How is jugular venous distension (JVD) documented?

Documentation of Jugular Venous Distension (JVD)

Jugular venous distension (JVD) should be documented as the estimated height of the mean jugular venous waveform above the right atrium in centimeters of water. 1

Proper Measurement Technique

• Position the patient at 30-45 degrees elevation and observe the highest point of pulsation in the internal jugular vein 2, 3
• When JVD is expressed in centimeters without further description, the number should be recorded as written 1
• When expressed as centimeters above the sternal angle, add 5 cm to account for the approximate distance from the sternal angle to the right atrium 1, 2
• For example: "JVP = 8 + 5 = 13 cm H₂O" (where 8 cm is the height above sternal angle) 1

Alternative Documentation Methods

• In the absence of a numerical estimate, descriptive terms can be recorded as positive for elevated jugular venous pressure 1:
  • "Jugular venous distension (JVD)"
  • "Distended neck veins"
  • "Halfway to the jaw"
  • "To the angle of the jaw"
• The hepatojugular reflux (HJR) should be noted if present, as it provides additional information about elevated right-sided pressures 1, 2

Ultrasound Assessment

• Ultrasound can provide more objective measurement of jugular vein diameter (JVD) when physical examination is difficult 4, 5
• Normal ultrasound-measured JVP is approximately 6.35 cm (slightly lower than the published normal examination-based JVP) 6
• Ultrasound assessment has excellent interrater reliability compared to traditional physical examination 6, 5
• Ultrasound can identify JVD even when not apparent on physical examination, particularly in patients with dyspnea 7

Clinical Significance of Documentation

• JVD is the most reliable sign of volume overload and reflects right atrial pressure 1, 2
• Proper documentation of JVD is critical for:
  • Assessing volume status in heart failure patients 1
  • Monitoring response to diuretic therapy 2
  • Risk stratification, as elevated JVD is associated with worse outcomes 4, 5
• The presence of JVD, when measured carefully, has high sensitivity (81%), specificity (80%), and predictive accuracy (81%) for detecting elevated pulmonary capillary wedge pressure (≥18 mmHg) 1

Common Pitfalls in JVD Assessment

• JVD measurement can be challenging in obese patients or those with respiratory disorders 2, 3
• Inspiratory collapse of jugular veins during deep inspiration suggests normal JVP, while lack of collapse indicates elevated pressure 8
• Apparent JVD may be confused with carotid pulsations; jugular venous pulsations are obliterated by light pressure at the base of the neck 1
• Complete normalization of JVP may not be appropriate in all patients, particularly those with pulmonary hypertension or tricuspid regurgitation 2, 3