Interactive Guide to Physical Examination

Evaluating the Jugular Veins

Estimating the venous pressure:

Jugular venous pressure is a reflection of right atrial events in general, and in particular, anything impairing right heart filling. Estimating venous pressure accurately can therefore provide valuable clinical information. There are four steps in evaluating the jugular veins:

  • Locate the internal veins deep to the sternomastoid muscle. If not visible, locate the external veins located superficial to the sternomastoid muscle.
  • Once a pulsation is identified, ensure it is venous, and not a transmitted carotid impulse. Venous pulsations disappear with applied pressure, whereas carotid impulses do not.
  • Measure the height of the venous column.
  • Assess the jugular venous wave forms.

Normal venous pressure is less than 3-4 cm above the sternal angle.

View video Click on the video icon to see a demonstration of how to measure the JVP.

Evaluating the venous wave forms:

Careful observation reveals that the JVP is composed of two quick elevations and two troughs. The first elevation is the "a" wave. It accompanies atrial contraction, occurring just before the first heart sound and the carotid impulse. The following trough is called the "x" descent and begins with atrial relaxation and continues through ventricular systole. The second elevation is called the "v" wave and is coincident with venous filling of the atria. The tricuspid valve then opens and right atrial blood flows passively into the ventricle creating the second trough or "y" descent.

To the examiner, the "x" and "y" descents are the most obvious events with the "x" descent occurring as the carotid impulse is rising before the second heart sound and the "y" descent following the second heart sound early in diastole. A more careful analysis of these wave forms may identify certain arrhythmias, provide important clues as to the presence of valvular heart disease, or pericardial disease. Further discussion is beyond the scope of this site.