How To Examine Jugular Venous Pressure

How To Examine Jugular Venous Pressure

Examination of jugular venous pressure is one of the main component of systemic examination of cardiology ward.The JVP can be estimated by observing the level of blood in either the internal or external jugular vein.Both vein have valve but it is less in internal jugular vein.As blood flow towards the heart,the do not affect  this and may even make the waveform easier to see.The normal waveform has 2 peaks per cycle which help them distinguish it from the carotid artery pulse.

The JVP reflects central venous or right atrial pressure(normally < 7mm/Hg/9cm H2O) and indirectly right ventricular function.The sternal angle is approximately 5cm above the right atrium ,so the JVP should be no more than 4cm above this angle when the patient lies at 45 degree.If the JVP is low ,the patient may have to lie flat for it to be seen,if high,the patient may need to sit upright.

Position Of Jugular Vein and Carotid Artery

The internal jugular vein enter the neck behind the mastoid process.It run deep to sternocleidomastoid muscle before entering the thorax between the sternal and clavicular head and can only be examined when the neck muscle are relaxed.Although the vein itself cannot be seen,a diffuse pulsation is visible when the pressure in the internal jugular vein is elevated.

The external jugular vein is more superficial ,prominent and generally easier to see.Although it can be obstructed as it traverse the deep fascia of the neck,this rarely present a problem.If it is visible,pulsatile  and not obstructed,it can be used to assess JVP.Due to the anatomy of the innominate vein,the JVP is best examined on the patient's right side and internal jugular vein is used.

The carotid pulsation best feel at the anterior border of sternocleidomastoid muscle along the superior border of thyroid cartilage.

Procedure:

1.Position the patient so that he is reclining supine comfortably until the waveform is clearly visible(at 45 degree).

2.Rest the patient 's head on a pillow to ensure that the neck muscle are relaxed.

3.Look across the neck from the right side of the patient .

4.Identify the jugular vein(can use torchlight for identification) and its pulsation.

5.If you are not certain,use the abdomino-jugular reflux or occlusion to confirm it is the JVP.

-Abdomino-jugular reflux:

Gently press over the abdomen for 10 seconds.This is increase venous return to the right side of the heart temporarily and JVP normally rises.This rise may take 15 second to decrease in congestive heart failure.

-Occlusion:

The JVP waveform is obligated by gently occluding the vein at the base of the neck with your finger.This help to differentiate between carotid artery and jugular vein .(Remember ,we need only jugular vein,not carotid artery).By pressing at the base of the neck with your finger,try feel for pulsation along SCM muscle.If there is still pulsation with pressing at the base,it will be the carotid artery.Due to the thick wall of artery ,pulsation will be present even with pressing.If the pulsation is absent with pressing at the base,then it is the jugular vein which we needed.

6.The JVP is the vertical height in cm between the top of the venous pulsation and the sternal angle,whether they are sitting at 45 degree or not.

7.Identify the timing and form of the pulsation and note any abnormality..

by Lakdhes.