A 4-month-old infant is being treated for developmental dysplasia of the hip (DDH) with a Pavlik harness. The parents report that the infant has been crying more than usual and seems uncomfortable. During the assessment, the nurse notices redness and skin breakdown on the infant's thighs. What is the most appropriate nursing intervention?

Adjusting harness straps reduces pressure on skin while maintaining therapeutic positioning, and educating parents prevents future complications. Other options either disrupt treatment or fail to address the underlying pressure issue.

Understanding the Complication
When an infant in a Pavlik harness develops skin breakdown on the thighs accompanied by increased crying, the priority is to address a common and preventable complication: pressure injury from an improperly fitted device. The harness works by maintaining the hips in a flexed and abducted position to facilitate spontaneous reduction of the femoral head into the acetabulum. If the straps are too tight or incorrectly positioned, they create sustained pressure on soft tissues, compromising microcirculation and leading to ischemia, redness, and eventually skin breakdown. The infant’s increased crying is a key behavioral cue indicating discomfort or pain, which in this context is highly suggestive of excessive strap pressure rather than a new underlying pathology. The foundational principle of nonsurgical management, as highlighted in the provided research on bracing for developmental dysplasia of the hip (DDH), is that treatment success depends on maintaining the correct hip position while avoiding complications like skin injury or, more critically, femoral head avascular necrosis (AVN) ^[1].

Analyzing the Options
The correct intervention is to adjust the harness straps to reduce pressure and provide skin care education to the parents. This directly targets the root cause—mechanical pressure—and empowers the caregivers with the knowledge to prevent recurrence. The skin should be kept clean and dry, and a protective barrier, such as a soft cotton onesie worn under the straps, can be recommended. This conservative, nurse-driven intervention is the appropriate first-line response for a stage 1 pressure injury.

The other options are incorrect for the following reasons:
- Removing the harness immediately and contacting the orthopedic surgeon is an overreaction for localized, non-infected skin redness. Abruptly discontinuing treatment disrupts the critical maintenance of hip reduction, which is the cornerstone of successful DDH management in children under 18 months ^[1]. This action is reserved for severe complications like femoral nerve palsy, significant vascular compromise, or a failure to achieve and maintain reduction.
- Applying topical antibiotic ointment is not indicated because the assessment findings describe redness and breakdown, which is a pressure injury, not a bacterial skin infection. Applying an unnecessary antibiotic does not relieve the causative pressure and can contribute to antimicrobial resistance.
- Increasing padding under the harness straps is counterproductive. Adding bulky material can alter the mechanical dynamics of the harness, potentially reducing its effectiveness at maintaining the hip in the correct flexed and abducted position. It may also create new pressure points and trap moisture, worsening skin integrity. The solution is to correctly adjust the existing straps, not to pad them.

Clinical Reasoning and Safe Practice
The nursing process guides this decision. During the assessment, the nurse identifies a localized injury (redness and breakdown on thighs) linked to a therapeutic device. The diagnosis is "Impaired Skin Integrity related to mechanical pressure from the Pavlik harness." The planning and implementation must first involve removing the source of pressure through proper strap adjustment. This approach aligns with the broader safety and efficacy goals of DDH bracing, which aim to achieve hip reduction while minimizing iatrogenic harm ^[1]. Parental education is a critical component of nursing care for DDH, as the family is responsible for the infant’s 23-hour-per-day wear schedule and must be able to perform daily skin assessments and basic harness care. By teaching the parents how to identify early signs of pressure and maintain skin hygiene, the nurse prevents the progression of the injury and avoids a treatment interruption that could compromise the long-term outcome of hip development.