1. How can you detect jugular pulsations that are difficult to perceive?
ANS: a. Shine a light tangentially from behind or in front of the neck to throw a jugular shadow.
b. The most accurate way of finding the top level of pulsations is to examine the silhouette of the neck. When you are examining the right side of the neck, you must lean over to the left side of the patient or stand on the left side of the bed temporarily to obtain a good view of the silhouette of the skin overlying the right internal jugular.
c. If the internal jugular pressure is high, the earlobes often pulsate. Unfortunately, a strong carotid pulse pressure can also cause slight earlobe pulsations.
2. What effect does inspiration have on jugular pulsations and their perception?
ANS: The top level may be lower because the drop in intrathoracic pressure on inspiration may be reflected in the jugulars. Inspiration may, however, make jugular pulsations easier to see because the RV has more blood volume on inspiration and contracts with more energy.
Note: Held respiration often eliminates jugular pulsations altogether, probably because of the slight Valsalva effect.
Jugular movements may be very subtle. Any slight movement of the hand holding the light can produce as much artifactual movement as movement from the jugulars themselves. Therefore, you must support your hand on either the pillow behind or the chest in front.
Leaning over to the left side of the patient to view an outline of the neck against the pillow will show you more subtle motion than could be seen even with an oblique light. Therefore, the true upper level of motion is best seen from this viewpoint.
3. How can you obtain an accurate number in centimeters for a venous pressure?
ANS: Mark the upper level of jugular pulsation during inspiration with a felt-tipped pen. Place a tongue blade marked off in centimeters vertically on the sternal angle. The rounded ends make a tongue depressor the most comfortable measuring stick. A carpenter's level will give the most accurate vertical level. If no ruler is available, you may use the thickness of your fingers for a rough estimate. The second interphalangeal joint is generally about 2 cm in thickness. Measure your own joint for future use. If you place a closed fist on the sternal angle, each finger breadth is about 2 cm.
Note the higher absolute level but smaller amplitude of pulsations on expiration. With bronchospasm jugular pulsations with normal pressures may only be visible above the clavicle during expiration due to the effect of straining, which elevates intrathoracic pressure with each expiration.
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