Assessment for Pericardial Rub,need some advice

EricJRN, MSN, RN · Mar 11, 2006

eMedicine says to use the diaphragm of the stethoscope and listen at the left lower sternal border. It says that serial exams may be needed to detect it. It's a scratching or grating sound, usually triphasic.

papawjohn · Mar 11, 2006

Hey!!!

Well, you have to face the simple fact that not too many Pt's will accomodate you by having Pericardial Friction Rubs. Infact, very very few.

So start by thinking of what kind of Pt is likely to have pericarditis and listen carefully to them. (You've heard the joke about the guy searching the sidewalk carefully one night under a street light. Passer-by says--'lose something?' Guy replies--'Yeah, dropped my car keys.' The two of them search around for a while. Finally passer-by asks--'Did you lose them here?' Guy says--'No, dropped them down the block but the light is better here.)

Seriously, if you think about who's likely to have a nice rub--you'll probably decide two groups of Pts are candidates. First is post-op heart surgeries, CABGs and the like. They tend to have a temporary pericarditis that leads to a set of symptoms called Dresslers Syndrome. They get a fever, develop a rub and go into atrial fib. So if you're post op CABG Pt starts having a mildly elevated fever, THEN you start listening for a rub. And when you call the surgeon and say--'his temp is 100.9 and I heard a soft rub'--he's gonna think you're just a heckofa nurse (altho he won't tell you so) and order a course of steroids.

The other Pt population is Dialysis Pts. They are likely to have chronic pericarditis. A rub would not be such a surprise in one of them--but if they have a rub when you do your initial assessment and then later on they start getting sicker and their BP is down and their Heart Rate is up and you re-assess and DO NOT hear the rub--THAT is when you make the call. Because the chronic pericarditis has developed into a pericardial effusion.

See--it's where you look and what you expect to find that is the cool thing about this job.

Papaw John

VickyRN, MSN, DNP, RN · Mar 12, 2006

Excellent posts, especially from papawjohn. I agree - generally a very rare condition, but we do encounter a transient type of pericardial friction rub quite frequently on our cardiac surgery stepdown unit clinical site. The "rub" is caused by the chest tubes interacting with the pericardium or lung pleura (some patients have several), and disappears within a half hour after the chest tubes are DC'd.

From my teaching notes:

Rubs: These are uncommon sounds caused by the beating of the heart against an inflamed pericardium or lung pleura; continuous creaky-scratchy noise as they rub together. Rubs are heard best sitting and leaning forward, using the diaphragm of the stethoscope. They can be accentuated by listening when the patient sits up, leans forward and exhales, bringing the two layers in closer communication. If the rub completely disappears when the patient holds his breath it is due to pleural, not pericardial, origin.

Excellent web site for listening to an actual rub: http://www.med.ucla.edu/wilkes/Rubintro.htm