• The jugular venous pressure (JVP) reflects pressure in the right atrium (central venous pressure); the venous pressure is estimated to be the vertical distance between the top of the blood column (highest point of oscillation) and the right atrium.

• Right and left internal jugular veins
• Largest paired neck veins draining the head and neck
• Originate from the dural venous sinuses
• Exit the skull via the jugular foramen
• Descend through the neck alongside the internal carotid arteries
• Joins the subclavian veins at the base of the neck
• Located posterior and superior to the medial fourth of the clavicle, running cephalad until it passes under the sternocleidomastoid muscle
• Not directly visible, identifiable only via pulsations transmitted to the surface of the neck
• Right internal jugular vein
• Communicates directly with the right atrium via the superior vena cava
• Right and left external jugular veins
• Drain superficial scalp and face structures
• As they descend through the lateral neck the pass diagonally over the top of the sternocleidomastoid muscles
• Empty into the subclavian veins
• Sternal angle of Louis
• The bony ridge adjacent to the second rib where the manubrium joins the body of the sternum
  
• Remains roughly 5 cm above the right atrium regardless of the patients position

• Pressure changes from right atrial filling, contraction, and emptying cause fluctuations in the JVP and its waveforms that are visible to the examiner.

• Routine cardiac examination in the evaluation of:
• Constrictive pericarditis
• Heart failure
• Pericardial tamponade
• Pulmonary hypertension
• Superior vena cava obstruction
• Tricuspid stenosis
• To determine the central venous pressure

• Begin with the patient relaxing comfortably in bed, head on a pillow (to relax the sternocleidomastoid muscles), view of neck and chest should be unobstructed (if possible), and the head of the bed elevated 30°- 45°
• Turn the patient's head slightly away from the side you are inspecting and extend the chin (ensure the sternocleidomastoid muscles are still relaxed)
• Use tangential light to identify the external jugular veins and then the internal jugular vein pulsations (lower half of the neck)
• If jugular venous pulsations cannot be seen, lower/raise the head of the bed until observed
• Take care to distinguish internal jugular pulsations from the carotid artery pulsations
• Observe the pulsations in the right side of the neck while timing the carotid artery pulse on the left side of the neck with the examiners right third finger
• Observe if both the left and right jugular veins distend at approximately the same degree of elevation during the same phase of respiration
• Observe for the fluttering waves in inspiration and expiration (this identifies the top of the venous column)
• In order to find the top of the column, the head of the bed may need to raised and lowered several times
• Avoid exaggerated breathing or breath holding because it distorts the normal mean venous pressure
• Focus on the right internal jugular vein
• Look for pulsations in the suprasternal notch
• Identify the highest point of pulsation
• Extend a long rectangular card/ruler horizontally from this point and a centimeter ruler vertically from the sternal angle (make an exact right angle)
• Measure the vertical distance (in centimeters) above the sternal angle where the horizontal card crosses the ruler
• Add to this distance 4 cm (the distance from the sternal angle to the center of the right atrium)

• Normal:
• JVP is 6 to 8 cm above the right atrium
• Abnormal/elevated:
• JVP is > 9 cm above the right atrium (> 4 cm above the sternal angle)

• JVP falls in hypovolemia
• JVP rises with:
• Constrictive pericarditis
• Pericardial compression/tamponade
• Pulmonary hypertension
• Right/left heart failure
• Superior vena cava obstruction
• Tricuspid stenosis

• The jugular veins/pulsations are difficult to detect in children < 12 years of age
• Consider the patient's volume status
• Hypovolemic patients may need to lie flat before you can observe neck veins
• Increased JVP (or volume-overload) you may need to elevate the head of the bed 60°- 90°
• In patients with obstructive lung disease, venous pressure may appear elevated on expiration only and the veins collapse during inspiration (dose not indicate heart failure)
• To determine if jugular venous distention is due to pressure from below or are simply prominent, use the method of "stripping" the vein
• Place our adjacent forefingers over a distended segment of the external jugular vein
• Strip the vein of its blood by moving your fingers apart while maintaining firm pressure on the vein (the vein should be flat as you maintain pressure on it)
• To test for "filling from below" (from the heart back up into the veins), release only the finger closest to the heart (keep the other finger in its place)
• If the central venous pressure is high enough, the vein will fill in a retrograde fashion ("from below")

1. Bickley LS et al. Bates' Guide to Physical Examination and History Taking. 11^th ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2013;361-5.
2. Marieb EN, Hoehn K. Anatomy & Physiology. 3^rd ed. San Fransisco, CA: Pearson Benjamin Cummings. 2008;668-71.
3. Orient, JM. Sapira's Art and Science of Bedside Diagnosis. 4^th ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2010;398-403.
4. Walker HK et al. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 19.

Editors:

• Anthony J. Busti, MD, PharmD, FNLA, FAHA
  

Last Reviewed: July 2015