You are performing jugular venous pressure measurement for your patient in heart failure. You see a pulse wave with the patient's head elevated at a 45-degree angle. Your action as a result of this assessment is to:

a. record this measurement as less than 9 cm H2O pressure.
b. record this measurement as more than 9 cm H2O pressure.
c. confirm that the pulsations decrease with inspirations.
d. confirm that the pulsations increase with inspirations.


C
Confirmation that you are assessing venous pressure, rather than a carotid wave pulse, is neces-sary. The jugular venous pulse will decrease on inspiration and increase on expiration, whereas the carotid pulse will not be affected.

Nursing

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