definition of jvp

8/13/2019 Definition of Jvp

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Visualization

The veins of the neck, viewed from in front.The patient is positioned under 45, and the filling

level of the jugular vein determined. Visualize the

internal jugular vein when looking for the

pulsation. In healthy people, the filling level of the

jugular vein should be less than 3 centimetres

vertical height above the sternal angle. A pen-light

can aid in discerning the jugular filling level by

providing tangential light.


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Above, it lies upon the rectus capitis lateralis, behind the

internal carotid artery and the nerves passing through thejugular foramen; lower down, the vein and artery lie uponthe same plane, the glossopharyngeal and hypoglossalnerves passing forward between them; the vagus descendsbetween and behind the vein and the artery in the samesheath (the carotid sheath), and the accessory runsobliquely backward, superficial or deep to the vein.

At the root of the neck, the right internal jugular vein is a

little distance from the common carotid artery, andcrosses the first part of the subclavian artery, while theleft internal jugular vein usually overlaps the commoncarotid artery.

The left vein is generally smaller than the right, and each

contains a pair of valves, which are placed about 2.5 cmabove the termination of the vessel.


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The JVP is easiest to observe if one looks alongthe surface of the sternocleidomastoid muscle,as it is easier to appreciate the movementrelative to the neck when looking from the side(as opposed to looking at the surface at a 90

degree angle). Like judging the movement of anautomobile from a distance, it is easier to seethe movement of an automobile when it iscrossing one's path at 90 degrees (i.e. movingleft to right or right to left), as opposed to

coming toward one.

Pulses in the JVP are rather hard to observe, buttrained cardiologists do try to discern these assigns of the state of the right atrium.


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The mean pressure in the right atrium is normally 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 thepulsation 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


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THE PROCEDURE

- Explain the procedure to the patient.

- Ensure there is adequate lighting.

- Adopt a position on the patients right.

- While ensuring privacy and maintaining the patients dignity,expose the upper chest. Remove any restrictive clothing fromaround the patients neck and chest.

- Position the patient at an angle of 45 degs, leaving onepillow under the head .

- Ask the patient to turn her or his head to the left .

- Observe the level of the jugular venous pulsations justabove the clavicle.

- Measure the vertical distance (cm) between the sternalangle (manubrio sternal joint or angle of Louis) and thehighest visible level of jugular vein pulsation. The normaldistance is


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- If it is difficult to see the jugular venous

pulsation, shine a bright light directly onto thepatients neck.

- If it is still difficult to see jugular venouspulsation or there is uncertainty whether thepulsation is venous or arterial, some authorities

recommend gentle compression on the rightupper quadrant of the abdomen. This willtransiently increase venous pressure resulting ina more prominent internal jugular vein. Venouspulsation usually returns to normal after a fewseconds (even with continued abdominalpressure); if it remains elevated this suggestsright-sided heart failure.

- Document the findings of whether the jugularvenous pulsation is visible and, if so, whether itis normal or elevated


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The JVP and carotid pulse can be differentiatedseveral ways:

multiphasic- the JVP "beats" twice (in quicksuccession) in the cardiac cycle. In other words,

there are two waves in the JVP for each contraction-relaxation cycle by the heart. The first beatrepresents that atrial contraction (termed a) andsecond beat represents venous filling of the rightatrium against a closed tricuspid valve (termed v) andnot the commonly mistaken 'ventricular contraction'.

These wave forms may be altered by certain medicalconditions; therefore, this is not always an accurateway to differentiate the JVP from the carotid pulse.The carotid artery only has one beat in the cardiaccycle.


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non-palpable - the JVP cannot be palpated.

If one feels a pulse in the neck, it isgenerally the common carotid artery.

occludable - the JVP can be stopped by

occluding the internal jugular vein by lightly

pressing against the neck. It will fill fromabove.

varies with head-up-tilt (HUT) - the JVP

varies with the angle of neck. If a person is

standing, his JVP appears to be lower on the

neck (or may not be seen at all because it is

below the sternal angle). The carotid pulse's

location does not vary with HUT.


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varies with respiration - the JVP usually

decreases with deep inspiration.Physiologically, this is a consequence of

the FrankStarling mechanism as

inspiration decreases the thoracic

pressure and increases blood movement

into the heart (venous return), which a

healthy heart moves into the pulmonary

circulation.


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The jugular venous pulsation has a biphasic waveform.

The " a " wave corresponds to right Atrial contraction and ends synchronously

with the carotid artery pulse. The peak of the 'a' wave demarcates the end ofatrial systole.

The " c " wave corresponds to right ventricular Contraction causing thetriCuspid valve to bulge towards the right atrium.

The " x " descent follows the 'a' wave and corresponds to atrial relaXation andrapid atrial filling due to low pressure.

JVP Waveform


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The " x' " (x prime) descent follows the 'c' wave and

occurs as a result of the right ventricle pulling thetricuspid valve downward during ventricular systole. The

x' (x prime) descent can be used as a measure of right

ventricle contractility.

The " v " wave corresponds to Venous filling when the

tricuspid valve is closed and venous pressure increases

from venous return - this occurs during and following the

carotid pulse.

The " y " descent corresponds to the rapid emptYing of

the atrium into the ventricle following the opening ofthe tricuspid valve.


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Certain wave form abnormalities, include "Cannon a-

waves", or increased amplitude 'a' waves, are

associated with AV dissociation (third degree heart

block), when the atrium is contracting against a

closed tricuspid valve, or even in ventriculartachycardia. Another abnormality, "c-v waves", can be

a sign of tricuspid regurgitation. The absence of 'a'

waves may be seen in atrial fibrillation.


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An elevated JVP is the classic sign of venous

hypertension (e.g. right-sided heart failure).JVP elevation can be visualized as jugularvenous distension, whereby the JVP isvisualized at a level of the neck that ishigher than normal. The paradoxical increase

of the JVP with inspiration (instead of theexpected decrease) is referred to as theKussmaul sign, and indicates impaired fillingof the right ventricle. The differential

diagnosis of Kussmaul's sign includesconstrictive pericarditis, restrictivecardiomyopathy, pericardial effusion, andsevere right-sided heart failure.


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Raised JVP, normal waveform

Bradycardia

Fluid overload

Heart Failure

Raised JVP, absent pulsation

Superior vena cava syndrome

Large 'a' wave (increased atrial contraction pressure)

tricuspid stenosis

Right heart failure

Pulmonary hypertensionCannon 'a' wave (atria contracting against closed tricuspid valve)

Atrial flutter

Premature atrial rhythm (or tachycardia)

third degree heart block

Ventricular ectopicsVentricular tachycardia

Absent 'a' wave (no unifocal atrial depolarisation)

atrial fibrillation


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Large 'v' wave (c-v wave)

Tricuspid regurgitation

Slow 'y' descent

Tricuspid stenosis

Cardiac Tamponade

Prominent & Deep 'y' descent

Constrictive pericarditis

Parodoxical JVP (Kussmaul's sign: JVP rises with inspiration,

drops with expiration)

Pericardial effusion

Constrictive pericarditis

Pericardial tamponade

definition of jvp

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