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Cardiovascular examination - Part one of a four-part series - Measuring jugular venous pressure

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Jugular venous pressure (JVP) is the blood pressure in the jugular veins. 

Abstract

VOL: 103, ISSUE: 25, PAGE NO: 28

Phil Jevon, PGCE, BSc, RN, is resuscitation officer/clinical skills lead and honorary clinical lecturer, University of Birmingham Medical School

Alan Cunnington, FRCP, MD, is consultant physician; both at Manor Hospital, Walsall

The internal jugular vein is observed to assess central venous pressure. The most common cause of raised JVP is congestive cardiac failure, in which the raised venous pressure reflects right ventricular failure (Epstein et al, 2003).

RELATED ANATOMY AND PHYSIOLOGY

The jugular veins drain blood from the head. There are internal and external branches. The internal jugular vein lies deep in the root of the neck, medial to the sternomastoid muscle (Fig 1). It is joined to the superior vena cava and the right atrium, without any intervening valves (Epstein et al, 2003).

The external jugular vein lies lateral to the sternomastoid muscle and is more superficial than the internal jugular vein, so is therefore easier to see. However, the external jugular vein can become compressed as it enters the chest so cannot be relied upon to assess the position or waveform of the JVP (Talley and O’Connor, 2001).

JUGULAR VENOUS PRESSURE

Pressure in the right atrium is an important indicator of cardiac or pulmonary disease; as the right atrium communicates directly with the right internal jugular vein, the pressure within the vein provides an accurate indication of right atrial pressure (Cox and Roper, 2005). When the pressure in the right atrium is sufficiently high, blood flows back into the internal jugular vein. This can be observed as a pulsation, which enables a clinician to estimate the pressure in the atrium (Talley and O’Connor, 2001).

The mean pressure in the right atrium is normally <7mmHg (9cm H2O); as the sternal angle is approximately 5cm above the right atrium, the normal jugular pressure pulse should not be >4cm (9cm-5cm) above the sternal angle. Therefore, in a healthy patient with normal right atrial pressure:

- Sitting at a 45 degs angle - the transition point between the distended vein and the collapsed vein may or may not be visible; if it is visible, the pulsation will be seen just above the clavicle;

- Lying flat - the jugular vein will be distended and the pulsation will not be visible;

- Sitting upright - the upper part of the vein will be collapsed and the transition point between it and the distended vein will be obscured, so the pulsation will not be seen (Fig 2) (Douglas et al, 2005).

Practitioners experienced in assessing JVP can gain further detailed information by scrutinising the JVP waveform.

In atrioventricular dissociation (atrial and ventricular contractions are not related in time), the right atrium sometimes contracts against a closed tricuspid valve, resulting in large jugular venous pulsations or ‘cannon waves’. These occur at irregular intervals because sometimes the tricuspid valve will be shut and sometimes it will be open (Cox and Roper, 2005).

Causes of a raised JVP include:

- Congestive heart failure;

- Right-sided heart failure;

- Cardiac tamponade;

- Pulmonary embolism;

- Obstruction of superior vena cava;

- IV fluid overload (Epstein et al, 2003).

Jugular venous pulsation can be distinguished from carotid pulse because it:

- Is visible but not palpable;

- Moves with respiration;

- Is affected when pressure is applied to the abdomen (Ford et al, 2005).

THE PROCEDURE

- Explain the procedure to the patient.

- Ensure there is adequate lighting.

- Adopt a position on the patient’s right.

- While ensuring privacy and maintaining the patient’s dignity, expose the upper chest. Remove any restrictive clothing from around the patient’s neck and chest.

- Position the patient at an angle of 45 degs, leaving one pillow under the head (Fig 3).

- Ask the patient to turn her or his head to the left (Fig 4).

- Observe the level of the jugular venous pulsations just above the clavicle.

- Measure the vertical distance (cm) between the sternal angle (manubrio sternal joint or angle of Louis) and the highest visible level of jugular vein pulsation (Fig 5) (McConnell, 1998). The normal distance is <4cm; add 5cm to this because the right atrium is 5cm below the sternal angle.

- If it is difficult to see the jugular venous pulsation, shine a bright light directly onto the patient’s neck (McConnell, 1998).

- If it is still difficult to see jugular venous pulsation or there is uncertainty whether the pulsation is venous or arterial, some authorities recommend gentle compression on the right upper quadrant of the abdomen (Fig 6). This will transiently increase venous pressure resulting in a more prominent internal jugular vein. Venous pulsation usually returns to normal after a few seconds (even with continued abdominal pressure); if it remains elevated this suggests right-sided heart failure (Cox and Roper, 2005).

- Document the findings of whether the jugular venous pulsation is visible and, if so, whether it is normal or elevated.

PROFESSIONAL RESPONSIBILITIES

This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.

- This article has been double-blind peer-reviewed.

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