Jugular venous pressure

1. Get the patient to relax, raise the bed so you are not straining.
2. Take the pillow away; the waveforms are often better seen with the head
lying directly against the examining table/bed.
3. Position the neck until you have the best view.
4. If you make sure the room is well lit, there is no need for shining a
flashlight, penlight or other direct light.
5. Make your first goal just to see a pulsation, and then decide if it is arterial
or venous by applying the following criteria to identify venous waves:

Venous wave is bifid, flicking like a snake's tongue.

It rises when you lower the head of the bed and sinks when you
raise the head of the bed.

It changes with respiration, sinking into the chest with inspiration.

It is not palpable.

It is fine to use the external jugular vein, as long as you

can see clear wave forms in it.

Commonly, a prominent pulsation is mistaken for that of the

carotid artery rather than of the JVP. To differentiate, press on the
RUQ while watching the neck. The JVP should rise in all
individuals with this maneuver; whereas a carotid pulsation should
not change.

6. The JVP can be assessed on either the right or left. On occasion

(musculoskeletal anatomy, venous clots) the pulsations can only be
visualized on one side. If you cannot clearly define the JVP on the right
internal jugular, examine the left.
7. If you cannot determine the JVP, report the exam as "JVP not visualized"
rather than "no JVD" (which implies that the JVP was visualized and is
not elevated).
Once you have determined that you are seeing the venous waves thenmeasure the
jugular venous pressure:
1. Identify JVP at the highest point of pulsation
2. Extend card or ruler horizontally from highest pulsation point , cross with
ruler placed on the sternal angle (Angle of Louis), (let's say it was 8cm).
3. Add 5 cm (to get to the center of the atrium) and then report the JVP as
"the jugular venous pressure was 13 cm of water" (not mercury).

Jugular Venous Waveform

Normal
There are two positive waves 'a' and 'v', one occurring just before the first heart sound or
the carotid impulse, and one just after. When the heart rate is 80 or less, they are fairly
easy to time, but if the heart rate is fast, then you may need to auscultate while you
observe.

"A" wave: atrial contraction (ABSENT in atrial fibrillation)

"C" wave: ventricular contraction (tricuspid bulges). YOU WON'T SEE

THIS

"X" descent: atrial relaxation

"V" wave: atrial venous filling (occurs at same of time of ventricular

contraction)

"Y" descent: ventricular filling (tricuspid opens)

Abnormal Jugular Venous Waveforms

Elevated "a" wave

o

Pulmonary Hypertension

Rheumatic tricuspid stenosis

Right atrial mass or thrombus

Large positive venous pulse during "a" wave. It occurs when an atrium
contracts against a closed tricuspid valve during AV dissociation.
Examples include:

Premature atrial/junctional/ventricular beats

Complete atrio-ventricular (AV) block

Ventricular tachycardia

Absent "a" wave

o

Cannon "a" wave

o

Resistance to right atrial emptying, may occur at or beyond the tricuspid

valve. Examples include:

No atrial contraction, common to atrial fibrillation.

Elevated "v" wave

o

Tricuspid regurgitation is the most common cause (Lancisi sign).

The ventricle contracts and if the tricuspid valve does not close
well, a jet of blood shoots into the right atrium.

Tricuspid regurgitation, if significant, will be accompanied by a

pulsatile liver (feel over the lower costal margin).

You will also hear the murmur of tricuspid regurgitationa

pansystolic murmur that increases on inspiration.

Other signs:
o

Kussmaul's sign: neck veins rise in inspiration rather than falloften a

sign of pericardial tamponade or right heart failure (acute right ventricular
myocardial infarction)

Friedrich's sign: exaggerated "x" wave or diastolic collapse of the neck

veins from constrictive pericarditis.