations with drug contraindications.

In recent years, non-pharmacological interventions for PONV have garnered significant attention and been incorporated into guidelines [8, 15, 17]. However, existing evidence exhibits some gaps. Current recommendations lack specificity for patients undergoing laparoscopic surgery and focus primarily on pharmacological treatments [18], meaning that nurse-led non-pharmacological treatment options have not yet been fully explored. Furthermore, significant heterogeneity in implementation practices (such as the timing of interventions and technical standards) has led to variations in clinical outcomes. Therefore, this evidence summary aimed to conduct a systematic review and integration of the evidence for the prevention and management of PONV in laparoscopic surgery, to provide the most reliable basis for clinical practice.

Material and methods

This evidence summary was reported according to the standard of evidence summary report of Fudan University Center for Evidence-based Nursing [19] and registered at the Center for Evidence-based Nursing of Fudan University (registration number ES20257623).

Question identification

Evidence-based nursing problems were identified based on the PIPOST framework. P (population): adult patients (≥18 years old) undergoing laparoscopic surgery; I (intervention): non-pharmacological management strategies for perioperative PONV; P (professional): healthcare providers, patients, or family members; O (outcome): PONV incidence and severity, antiemetic usage, hospital-related indicators (postoperative length of stay, unplanned hospital readmissions due to PONV), and health economics indicators; S (setting): hospital, clinic, or patient’s home; T (type): evidence summary, clinical decision, guidelines, expert consensus statements, systematic reviews and meta-analyses.

Evidence retrieval

Based on the evidence pyramid “5S” model [20], the search was performed from top to bottom. The following databases were searched: BMJ best practice, JBI Best Practice Database, Up To Date, Yimaitong, National Institute for Health and Clinical Excellence (NICE), Registered Nurses Association of Ontario (RNAO), Guidelines International Network (GIN), National Guideline Clearinghouse (NGC), New Zealand Guidelines Group (NZGG), European Association for the Study of the Liver (EASL), American Association for the Study of Liver Diseases (AASLD), PubMed, Embase, Cochrane Library, CINAHL, SinoMed, China National Knowledge Infrastructure (CNKI), and Wanfang Database.

The search was performed using a combination of subject words and free words. Search keywords included postoperative nausea and vomiting, laparoscopy, cholecystectomy, bariatric surgery, appendectomy, gynaecological surgery, minimally invasive surgery, evidence summary, clinical decision, guidelines, expert consensus, systematic reviews and meta-analyses. Search dates ranged from database inception to December 4, 2025. Detailed search strategies were provided in Supplementary Material 1.

Inclusion and exclusion criteria of evidences

The inclusion criteria for this study were: (1) study subjects must be patients undergoing laparoscopic surgery, aged ≥ 18 years; (2) studies must focus on the prevention and management of perioperative PONV, including assessment and non-pharmacological interventions; (3) study types must include evidence summary, clinical decision, guidelines, expert consensus, systematic reviews and meta-analyses; (4) studies must be in English or Chinese.

Exclusion criteria include: (1) original research; (2) duplicated literature; (3) studies classified as plans, drafts, or containing only abstracts; (4) studies failing quality assessment.

Literature screening

EndNote 20.6 (Clarivate Analytics) was used for literature management. Duplicate references were removed through EndNote. Two trained researchers (Qin Xu and Weidi Wang) independently conducted literature screening and quality assessment. In cases of disagreement during evaluation, a third expert (Juan Han) was consulted to reach consensus.

Methodological quality of included evidence

In this study, we employed different evaluation tools to assess various types of literature. Clinical decision and evidence summary are sourced from authoritative databases (such as Up to Date and JBI), representing the highest level of evidence. Their evidence is assumed to be extracted directly from high-quality research [21, 22].

The guidelines were assessed using the 2017 version of The Appraisal of Guidelines for Research and Evaluation II (AGREE II) [23]. It encompasses 23 items across six domains, including scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Each item is scored on a scale of 1 to 7 (1 indicating strongly disagree, 7 indicating strongly agree). Scores for each domain are calculated as follows: (actual score - lowest possible score)/(maximum possible score - lowest possible score) × 100%. If scores in 6 domains are ≥60%, the guideline is rated Grade A and directly recommended. If one or more areas have scores < 60% and three or more areas have scores ≥ 30%, it is rated Grade B and recommended after revision. If scores in more than 3 domains < 30%, it is rated Grade C and not recommended. The consistency between evaluators was assessed using the intraclass correlation coefficient (ICC). For expert consensus, the 2016 edition of the Australian JBI Centre for Evidence-Based Health Care evaluation criteria for expert consensus was used [24, 25]. For systematic reviews and meta-analyses, the 2016 version of the Australian JBI Centre for Evidence-Based Health Care Systematic served as the quality assessment tool [25, 26].

Evidences extraction

Two trained researchers (Qin Xu and Weidi Wang) independently extracted, categorized, and synthesized the evidence. The evidence extraction process adhered to the following principles: (1) if recommendations were identical, the most concise and logically clear statement was selected; (2) if recommendations were complementary, they were merged based on logical relationships and linguistic expression; (3) if content was conflicting, priority was given to evidence from high-quality, recently published literature in authoritative journals. Each evidence was disassembled and analyzed across multiple dimensions.

Evidences summary

Following integration, evidence was scored using the 2014 version of the JBI Evidence Pre-grading System and Evidence Rank System [27, 28]. The evidence levels categorized from 1 to 5 based on study design. The more rigorous the study design, the higher the level of evidence. Based on the FAME framework (feasibility, applicability, meaningfulness, and effectiveness) of JBI, evidence was classified into Grade A (strong recommendation) and Grade B (weak recommendation). If the content of multiple different types of literature was integrated into a single piece of evidence, the highest grade among the literature was used as the grade of that evidence.

Results

Literature search results and general information

Initially, 1,564 studies were retrieved. Of these, 1,240 required reviews of titles and abstracts. Following exclusion of 1150 irrelevant studies, 90 studies warranted full-text assessment. Ultimately, 39 studies were included: five evidence summaries, one clinical decision, eight guidelines, four expert consensuses and twenty-one systematic reviews. The specific reasons for excluding the literature after reading the full text can be found in Supplementary Material 2. The literature screening flowchart was presented in Fig. 1. The overall characteristics of the included studies were summarized in Table 1.

Fig. 1.

Selection of studies included in this best evidence summary. BMJ, BMJ best Practice; JBI, Joanna Briggs Institute; GIN, guidelines International network

Table 1.

Basic characteristics of included studies (n = 39)

Included literature	Source	Year of publication	Type of literature	Title and topic
Moola et al.[29]	JBI	2021	Evidence summary	Postoperative nausea and vomiting: risk assessment.
Marin et al.[30]	JBI	2021	Evidence summary	Postoperative nausea and vomiting: aromatherapy.
Aginga et al.[31]	JBI	2021	Evidence summary	Postoperative nausea and vomiting: acupressure and acupuncture.
Magtoto et al.[32]	JBI	2021	Evidence summary	Postoperative nausea and vomiting: carbohydrate intake.
Sivapuram et al.[33]	JBI	2021	Evidence summary	Postoperative care (major surgical procedures): management after general anesthetic.
Jessica et al.[34]	UpToDate	2025	Clinical decision	Postoperative nausea and vomiting.
Mccracken et al.[35]	UpToDate	2008	Guideline	Guideline for the management of postoperative nausea and vomiting.
Apfelbaumet al.[36]	UpToDate	2013	Guideline	Practice guidelines for postanesthetic care.
Gan et al.[15]	UpToDate	2020	Guideline	Fourth consensus guidelines for the management of postoperative nausea and vomiting.
Gan et al.[37]	Yimaitong	2014	Guideline	Consensus guidelines for the management of postoperative nausea and vomiting.
Gan et al.[17]	Yimaitong	2025	Guideline	Fifth consensus guidelines for the management of postoperative nausea and vomiting: executive summary.
Wang et al.[8]	Yimaitong	2025	Guideline	Clinical practice guidelines for prevention and management of postoperative nausea and vomiting (2025 edition).
Carmichael et al.[38]	PubMed	2017	Guideline	Clinical practice guideline for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons.
Gan et al.[39]	Wanfang	2008	Guideline	Guidelines for the management of postoperative nausea and vomiting by the Society of Ambulatory Anesthesia.
Liu et al.[40]	Wanfang	2017	Expert consensus	Chinese expert consensus on enhanced recovery after surgery for laparoscopic hepatectomy (2017 edition).
Zhu et al.[16]	Wanfang	2022	Expert consensus	Chinese expert consensus on the prevention and treatment of postoperative nausea and vomiting after laparoscopic sleeve gastrectomy (2022 edition)
An et al.[41]	Yimaitong	2019	Expert consensus	Expert guidance on the prevention and treatment of postoperative nausea and vomiting by acupoint stimulation.
Wu et al.[42]	Yimaitong	2012	Expert consensus	Expert recommendations for the prevention and management of postoperative nausea and vomiting (2012).
Chen et al.[43]	Wanfang	2023	Systematic review	Transcutaneous electrical acupoint stimulation in promoting gastrointestinal function recovery after laparoscopic colorectal cancer surgery: a meta-analysis.
Huang et al.[44]	Wanfang	2023	Systematic review	A meta-analysis of efficacy of acupuncture treatment in preventing nausea and vomiting after laparoscopic surgery.
Wang et al.[45]	Wanfang	2024	Systematic review	Effect of transcutaneous electrical acupoint stimulation on postoperative nausea and vomiting after laparoscopic non-gastrointestinal surgery: a meta-analysis.
Ahn et al.[46]	PubMed	2011	Systematic review	A systematic review of interventions to facilitate ambulatory laparoscopic cholecystectomy.
Davey et al.[47]	PubMed	2024	Systematic review	Evaluating the impact of enhanced recovery after surgery protocols on surgical outcomes following bariatric surgery-a systematic review and meta-analysis of randomised clinical trials.
Gao et al.[48]	PubMed	2023	Systematic review	Efficacy and safety of enhanced recovery after surgery protocol on minimally invasive bariatric surgery: a meta-analysis.
Huang et al.[49]	PubMed	2023	Systematic review	Efficacy of acupuncture for nausea and vomiting after laparoscopic surgery: A systematic review and meta-analysis.
Huang et al.[50]	PubMed	2022	Systematic review	Effectiveness and safety of electroacupuncture for the treatment of pain after laparoscopic surgery: a systematic review.
Istrate et al.[51]	PubMed	2024	Systematic review	Enhanced recovery after surgery in laparoscopic cholecystectomy-a systematic review.
Lv et al.[52]	PubMed	2025	Systematic review	Efficacy of acupuncture assisted anesthesia in laparoscopic cholecystectomy: a systematic review and meta-analysis.
Maheta et al.[53]	PubMed	2024	Systematic review	The effectiveness of patient education on laparoscopic surgery postoperative outcomes to determine whether direct coaching is the best approach: systematic review of randomized controlled trials.
Parisi et al.[54]	PubMed	2020	Systematic review	Enhanced recovery after surgery: a systematic review of randomised controlled trials in bariatric surgery.
Qazi et al.[55]	PubMed	2025	Systematic review	Effects of preoperative carbohydrate loading on postoperative outcomes in patients undergoing laparoscopic cholecystectomy: a systematic review and meta-analysis.
Salamah et al.[56]	PubMed	2023	Systematic review	The effects of acupressure on postoperative nausea and vomiting among patients undergoing laparoscopic surgery: A meta-analysis of randomized controlled trials.
Tang et al.[57]	PubMed	2025	Systematic review	The impact of acupuncture on pain intensity, nausea, and vomiting for laparoscopic cholecystectomy: a meta-analysis study.
Tramèr et al.[58]	PubMed	2001	Systematic review	A rational approach to the control of postoperative nausea and vomiting: evidence from systematic reviews. Part I. Efficacy and harm of antiemetic interventions, and methodological issues.
Lu et al.[59]	PubMed	2024	Systematic review	Transcutaneous electrical acupoint stimulation for preventing postoperative nausea and vomiting after laparoscopic surgery: a meta-analysis.
Zhang et al.[60]	PubMed	2021	Systematic review	Systematic review and meta-analysis of the effect of transcutaneous electrical acupoint stimulation on gastrointestinal function after laparoscopic surgery.
Zhao et al.[61]	PubMed	2024	Systematic review	The efficacy of acupressure for nausea and vomiting after laparoscopic cholecystectomy: a meta-analysis study.
Zhou et al.[62]	PubMed	2021	Systematic review	The application of enhanced recovery after surgery for patients undergoing bariatric surgery: a systematic review and meta-analysis.
Vivien et al.[63]	CINAHL	2009	Systematic review	The effectiveness of non-invasive complementary therapies in reducing postoperative nausea and vomiting following abdominal laparoscopic surgery in women: a systematic review.

Literature quality-evaluation results

Evidence summary and clinical decision

The five evidence summaries from JBI and one clinical decision from Up to Date were incorporated directly as high-quality evidence.

Guidelines quality evaluation

This study comprised eight guidelines, with detailed quality assessment presented in Table 2. The percentage of standardization across all guideline met the inclusion criteria. Furthermore, the ICC ranged from 0.72 to 0.97.

Table 2.

Quality evaluation results of guidelines (n = 8)

Inclusion guidelines	Normalized percentage of scores (%)						≥60%of fields	≥30%of fields	Recommendation level	ICC
	Scope and purpose	Stakeholder involvement	Rigor of development	Clarity of presentation	Applicability	Editorial independence
Mccracken et al.[35]	94.44	63.89	82.29	97.22	68.75	54.17	5	6	A	0.93
Apfelbaumet al.[36]	100	75	98.96	94.44	60.42	91.67	6	6	A	0.97
Gan et al.[15]	100	77.78	93.75	97.22	89.58	91.67	6	6	A	0.82
Gan et al.[37]	100	80.56	90.63	100	85.42	100	6	6	A	0.95
Gan et al.[17]	97.22	94.44	95.83	100	85.42	91.67	6	6	A	0.72
Wang et al.[8]	100	88.89	96.88	97.22	72.92	100	6	6	A	0.85
Carmichael et al.[38]	97.22	77.78	94.79	94.44	70.83	100	6	6	A	0.93
Gan et al.[39]	97.22	77.78	78.13	97.22	75	70.83	6	6	A	0.89

Note: The guidelines were assessed using the 2017 version of AGREE II

Expert consensus quality evaluation

This study included four expert consensuses. Among these, all entries in the two studies were rated “Yes”, demonstrating the high quality of the research [16, 40]. The remaining two studies were deemed to be of good quality [41, 42]. Specific details were shown in Table 3.

Table 3.

Quality evaluation results of expert consensus (n = 4)

Items	Liu et al.[40]	Zhu et al.[16]	An et al.[41]	Wu et al.[42]
1. ls the source of the opinion clearly identified?	Yes	Yes	Yes	Yes
2. Does the source of opinion have standing in the field of expertise?	Yes	Yes	Yes	Yes
3. Are the interests of the relevant population the central focus of the opinion?	Yes	Yes	Yes	Yes
4. ls the stated position the result of an analytical process, and is there logic in the opinion expressed?	Yes	Yes	Yes	Yes
5. Is there reference to the extant literature?	Yes	Yes	Yes	Unclear
6. ls any incongruence with the literature/sources logically defended?	Yes	Yes	Unclear	No

Note: The expert consensus was evaluated using the 2016 edition of the Australian JBI Centre for Evidence-Based Health Care evaluation criteria for expert consensus

Systematic reviews quality evaluation

This study comprised 21 systematic reviews, the overall quality of which was considered to be high. For specific details, please refer to Table 4.

Table 4.

Quality evaluation results of systematic review (n = 21)

First author	Evaluation indicators
	1	2	3	4	5	6	7	8	9	10	11
Chen et al.[43]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Huang et al.[44]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes
Wang et al.[45]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Unclear
Ahn et al.[46]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	No	Yes	Yes
Davey et al.[47]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes
Gao et al.[48]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No
Huang et al.[49]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Unclear	Yes	Yes
Huang et al.[50]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes
Istrate et al.[51]	Yes	Yes	Yes	Unclear	Yes	Yes	Yes	No	No	Unclear	Yes
Lv et al.[52]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Unclear	Yes
Maheta et al.[53]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	No	Yes	Yes
Parisi et al.[54]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Qazi et al.[55]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Salamah et al.[56]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Unclear
Tang et al.[57]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes
Tramèr et al.[58]	Yes	Yes	Yes	Yes	Yes	Unclear	Unclear	Yes	Yes	Yes	Yes
Lu et al.[59]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Zhang et al.[60]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes
Zhao et al.[61]	Yes	Yes	Yes	Yes	Yes	Unclear	Unclear	Yes	No	Yes	Yes
Zhou et al.[62]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Vivien et al.[63]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes

Note: The systematic reviews were evaluated using the systematic review tool by the Australian JBI Centre for Evidence-Based Health Care (2016 version)

The specific assessment details are as follows: Whether the evidence-based questions raised are clear and unambiguous (item 1); Whether the literature inclusion criteria were appropriate for this evidence-based question (item 2); Is the search strategy appropriate (item 3); The adequacy of databases or resources for searching literature (item 4); Whether the literature quality evaluation criteria used are appropriate (item 5); Whether two or more reviewers independently complete the quality evaluation of the literature (item 6); Whether to take certain measures to reduce errors when extracting data (item 7); Whether the methods of pooling studies were appropriate (item 8); Whether the possibility of publication bias was assessed (item 9); Whether the proposed policy or practice recommendations are based on the results of systematic reviews (item 10); Whether the proposed directions for further research are appropriate (item 11)

Evidence summary and description

The research content specifically focused on five key aspects of PONV prevention and management (pre-operative risk assessment, intraoperative preventive interventions, post-operative symptom management, follow-up care, system support). A total of 28 evidence-based strategies for preventing and managing PONV following laparoscopic surgery were summarized, as shown in Table 5. Common acupoints for different types of laparoscopic surgery were shown in Fig. 2. The JBI Evidence Pre-grading System and Evidence Rank System used in this study was mainly used to evaluate and present the levels of evidence. Its results should be regarded as key points of evidence-based practice or summary statements of evidence, rather than formal grading recommendations.

Table 5.

Summary of the best evidence for PONV management in adult laparoscopic surgery patients

Classification		Summary of evidence	JBI Levels of Evidence
Pre-operative risk assessment	Identification of risk factors	1. Patient factors: female, history of PONV or motion sickness, non-smoker, younger age, pre-operative nausea and vomiting, and reduced pre-operative physical fitness (ASA classification 3 or higher) (Level 1) [8, 15–17, 34, 35, 38–40]; 2. Anesthesia factors: general anesthesia, inhalation anesthetics, postoperative opioid use, high-dose neostigmine, and prolonged anesthesia duration (Level 1) [8, 16, 34, 35, 38, 40]. 3. Surgical factors: laparoscopic surgery (Level 1) [8, 15–17, 34, 38]), prolonged surgical duration (Level 1) [8, 16, 35, 38].	A A A
	Risk quantification tools	4. The Apfel simplified risk score: it includes 4 risk factors (female gender, non-smoking, history of motion sickness or PONV, postoperative opioid use), with 1 point for each factor. The total score of 0 – 4 points correspond to PONV incidence rates of 10, 20, 40, 60, and 80% respectively (Level 1) [8, 15–17, 34]. 5. The Koivuranta score includes four Apfel risk predictors and a surgery duration exceeding 60 minutes (Level 1) [15, 16].	A A
	Stratified PONV prophylaxis	6. Low-risk patients (with 0 – 1 risk factors) should select preventive measures based on shared decision-making between doctors and patients; medium-risk patients (with 2 – 3 risk factors) should choose one or two intervention measures; high-risk patients (with >3 risk factors) should adopt multi-modal prevention (Level 5) [29].	B
Intraoperative preventive interventions	Fluid management	7. For patients undergoing general anesthesia, maintaining appropriate perioperative fluid balance reduces PONV caused by hypovolemia (Level 1) [8, 15]. 8. Intraoperative fluid volume and rapid fluid administration can reduce PONV incidence (Level 1) [16, 46].	A A
	Acupoint stimulation	9. Acupoint stimulation can be categorized into invasive and non-invasive methods. Invasive techniques include acupuncture and electroacupuncture, while non-invasive approaches encompass acupoint pressure and transcutaneous electrical nerve stimulation (Level 5) [41]. 10. Acupoint stimulation can significantly reduce the incidence of PONV in laparoscopic patients, and it can synergistically enhance the effect with drug to achieve multimodal prevention (Level 1) [8, 16, 39, 44, 50, 57, 58]. 11. The timing of acupoint stimulation does not affect PONV; stimulation is generally initiated either before or after induction of anesthesia (Level 1) [37, 52]. 12. To prevent and treat PONV, different acupoints could be selected based on the surgical site. For hepatobiliary surgery, commonly selected points include PC6 (Neiguan), LI4 (Hegu), LI11 (Quchi), LR3 (Taichong), and GB34 (Yanglingquan). For gynecological surgery, commonly selected points include PC6 (Neiguan), LI4 (Hegu), ST36 (Zusanli), and SP6 (Sanyinjiao). For gastrointestinal surgeries, commonly selected points include PC6 (Neiguan), LI4 (Hegu), ST36 (Zusanli), SP6 (Sanyinjiao), LI11 (Quchi), ST37 (Shangjuxu), RN12 (Zhongwan), RN13 (Shangwan), LR3 (Taichong), RN6 (Qihai), and ST25 (Tianshu) (Level 5) [41]. 13. Auricular acupuncture: selectable points include TF4 (Shenmen), AH6a (Jiaogan), AT4 (Pizhixia), CO13 (Pi), and CO4 (Wei) [41].	A A B A A
	High-concentration oxygen	14. In patients undergoing inhalation anesthesia without preventive antiemetic treatment, high-concentration oxygen therapy has a certain beneficial effect on POV. (Level 1) [15].	A
Post-operative symptom management	Symptom assessment tool	15. Visual analogue scale: Quantify the severity of PONV on a scale of 0–10 (0 points indicate no symptoms, 10 points indicate extremely severe). If the score is ≥ 4 points, drug intervention needs to be initiated (Level 5) [16]. 16. Verbal descriptive scale: 0 indicates no nausea, 1 indicates mild nausea, 2 indicates moderate nausea, 3 indicates severe nausea (Level 5) [16]. 17. PONV frequency score: 0 indicates no nausea, 1 indicates occasional nausea, 2 indicates frequent or most of the time nausea, 3 indicates persistent nausea; 0 indicates no vomiting, 0 indicates 1 episode of vomiting, 2 indicates 2 episodes of vomiting, 3 indicates ≥ 3 episodes of vomiting. A combined nausea and vomiting score ≥ 5 warrants clinical attention (Level 5) [16].	B B B
	Non-pharmacological management	18. Body position: maintaining a head-elevated position postoperatively reduces the incidence of PONV (Level 1) [8, 42]. 19. Chewing gum: chewing gum after surgery reduces the incidence of POV (Level 1) [8, 15, 17]. 20. ERAS: adherence to specific ERAS protocols reduces the incidence of PONV in laparoscopic surgery patients (Level 1) [47, 48, 51, 54, 62]. 21. Aromatherapy: the efficacy of aromatherapy in preventing and treating PONV varies depending on the type of aromatic substance used. Peppermint has not been shown to be more effective than a placebo in preventing PONV (Level 1) [15, 17]; lemon and lavender essential oils could reduce PONV incidence (Level 1) [17, 30]; ginger could reduce PON risk but not POV risk (Level 1) [15, 17, 58, 63]; inhalation of isopropyl alcohol provides short-term efficacy for PONV and may serve as an immediate antiemetic measure when other antiemetic medications are not readily available (Level 1) [15, 17, 34, 63].	A B A A
Follow-up care	Health education	22. Educational formats should include oral, written, multimedia, mobile applications, and one-on-one or group counseling. Educational guidance should cover all information related to preoperative, intraoperative, and postoperative care plans (level 1) [53]. 23. Discuss risk factors for PONV with patients, establish shared approaches to managing PONV, and discuss the risk of nausea and vomiting after discharge (level 5) [29].	A A
	Prevention and control of PDNV	24. The simplified PDNV risk score incorporates five risk factors (female gender, age < 50 years, history of PONV, opioid use in the post-anesthesia care unit, nausea in the post-anesthesia care unit). The incidence of PDNV corresponds to 10, 20, 30, 50, 60, and 80% when 0, 1, 2, 3, 4, or 5 risk factors are present, respectively (Level 1) [17, 34]. 25. Patients undergoing surgery in a day surgery unit may experience PONV after discharge and should be provided with management guidance (Level 1) [35].	A A
System support	Organizational management	26. Healthcare providers should receive training in accordance with local policies and guidelines (Level 5) [33]. 27. During recovery and awakening, healthcare providers should routinely assess and monitor patients for nausea and vomiting symptoms, using selected tools to evaluate and document the risk of PONV (Level 1) [29, 33, 36]. 28. Tailored multimodal therapy should be employed to prevent and treat PONV (Level 1) [38].	B A A

Abbreviation: PONV, postoperative nausea and vomiting; ASA, the American Society of Anesthesiologists; PON, postoperative nausea; POV, postoperative vomiting; ERAS, enhanced recovery after surgery; PDNV, post discharge nausea and vomiting

Fig. 2.

Common acupoints used in different types of laparoscopic surgery. PONV, postoperative nausea and vomiting

Discussion

Screening and assessment of PONV in patients undergoing laparoscopic surgery

Laparoscopic surgery is one of the independent risk factors for PONV [64]. PONV significantly impacts patient experience and prognosis, potentially leading to serious complications such as wound dehiscence, aspiration, and dehydration [11]. Furthermore, some patients reported that the distress caused by PONV exceeds postoperative pain [10]. In clinical practice, PONV management often involves reactive medication administration after symptoms arise, with insufficient awareness and implementation of proactive preventive measures. As the primary implementers of perioperative patient care, nurses can change this situation through systematic interventions.

Evidence items 1 to 5 summarized high-risk factors and assessment tools for PONV in laparoscopic surgery patients. During the preoperative phase, nurses can utilize the Apfel simplified risk score and the Koivuranta score to stratify patient risk [8, 15]. The Koivuranta score incorporates risk factors from the Apfel score and additionally includes a surgery duration exceeding 60 minutes. When patients present with 0, 1, 2, 3, 4, or 5 risk factors, their corresponding risks of PONV are 17, 18, 42, 54, 74, and 87%, respectively. Prior to surgery, nurses can collect key information including female gender, history of postoperative nausea/vomiting or motion sickness, smoking status, as well as core data such as anesthesia method and expected surgical duration [8, 17, 34]. For high-risk individual, nurses should collaborate with the medical team to develop personalized prevention plans in advance. For patients undergoing surgery in clinic, enhanced education on PONV risk is required, guiding patients and their families to recognize early symptoms [17, 65].

Although the Apfel simplified risk score and Koivuranta score are commonly used tools for assessing PONV risk, their predictive dimensions are relatively limited, resulting in restricted predictive efficacy within specific populations. For example, the risk of PONV in bariatric surgery patients is influenced by unique factors such as BMI and surgical technique. Existing scoring systems do not incorporate these variables, potentially leading to mismatches between prevention protocols and actual needs [66]. Therefore, more specific PONV risk assessment tools tailored to different disease types or surgical populations need to be developed in the future to enhance the accuracy of assessment.

Non-pharmacological management of PONV in patients undergoing laparoscopic surgery

Evidence items 6 to 21 summarized non-pharmacological interventions for PONV in patients undergoing laparoscopic surgery.

The ERAS protocol, as a structured, evidence-based perioperative management approach, optimizes nursing processes by integrating multidimensional measures including preoperative counseling, early nutritional support, multimodal pain management, and early mobilization [67]. The ERAS protocol has been proven to effectively reduce the incidence of PONV [47].

In the non-pharmacological management of PONV, the most frequently mentioned approach is acupoint stimulation. Acupoint stimulation is categorized into invasive and non-invasive methods. Invasive stimulation includes acupuncture, electroacupuncture, acupoint injection, and thread implantation; non-invasive stimulation includes acupoint pressure, transcutaneous electrical nerve stimulation, and ultra-laser irradiation [41, 68]. Many studies indicate that acupoint stimulation demonstrates favorable efficacy in preventing PONV [69, 70] following laparoscopic surgery. Acupoint stimulation not only alleviates pain and reduces patients’ medical expenses, but also accelerates the recovery process by regulating the body’s qi and blood [71]. For acupoint stimulation, nurses can lead the implementation of non-invasive techniques such as acupoint pressure and transcutaneous electrical nerve stimulation [72]. Recommended acupoints like Zusanli (ST36) and Neiguan (PC6) should be prioritized [41], with additional auxiliary points selected flexibly based on surgical type [41]. Standardized procedures ensure consistent stimulation efficacy.

Aromatherapy is also a common non-pharmacological treatment. Aromatherapy is a therapeutic practice that utilizes essential oils extracted from plants (flowers, herbs, trees) to address health concerns. Administration methods include olfactory inhalation, direct skin contact (such as massage or topical application), pulmonary inhalation (such as nebulization), and oral administration [73, 74]. However, the efficacy of aromatherapy in preventing PONV varies depending on the intervention protocol, the type of essential oil used, and differences in patient demographics [75]. In previous studies, ginger oil, lavender oil, and peppermint oil proved particularly effective in managing postoperative nausea compared to isopropyl alcohol and sage oil [74, 75]. In addition to single-ingredient essential oils, customized essential oil blends (containing lavender, peppermint, ginger, and lemon) may be considered to reduce the incidence of postoperative PONV [76]. As the primary practitioners of aromatherapy, nurses should adhere to evidence-based guidelines when selecting essential oils (single or blended) for clinical use. Nurses should tailor administration methods to individual characteristics and enhance the safety and suitability of interventions through standardized procedures.

Additionally, nurses must dynamically assess patient responses during interventions, promptly documenting data (such as tolerance levels to acupoint stimulation and the onset time of aromatherapy effects) to provide clinical evidence for optimizing non-pharmacological intervention strategies.

The dynamic assessment of patients relies on standardized tools. Dynamic assessment of PONV severity is a core component for precisely adjusting treatment regimens during intervention. Currently, tools for assessing the severity of PONV include visual analogue scale, verbal descriptive scale and PONV frequency score [16]. These tools provide objective, quantifiable decision-making support for adjusting drug and non-drug treatment regimens, serving as a key safeguard for enhancing intervention effectiveness.

Education and follow-up of PONV in patients undergoing laparoscopic surgery

Evidence items 22 to 28 summarized follow-up measures for PONV in laparoscopic surgery patients and management strategies for PDNV.

During the preoperative phase, nurses can employ diverse methods to systematically explain typical symptoms, risk factors, and potential impacts of PONV to patients. Nurses should guide patients in using tools to proactively report postoperative discomfort, thereby strengthening patients’ awareness of self-monitoring [34, 77]. In postoperative care, nurses should increase assessment frequency for high-risk patients, implement multidimensional dynamic evaluations using standardized tools, promptly identify early symptoms, and adjust intervention plans accordingly. For patients with ambulatory surgery, nurses can provide continuity of care through postoperative bedside health education and telephone follow-ups [78, 79]. Nurses can instruct patients and their families to recognize changes in symptoms, ensuring continuity of intervention. At the same time, nurses can document data such as patient education outcomes and follow-up feedback to provide clinical evidence for optimizing PONV management strategies.

Implications for nursing practice and research

This study summarizes 28 non-pharmacological interventions for PONV in laparoscopic surgery patients, covering pre-operative risk assessment, intraoperative preventive interventions, post-operative symptom management, follow-up care and system support. Nurses’ comprehensive interventions can transform PONV management from a reactive approach to proactive prevention. Through risk screening, dynamic monitoring, individualized interventions, and data feedback, nurses could effectively enhance patient comfort and recovery quality during the perioperative period. This study facilitates nurses in rapidly identifying high-risk individuals and implementing tailored interventions according to the risk and severity of PONV. Furthermore, it promotes standardized nursing practice, enhancing the professional competence and consistency of interventions within nursing teams (e.g., timing of non-pharmacological interventions, selection of acupoints).

Limitation

Although this evidence summary systematically integrated current best evidence regarding nurse-led non-pharmacological interventions for PONV prevention and management in adults undergoing laparoscopic surgery, several limitations should be acknowledged. The search strategy was restricted to publications in Chinese and English, potentially omitting relevant studies published in other languages and introducing language bias. While we followed a rigorous, standardized process for literature screening and quality appraisal involving independent reviewers, some degree of subjective judgment is inevitable in applying tools like AGREE II and JBI checklists. Furthermore, this summary constitutes a descriptive synthesis of evidence. We did not perform a quantitative meta-analysis to pool effect sizes, which limits our ability to provide statistically precise estimates of intervention effectiveness or to conduct subgroup analyses. Lastly, while we aimed to provide clinically actionable recommendations, the process of translating aggregated evidence into specific, context-sensitive nursing protocols was beyond the scope of this review. The feasibility and effectiveness of implementing these evidence-based recommendations in diverse clinical environments, considering variable resources and workflows, warrant further investigation through implementation science studies.

Conclusion

This study employed an evidence-based methodology to summarize the best evidence for the nurse-led non-pharmacological prevention and management of PONV in patients undergoing laparoscopic surgery. Implementing standardized non-pharmacological interventions and dynamic assessment in clinical practice can directly reduce the incidence of PONV in laparoscopic surgery patients and enhance postoperative comfort. Additionally, nurses must translate practice guidance into personalized care plans. As clinical observers, nurses can also document patients’ responses to interventions, thereby tracking emerging evidence for future research and driving the continuous refinement of evidence-based practice.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

JH and QX contributed equally to this work. Study conception and design: JH, QX, WW, YZ. Literature search and screening: QX, WW, JH. Quality assessment and data extraction: QX, WW, JH. Manuscript drafting: JH, QX. Critical revision of the manuscript: WW, YZ. All authors read and approved the final manuscript.

Funding

This work was supported by the Tongji Hospital Research Fund Project [2025C09], and the Second Clinical College Undergraduate Teaching Research Fund Project [TJSZ2025032, TJJXYJ2025028]. The funders had no role in the design of the study, data collection, analysis, interpretation, or in writing the manuscript.

Data availability

The data from this study have been presented in the manuscript and supplementary materials.

Declarations

Ethical approval

Not applicable.

Consent for publish

Not applicable.

Competing interests

The authors declare no competing interests.