INTRODUCTION

Chest pain is one of the most common causes of hospitalization in emergency departments, affecting approximately 70% of patients with acute coronary syndrome. This syndrome is characterized by ischemic manifestations of the myocardial muscle due to complete or partial occlusion of the coronary arteries and can be divided into three clinical forms: unstable angina, non-ST-segment elevation myocardial infarction, and ST -segment elevation myocardial infarction. These severe conditions require nurses to exercise clinical reasoning to make quick and safe decisions^1,2.

Risk classification is a tool that helps nurses, through qualified listening, to take on the role of regulating care demand and determining the priority of care for these patients. These professionals are responsible for using protocols to optimize and provide quality care.

During the admission of a patient with chest pain, the nurse’s assessment becomes essential, as he or she is the professional responsible for classifying risk and regulating care demand, determining the priority of care and referring the patient to the treatment area according to their demands, in an agile and effective manner³.

To this end, the use of assistance instruments, such as flowcharts, can contribute to nursing care through the standardization of care in the initial care of patients with chest pain, providing greater safety and agility in work processes, as it guides decision-making and also contributes to the training and qualification of nursing professionals in emergency services⁴.

Flowcharts can also assist nurses in their management activities by reducing costs and the risk of duplicating tasks. They also improve the effectiveness of care and, consequently, patient safety, in addition to aiding in the visualization of information^4,5.

However, the assistance instruments available in the scientific literature for treating patients with chest pain present decision-making that guides, almost exclusively, medical conduct and does not consider the diversity of nursing actions.

The development of a care flow based on nursing interventions and activities and the main guidelines and recommendations of good practices, allows the nurse and the nursing team to quickly visualize specific nursing actions for these patients in the emergency room⁶.

Thus, the objective is to develop and validate a nursing care flowchart for approaching patients with acute coronary syndrome in emergency services, aiming at standardizing procedures and improving the quality of care.

METHODS

RESULTS

During the integrative literature review process, 664 articles were found, of which 59 were excluded due to duplication, 496 after reading the titles and 63 after reading the abstracts, leaving 46 full articles. Furthermore, 18 studies were excluded because they did not answer the guiding question, leaving 28 articles to be included in the integrative review (figure 01).

Figure 1 : Flowchart of the article search and selection process. 

Regarding the databases, 3 (11%) studies were accessed via LILACS and 25 (89%) via MEDLINE. Among the journals, the Journal of the American Heart Association and the American Journal of Cardiology, both with 3 (11%) indexed searches.

Regarding methodology, 8 (29%) articles were clinical trials, 7 (25%) retrospective studies, 6 (21%) cross-sectional studies, 4 (14%) prospective studies, 1 (4%) descriptive exploratory study, 1 (4%) cohort study, and 1 (4%) with a quantitative approach.

Of the 28 articles, 199 clinical indicators were identified which, after grouping, resulted in 38 standard terms (Chart 1).

The standard terms were mapped with 17 nursing interventions and 115 nursing activities present in the NIC, being: 05 interventions of the Basic Physiological domain in five classes (Elimination Control, Immobility Control, Nutritional Support, Promotion of Physical Comfort and Facilitation of Self-Care); 07 (63%) interventions of the Complex Physiological domain in seven classes (Electrolyte and Acid-Base Control, Medication Control, Neurological Control, Respiratory Control, Skin/Injury Control, Thermoregulation and Tissue Perfusion Control); 01 (02%) intervention of the Behavioral domain in one class (Promotion of Psychological Comfort); 02 (10%) interventions of the Safety domain in two classes (Crisis Control and Risk Control) and 02 (07%) interventions of the Health System domain in two classes (Health System Mediation and Health System Control). No clinical indicators were mapped in the Family and Community domains.

Afterwards, the care flowchart was structured and presented for content assessment in focus group meetings, composed of 7 nurses, who redefined the terminology to “Patient admitted via Spontaneous Demand” and “Patient referred via SAMU”.

Regarding the clinical criteria assessed for patient admission during Risk Classification using the Manchester Protocol, the group added “Altered level of consciousness”; redefined the “Chest pain” indicator to “Precordial or cardiac pain”; and preferred to use “ Acute dyspnea and very low SatO²” instead of “Tachypnea (RR: 25 IRPM) and SatO² < 92%.” Participants unanimously maintained the bradycardia value (HR <50 bpm), but focused more discussion on the tachycardia value, which was defined as greater than 140 beats per minute. There was also consensus on the systolic blood pressure value equal to or less than 80 mmHg.

For patients under clinical observation, the focus group suggested adding a care process box called “ Observation Follow-up” containing nursing activities. The addition of hygiene-related activities to the flowchart was also suggested and accepted.

The focus group requested that electrocardiograms be performed daily for up to 96 hours, considering the time of admission to the cardiac emergency department. The following nursing activity was also added: “Arrange for an electrocardiogram within 10 minutes,” correlating with the recommendations for the test to be performed within the first few minutes of care.

The group discussed that fluid balance should be performed every six hours and vital signs should be recorded according to the complexity and clinical response of the patient.

Everyone agreed that the service should be organized by level of complexity in the flowchart and that similar activities should be excluded in order to bring more objectivity.

After assessment and adjustments made by the focus group, 18 judges were invited to carry out the content validation process. However, only 8 participated in the research: 5 (62.5%) were female; 3 (37.5%) with a lato sensu postgraduate degree and 5 (62.5%) with a stricto sensu postgraduate degree (master’s/doctorate); 1 (12.5%) with a specialization in Urgency and Emergency, 2 (25%) in Intensive Care, 2 (25%) in Cardiology Nursing and 3 (37.5%) with other specializations; 3 (37.5%) have worked or work as a teacher and 4 (50%) have worked or work with clinical research. The average time working in Urgency and Emergency was 9 years. The average age among the judges ranged from 31 to 40 years.

According to the responses regarding clinical relevance, practical relevance and clarity of language, the items evaluated by the judges obtained a CVI equal to or greater than 0.80 in two or more requirements (table 1).

Considering that most items obtained evidence of validity among the judges with CVI ≥0.80, the suggestions made during the evaluation of each box were analyzed and many were incorporated into the flowchart in order to enrich it with the experience and knowledge of the participants.

In the space provided for suggestions in BOX 01, the judges indicated obtaining or changing peripheral venous access to the left upper limb, favoring the right upper limb for performing procedures via the right radial artery.

They also suggested the inclusion of 12 precordial leads for performing an electrocardiogram and reinforced the importance of patient identification.

Regarding emotional support, they expressed special attention in BOX 02, incorporating the activity “ Provide factual information regarding diagnosis, treatment and prognosis”.

The nursing activities “Keep the head of the bed elevated at 30 to 45 degrees, except when contraindicated (i.e., hemodynamic instability)” and “Document all changes in the respirator configuration, with justification for changes” were also added to BOX 03.

BOX 04 received a CVI of 0.75 for clarity of language. Therefore, the judges suggested performing a fluid balance, although this activity is detailed in the box labeled “Routine Care.” They also suggested describing the signs and symptoms of decreased cardiac output in the activity “Monitor signs and symptoms of decreased cardiac output”.

The activity “Identify the patient’s cognitive or physical deficits that may increase the potential for falls” was included in BOX 07 due to the precaution regarding the risk of falls in light of the clinical indicators evaluated.

For patients who present anxiety, confusion, or restlessness, the judges suggested evaluating the need for physical restraint with other team members and considering the inclusion of a family member.

Regarding the clarity of language in the “Discharge Guidelines,” the CVI was 0.75, with adjustments requested by the judges, who suggested describing the characteristics of pain that would motivate seeking prompt help. However, after discussion, the researchers concluded that this issue is addressed in the activity “Provide guidance on signs/symptoms of early heart disease and worsening heart disease”.

Regarding “Admission care”, the activity “Ensure continuous ECG monitoring at the bedside” was added at the suggestion of the judges.

In “Routine Care”, the activity was modified to “Obtain an ECG when necessary and within 96 hours of admission”, allowing for identification of changes. The activities “Document assessments, diagnoses, interventions, and outcomes of nursing care provided”, documenting nursing records, and “Use an assessment tool for risk of skin breakdown and falls”, were also included , as suggested.

Thus, the nursing care flowchart, in its final version, was structured as follows (figure 02).

Figure 2a : Nursing care flowchart for patients with chest pain in acute coronary syndrome in the emergency room, Brazil, 2025. Source: Prepared by the authors 

Figure 2b : Nursing care flowchart for patients with chest pain in acute coronary syndrome in the emergency room, Brazil, 2025. Source: Prepared by the authors 

DISCUSSION

This research developed and validated a nursing care flowchart for patients with chest pain associated with acute coronary syndrome treated in an emergency unit, based on the care sequence of the American Heart Association Acute Coronary Syndrome Algorithm.

This flowchart is considered a unique care tool because it encompasses a set of clinical indicators that can contribute to nurses’ decision-making for the standardization of actions during the different phases of emergency care for patients with acute coronary syndrome, based on the main nursing interventions and activities and the main guidelines and recommendations for good practices.

In the admission stage of the flowchart, the inclusion of the assessment of precordial or cardiac pain becomes of great importance, as it is considered the most common manifestation of acute coronary syndrome¹⁹. It is characterized by the Levine sign, which contributes to the suspicion of ischemia, where the patient places the clenched fist on the sternum, and describes the pain as a sensation of tightness or burning that can spread to the upper limbs and face²⁰.

Other typical symptoms, such as dyspnea, bradycardia, altered level of consciousness, hypotension, pain radiating to the jaw/neck, associated diaphoresis, and pain worsening with exertion, should also be assessed upon emergency room admission and become important markers for reducing nursing staff response time, helping to reduce complications and mortality. Furthermore, pain radiating to the right arm or both arms, vomiting, chest pain, and sweating made acute myocardial infarction more likely, considering advanced age, male gender, and electrocardiogram changes²¹.

Although the literature highlights these characteristic symptoms, considered typical, nursing staff should be aware that only 70% of patients admitted to the cardiac emergency room present one of these symptoms. Approximately 13% present none of these typical symptoms, and the use of clinical history alone is inadequate to reliably diagnose or exclude acute coronary syndrome²².

Another important factor to consider upon admission is age. However, although older adults have an increased risk of cardiovascular disease, care for young adults in cardiac emergency departments should not be neglected, considering the elevated risk of cardiovascular disease in this population, especially with heart failure²³, although a study conducted in Brazil demonstrated a stabilization in the risk of death among young adults from coronary artery disease in recent years²⁴.

After admission to the emergency department, patients presenting with chest pain with ischemic characteristics should immediately begin the Chest Pain Protocol, which prioritizes immediate nursing care. During this phase, the patient should be monitored and kept at rest, oxygen levels measured, and peripheral venipuncture performed for medication administration. In parallel, data collection begins, contributing to effective nursing care and promoting patient safety.

Another priority in nursing care is performing an electrocardiogram within the established 10-minute timeframe after the patient’s arrival, known as the door-to-electrode time. It is a painless, noninvasive, low-cost, and fast-acting test that captures electrical waves from the heart through electrodes attached to the patient, identifying possible coronary obstructions, heart chamber problems, and heart rate and rhythm²⁶.

It is also important to highlight the importance of collecting laboratory tests, with troponin levels considered the gold standard in the diagnosis of acute myocardial infarction due to their extremely high sensitivity, allowing the identification of small myocardial lesions. Cardiac enzymes should be collected upon admission and again 6 hours after the first collection, to ensure accurate analysis and a definitive medical diagnosis²⁷.

Considering the complexity of actions to be performed by the nurse in caring for these patients, the preparation of the care flowchart becomes fundamental with the aim of standardizing the assessment, management and treatment non-pharmacological , thus enabling more qualified and safe nursing care¹².

Furthermore, the flowchart highlights the patient’s admission to the service: whether through spontaneous demand, preceded by the Manchester Protocol Risk Classification, whose outcome is determined by the patient’s clinical presentation, or through referrals via the Emergency Medical Service (SAMU), promptly admitted to the emergency room. In this phase, classified patients who show no signs of severity will remain under observation for diagnostic and therapeutic determination, while referred patients are quickly transferred to the therapy of choice with diagnostic confirmation, taking into account the recommended reperfusion times.

It is worth noting that the flowchart, developed in this study by professionals with clinical experience in emergency care , follows a sequence of care according to severity and/or complexity and, consequently, the nursing care inherent to each stage of the process. It includes discharge guidelines and highlighted boxes for emergency care, admission care, routine care, and transfer care.

Therefore, developing a nursing care flowchart for patients with acute coronary syndrome in the emergency room represents a novel, feasible, accessible, and necessary care technology for emergency services. It is based on the main interventions and activities contained in the NIC and on key guidelines and best practice recommendations.

Furthermore, it can be readily viewed by the nurse and the nursing team to define the appropriate actions to be followed and implemented, guided by the clinical indicator and the complexity presented by the patient during the different phases of care, assisting in decision-making, emphasizing the context of urgency and emergency, in addition to promoting and providing visibility to nursing conducts.

CONCLUSION

The development of a nursing care flowchart is a viable, accessible and necessary care technology to qualify care for patients with chest pain resulting from acute coronary syndrome, in all phases of emergency care.